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. 2023 Apr 29;17(3):160–173. doi: 10.22074/IJFS.2023.541991.1215

A Meta-Analysis of The Prevalence and Etiology of Infertility in Iran

Ghobad Abangah 1, Tayebeh Rashidian 2, Marzieh Parizad Nasirkandy 3,*, Milad Azami 1
PMCID: PMC10189156  PMID: 37183842

Abstract

Infertility is a serious health issue in the world affecting approximately 8-10% of couples worldwide. The meta-analysis study was performed to assess the prevalence and etiologic factors associated with infertility in Iran. We made sure that the implementation of study and reporting the results were consistent with the MOOSE and PRISMA guidelines, respectively. All stages of the research were conducted by two authors, and the disagreement at each stage of the research was resolved by consensus. On January 1, 2020, we started a detailed literature search on international online databases, and Iranian Online databases, as well as specialized journals, several authentic international publishers and Google Scholar. We reviewed the reference list of identified articles for missed articles and then searched online for them. Data analysis was performed to estimate the prevalence using a random effects model. The lifetime infertility prevalence was found to be 11.3% [95% confidence interval (CI): 8.6-14.7] and the current infertility was evaluated to be 3.7% (95% CI: 3.2-4.3). The prevalence of primary infertility (based on 45 articles consisting of 51,021 samples) as well as secondary infertility (based on 13 articles consisting of 35,683 samples) in Iran were estimated to be 18.3% (95% CI: 15.4-21.6) and 2.5% (95% CI: 1.6-4.0), respectively. The prevalence of female, male, both and unexplained causes was estimated to be 32.0% (95% CI: 27.6-36.8), 43.3% (95% CI: 38.2-48.6), 12.5% (95% CI: 9.6-16.2) and 13.6% (95% CI: 10.2-17.8), respectively. The prevalence of causes related to ovulation, uterine tubes, and endometriosis in infertile women was estimated to be 54.0% (95% CI: 45.6-62.2), 15.5% (95% CI: 11.3-21.0), 6.2% (95% CI: 3.5-10.6), and 5.4% (95% CI: 2.5-11.3), respectively. In summary, the estimate of infertility burden in Iran did not change between 1990 and 2017 and its prevalence remains high. This research presents a unified and up-to-date overview regarding the burden of infertility in Iran.

Keywords: Etiology, Infertility, Iran, Prevalence

Introduction

Infertility is a serious worldwide health problem affecting almost 8-10% of couples global (1). According to the World Health Organization (WHO), 186 million ever-married women in sexual age in developing countries are affected by infertility (2). This serious problem requires urgent action, especially where most infertility cases are avoidable. According to the latest global described as failure to reach clinical pregnancy after regular unprotected intercourse for twelve months omore. Having regular sexual intercourse is a key factor in pregnancy. Primary infertility is the lack of ability to give birth either because of not having the ability to get pregnant or carry a baby till live birth, which can encompass miscarriage or stillbirth. Secondary infertility is the lack of ability to conceive or give birth despite a previous pregnancy or a live birth (3).

Infertility is a very important part of sexual health and efforts that have often been ignored (4) in this regard. Failure to give birth to an infant influences many couples around the world. The United State Centers for Disease Control and Prevention emphasize that infertility is beyond just a problem that affects the quality of life with significant consequences for public health, such as mental discomfort, social stigma, economic stress and marital separation. According to the results comparing stressful life events, after mother’s death, father’s death and spouse's infidelity, infertility is ranked as fourth stressful life event (5). Not considering the emotional afflictions of infertile men and women and secondary signs of infertility (interpersonal problems, marital discontent and loss of libido) may lead to a flawed cycle that increases infertility incidence (6). On the other hand, in recent years, factors such as changes in women’s role in social activities, delaying marriage, changes in childbearing age, increasing use of contraceptive methods, liberal abortion laws, and undesirable economic status have decreased fertility rates and increased infertility (7).

There are over one million infertile couples living in Iran, and since childbearing is so important in the religious, historical, and cultural context of Iranian society, infertility can be one of the causes of divorce (8). Gaining accurate information about the prevalence, and infertility trends is the first main step in providing evidence-based measures and policies for decreasing the difficulties of this issue worldwide. There have been numerous studies in Iran on the prevalence and etiology of infertility and the results vary widely (9-43), and a systematic review of the original studies now seems necessary. The metaanalyses combine various studies with similar objectives, which involves increasing the number of samples and decreasing the confidence interval, and this can provide a more reliable estimate (44, 45). The purpose of this metaanalysis was to assess the prevalence and etiologic factors associated with infertility in Iran.

Materials and Methods

Study protocol

The protocol of the present study was posted on International Prospective Register of Systematic Reviews (PROSPERO 2020) prior to implementation (CRD42020170926 Available from: https://www.crd.york.ac.uk/prospero/ display_record.php?ID=CRD42020170926). We made sure that the implementation of study and reporting the results were consistent with the Meta-analyses Of Observational Studies in Epidemiology (MOOSE) (46) and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, respectively (47). All stages of the research were conducted by two authors, and the disagreement at each stage of the research was resolved by consensus.

Data sources and search strategy

On January 1, 2020, we started a detailed literature search on international databases of Web of Science (ISI), Ovid, Scopus, EMBASE, PubMed/Medline, Cochrane Library, EBSCO, CINAHL, and Iranian Online databases Scientific Information Database (SID), elmnet , Civilica, Regional Information Center for Science and Technology (RICST), , IranDoc , Magiran Barakat Knowledge Network System, and Iranian National Library, as well as specialized journals, several authentic international publishers including Wiley online library, Science Direct, and Springer and search engines such as Google Scholar. We reviewed the reference list of identified articles for missed articles and then searched online for them.

The following search strategy is an example of what was used in PubMed: (“prevalence” OR “frequency” OR “incidence” OR “rate” OR “epidemiology” OR “etiology” OR “cause”) AND (“infertility”) AND Iran.

Study selection

After excluding duplicate studies, the two writers reviewed the title and abstract of the studies independently. In case of disagreement, a third author was consulted or it resolved through consensus. Then, the full text of each study was reviewed based on the target inclusion criteria (Fig .S1, See Supplementary Online Information at www.ijfs.ir).

Fig 1.

Fig 1

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Prevalence of infertility. A. Lifetime infertility and B. Current infertility. Red rhombus; Overall estimate.

Inclusion and exclusion criteria

Eligible studies according to PECOS (population, exposure, comparison/comparator, outcome and study type) criteria: i. Population: Iranian population, ii. Exposure: infertility, iii. Comparison/comparator: type of infertility and its cause, iv. Outcome: prevalence of infertility, and v. Study type: cross-sectional study.

Definition

Infertility was defined as failure to achieve pregnancy after unprotected intercourse for 12 months. Primary infertility was defined as not experiencing a previous pregnancy and secondary infertility was defined as having a previous pregnancy (48). Infertility is considered as lifetime when a couple has experienced infertility in their whole lives. However, current infertility is defined as having the problem of infertility at present (49).

Data extraction

Two researchers extracted the required data from all studies based on data encryption list. The following variables were obtained for each article: i. Study information (authors, publication year, place of study and completion year), ii. Design of the study, iii. Sample selection, iv. Reliability coefficient of the instrument, v. Sample size, vi. Prevalence (lifetime infertility, current infertility, primary infertility, secondary infertility, and etiology of infertility).

Qualitative evaluation

Newcastle-Ottawa Scale adapted for cross-sectional research was used to assess the quality of articles (50). The highest achievable score was 9. Three categorizations were defined for the quality of studies with a score of less than 6, 6-7, and 8-9 as low, medium and high quality, respectively.

Data analysis

The program used here was Comprehensive Metaanalysis Software ver. 2, and the results were shown as forest plot. The heterogeneity of the data was evaluated using I2 index. This test evaluates the percent of variability in estimating the effect of heterogeneity. Significant heterogeneity exists if I2 values are above 50% (51). Meta-analysis was performed to estimate the prevalence using a random effects model by DerSimonian and Laird for point estimation and 95% confidence interval (CI). Publication bias was assessed according to regression asymmetry tests (52). Sensitivity analysis was used to investigate the effect of individual studies on overall prevalence. Subgroup-analysis and meta-regression were conducted to determine the source of heterogeneity. Significance level was defined less than 0.05 in all tests.

Results

Study selection process and study characteristics

The infertility prevalence

The lifetime infertility prevalence (in 14 studies with 46,466 samples) (Table 1) was 11.3% (95% CI: 8.6-14.7) and current infertility (in 34 studies with 30,069 samples) estimated to be 3.7% (95% CI: 3.2-4.3) (Fig .1).

Table 1.

Summary of characteristics in studies into a meta-analysis

Ref. First author, Published Year Year Place Number Lifetime infertility Current infertility Method Quality
(9) Badr et al., 2009 2004 Tabriz 3183 104 88 15- to 49-year-old couples Moderate quality
(10) Vahidi et al., 2006 2004-5 East Azarbaijan 610 14 19- to 49-year-old women Moderate quality
West Azarbaijan 502 5 19- to 49-year-old women Moderate quality
Ardabil 236 4 19- to 49-year-old women Moderate quality
Isfahan 675 18 19- to 49-year-old women Moderate quality
Ilam 114 8 19- to 49-year-old women Moderate quality
Bushehr 149 8 19- to 49-year-old women Moderate quality
Tehran 1730 58 19- to 49-year-old women Moderate quality
Chaharmahal and Bakhtiari 147 5 19- to 49-year-old women Moderate quality
Khorasan 1197 45 19- to 49-year-old women Moderate quality
Khuzestan 741 30 19- to 49-year-old women Moderate quality
Zanjan 205 10 19- to 49-year-old women Moderate quality
Semnan 86 3 19- to 49-year-old women Moderate quality
Sistan-Baluchestan 330 20 19- to 49-year-old women Moderate quality
Fars 742 26 19- to 49-year-old women Moderate quality
Qazvin 290 15 19- to 49-year-old women Moderate quality
Qom 136 8 19- to 49-year-old women Moderate quality
Kurdistan 254 8 19- to 49-year-old women Moderate quality
Kerman 371 8 19- to 49-year-old women Moderate quality
Kermanshah 384 7 19- to 49-year-old women Moderate quality
Kohkiluyeh and Boyer Ahmad 90 2 19- to 49-year-old women Moderate quality
Golestan 261 8 19- to 49-year-old women Moderate quality
Guilan 427 19 19- to 49-year-old women Moderate quality
Lorestan 317 7 19- to 49-year-old women Moderate quality
Mazandaran 545 13 19- to 49-year-old women Moderate quality
Markazi 219 7 19- to 49-year-old women Moderate quality
Hormozgan 208 20 19- to 49-year-old women Moderate quality
Hamedan 292 7 19- to 49-year-old women Moderate quality
Yazd 148 2 19- to 49-year-old women Moderate quality
(11) Mohammad Baygi, 2002 2002 Sanandaj 902 166 15- to 49-year-old women Moderate quality
(12) Kamali et al., 2007 1995-2001 Tehran-Royan institute 2492 Infertile couples High quality
(13) Bakhtiari, 1999 1999 Babol –Fatematazahra 920 Infertile couples High quality
(53) Karimpour Malekshah et al., 2011 2003-8 Mazandaran- clinics 3734 consecutive couples High quality
(15) Moghaddam et al., 2000 1999 Mazandaran 2953 389 15- to 49-year-old couples Moderate quality
(16) Esmailzadeh et al., 2002 1996-8 Babol –Fatematazahra 2169 Infertile couples Moderate quality
(17) Sadegh Moghadam et al., 2008 2006 Gonabad 380 45 15- to 49-year-old women Moderate quality
(18) Ardalan et al., 2010 2004–2005 Iran 10783 1592 19- to 49-year-old women High quality
(19) Sedaghat Siahkal et al., 2003 2001 Tehran 1987 173 50 25- to 49-year-old women High quality
(20) Parsanezhad and Alborzi, 1998 1993 Shiraz 1430 159 15- to 49-year-old couples Moderate quality
(20) Shiraz 693 20- to 49-year-old women Moderate quality
(21) Barouti et al., 1999 1997 Tehran 1784 19- to 49-year-old women Moderate quality
(22) Nojomi et al., 2002 2000 Tehran 1174 141 49 40- to 50-year-old women High quality
(23) Moini and Yazdan Panah, 1999 1990-5 Tehran-Royan Institute 4360 High quality
(14) Karimpour et al., 2005 2001-3 Sari 657 37 Infertile couples High quality
(24) Delpishe et al., 2014 2013 Ilam- clinics 1013 117 44 High quality
(25) Shagheibi et al., 2018 2014-15 Sanandaj-hospital 579 Infertile couples High quality
(26) Kazemijaliseh et al., 2015 1998 Tehran 1067 18- to 57-year-old couples High quality
(27) Noorbala, 2001 2001 Iran 10418 292 High quality
(28) Shafi et al., 2016 2012 Babol 1081 20- to 45-year-old women High quality
(29) Vizheh et al., 2015 2014 Tehran 123 infertile couples High quality
(30) Esfahani Shahsavari et al., 2010 2008-9 Jahrom 169 infertile couples Moderate quality
(31) Aflatoonian et al., 2009 2004-5 Yazd 5200 333 Couples High quality
(32) Rostami Dovom et al., 2014 2008-10 Iran 888 256 57 non-menopausal women age 18-49 High quality
(33) Masoumi et al., 2015 2010-2011 Hamadan 1200 infertile couples High quality
(35) Akhondi et al., 2013 2010-2011 Iran 13750 2819 20- to 40-year-old women High quality
(36) Sepidarkish et al. (36), 2016 2014-15 Iran-Royan Institute 405 infertile patients High quality
(37) Taghavi et al., 2011 2005-2010 Mashhad 2000 Infertile males Moderate quality
(38) Farmani et al., 2016 2016 Qom 100 Infertile males Moderate quality
(39) Hossein Rashidi B, 1998 1998 Tehran 1293 infertile couples Moderate quality
(40) Yousefi Z, 2001 1999-2000 Mashhad 1846 Infertile couples Moderate quality
(41) Natami M, 2016 2016 Bandar Abbas 151 Infertile males Moderate quality
(42) Mirzaei et al., 2018 2014-2015 Yazd 2611 135 20-69 years old people High quality
(43) Ershadi, 2006 2006 Gonabad 212 25 88 15- to 49-year-old women Moderate quality
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Subgroup analysis of infertility

The subgroup analysis regarding the prevalence of lifetime infertility according to the region (P=0.069), year (P=0.069) and studies quality (P=0.069) was insignificant (Fig .S2, See Supplementary Online Information at www.ijfs.ir). Subgroup analysis of current infertility prevalence was significant based on year (P<0.001) but not significant based on region (P=0.321) and studies quality (P=0.593, Fig .S3, See Supplementary Online Information at www.ijfs.ir).

Fig 2.

Fig 2

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Prevalence of infertility. A. Primary infertility and B. Secondary infertility. Red rhombus; Overall estimate.

Fig 3.

Fig 3

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The prevalence of infertility. A. Female, B. Male, C. Both, and D. Unexplained causes. Red rhombus; Overall estimate.

Prevalence of primary and secondary infertility

The primary infertility prevalence (in 45 studies with 51,021 samples) and secondary infertility (in 13 studies with 35,683 samples) in Iran was 18.3% (95% CI: 15.4-21.6) and 2.5% (95% CI: 1.6-4.0), respectively (Fig .2).

Subgroup analysis of primary and secondary infertility

Subgroup analysis of primary infertility prevalence was significant based on year (P<0.001) and studies quality (P=0.069) but not significant based on region (P=0.430) (Fig .S4, See Supplementary Online Information at www.ijfs.ir). Subgroup analysis of secondary infertility prevalence according to region (P=0.321), and studies quality (P=0.593) was not significant, but was significant based on year (P<0.001, Fig .S5, See Supplementary Online Information at www.ijfs.ir).

Fig 4.

Fig 4

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The prevalence of causes related to infertility. A. Ovulation, B. Uterine tubes, and C. Endometriosis in infertile women. Red rhombus; Overall esti- mate.

Fig 5.

Fig 5

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Meta-regression based on year for the prevalence of infertility. A. Lifetime, B. Current infertility, C. Primary infertility, and D. Secondary infertility.

The etiology of infertility

The prevalence of female, male, both and unexplained causes was estimated to be 32.0% (95% CI: 27.6- 36.8), 43.3% (95% CI: 38.2-48.6), 12.5% (95% CI: 9.6-16.2) and 13.6% (95% CI: 10.2-17.8), respectively (Fig .3).

Female etiology

The prevalence of causes related to ovulation, uterine tubes, and endometriosis in infertile women was estimated to be 54.0% (95% CI: 45.6-62.2), 15.5% (95% CI: 11.3- 21.0), 6.2% (95% CI: 3.5-10.6), and 5.4% (95% CI: 2.5- 11.3), respectively (Fig .4).

Semen analysis

Abnormal semen analysis was estimated to be 55.6% (95% CI: 45.7-65.2) among infertile men (Fig .S6, See Supplementary Online Information at www.ijfs.ir).

Meta-regression

Meta-regression based on year was not significant in terms of lifetime infertility prevalence (coefficient:- 0.000, 95% CI:-0.057 to 0.055, P=0.976) and current infertility (coefficient: 0.057, 95% CI:-0.005 to 0.119, P=0.073), primary infertility (coefficient:-0.021, 95% CI:-0.084 to 0.040, P=0.496), and secondary infertility (coefficient:-0.017, 95% CI:-0.106 to 0.071, P=0.700, Fig .5).

Sensitivity analysis

Sensitivity analysis with individual study elimination for all meta-analyzes showed a strong overall result (Fig .S7-Fig S9, See Supplementary Online Information at www.ijfs.ir).

Publication bias

Publication bias tests were not significant for studies about the prevalence of lifetime, current, primary, and secondary infertility (Fig .S10, See Supplementary Online Information at www.ijfs.ir).

Discussion

Infertility is a common situation with complex socioeconomic and health outcomes for the individuals and the whole society. In spite of the important outcomes of infertility, estimating its prevalence is faced with limitations. In this systematic meta-analysis, the lifetime infertility prevalence was estimated at 11.1%, while 3.7% had current infertility. The estimated incidence of infertility is between 3.5 and 30% in various countries, and this variety is probably due to the population under study, the definitions of infertility and the estimation method (4). Therefore, the major challenges in evaluating the true infertility burden include the lack of populationbased researches and the variety of definitions. In addition, advancements in diagnosing, treating and preventing infertility in recent decades have caused great changes in infertility prevalence worldwide. In least developed countries, the prevalence of 12-month infertility varies from 6.9 to 9.3%. Significant geographic diversities have been noted in its prevalence, and the diversities are mostly explained by the difference in cultural, environmental, and socioeconomic effects and having evaluate to the health-care system (54). The prevalence varies widely from 9% in Gambia to 11.8% in Ghana compared to 21.2% in northwest Ethiopia and between 20 and 30% in Nigeria (3, 8, 55-57). We do not have much information about Asian countries and Latin America. Based on the statistics provided by WHO, infertility prevalence in these areas varies from 8 to 12% in women of childbearing ages (2). Universally, the age-standardized female infertility prevalence has elevated by 14.96% (from 1366.85 per 100,000 in 1990 to 1571.35 per 100,000 in 2017) (58). Based on a previous meta-analysis in 2013, lifetime infertility and current infertility prevalence in Iran was reported to be 10.9 and 3.3%, respectively (59), and our estimate shows a slight increase compared to the previous estimate.

Searching for assistive behaviors related to infertility services is common in Iranians. In one study, more than 75% of people with fertility problems sought medical help. An international survey reported that 56% of women in more advanced countries seek help from infertility treatment systems (54), and a Trävä study (60) found that 57% of all infertile women did so. The popularity of seeking help for infertility treatment in Iran may be owing to the present perception that in Iran, having a child is the only way to improve one’s position in the family and society (61). There have been several explanations for not seeking (or following up) infertility assistance, including lack of understanding or acknowledgment of the problem (62), fear of being labeled infertile, worrying about the cost of treatment , having no intention to provoke , and the physical and psychological burden of treatment.

Decrease in fertility rates does not imply that infertility has elevated. Despite the reports of increased infertility rates in some parts of the world, the evidence suggests the total prevalence of infertility has not changed significantly over the past thirty years. In this study, no significant change was found in the prevalence of infertility in Iran based on the meta-regression models over time (between 1990-2016). The important point is the noteworthy reduction in total fertility rate (TFR) in Iran; TFR in Iran was 7 children per woman in 1960, 6.5 in 1980, 2.06 in 2000, 1.83 in 2010, and 2.11 in 2017 (1). TFR is decreasing in the world. Europe has the lowest level of fertility rate among all regions of the world. Partnership instability, better cooperation of women in education and occupations, postponement of parenthood, changes in values and economic burdens impose significant effects on fertility rates (63). On the other hand, infertility is more commonly experienced by married people, reflecting the fact that people in stable relationships are more likely to become pregnant and are hence aware of fertility problems (62). Much lower prevalence among young people somewhat indicates that they may never attempt to become pregnant. Previous studies have shown prolonged transition to adulthood and increase in the interval between important reproductive events such as first sexual relationship, marriage, and birth of first child (64). On the other hand, much of the literature describes the tendency of women in developed countries to delay having children (65) and it is suggested that this tendency is rapidly becoming a global phenomenon (66).

In the previous meta-analysis, the primary infertility prevalence was 10.6% and secondary infertility prevalence was 2.7% (59), which was higher in our study. A global study in 2010 among one hundred and ninety countries, among pregnant women aged 20-44, primary infertility was 1.9% and secondary one was 10.5%. Some regions have a high incidence of primary infertility, but secondary infertility is low, like North Africa and the Middle East, especially Adetoro and Ebomoyi (3). However, some areas have a high incidence of secondary infertility, but the incidence of primary infertility is low, such as in Central and Eastern Europe and Central Asia. In addition, several previous studies provided information on the prevalence of gender-related infertility. For instance, the prevalence of infertility in England was 12.5% in women, but it was 10.1% in men (62). It is worth noting that in these published studies, some only examined women (42). Others only evaluated the records of men in infertility clinics (67). Likewise, these articles are performed on fairly small groups which do not represent the majority of the infertile population (36).

Results of the causes of infertility in Iran showed that the causes of infertility were as follows: 32.0% male cause, 43.3% female cause, 12.5% both genders and 13.6% unknown. This calculated percentage is consistent with reported estimates of major causes of infertility in other studies (6).

Research shows that different studies provide different definitions of infertility, which may lead to misunderstanding of the actual situation (68). Some sources define infertility as lack of pregnancy after two years of unprotected intercourse , while others consider the couple infertility if pregnancy does not occur after unprotected intercourse for 12 months (69). We only provided studies with a 12-month definition. Therefore, we even excluded good-quality studies with more than 12 months of measurement (such as the study of Safarinejad) (70).

There was a high heterogeneity among articles across all of meta-analyses, and by considering the present data, we were able to ascribe this difference to the geographical area and year based on subgroup analysis. Other differences, including the partnership instability, increased cooperation of women in better education and occupations, postponement of parenthood, changes in values and economic burdens could not be investigated by using available data.

The strengths of the present study included the use of a comprehensive search strategy, selection of studies, extracting data and even analyzing the data by two independent researchers based on MOOSE guidelines, while the diversities were sorted out via group discussion. In case of any doubt of duplicate publications or more information that was required, we contacted the first or corresponding authors. We performed a conservative estimate using the random effects model, adopted a subgroup analysis and a meta-regression model to discover the heterogeneity causes. In the present study, in addition to updating previous meta-analyses to estimate the prevalence of lifetime and current infertility with a much higher sample size, we meta-analyzed the etiological details of infertility for the first time. The weaknesses of our study included the restricted search in internal databases and exclusion of studies with different infertility definitions.

Conclusion

In summary, the estimate of infertility burden in Iran did not change between 1990 and 2017 and its prevalence remains high. This study provides a comprehensive and upto-date understanding of the that we need prevention and management interventions to alleviate infertility in Iran. Further research is required to evaluate the risk factors of infertility for developing effective prevention and management strategies to decrease the burden of this issue.

Supplementary PDF

Acknowledgements

We would like to thank Ilam University of Medical Sciences for financial support. The authors declare that they have no competing interests.

Authors’ Contributions

M.A., T.R., Gh.A., M.P.N.; Contributed to conception and design. M.A., Gh.A., M.P.N.; Contributed to all experimental work, data and statistical analysis, and interpretation of data. M.A., M.P.N.; Were responsible for overall supervision. M.A.; Drafted the manuscript, which was revised by M.A., T.R., Gh.A., M.P.N. All authors read and approved the final manuscript.

References

  • 1.Karabulut S, Keskin İ, Kutlu P, Delikara N, Atvar Ö, Öztürk MI. Male infertility, azoozpermia and cryptozoospermia incidence among three infertility clinics in Turkey. Turk J Urol. 2018;44(2):109–113. doi: 10.5152/tud.2018.59196. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.World Health Organization. Reproductive health indicators for global monitoring : report of the second interagency meeting, WHO Geneva, 17-19 July 2000.Geneva. World Health Organization. 2001 https://appswhoint/iris/handle/10665/66918. [Google Scholar]
  • 3.Adetoro OO, Ebomoyi EW. The prevalence of infertility in a rural Nigerian community. Afr J Med Med Sci. 1991;20(1):23–27. [PubMed] [Google Scholar]
  • 4.Larsen U. Research on infertility: which definition should we use? Fertil Steril. 2005;83(4):846–852. doi: 10.1016/j.fertnstert.2004.11.033. [DOI] [PubMed] [Google Scholar]
  • 5.Schmidt L. In: Reproductive endocrinology and infertility. Carrell DT, Peterson CM, editors. New York: Springer; 2010. Psychosocial consequences of infertility and treatment; pp. 93–100. [Google Scholar]
  • 6.Meng Q, Ren A, Zhang L, Liu J, Li Z, Yang Y, et al. Incidence of infertility and risk factors of impaired fecundity among newly married couples in a Chinese population. Reprod Biomed Online. 2015;30(1):92–100. doi: 10.1016/j.rbmo.2014.10.002. [DOI] [PubMed] [Google Scholar]
  • 7.Badfar G, Shohani M, Nasirkandy MP, Mansouri A, Abangah G, Rahmati S, et al. Epidemiology of hepatitis B in pregnant Iranian women: a systematic review and meta-analysis. Arch Virol. 2018;163(2):319–330. doi: 10.1007/s00705-017-3551-6. [DOI] [PubMed] [Google Scholar]
  • 8.Okonofua FE. The case against new reproductive technologies in developing countries. Br J Obstet Gynaecol. 1996;103(10):957–962. doi: 10.1111/j.1471-0528.1996.tb09542.x. [DOI] [PubMed] [Google Scholar]
  • 9.Ahmadi Asr Badr Y, Madaen K, Haj Ebrahimi S, Ehsan Nejad AH, Koushavar H. Prevalence of infertility in Tabriz in 2004. Urol J. 2006;3(2):87–91. [PubMed] [Google Scholar]
  • 10.Vahidi SAD, Ardalan A, Mohammad K. The epidemiology of primary infertility in the Islamic Republic of Iran in 2004-5. J Reprod Infertil. 2006;7(3):243–251. [Google Scholar]
  • 11.Mohammad Beigi R. Prevalence of infertility in Sanandaj in 2002. Scientific Journal of Kurdistan University of Medical Sciences. 2002;7(1):22–26. [Google Scholar]
  • 12.Kamali M, Baghestani AR, Kashfi F, Kashani H, Tavajohi S, Amirchaghmaghi E. A survey on infertility in Royan Institute. Int J Fertil Steril. 2007;1(1):23–26. [Google Scholar]
  • 13.Bakhtiari A. Assessment of infertility reasons and some effective factors on infertile couple, Babol, 1999. J Babol Univ Medical Sci. 2000;2(2):50–56. [Google Scholar]
  • 14.Karimpour AA, Esmaeelnezhad Moghadam A, Moslemizadeh N, Mousanezhad N, Peyvandi S, Gahandar M. Incidence and main causes of infertility in patients attending the infertility center of Imam khomeini hospital in 2002-2004. J Mazandaran Univ Med Sci. 2005;15(49):44–49. [Google Scholar]
  • 15.Moghaddam A, Karimpoor Malakshah AA, Talebpoor Âmiri F, Taringou F. he Prevalence of infertility in central region of mazandaran province in 1999. J Mazandaran Univ Med Sci. 2000;10(27):12–18. [Google Scholar]
  • 16.Esmaeilzadeh S, Farsi M, Nazari T. The cause of infertility frequency in the patients referring to Babol township Fatemeh Zahra Infertility Center from May 1996 to May 1998. J Mazandaran Univ Med Sci. 2002;12(35):29–34. [Google Scholar]
  • 17.Sadegh Moghadam L, Moslem A, Gharche M, Chamanzari H. Study of women infertility of Gonabad. Quarterly of Horizon of Medical Sciences. 2008;13(4):82–86. [Google Scholar]
  • 18.Ardalan A, Vahidi S, Mohammad K, Russel M. Service utilization patterns for presumed infertile women in the Islamic Republic of Iran, 2004-2005. Int J Health Plann Manage. 2010;25(3):287–297. doi: 10.1002/hpm.985. [DOI] [PubMed] [Google Scholar]
  • 19.Sedaghat Siahkal M, Nojoomi M, Kamali M, Tavajjohi SH, Kashfi F. The prevalence of infertility and subfertility in Tehran. Tehran Uni Med J. 2003;61(5):371–376. [Google Scholar]
  • 20.Parsanezhad M, Alborzi S. Epidemiologic and etiologic aspects of infertility.Yazd Univ Med Sci Med J Special Issue on Infertility. Yazd Univ Med Sci Med J Special Issue on Infertility; 1998. pp. 58–64. [Google Scholar]
  • 21.Baruti M, Ramazni F, Heidari S, Khalajabadi F, Mohamad K. Primery infertility in Tehran based on marriage age in Tehran. Hakim. 2001;15(2):88–93. [Google Scholar]
  • 22.Nojomi M, Ashrafi M, Koohpayehzadeh J. Study of couples infertility in the west of tehran, in the year of 2000. RJMS. 2002;8(27):633–639. [Google Scholar]
  • 23.Moini A, Yazdan Panah MF. Prevalence of factors involved in infertility at Royan Institute. J Shaeed Sadoughi Univ Med Sci Yazd. 1999;2:78–83. [Google Scholar]
  • 24.Delpishe A, Direkvand Moghadam A, Moradi Z, Mir Moghadam N. Aspects of epidemiology of infertility in Ilam in 2013. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2014;17(98):8–14. [Google Scholar]
  • 25.Shagheibi Sh, Seyedoshohadaie F, Moradi Gh, Gholami A, Rouhi S. The prevalence of infertility and related factors in patients referred to infertility center in Besat hospital, Sanandaj, Iran. Chron Dis J. 2018;6(1):36–40. [Google Scholar]
  • 26.Kazemijaliseh H, Ramezani Tehrani F, Behboudi-Gandevani S, Hosseinpanah F, Khalili D, Azizi F. The prevalence and causes of primary infertility in Iran: a population-based study. Glob J Health Sci. 2015;7(6):226–232. doi: 10.5539/gjhs.v7n6p226. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Nourbala A, Ramezanzadeh F, Abedinia N, Bagheri Yazdi SA. Psychiatric disorders among infertile and fertile women. Daneshvar Medicine. 2008;16(3):63–70. doi: 10.1007/s00127-008-0467-1. [DOI] [PubMed] [Google Scholar]
  • 28.Shafi H, Agajani Delavar M, Esmaeilzadeh S. Comparing the prevalence of infertility in urban and rural areas in Babol. J Mazandaran Univ Med Sci. 2016;25(133):335–339. [Google Scholar]
  • 29.Vizheh M, Pakgohar M, Rouhi M, Veisy A. Impact of gender infertility diagnosis on marital relationship in infertile couples: a couple based study. Sexuality and Disability. 2015;33(4):457–468. [Google Scholar]
  • 30.Shahsavari Esfahani S, Morshed Behbahani B, Beigizadeh Sh, Sobhanian S. Epidemiologic study of causes and factors associated with infertility in infertile couples referred to the clinic of Jahrom Peymanieh Hospital from 1998 to 2009. Journal of Knowledge < Health in Basic Medical Sciences. 2010;5(Suppl):51–51. [Google Scholar]
  • 31.Aflatoonian A, Seyedhassani SM, Tabibnejad N. The epidemiological and etiological aspects of infertility in Yazd province of Iran. IJRM. 2009;7(3):177–122. [Google Scholar]
  • 32.Rostami Dovom M, Ramezani Tehrani F, Abedini M, Amirshekari G, Hashemi S, Noroozzadeh M. A population-based study on infertility and its influencing factors in four selected provinces in Iran (2008- 2010) IJRM. 2014;12(8):561–570. [PMC free article] [PubMed] [Google Scholar]
  • 33.Masoumi SZ, Parsa P, Darvish N, Mokhtari S, Yavangi M, Roshanaei G. An epidemiologic survey on the causes of infertility in patients referred to infertility center in Fatemieh Hospital in Hamadan. IJRM. 2015;13(8):513–516. [PMC free article] [PubMed] [Google Scholar]
  • 34.Akhondi MM, Ranjbar F, Shirzad M, Behjati Ardakani Z, Kamali K, Mohammad K. Practical difficulties in estimating the prevalence of primary infertility in Iran. Int J Fertil Steril. 2019;13(2):113–117. doi: 10.22074/ijfs.2019.5583. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Akhondi MM, Kamali K, Ranjbar F, Shirzad M, Shafeghati Sh, Behjati Ardakani Z, et al. Prevalence of primary infertility in Iran in 2010. Iran J Public Health. 2013;42(12):1398–1404. [PMC free article] [PubMed] [Google Scholar]
  • 36.Sepidarkish M, Almasi-Hashiani A, Shokri F, Vesali S, Karimi E, Omani Samani R. Prevalence of infertility problems among iranian infertile patients referred to Royan Institute. Int J Fertil Steril. 2016;10(3):278–282. doi: 10.22074/ijfs.2016.5043. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Taghavi R, Tavakkoli Tabassi K, Mohammadi S, Kor K. Epidemiologic study 2000 infertile males in urology clinic of Imam Reza hospital of Mashhad. International Journal of Basic Science in Medicine. 2011;3(1):11–16. [Google Scholar]
  • 39.Rashidi B AA Hossein, H Khosrobeigi. Presented for the Ph.D. Tehran: Tehran University of Medical Sciences; 1999-2000. The causes of primary and secondary infertility in couples referred to infertility clinics of Valiasr Hospital in 1998. [Google Scholar]
  • 40.Yousefi Z. Prevalence of infertility causes infertility center in Mashhad University of Medical Sciences for 2 years.Presented for the Ph.D.Mashhad. Mashhad University of Medical Sciences. 2001;44(73):91–95. [Google Scholar]
  • 41.Natami M. Evaluation of risk factors for infertility in men attending infertility clinics in the city of Bandar Abbas in 2016.Presented for the M.D., Bandar Abbas.Hormozgan University of Medical Sciences. Hormozgan University of Medical Sciences; 2016. [Google Scholar]
  • 42.Mirzaei M, Namiranian N, Dehghani Firouzabadi R, Gholami S. The prevalence of infertility in 20-49 years women in Yazd, 2014-2015: a cross-sectional study. Int J Reprod Biomed. 2018;16(11):683–688. [PMC free article] [PubMed] [Google Scholar]
  • 43.Ershadi F. Prevalence of infertility in married women aged 15-49 in Gonabad in 2006.Presented for the M.D., Gonabad.Gonabad University of Medical Sciences. Gonabad University of Medical Sciences; 2006. [Google Scholar]
  • 44.Mamizadeh M, Tardeh Z, Azami M. The association between psoriasis and diabetes mellitus: a systematic review and meta-analysis. Diabetes Metab Syndr. 2019;13(2):1405–1412. doi: 10.1016/j.dsx.2019.01.009. [DOI] [PubMed] [Google Scholar]
  • 45.Darabi B, Rahmati S, HafeziAhmadi MR, Badfar G, Azami M. The association between caesarean section and childhood asthma: an updated systematic review and meta-analysis. Allergy Asthma Clin Immunol. 2019;15:62–62. doi: 10.1186/s13223-019-0367-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting.Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–2012. doi: 10.1001/jama.283.15.2008. [DOI] [PubMed] [Google Scholar]
  • 47.Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1–1. doi: 10.1186/2046-4053-4-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Zegers-Hochschild F, Adamson GD, Dyer S, Racowsky C, de Mouzon J, Sokol R, et al. The International Glossary on Infertility and Fertility Care, 2017. Hum Reprod. 2017;32(9):1786–1801. doi: 10.1093/humrep/dex234. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Bushnik T, Cook JL, Yuzpe AA, Tough S, Collins J. Estimating the prevalence of infertility in Canada. Hum Reprod. 2012;27(3):738–746. doi: 10.1093/humrep/der465. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Ottawa: Ottawa Hospital Research Institute; 2011. pp. 1–12. [Google Scholar]
  • 51.Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. John Wiley & Sons; 2011. Available from: www.training. cochrane.org/handbook/arshive/v5.1/ (Mar 2011). [Google Scholar]
  • 52.Egger M, Davey Smith G, Schneider M, Minder C. Bias in metaanalysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–634. doi: 10.1136/bmj.315.7109.629. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Karimpour Malekshah A, Esmailnejad Moghaddam A, Moslemizadeh N, Peivandi S, Barzegarnejad A, Musanejad N, et al. Infertility in Mazandaran province - north of Iran: an etiological study. IJRM. 2011;9(1):21–24. [PMC free article] [PubMed] [Google Scholar]
  • 54.Boivin J, Bunting L, Collins JA, Nygren KG. International estimates of infertility prevalence and treatment-seeking: potential need and demand for infertility medical care. Hum Reprod. 2007;22(6):1506–1512. doi: 10.1093/humrep/dem046. [DOI] [PubMed] [Google Scholar]
  • 55.Sundby J, Mboge R, Sonko S. Infertility in the Gambia: frequency and health care seeking. Soc Sci Med. 1998;46(7):891–899. doi: 10.1016/s0277-9536(97)00215-3. [DOI] [PubMed] [Google Scholar]
  • 56.Haile A. Fertility conditions in Gondar, northwestern Ethiopia: an appraisal of current status. Stud Fam Plann. 1990;21(2):110–118. [PubMed] [Google Scholar]
  • 57.Ebomoyi E, Adetoro OO. Socio-biological factors influencing infertility in a rural Nigerian community. Int J Gynaecol Obstet. 1990;33(1):41–47. doi: 10.1016/0020-7292(90)90653-3. [DOI] [PubMed] [Google Scholar]
  • 58.Sun H, Gong TT, Jiang YT, Zhang S, Zhao YH, Wu QJ. Global, regional, and national prevalence and disability-adjusted life-years for infertility in 195 countries and territories, 1990-2017: results from a global burden of disease study, 2017. Aging (Albany NY) 2019;11(23):10952–10991. doi: 10.18632/aging.102497. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.Parsanezhad M, Namvar Jahromi B, Zare N, Keramati P, Khalili A, Parsa-Nezhad M. Epidemiology and etiology of infertility in Iran, systematic review and meta-analysis. J Womens Health, Issues Care. 2013;2(6):2–2. [Google Scholar]
  • 60.Terävä AN, Gissler M, Hemminki E, Luoto R. Infertility and the use of infertility treatments in Finland: prevalence and socio-demographic determinants 1992-2004. Eur J Obstet Gynecol Reprod Biol. 2008;136(1):61–66. doi: 10.1016/j.ejogrb.2007.05.009. [DOI] [PubMed] [Google Scholar]
  • 61.Hasanpoor-Azghdy SB, Simbar M, Vedadhir A. The emotional-psychological consequences of infertility among infertile women seeking treatment: results of a qualitative study. IJRM. 2014;12(2):131–138. [PMC free article] [PubMed] [Google Scholar]
  • 62.Datta J, Palmer MJ, Tanton C, Gibson LJ, Jones KG, Macdowall W, et al. Prevalence of infertility and help seeking among 15 000 women and men. Hum Reprod. 2016;31(9):2108–2118. doi: 10.1093/humrep/dew123. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.ESHRE Capri Workshop Group. Europe the continent with the lowest fertility. Hum Reprod Update. 2010;16(6):590–602. doi: 10.1093/humupd/dmq023. [DOI] [PubMed] [Google Scholar]
  • 64.Stone J, Berrington A, Falkingham J. Gender, turning points, and boomerangs: returning home in young adulthood in Great Britain. Demography. 2014;51(1):257–257. doi: 10.1007/s13524-013-0247-8. [DOI] [PubMed] [Google Scholar]
  • 65.Schmidt L, Sobotka T, Bentzen JG, Nyboe Andersen A. ESHRE Reproduction and Society Task Force.Demographic and medical consequences of the postponement of parenthood. Hum Reprod Update. 2012;18(1):29–43. doi: 10.1093/humupd/dmr040. [DOI] [PubMed] [Google Scholar]
  • 66.Sobotka T. In: A young generation under pressure?.Berlin.Springer.Heidelberg. Tremmel J, editor. Heidelberg; 2010. Shifting parenthood to advanced reproductive ages: trends, causes and consequences; pp. 129–154. [Google Scholar]
  • 67.Karabulut S, Keskin İ, Kutlu P, Delikara N, Atvar Ö, Öztürk Mİ. Male infertility, azoozpermia and cryptozoospermia incidence among three infertility clinics in Turkey. Turk J Urol. 2018;44(2):109–113. doi: 10.5152/tud.2018.59196. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 68.Fritz MA, Speroff L. Clinical gynecologic endocrinology and infertility. 8th ed. Philadelphia (PA): Lippincott Williams and Wilkins; 2011. [Google Scholar]
  • 69.National Collaborating Centre for Women's and Children's Health (UK) Fertility: assessment and treatment for people with fertility problems.London (UK).RCOG Press. RCOG Press; 2004. [PubMed] [Google Scholar]
  • 70.Safarinejad MR. Infertility among couples in a population-based study in Iran: prevalence and associated risk factors. Int J Androl. 2008;31(3):303–314. doi: 10.1111/j.1365-2605.2007.00764.x. [DOI] [PubMed] [Google Scholar]

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