Infertility is defined as failure to achieve pregnancy during one year of frequent, unprotected intercourse1.If the couple has never conceived despite cohabitation and exposure to pregnancy (i.e. sexually active, non- lactating) for a period of one year, it is called as primary infertility; primary infertility is also referred as primary sterility2.The female factors contribute almost half of the etiology of infertility followed by male factors (30%) and rest is attributed to a mixture of both or by problems unknown3. In addition to the core prevalence of infertility due to pathophysiological and anatomical conditions, additional cases are caused by the incidence of preventable conditions such as infection, "lifestyle factors", advancing maternal age, age at marriage, postponement in child bearing for more than 1 year or more, socio-economic status and occupational hazard. The present study is done with the aims to evaluate the anatomical & pathophysiological causes of primary infertility in couple. This study would certainly help the clinician to clinch the exact etiological diagnosis by adopting the most relevant investigative procedure and to contemplate the most rational therapy in the treating a particular case.

The present study was carried out to find the common etiological factors of primary infertility using some common investigative procedure. The present study was conducted on 200 couples in Index Medical College. Subjects with the complaint of primary infertility in the child bearing age span had provided the necessary clinical material for this study. In the present study inclusion criteria was, age more than 20 years and less the 50 years, married and living together for more than 1 year and nulliparous women. A detail history was taken and emphasis was given on the age, duration of marriage, menstrual history, drug history, history of contraceptives used and duration it was used for, smoking and alcohol consumption were noted. In the men, attention was paid to sexual and ejaculatory function, history of inguinal surgery, cryptorchidism, mumps, orchitis, testicular torsion, environmental or occupational factors and drug or medication intake. In the women, history of menstrual regularity, abdominal surgery, urinary tract infection, vaginal or nipple discharge, frequency of intercourse, dysparonia and drug or hormone intake, were determined. Past medical and surgical history was recorded, family history especially infertility among other siblings if present was recorded. This was followed by a thorough clinical examination, radiological, routine haematological and biochemical examination. Hysterosalpingography (HSG):HSG was performed using water-soluble non-ionic contrast medium under fluoroscopic guidance (Siemens) during the follicular phase of menstrual cycle, when menstrual bleeding had stopped, between cycle days 6 and 11, under all aseptic precautions.  All the patients were admitted a day before the procedure. Pre-anesthetic evaluation was carried out in the evening. Prophylactic antibiotics were injected. Before injecting contrast, a supine control radiograph was obtained. The contrast medium was injected until the uterine cavity was distended, tubes filled and the contrast seen to spill freely from the distal ends of the fallopian tubes. Radiographic films were obtained to show uterine and tubal anatomy and peritoneal spillage.  First film was taken on visualization of the uterine cavity, the second during early tubal filling and the third after peritoneal spillage. These films were reviewed and the findings analyzed. Semen analysis : The most important part of male investigation is the semen analysis and certain points regarding the method and timing of collection of specimen are noteworthy. The best specimen is one obtained by masturbation in the vicinity of laboratory, since this guarantees its freshness. If this is objectionable to the man, coitus interruptus into a wide necked bottle may be employed. The production of a condom specimen is to be discouraged as the condom contain spermicidal chemical and a false low reading may thereby be obtained. The best specimen is produced if a short period of abstinence of 3-5 days is observed. A more prolonged period of abstinence does yield better result. A typical normal specimen shows the following features when examined within two hours of production. The semen would coagulate soon after the ejaculation due to enzyme in the seminal vesicle but liquefies in 30 minutes because of prostatic enzyme. The semen is greyish white in color. Pus cell should be absent. The seminal fluid is normally viscous with a pH of 8 and contains fructose. Apermia means no semen . Oligospermia is defined as a sperm concentration less than 20×106 million/ml, asthenospermia was defined as sperm motility less than 50%, teratospermia was defined as normal sperm morphology less than 30% and azoospermia confirmed when no sperm was seen in the semen. Necrospermia means dead sperm.

Table No. 1 Etiology of Primary Infertility in Female Patients

The table no 1 shows the various etiological factors in females which were the cause of primary infertility.

Table No. 2 Etiology of Primary Infertility in Male Patients

The table above shows the etiology of infertility in male patients.

Infertility is a major public health problem worldwide that has been encountered more during recent years. It seems to be effected by changes in familial condition and tendency to marriage, having child in higher age, more excessive use of contraception methods, illegal abortion, and unfavourable socioeconomic condition, agents related to climate and geographic areas and perhaps genetic diversity. Even though curtailing population growth is a major national concern, a substantial number of infertile couples in the Indian population have an equally great concern, that of having a child. Thus the medical case studies, escalating incidence as well as the rising number of infertility clinics in urban areas of the country are pointing to the fact that infertility is becoming a health challenge in the country

In the present study an effort has been made to find out the common factors responsible for primary infertility in couples and to detect any anatomical defect of the genital tract responsible for primary infertility by common diagnostic procedures that are available in many settings.

Comparison On the Basis of Pathological Factor Responsible for Primary Infertility in Female Patients

Tubal blockage:

The common factors responsible for infertility in females are tubal factors, endometriosis, uterine and cervical factors1. According to the present study tubal factors account for 49.63% and endometriosis was 12.04% and uterine factors 27.79% and cervical factors 0.75%. Sinawat et al. reported tubal abnormalities in over one fourth of all infertile females including distal tubal occlusion (8.42%), hydrosalpinx (3.47%) and peritubal adhesions in (3.96%) cases6. In present study the tubal blockage accounts for 49.63% of primary infertility which is higher compared to other studies. The study conducted by Mahmood showed incidence of endometriosis in 13.6% of patients in cases of primary infertility7 while in present study the incidence of endometriosis is 12.04%.

Comparison On the Basis of Anatomical Factors Responsible for Primary Infertility in Females

Congenital uterine malformations are one of the major causes of abnormalities, and among these, septate uterus is the most frequent8. Septate uterus is the most common cause of congenital uterine anomalies with an incidence of 50% to 80% in various reports. Only 10% of our patients had bicornuate uterus. In present study, septate uterus accounts for 6.02% of cases and bicornuate uterus 3.00% of cases. Whereas the other congenital anomalies like subsepate uterus accounts for 4.52% and unicornuate uterus 2.26%of cases. And as per studies done by Fayez JA8 and Fedele L, Arcaini L, Parazzini F, Vercellini P, Di Nola G.9 reported 50-80% of septate uterus out of all congenital causes of infertility proving that septate uterus is the most common cause.

The study that was done at the Nnamdi Azikiwe University Teaching Hospital in South-east Nigeria showed that oligozoospermia (35.9%) and asthenozoospermia (32.3%) were the most common etiological factors responsible for male infertility10. As per the present study, on seminal examination 41.94% azoospermia, 29.03% oligozoospermia, 11.29% asthenozoospermia and 6.45% aspermia cases were seen. Contrary to the present study other studies have shown that azoospermia was present in 6.6% of males attending a general infertility clinic and 35% in those attending male infertility clinics. One study in an African nation reported that azoospermia was present in 31% (192) and oligospermia in 69.40% (413) infertile African males (595) attending male infertility clinics. A similar result was observed in an infertility clinic in Lagos and Ibadan, Southwestern Nigeria as reported in Ogunbanjo et al.11 Yaboah ED, Wadhwani JM, Wilson JB 12 study found obstruction to the vas or epididymis in 32.2% and 40% in Nigeria and Ghana respectively, compared to 7% in developed countries.

Primary infertility is a common, preventable but neglected reproductive health problem in developing countries like India. Medical case studies, escalating incidence as well as the rising number of infertility clinics in urban areas of the country are pointing to the fact that infertility is becoming a health challenge in the country. An accurate diagnosis is the key to successful treatment. Of course, infertility is often a combination of male and female factors and most couples experience infertility consider it to be a “couple” problem, not an individual one, facing infertility as a unit without indicating blame factors.

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