27 Iranian Journal of Nursing and Midwifery Research | January-February 2013 | Vol. 18 | Issue 1
Preconception risk assessment of infertile couples
Nafisehsadat Nekuei, Ashraf Kazemi, Soheila Ehsanpur, Nastaran Mohammad Ali Beigi
Background: With regard to the importance of preconception conditions in maternal health and fertility, preconception risk
assessment makes treatment trends and pregnancy outcome more successful among infertile couples. This study has tried to
investigate preconception risk assessment in infertile couples.
Materials and Methods: This is a descriptive analytical survey conducted on 268 subjects, selected by convenient sampling,
referring to Isfahan infertility centers (Iran). The data were collected by questionnaires through interview and clients’ medical
records. Pre-pregnancy risk assessment including history taking (personal, familial, medical, medications, menstruation, and
pregnancy), exams (physical, genital, and vital signs), and routine test requests (routine, cervix, infections, and biochemical
tests) was performed in the present study.
Results: The results showed that the lowest percentage of taking a complete history was for personal history (0.4%) and the
highest was for history of menstruation (100%). The lowest percentage of complete exam was for physical exam (3.4%) and the
highest for genital exam (100%). With regard to laboratory assessment, the highest percentage was for routine tests (36.6%)
and the lowest was for infection tests (0.4%).
Conclusion: Based o the results of the present study, most of the risk assessment components are poorly assessed in infertile
couples. With regard to the importance of infertility treatment, spending high costs and time on that, and existence of high-risk
individuals as well as treatment failures, health providers should essentially pay special attention to preconception risk assessment
in infertile couples in order to enhance the chance of success and promote treatment outcome.
Key words: Infertility, preconception care, risk assessment, Iran
Department of Midwifery and Reproductive Health, School of
Nursing and Midwifery, Isfahan University of Medical Sciences,
Address for correspondence: Mrs. Nafisehsadat Nekuei,
Faculty of Nursing and Midwifery, Isfahan University of Medical
Sciences, Hezar Jarib Street, Isfahan, Iran.
a positive pregnancy test (when the mother is unaware of
pregnancy). This time is a golden time to promote mother’s
biologic conditions to accept the fetus as much as possible.
Therefore, preconception counseling concerning a healthy
lifestyle and reduction of risk factors should start before
pregnancy to ensure mothers’ good health in this crucial time
and during the whole pregnancy period. Inappropriate
conditions that influence pregnancy can be detected by
preconception risk assessment (as an important part of
preconception care (PCC)), either to be deleted or to be
modified in order to promote pregnancy outcome. The result
of this latter action is provision of the best quality of life for
the fetus, infants, and children through primary prevention
as the goal of PCC. One of the important target groups for
this function is infertile couples. Based on statistics, about
5‑10% of couples at reproductive age s uffer from infertility.
Nowadays, infertility is treated by various methods, but
most of these methods have high failure rate and cost, and
need a long‑term process. Infertile couples are among the
high‑risk groups who may face high fetal and congenital
complications and low success is pregnancy. In addition, in
many cases, existence of systematic diseases and undesired
biological conditions is linked with couples’ infertility leading
to hard situations endangering a healthy productivity.
For instance, there are some gastrointestinal diseases,
Positive pregnancy outcome is tied to mother’s preconception
health. Mother’s background diseases influence pregnancy
outcome. For instance, previous studies have shown that
pregnancy, accompanied with diabetes, leads to high
prevalence of macrosomia, shoulder dystocia, intrauterin
fetal death (IUFD), preganacy induced hypertention (PIH),
intrauterin growth restriction (IUGR), preterm labor, and
congenital malformation of renal system and heart, as well as
neural tube defects such as sacral agenesia. Ideal health of
women before and during pregnancy should be considered
as a process. The most vulnerable period concerning
congenital defects is within 4‑10 weeks of pregnancy, of
which a period of time is from beginning of pregnancy to
aternal–child health is an important element in
community health. In fact, fetal period makes
a background for an individual’s future health.
Nekuei, et al.: Preconception risk assessment in infertility
Iranian Journal of Nursing and Midwifery Research | January-February 2013 | Vol. 18 | Issue 1 28
accompanied with infertility and primary abortion, such as
celiac disease, inflammatory bowel disease (ulcerative colitis
and Crohn’s disease), and hemochromatosis.
If health providers know well about the effects of these
diseases on fertility system, they can change the trend of
both the disease and infertility treatments based on the
existing conditions through their preconception assessment.
Since idiopathic infertility can be a sign for initial stage of
aforementioned diseases, primary assessment of infertile
couples concerning these diseases can result in a higher
chance of a successful and complication‑free pregnancy,
as well as mothers’ health promotion. Former researches
have shown that health providers can increase the chance of
successful treatment through preconception risk assessment
and modification of risk factors, and ultimately promote
pregnancy outcome. The necessity of infertile couples’
comprehensive assessment before any treatment programs
has been emphasized in other studies. Previous researches
have shown other risk factors accompanied with infertility
and pregnancy complications,[7‑9] whose modification
before pregnancy can enhance the chance of fertility and
reduce pregnancy complications.[10‑16] Through detection
and assessment of these risk factors before pregnancy, their
modification can be programmed and infertility treatment
outcome can be promoted.
As, to the best knowledge of the researchers, no studies
concerning the status of infertile couples’ counseling
before pregnancy, especially their risk assessment, had
been already conducted in Iran, the present study aimed
to define the manner of preconception risk assessment in
MAterIAls And Methods
This is a descriptive analytical survey conducted on 268
infertile couples, selected by convenient sampling, referring
to all infertility services centers in Isfahan, Iran, at least for
the second time during September 2008 to June 2009. The
candidates for egg (oocyte) donation, sorogacy, and embryo
donation did not enter the study. The data were collected
through interviews and inquiring as well as going through
clients’ medical records after taking a written consent from
them. The research tools were questionnaires and checklists.
First section of the questionnaire included personal
information and the second section contained preconception
risk assessment, which had been designed based on its
standard components indicated in reference textbooks.
Risk assessment was divided into three items in the
present study: 1) History taking (familial, personal,
medical, menstrual, medications, and pregnancy); 2)
exams (physical, genital, and vital signs); and 3) laboratory
assessment (routine tests, cervix, infection, and biochemical
tests). The quality of risk assessment was recorded as
complete, incomplete, and not done, based on medical
records and clients’ explanations. Content validity was
adopted to confirm scientific validity of data collection
tool. A researcher‑made questionnaire was designed
through literature review of related books and articles and
with regard to the study goals and related variables. They
were distributed among 10 expert academic members
(gynecologist, masters of midwifery, and infertility center
staffs). Then, their corrective indications were collected
and the necessary modifications were done to increase
content validity. The reliability of the questionnaire was
confirmed by a pilot study conducted on 20 individuals,
identical to those of the study, and Cronbach’s alpha of
0.75. The latter 20 individuals did not enter the study. The
data were analyzed by descriptive and analytical statistical
tests (Pearson, Spearman, and Chi‑square) through SPSS
In the present study, the status of risk assessment among
268 couples referring to infertility centers was investigated.
Ten couples due to incomplete medical records and five
couples due to personal problems were left out of the
study. The findings of subjects’ demographic characteristics
have been presented in [Table 1]. In 88.1% of the subjects,
there was primary infertility, with the highest prevalence
of male infertility (38.8%). About 72.8% of the subjects
had no history of former pregnancies, and the highest
Table 1: Frequency distribution of basic individual
characteristics of infertile couples
Age n (%)
150 (56)69 (25.7)
30-35 (years)84 (31.3)117 (43.7)
33 (12.3)82 (30.6)
29.41 (±4.99)32.68 (±5.17)
Education level n (%)
Less than high school 84 (31.4)138 (51.5)
High school diploma115 (42.9)95 (35.41)
University degree69 (25.7)30 (11.19)
Occupation n (%)
Housekeeper 212 (79.1)–
Employed 50 (18.7) 75 (28)
Others6 (2.2) 24 (9)
Nekuei, et al.: Preconception risk assessment in infertility
29 Iranian Journal of Nursing and Midwifery Research | January-February 2013 | Vol. 18 | Issue 1
prevalence of previous treatment method was for ovulation
The highest number of past treatments was 2 (44.8%) and
the highest former treatment outcome was treatment failure
(69%). Mean length of infertility time was 5.06 years, with
the highest prevalence of 2 years among 35 subjects; mean
treatment time was 3.64 years, with the highest prevalence
of 3 years among 48 subjects.
The findings concerning history taking, physical exam,
and laboratory tests requests have been presented in
[Tables 2 and 3]. Based on the results, in 100% of the couples,
history taking of menstruation and genital exams has been
complete. In 61.1% of the couples with infertility problem
due to pelvic factors, over 75% of the information related to
history had been obtained (the highest partial frequency),
while in infertility due to ovarian defect, in 77.8% of the
couples, taking a history had reached over 75%. In 20.3%
of the subjects with ovarian infertility, physical exam had
been performed up to over 75%. Physical exam among the
subjects with male infertility was 9.6%.
The level of subjects’ laboratory assessment did not
reach over 75% in all infertility reasons. With regard
to investigation of the association between infertility
causes and risk assessment components, data analysis of
Chi‑square test showed a significant association between
infertility reasons and the level of history taking and level of
laboratory assessment, respectively (P = 0.001, P = 0.002).
However, there was no significant association between
infertility causes and the level of physical exams performed.
The correlation between risk assessment components and
subjects› personal characteristics was significant. There was
a direct significant association observed between length
of infertility and taking a history from the clients, physical
exam, and routine laboratory tests [Table 4].
The present study was conducted to define preconception
risk assessment in components of taking a history, physical
exam, and laboratory assessment. It showed that most
of the history taking components had been investigated
incompletely in the studied subjects. Most history
components can influence an individual’s pregnancy
outcome and infertility treatment. One of the most
important parts of history is personal history. This part
includes several items such as client’s occupation, nutritional
status, physical activities, sport, marital relationship, and so
on, which are effective on fertility, infertility treatment, and
Therefore, taking a personal history should be crucially
considered and investigated as an important action before
beginning infertility treatment. The second section of taking
a history from the clients, studied in the present research,
was family history. The present study showed that family
history assessment was incomplete in most of the studied
subjects, although various studies have shown that some
diseases such as rheumatoid arthritis diseases, diabetes,
and thyroid disorders which are accompanied with a
positive family history lead to fertility problems and a poor
pregnancy outcome.[20‑23] With consideration and a further
assessment in high‑risk groups with a positive family history
concerning the existing diseases, preconception risk factors
can be detected to enhance the chance of fertility through
Table 2: Partial frequency distribution of risk assessment items
Risk assessment quality n (%)
50% n (%)
185 (69.03)6 (2.2)221 (81.7) 41 (15.3) Familial
19 (7.09)0 (0)267 (99.6)1 (0.4)Personal
133 (49.63)0 (0)229 (85.45) 39 (14.6)Medical
–7 (2.6)3 (1.1)258 (96.6)Drug
–0 (0)0 (0) 268 (100)Menstrual
221 (82.25) 0 (0)105 (39.18) 163 (60.82) Pregnancy
14 (5.22) 5 (1.9) 254 (94.78) 9 (3.4)Physical exam
268 (100)0 (0)0 (0) 268 (100) Genital exam
–52 (19.4) 3 (1.1) 193 (72)Vital sign
116 (80.6) 37 (13.3)134 (49.6)98 (36.6)Routine
–76 (28.4) 190 (70.9) 2 (0.7) Cervix
16 (5.97) 126 (47 141 (52.61)1 (0.4)Infections
11 (4.1) 151 (56.3)106 (39.96) 11 (4.1) Biochemical
Table 3: Partial frequency distribution of risk assessment according to infertility factors
History taking n (%)Physical exam n (%)Laboratory assessment n (%)
Ovarian factors3 (3.8)54 (68.4)22 (27.8) 21 (26.6) 42 (53.2)16 (20.3) 65 (82.3) 14 (17.7)0.0 (0)
Pelvic factors 2 (3.7)19 (35.2) 33 (61.1)13 (24.1) 34 (63) 7 (13) 39 (72.2)15 (27.8)0.0 (0)
Male factors2 (1.9)51 (49) 51 (49)25 (24) 69 (66.3)10 (9.6) 64 (61.5)40 (38.5)0.0 (0)
Unknown factors 0 (0)15 (48.4)16 (51.6)10 (32.3) 17 (54.8)4 (12.9)15 (48.4) 16 (51.6)0.0 (0)
Nekuei, et al.: Preconception risk assessment in infertility
Iranian Journal of Nursing and Midwifery Research | January-February 2013 | Vol. 18 | Issue 1 30
At the time of taking a history from the clients, its
components are usually asked as a general concept and
not as item‑by‑item in detail, so the responder’s answers
are also general.
Defective function of taking a history revealed by the present
study can be due to the aforementioned reason. In this case,
going through the details (inquiring the history of the diseases
one by one) may solve this problem. The third section of
assessment under study was taking a personal medical history.
The findings showed that taking subjects’ medical history
before pregnancy was incomplete, although previous studies
have shown negative effects of the diseases on the trend of
pregnancy.[24,25] A study showed that among the patients
suffering from lupus erythematosus, in vitro fertilization (IVF)
is a safe method only when this disease has been precisely
investigated and treated before pregnancy. Some other
researchers argue that infertility and endocrine disorders are
seen more in epileptic patients compared to other individuals.
In fact, 38.4% of epileptic patients are infertile. They receive
more antiepileptic medication and less education; therefore,
preconception assessment is essential for them.[27‑29]
Various studies have shown that mothers’ mortality and
pregnancy complications are related to the chronic diseases
which are preventable and treatable before pregnancy.
Since the women undergoing infertility treatment are
mostly at higher ages compared to other people, they
are at a higher risk of chronic diseases, and as chronic
diseases increase IVF complications, these diseases should
be assessed and treated before administration of infertility
treatment in order to guarantee the safety of treatment
and pregnancy. Other researchers also emphasize on
the need for preconception diseases’ assessment. With
regard to the components of history, it seems essential
to go through these components more precisely before
infertility treatment starts, in order to modify the risk
factors and promote pregnancy outcome and infertility
treatment techniques. The second studied component
in preconception risk assessment was physical exam.
A perfect physical exam can reveal the existence of many
problems in an individual. These problems determine an
individual’s general health, which affects pregnancy and
infertility treatment outcome. In the present study, only
physical exam of genital system had been completely
conducted for all the subjects, while a systematic exam had
not been completed for a high percentage of the subjects.
This problem is possibly due to the fact that initial assessment
of genital system health and disorders is mostly considered
to be related to the issue of infertility, while all of the systems
within the body interact with one another to keep an organism
healthy. Although each system has specific functions, they
are all interconnected and dependent on one another. Some
studies have shown that central body obesity is directly
associated with menstrual disorders and/or increased wrist
size can be associated with oligomenorrhea and results in
infertility. The third studied component in preconception
risk assessment was laboratory assessment. The present
study showed laboratory assessment was either incomplete
or even ignored in all the subjects. These results show a very
low consideration of this important issue, although in some
cases, routine tests had been somehow considered.
In fact, treatment team had considered these tests notable
just in the trend of infertility treatment, while clinical tests
can also reveal development of some other diseases which
can, based on several studies, affect the infertility treatment
and pregnancy outcomes.[24,25,33]
Several studies have shown that some preconception
abnormal laboratory values can predict undesirable outcome
Table 4: Correlation between individuals’ characters and some risk assessment items (r)
Risk assessment (%) LiteracyDuration of infertility
Duration of infertility
Personal history 0.13* −0.07*** −0.02***0.08
Medical history −0.07***0.05***0.01*** 0.04
Familial history −0.1*** 0.17* 0.11***0.12
Drug history0.11***0.11*** 0.11***0.04
Pregnancy history−0.12***0.2* 0.18*0.26
Physical exam 0.04***0.18* 0.13*0.21
Vital signs0.0***0.09*** 0.12***0.1
Routine test0.13*0.2* 0.2*0.12
Cervical test0.1*** 0.33** 0.27**0.23
Infection test0.12***0.07*** 0.06*** −0.12
Individuals characters (r), *P<0.05**, P<0.001***, P>0.05
Nekuei, et al.: Preconception risk assessment in infertility
31 Iranian Journal of Nursing and Midwifery Research | January-February 2013 | Vol. 18 | Issue 1
of a pregnancy after IVF . Some others may be associated
with systematic complications affecting the pregnancy
outcome. It should be considered that some diseases
have no specific clinical signs, and screening of diseases
such as diabetes is a major component of preconception
assessment, especially among infertile women. For instance,
polycystic ovarian syndrome (PCOS), which exists in 5‑10%
of women at reproductive age, is one of the major reasons
for infertility, and is a risk factor for cardiovascular diseases,
insulin resistance, dyslipidemia, diabetes mellitus, arterial
hypertension, endothelial dysfunction, metabolic syndrome,
and central obesity. Preconception assessment, screening
for these diseases, and administration of interventional
treatments among these patients can reduce oligomenorrhea
and infertility.[36,37] Based experince of researcher assessment
of all infertile persons, especially in PCOS group, in the
process of infertility treatment is essential in order to screen
for the existing diseases through complete laboratory tests
and leads to prevention and treatment of many diseases
and their complications. Meanwhile, these tests were taken
not more than others in this group in the present study. The
findings of the present study showed a direct and significant
association between the causes of infertility and the level of
history taking and laboratory assessments. This association
was not significant for physical exam. In the first two sections,
the highest weakness was in relation to ovarian causes of
infertility, possibly as a result of a more absolute diagnosis,
which has probably hidden the necessity for a more
comprehensive assessment from the view of the treatment
team. In fact, taking a history and laboratory assessment
was of minor importance from the viewpoint of treatment
personnel in this group, while infertility problems of this
group, like the other causes, could be associated with clients’
negative history and possibly their laboratory disorders.
Another reason for interventional defect in this group can
be argued. As these individuals formed the best group
responding to ovulation induction, treatment was started
for them before a complete assessment.
On the other hand, taking a history has been considered
more in the idiopathic infertile group, possibly as a result of
clients’ more referring to the centers and a more attention
paid by the treatment team to diagnose the cause of
infertility. Another important finding of the present study
was the association between risk assessment and length of
infertility, and then, duration of treatment.
Finally, infertile couples, facing the infertility problem for
a longer period of time and with more frequent referring
to the infertility centers possibly, gave the treatment team
more chance and motivation to conduct a more precise
and complete assessment.
The results of the present study showed that the approach
by the infertility team considering preconception risk
assessment as not only essential to achieve success
in treatment but also as an essential element to make
appropriate conditions for pregnancy was of minor
importance in infertility treatment team. Risk assessment
has been conducted just to succeed in infertility treatment
and not to promote pregnancy outcome, whereas it can
not only lead to more success of treatment but also make
an appropriate biological environment for women to
accept pregnancy as well, if assessments are completely
administered at the very early stages when the clients refer
to the centers.
The authors would like to express their gratitude toward officials,
personnel, and patients of fertility and infertility centers of Isfahan
city. Also, they appreciate Vice‑Chancellery for Research and
Technology of Isfahan University of Medical Sciences for their
collaboration and financial support of this research project (Project
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How to cite this article: Nekuei N, Kazemi A, Ehsanpur S, Beigi
NMA. Preconception risk assessment of infertile couples. Iranian J
Nursing Midwifery Res 2013;18:27-32.
Source of Support: This study was funded by approval and financial
support of the Vice-Chancellery for Research and Technology
of Isfahan University of Medical Sciences (Project No. 286168).,
Conflict of Interest: None.