Description of the characteristics influencing the therapeutic managment of infertile couples in western Algeria

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Citation: Belhachemi N, Zelmat SA, Chafi B, Foughal M, Arabe WM (2020) Description of the characteristics influencing the therapeutic managment of infertile
couples in western Algeria. Glob J Fertil Res 5(1): 016-022. DOI: https://dx.doi.org/10.17352/gjfr.000017
https://dx.doi.org/10.17352/gjfrDOI:
2640-7884ISSN:
MEDICAL GROUP
Introduction
Infertility is characterised by a couple’s inability to conceive
a child. It is defi ned by the World Health Organization (WHO)
in 2009 [1] as the failure to achieve a clinical pregnancy after
12 months of unprotected sexual intercourse and after six
months [2] if the woman is over 35 years of age. Infertility is
said to be ‘‘primary’’ if the couple has never conceived,and
it is said to be “secondary” if a pregnancy has occurred [3,4]
in the past. According to the WHO, 10 to 15℅ couples in the
world are concerned [5], which corresponds to more than 186
million people worldwide, the majority of whom are from the
developing countries [6]. Africa counts about 20 - 35 million,
particularly higher in Sub-Saharan Africa [7]. In Canada, 11-
16% of couples are estimated to be affected [8]. In France, one
in seven couples are infertile and one in ten are undergoing
treatment [9]. In Tunisia, 15% of couples of childbearing age
[10]. In Algeria, despite population growth, the Ministry of
Health estimates this rate at 10.6% [11].
Faced with a couple who decide to consult for infertility, the
gynaecologist has to identify the various social, psychological,
medical and sexological elements. He also has the task of
investigating the factors that infl uence infertility, which are
represented by: the primary or secondary type of infertility, the
Summary
Objective: The aim of this work is to describe and identify the characteristics that can infl uence the care of these infertile couples.
Material and method: This is a prospective, monocentric study, extending over a period of four years. It is descriptive of a sample of 760 infertile couples treated in
the gynaecology and obstetrics department of the Oran hospital and university establishment of 1st November 1954.
Results: The study revealed that primary infertility was 74%. The average duration of infertility was 4.8 ± 0.2 years (minimum 6 months, maximum 25 years); the
average age of infertile couples was 33.2 ± 0.4 years (minimum 18 years, maximum 45 years) in women and 39.5 ± 0.5 years (minimum 23 years, maximum 71 years) in
men. The male origin of infertility was 30.4%, mixed at 29.2%, female at 27% and unexplained at 13.4%. Oligo-astheno-severe teratospermia dominated male infertility at
30.4%. Tubal causes 23.4% and ovulatory causes 22.8% were mainly of female origin of infertility.
Conclusion: The study of these characteristics showed a delay in the treatment of infertile couples. The primary type and long duration of infertility and the advanced
age of both women and men make the chances of conception minimal. The male origin of infertility is more important than the female origin, suggesting a deterioration in
sperm parameters. Tubal causes in the female origin of infertility are important because of the increasing prevalence of sexually transmitted infections.
Research Article
Description of the
characteristics infl uencing
the therapeutic managment
of infertile couples in western
Algeria
Belhachemi N*, Zelmat SA, Chafi B, Foughal M and
Mohand Arabe W
Medical School Ahmed Benbella 1 Oran, Head of Unit in Medically Assisted Procreation, Obstetric
Gynecology Service Hospital and University, Oran, Algeria
Received: 07 November, 2020
Accepted: 15 December, 2020
Published: 16 December, 2020
*Corresponding author: Belhachemi N, Medical
School Ahmed Benbella 1 Oran, Head of Unit in
Medically Assisted Procreation, Obstetric Gynecol-
ogy Service Hospital and University, Oran, Algeria, Tel:
0798296672; E-mail:
Keywords: Infertile couple; Type and Duration of in-
fertility; Age of woman; Age of man; Origin and cause
of infertility
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Citation: Belhachemi N, Zelmat SA, Chafi B, Foughal M, Arabe WM (2020) Description of the characteristics influencing the therapeutic managment of infertile
couples in western Algeria. Glob J Fertil Res 5(1): 016-022. DOI: https://dx.doi.org/10.17352/gjfr.000017
duration of infertility, the age of the woman and the age of the
man, and the origin or cause of the infertility.
Some studies [12,13] have shown that primary infertility
reduces the chances of pregnancy compared to secondary
infertility.
As the duration of infertility increases, the chances of
pregnancy decrease. In fact, 80% of pregnancies are obtained
in the fi rst six cycles of pregnancy. 55% of those who remain
so-called hypofertile will achieve a pregnancy in 36 months
and after 2 years, 5% of couples are said to be infertile with an
almost zero rate of spontaneous pregnancy [14].
A woman’s age is a determining factor in fertility. Fertility
in women declines with increasing age, with a sharp increase
in fertility decline from the age of 35 onwards [15]. For men,
sperm changes are not noticeable until the age of 45 [16];
however, the foetal risk of genetic diseases such as Down’s
syndrome, when the father’s age exceeds 45, is recognised [16].
Infertility is no longer a woman’s prerogative, as is the
case in our society, where she is considered to be the primary
cause of the problem. The epidemiological investigation by
Thonneau, et al. in 1991 highlighted the shared responsibility
of men and women for the couple’s infertility [9]. Infertility in
men quickly emerged as an important factor, accounting for
50% of the causes of diffi culties in conceiving [17]. The study
by Agarwal, et al. showed that male infertility rates were higher
in Africa and Central and Eastern Europe, compared to North
America and Australia [18]; It has been observed that a high
proportion of young men currently have unfavourable sperm
characteristics [19], with damaged mucus-sperm histocounts
[20].
The identifi cation of these characteristics makes it possible
to establish a prognosis and consequently infl uence therapeutic
management.
The aim of this work was to describe and identify the
characteristics which infl uence the management of these
infertile couples.
Material and method
Type of study
This is a prospective and descriptive study of a sample of
infertile couples cared for in the gynaecology and obstetrics
department of the Oran hospital and university establishment.
It is a monocentric study over a period of 4 years, from 1
January 2009 to 31 December 2012.
Study population
This is a population of infertile couples who have
consulted for the fi rst time in the fertility unit of the obstetric
gynaecology department. The recruitment of couples was done
in an exhaustive manner.
Criteria for inclusion
We included in the study:
• infertile couples residing in western Algeria.
• infertile couples whose man and woman were jointly
involved in the care within the unit.
• couples whose wife was 45 years old or less.
Exclusion criteria
• couples who refused to do their follow-up jointly within
the unit
Thus our study sample was reduced to 760 instead of 972
couples.
Data collection
The survey was carried out by means of a questionnaire
which consisted of four parts:
- The fi rst part allows the identifi cation of the infertile
couple, age of the woman, man and socio-economic
level.
- The second part specifi es the history, type and duration
of infertility.
- The third section deals with the origin of the infertility
(female, male, mixed or unexplained) and allows the
identifi cation of the possible cause(s) of basic infertility
by means of a check-up.
This assessment includes:
- in men: a spermogram and a spermocytogram,
- in women:
 a hormone test:
• Prolactin and TSH us
• FSH, LH, oestradiol performed on the 2nd-3rd day of
the cycle.
• and progesterone made on the 23rd day of the cycle.
 Endovaginal ultrasound (at the beginning of the
cycle). A follicular monitoring of j10-j14) and
hysterosalpingography.
- in the couple: a post-coital test was carried out despite all
the discussions on this subject.
Informed and signed consent was obtained from the couple.
Factors studied
General factors
- Socio-economic level

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Citation: Belhachemi N, Zelmat SA, Chafi B, Foughal M, Arabe WM (2020) Description of the characteristics influencing the therapeutic managment of infertile
couples in western Algeria. Glob J Fertil Res 5(1): 016-022. DOI: https://dx.doi.org/10.17352/gjfr.000017
We grouped them into three levels: the high level group :
couples with a high income and a high intellectual level. The
medium level includes a working member of the couple and a
medium intellectual level. The low level represents the couple
with a low income and no level of education.
- Type of infertility: is classifi ed as primary or secondary.
- Duration of infertility is assessed according to its duration
(years): ≤ 2, 3-5, > 5.
After 2 years, the chances of spontaneous conception
become nil. Each additional year constitutes a pejorative
element.
- The age of the woman is divided into classes: ≤ 30, 30-35,
36-40, 41-45
- The age of the man is also divided into classes: ≤ 30, 30-
35, 36-40, 41-45, > 45 years old.
At the age of 35 years for women and 45 years for men are
taken as a benchmark for a clear decline in fertility.
The origin of infertility is classifi ed as female, male, mixed
or unexplained.
- The female origin of infertility is divided into ovulatory,
tubal, endometriosis, uterine and cervical causes.
- The masculine origin is divided according to the anomalies
of the spermogram interpreted according to the WHO
2010 standards and for morphology, the classifi cation
used was David’s classifi cation:
• The spermogram is considered normal if the count is
≥15 million spermatozoa per ml, motility a+b > 30% and
typical shape ≥ 30%.
• Asthenospermia corresponds to (a+b < 30%),
• Teratospermia is when the typical form < 15%.
• Moderate oligo-astheno-teratospermia (OAT): the
count is 5 - 15 millions/ ml, mobility 10 < a+b < 30%
and the typical form at least 15%.
• Severe OAT: the count is < 5 million/ml, mobility a+b <
10% and the typical form less than 10%.
Statistical analysis
The statistical analysis of the data was carried out using EPI
Data 3.1 software.
The estimation was made by frequency for qualitative
variables and average for quantitative variables.
Results
Causes of exclusion
- Of the 972 infertile couples recruited, only 760 (78%)
infertile couples constituted the sample to be studied.
22% of the couples were disqualifi ed, the main causes
being: 10.7% of the couples never came back to the unit,
4.8% the woman was over 45 years of age and 6.5% the
spouse refused to have a spermogram (Figure 1).
Study of the characteristics infl uencing the infertility of
couples
A. General factors: Table 1
- 71% of the couples had a medium socio-economic level
and 14% a low socio-economic level.
972 Infertile
Couples
(100%)
212 Rejected
Couples
(
22%
)
760 Infertile
Couples
(78%)
62 Couples
refusal of
practice
of
spermogram
46 Couple,
Women age
> 45
(4.8%)
104 Couples
lost to follow -
up
(10.7%)
Figure 1: Causes of exclusion of infertile couples.
Table 1: General parameters.
Infertility Factors Percentage % Number
Socio- économic level
High 15 114
Average 71 540
Low 14 106
Type of infertility
Primary 74 566
Secondary 26 194
Duration of infertility (ans)
≤ 2 31,2 237
3- 5 37,8 287
≥ 5 31 236
Woman’s age
≤ 30 34.5 262
31-35 32 243
36-40 22.8 173
41-45 10.7 82
Age of man
≤ 30 8.8 66
31-35 23.3 177
36-40 28.6 217
41-45 18.8 143
> 45 20.5 157
Total 100 760

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Citation: Belhachemi N, Zelmat SA, Chafi B, Foughal M, Arabe WM (2020) Description of the characteristics influencing the therapeutic managment of infertile
couples in western Algeria. Glob J Fertil Res 5(1): 016-022. DOI: https://dx.doi.org/10.17352/gjfr.000017
- 74% of the couples had primary infertility and 26%
secondary infertility.
- The average duration of infertility was 4.8 ± 0.2 years
(min 6 months, max 25 years) and the median was 4
years. 69% of the infertile couples had infertility for
more than 2 years and 31% for more than 5 years.
- The average age of women was 33.2 ± 0.4 years (min 18,
max 45), and the median was 33 years. The distribution
by age group shows that 33.5% were over 35 years of
age, of which 10.7% were over 40 years of age.
The average age of men was 39.5 ± 0.5 years (minimum was
23, maximum 71) and the median was 39years. 68% of men
were over 35 and 20.5% over 45.
B. Origins of infertility and different male and female causes
The male origin of infertility was the most dominant at
30.4%, mixed at 29.2% and female at 27%. The unexplained
origin was 13.4%.
1- Male causes (Figure 2)
The spermogram came back normal in 41.5%. Sperm
count anomalies were dominated by severe OAT at 18.8%,
asthenospermia at 16% and moderate OAT at 15.7%.
Azoospermia was 4.2% and teratospermia 3.8%.
2- Female causes (Table 2)
- The female origin of infertility was dominated by tubal
causes at 23.4%, ovulatory causes at 22.8%.
- Of the 22.8% of ovulatory disorders, polycystic ovary
syndrome (PCOS) was the leading cause of ovulatory
disorders at 9%, followed by early ovarian failure at 6%
and luteal insuffi ciency at 2.5%.
Discussion
Causes of exclusion of couples
Caring for infertile couples is diffi cult and demanding.
Many couples who consult for infertility are abandoned for
a variety of reasons. In our study, 22% of the couples were
not included with 10.7% lost, 4.8% of the women were over
45 years old with a collapsed ovarian reserve and in 6.5% the
man refused to have a spermogram and/or to be involved in
the follow-up. Ferreira, et al. [21] in their 2007 study, out of
685 infertile couples who consulted the Reproductive Medicine
department of Toulouse University Hospital for the fi rst time,
found a drop-out rate of 19.6% before treatment and 22.8%
during treatment. Brandes, et al. in 2009 [22] showed that half
of the couples who dropped out stopped before starting any
treatment. Couple drop-out rates differ from one centre to
another and the reasons for dropping out are: poor prognosis,
spontaneous pregnancy, psychological suffering, adoption or
separation of the couple.
Characteristics infl uencing couple infertility
General factors
- Type of infertility: Recent studies show a predominance
of primary over secondary infertility: 74% in our study,
68% in the Walschaerts study [23] and for Safarinejad,
[24] a signifi cant increase in primary infertility from 2.6
to 5.5% from 1985-2000. While other studies estimate
that secondary infertility is the most prevalent form
of infertility in the world [25,26]. secondary infertility
is mainly related to post-abortion and postpartum
infections [6]. These infertilities are described as
“preventable” infertilities [27].
- Duration of infertility: In our study the average duration
of infertility was 4.8 years ± 0.2, 3 years in Stan’s study
[28] and 2.8 ± 2 years in Walschaerts’ study [23]. This
seniority of infertility can be explained by taking several
factors into account:
Medical factor: In the absence of a specialised centre, care
for the infertile couple remains poor and the couple remains lost
in the face of sometimes multiple and contradictory opinions.
Whereas the infertile couple must be cared for in a specialised
centre with a multidisciplinary team which makes it possible to
establish a prognosis and guide the couple towards a codifi ed
course of action.
Social factor: The woman is the fi rst person responsible
for the infertility in the couple and she is the fi rst to present
herself for consultation. We sometimes note a resistance on
0
10
20
30
40
50 41.5
15.7 18.8 16
3.8 4.2
%
Figure 2: Male causes according to spermogram anomalies.
Table 2: The different female causes of infertility.
Female causes Percentage (%)
Présence 56.2
- tubal 23.4
- ovulatory 22.8
- utérine 3.9
- endométriosis 3.5
- cervical abnomalities 2.6
Absence 43.8
Total 100

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Citation: Belhachemi N, Zelmat SA, Chafi B, Foughal M, Arabe WM (2020) Description of the characteristics influencing the therapeutic managment of infertile
couples in western Algeria. Glob J Fertil Res 5(1): 016-022. DOI: https://dx.doi.org/10.17352/gjfr.000017
the part of men in our society to have a spermogram because
of the confusion in terms of virility and fertility. This is why in
our study we continued to favour the post-coital test although
it was abandoned by most of the authors. However, it remains
reliable when it comes back positive.
If the man in the couple presented himself for the fi rst
time at an andrology consultation, it is the woman who has to
follow up instead of her husband by taking the results of the
spermogram or other paraclinical tests back to the andrologist.
In fact, it has been found that 60% of andrological consultations
are made up of women. They act as an intermediary between
the andrologist and their husbands for the most motivated of
them.
We have also noted that many men have sometimes repeated
failures in sperm collection due to the fact that the conditions
for collection are not completely fulfi lled. Hence the interest in
improving the conditions and creating specialised centres to
freeze sperm for use in Medically Assisted Procreation (MAP).
Economic factor: It constitutes a prognostic factor in the
care of the infertile couple. Several studies show that the cost
of treatment is a very important factor in abandonment in
some countries [29,30].
Care for infertile couples in Algeria is free of charge in
public hospitals. The estimate of the socio-economic level of
the population studied found an average level in 71% and a low
level in 14%. This population could not afford examinations,
hormone therapies that are 80% reimbursable by social security
for the contributing population who remain benefi ciaries, and
LDC techniques, particularly IVF/ICSI, which are excessively
expensive. In our study, it was noted that only 5.8% of infertile
couples had used LDC techniques in their past, with 1.8% using
IVF/ICSI, in private and sometimes foreign centres.
- The woman’s age is probably the most important factor
in any care for the infertile couple. All the studies show that as
the age of women in the care centres is increasing, the results
are likely to be poorer due to the decrease in natural fertility in
women from the age of 35 onwards [31]. The age assessment
of women in our population remains similar to other infertility
consultant populations.
In our society and according to the National Multiple
Indicator Survey 3 [32], the decrease in the age of marriage
and consequently the age of fi rst pregnancy contribute to
an increase in the age of patients seeking medically assisted
reproduction. The average age of marriage has risen to 29.8
years for women and 33.5 years for men, whereas ten years ago
the average age of marriage was 18.3 and 23.8 years for women
and men respectively. The age of fi rst pregnancy is currently
reported to be 31.02 years for women.
According to the FIVNAT [33] data, the age of patients
entering the in vitro fertilisation (IVF) cycle has risen in
20 years from 33.3 years in 1986 to 34.5 years in 2004, and
those aged 40 and over from 12% to 17%. A Dutch team from
Groningen [34] has shown, in a study of 10,436 women, that
parallel to this increase in age at fi rst pregnancy, there is a
decrease in age at the fi rst consultation in their infertility
centre. The average age at the fi rst consultation rose from 27.7
years in 1985 to 31.3 years in 2005. Moreover, the percentage
of women over 35 years of age was 7.9% in 1985, compared to
29.5% in 2005.
- Age of the man: similarly an increase in the age of
men who consult for infertility has been noted. In his study
Walschaerts. M [20] reports that the average age of infertile
men was 34 ± 6 years (62% had ≤ 35 years); the average age
of men was 34.3 in insemination (2204 IUI) and 34.8 in IVF
(1286 IVF) for Bellvers [35]. Our study found a much older male
population compared to these two studies (39 versus 34 years)
with a percentage in the age distribution which represents the
opposite of ours (62% for those 35 years and under versus 68%
for those over 35 years).
Origins and causes of infertility
Our study reveals that male infertility accounts for 30.4%,
similar to other studies [20,36]. Other studies show a higher
rate: more than 33% in a Dutch study in 2002 and in another
study published the same year [37,38], 39% according to
FIVNAT data [33]. The Donkers study [39] gives a lower fi gure
of 25%.
For Donckers [39], the etiologies listed are male factors
(25%), ovulatory disorders (17%), tubal alterations (7%) and
unexplained infertility (10%). Snick, et al. [20] report 30%
unexplained infertility, 30% male infertility including 4.5%
azoospermia, 26% ovulatory disorders, 13% tubal alterations,
3.2% endometriosis and 28% cervical mucus alterations. A
study by Maheshawani [40.] found 20% ovulatory problems,
19% tubal, 34.4% male and 22.4% unexplained. Disaggregating
women over and under 35 years of age, he fi nds a much higher
rate of unexplained in those over 35 years of age indicating
hidden ovarian failure [40.]. Anovulation, fallopian tube
disease, pelvic adhesions, endometriosis and unexplained
infertility are the main female causes for Robert, et al. [41].
All these studies demonstrate the predominance of the
male origin of infertility in different countries of the world
in relation to a decrease in sperm quality and quantity.
This deterioration in sperm concentration, which has been
observed since the second half of the twentieth century [19]
in western countries and probably in our own, is revealed by
this percentage which is consistent with these studies. This
alteration in sperm concentration is such that it could result
in a decrease in the occurrence of pregnancy. In the study by
Snick and Maheshawani [20,40], the frequency of the different
origins and causes of infertility was found to be more or less the
same. Snick’s study found an azoospermia rate identical to ours
and raised an alteration of the cervical mucus in 28%, which
is an avenue of research on mucus-sperm histocompatibility
[20].
However, the tubal causes in our population are much more
important than the fi gures reported in these studies, in relation
to the increase in salpingitis secondary to sexually transmitted
infections.

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Citation: Belhachemi N, Zelmat SA, Chafi B, Foughal M, Arabe WM (2020) Description of the characteristics influencing the therapeutic managment of infertile
couples in western Algeria. Glob J Fertil Res 5(1): 016-022. DOI: https://dx.doi.org/10.17352/gjfr.000017
Given the high prevalence of Chlamydiae trachomatis
infection in upper genital infections and the often symptomatic
or even asymptomatic pauci character of this pathology linked
to this germ, some recommendations have underlined the need
for systematic screening for Chlamydiae trachomatis among
young populations at risk. Other authors have also suggested
that this screening should be extended to couples suffering
from infertility [41].
Conclusion
Infertility is a problem encountered by an increasing
number of couples.
Indeed, the analysis of the factors infl uencing infertility
has shown that the primary type and signifi cant duration of
infertility, the advanced age of the woman and the man are
pejorative elements in the care of couples because they make
the chances of conception minimal even when MPA techniques
are used the success rate is likely to be low.
The greater male origin of infertility than the female
suggests a deterioration in sperm parameters probably related
to environmental factors that are toxic to human fertility. The
management of tubal infertility remains expensive and is the
responsibility of LDC technologies, mainly IVF.
Information for couples on human reproduction is essential.
Couples should be encouraged to marry at a younger age and
to plan their desire for children as early as possible. In case
of diffi culty, they should be encouraged to consult earlier in
specialised centres as the risk of infertility will be increased.
Limitations of the study
The search for the causes of infertility was limited to the
basic infertility check-up. The therapy received by the couple
was limited and depended on their socio-economic level.
Acknowledgements
I would like to thank the couples who participated and gave
their consent to carry out this study. I would also like to thank
all the staff of the unit and fi rst and foremost the former head
doctor Pr CHAFI. B who has the merit of having opened this
unit within the public hospital, a fi rst in Algeria.
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https://www.peertechz.com/journals/global-journal-of-fertility-and-research
Citation: Belhachemi N, Zelmat SA, Chafi B, Foughal M, Arabe WM (2020) Description of the characteristics influencing the therapeutic managment of infertile
couples in western Algeria. Glob J Fertil Res 5(1): 016-022. DOI: https://dx.doi.org/10.17352/gjfr.000017
Copyright: © 2020 Belhachemi N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
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