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    Infertility A Tabulation of Available Data

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    WORLD HEALTH ORGANIZATION WHO/MCH/91.9 Distr.: LIMITED ORGANISATION MONDIALE DE LA SANTE English Only Infertility A tabulation of available data on prevalence of primary and secondary infertility Programme on Maternal and Child Health and Family Planning Division of Family Health World Health Organization Geneva 1991 WHO/MCH/91.9 ENGLISH ONLY Distr.:LIMITED INFERTILITY A Tabulation of Available Data on Prevalence of Primary and Secondary Infertility » Page Introduction .. ee evsenene Purpose of the Tabulations «..rjsamnonene vst Definition of Infertility wuss unmmnnannnnanennnnanennnenees Measuring the Extent of the Problem sn... evstnunucesansint ‘Type of Studies and their Constraints Concepts and their Constraints ...jmsnsnenmnneneinenenmaneenuanenineses Explanation of the Tabulations wives sanermneneaienensee Explanation of the Columms and Terminology... esenensmtnsssee Alphabetical List of Abbreviations used in the Note Column Tabulations of Available information by Country «1... List of Data Sources sss sestnnistseneie Acknowledgements ‘The World Health Organization gratefully acknowledges the financial support of the UNFPA in the preparation of this database. WHO/MCH/91.9 Page 2 1 - INTRODUCTION Infertility. or the inability to have children, affects both men and women of reproductive age in all parts of the world. For the individual, infertility has profound soctal and personal implications, Besides the strain of the personal failure, sometimes a tragedy, the infertile couple 4s often exposed to a variety of family and social pressures, In some regions infertility is found to be widespread and its prevalence reaching such proportions that it can be considered a public health problem affecting the if of the whole society. Initts extreme, infertility, compounded by pregnancy wastage, infant and child mortality, may lead to depopulation, which poses serious threat to the social and economic development of the region. World wide tt may be expected that between 8 to 12% of couples experience some form of infertility during their reproductive lives, thus affecting some 50 to 80 million people. The level. underlying causes and contributing factors of infertility clearly vary from one county to another and even from one locality to another. Yet, beyond a core level of about 5% of couples in whom the causes are attributable to anatomical, genetic, endocrinological or immunological factors, the global problems of primary and secondary infertility, in the majority of cases (55% and above), arise as the consequence of sexually transmitted diseases or of complications suffered post partum or post abortion, particularly illegally induced abortion, All of these are to a large extent preventable. The role of sexually transmitted diseases in infertility has become more clear in recent years. This progress has cotncided with the development of sophisticated methods of diagnosis, such as laparoscopy, and expensive methods of treatment such as microsurgery and in-vitro fertilization, While successful in highly selected cases in developed countries with excellent diagnostic and management facilities, such methods cannot have a significant impact on infertility as a public health problem, particularly in developing countries. In fact, it has been shown that infertility rates are often highest in areas where health care resources are most limited. In some African counties, for example, as much as one third of all gynaecological and family planning resources are devoted to infertility and related problems. In many countries, the magnitude of the problem hhas significant impact on the health services of the area, because infertile couples often need detailed and costly laboratory examinations and therapy over long periods of time. In general, preventive action has lagged far behind some of the new developments in curative medicine. This ts especially disturbing since simple strategies to prevent a sizeable portion of infertility do exist and can be smplemented by primary health care (PHC) workers supported by an adequate referral system. There are immediate opportunities for improving the health of people in developing countries by applying the existing technologies in a systematic and organized way within primary health care systems. 2.- PURPOSE OF THE TABULATIONS In order to design and plan rational prevention and management services. to adapt procedures and establish efficient referral systems, reliable estimates of the inetdence of infertility as well as studies of the trends and changes over time are needed. However, until recently adequate knowledge of the magnitude and geographical distribution of infertility has constituted the missing link in its effective management. ‘These tabulations represent a global attempt at collecting, abstracting and presenting all avalable information on the extent of primary and secondary infertility from studies, reports, surveysete. done invarious parts ofthe world, Their aim is to increase awareness and alert various roups of persons, including decision makers. in the International and national communities to the prevalence of primary and secondary infertility by providing an overview of what has already been documented. The tabulations may be useful for researchers, health planners and policy makers to identify the information gaps, and suspected zones, illustrate and support the need to chart the problem ‘WHO/MCH/91.9 Page 3 ‘and monitor the trends, or to carry out follow-up studies where infertility has once been registered. It has become increasingly evident that infertility offers a particular challenge, as high levels of infertility may be masked by high fertility in the same area, and/or affect a particular ethnic group. Where data point to the exsistance of a problem, the tabulations may provide an information basis upon which health planners can build, develop and implement programme activities according to their priorities and plan for resources and services in the future through careful analysis of patterns and trends. 3 - DEFINITION OF INFERTILITY An important first step in the collation of this database was to clarify the definitions of infertility, because the lack of uniform definitions has brought about some confusion, particularly between clinicians, epidemiologists and demographers. The theoretical/operational definitions (different fom the clinical definitions}, used in this database are based on those drawn up by a WHO ‘Scientific Group on the Epidemiology of Infertility (WHO 1975) and refined according to the data available for tabulation. These are: (a) Primary infertility: The woman has never coneetved despite cohabitation and exposure to pregancy for a period of two years. (For clinical purposes most physicians use one year of unsuccessful efforts to conceive, as the criteria for initiating diagnostic procedures and therapeutic action), ‘Sccondary infertility: The woman has previously conceived, but is subsequently unable to conceive, despite cohabitation and exposure to pregnancy for a pertod of two years; if the woman has breast-fed a previous infant then exposure to pregnancy is ‘calculated from the end of the period of lactational amenorrhoea. Pregnancy wastage: The woman is able to conceive, but unable to produce a live birth. Loss of pregnancy during the first 28 weeks is referred to as abortion or early and sntermediate fetal death, and may be spontaneous or induced, Beyond 28 weeks of gestation and up to term, such losses are referred to as late fetal deaths, or stillbirths, Child mortality: All deaths of children born alive up to their fifth birthday. (Perinatal mortality, Le. stillbirth plus all deaths of offspring within the first week after birth, may be recorded separately, In some cultures, however, the early neonatal deaths may be perceived as stillbirths and hence be difficult to elicit). “Unproven infertility” or “unproven fertility” refers to problems sometimes perceived by individuals or couples as infertility or included as infertility in demographic surveys, whereas in fact, the woman ts virtually not at risk of conception. The problem may be biological, such as among lactating women who are anovulatory, or couples practising contraception (voluntary infertility): or cireumstantial, when there is the absence of cohabitation or coitus (e.g. women whose consort fs temporarily away). 4- MEASURING THE EXTENT OF THE PROBLEM Estimates of the magnitude of primary and secondary infertility are often imprecise because they are based either on demographic data or health service statistics. Both these sources of data present limitations for assessing the magnitude of the problem, as illustrated in Figs. 1 and 2a - 2c, The universe of couples in which the woman is of reproductive age is represented in Fig.1. Demographic data (Fig. 2a) provide estimates of primary infertility only, but do not always distinguish between involuntary or voluntary infertility, or unknown fertility. Hospital or clinic based data (Fig. 2b) do not indicate the prevalence of the problem unless all couples suflering from involuntary infertility use the services under study. \ Belsey, M.A. and Ware, H., Epidemiological, soctal and paychosoctal aspects of infertility: in: Insier, V. and Lunenfeld,B. (eds), Inferfity: Male and Female, Churchill Livingstone (1986). WHO/MCH/91.9 Page 4 'b) Fertile but selt-perceived as infertile €) Primary infertility requests care d) Secondary infertility: requests care ¢) Primary. infertitity No HS contact a) Fertile couples 1) Secondary infertility No HS contact 9) Voluntary —~ infertility h) Unknown fertility sngo 42144 Fig. 1. The universe of couples with the woman of reproductive ag b) Fertile but self-perceived as infertile ©) Primary infortitiey- requests care 9) Secondary infertility: requests care! ©) Primary tofertiity No HS contact a) Fertile couples 1) Secondary infertitity No HS contact 9) Voluntary = infertility 1) Unknown fertitity Demographic data on childiessness = creta+ int Not included : d + f e “wamen with no children due to abortion and child loss vo 922 Fig. 2a. Demographic data on childlessness as an indicator of infertility. WHO/MCH/91.9 Page 5 b) Fertile but self-perceived as infertile ~—_ ) Primary infertility: requests care 4) Secondary infertility. requests care a) Fertile couples 7 a Be ee eececeee Heatth service based data = etd + ib) ; Not included :e +f ago 92113 Fig. 2 Health service-based data as an indicator of infertility b) Fertile but selt-perceived as infertile ) Primary infertility requests care Secondary infertility, requests care e) Primary infertitity, No HS contact 2) Fertile couples #) Secondary infertility No HS contact 9) Voluntary infertility h) Unknown fertility ‘The prevalence of infertility = ctdtert ene x 1000 = rate / 1000 at risk Fig. 2 The prevalence rate of infertility WHO/MCH/91.9 Page 6 Any reliable estimate of the prevalence of infertility in the population would mean the identification of all couples who suffer primary ot secondary infertility, regardless of whether they have requested care from the health services (Fig. 2c). Such prevalence data are obtainable from community based surveys of a population sample, even though they would not provide informa- tion on etiology. Only a few such specific epidemiological studies have been conducted, and in thelr absence, the prevalence of infertility 1s measured by direct indicators such as primary and secondary infertility. or by indirect indicators, such as childlessness. To assess changes in the pattern of infertility over time, repeated studies of the same population are needed. Such studies are relatively difficult to do and only rare examples exist. The study of infertility 1s compounded by wide variations of prevalence from county to country and within countries from one region to another and between tribal groups. Global data on childlessness, for example, for a country may hide the extent of the problem in some regions or among parlicular groups where the problem may be of a local character. ‘An examination of the proportion of couples in a community suffering from primary versus secondary infertility may in some circumstances provide suggestions as to the causes of infertility In that particular setting, e.g. high proportion of secondary infertility may indicate an important presence of postpartum and post abortion infection, Detailed information on etiological factors will, however, be obtained from specific clinical studies, whereas data on the magnitude of the problem fs available from epidemiological studies or can be drawn from demographic or fertility surveys, 5 - TYPE OF STUDIES AND THEIR CONSTRAINTS. Clinical Studies Clinical infertility studies are the prime source for determining the etiology of infertility, but do not indicate the prevalence of the problem in the population as it is impossible to reach all affected couples in the services providing infertility care. Besides, the vast majority of couples suffering from involuntary infertility do not avail themselves of such services. Clinteal data are, however, an essential complement to prevalence data in order to identify the underlying causes of the infertility problem and to devise management and prevention strategies. Jn the present tabulations only those clinical studies that focus on the prevalence ina specific Population, e.g all women using gynaecological services, are included. Epidemtological Studies on Infertility Epidemiological infertdity research in the community can provide the prevalence of both primary and secondary infertility and give some indication or explanation for the causes of infertility. Ideally it should establish the presence of infertility in a medical context. Epidemiol- ogical studies can also explore factors such as the local postpartum customs, contraceptive behaviour, migration pattems ete., in order to establish the possible causes of the infertility status, But such studies are rare. Fertility Surveys Fertility surveys often cover aspects relevant to infertility and can provide good indicative and. qualitative data, such ason contraceptive behaviour, However, for the most part, data is presented as demographic information and has to be used with its inherent limitations, Demographic Surveys Demographic or census surveys can only provide rough indirect measurements of primary infertility, e.g, childlessness, or “only one child” as an unprecise indicator of secondary infertility. Often such data has to be relied upon failing more specific studies and therefore has to be interpreted in light of its constraints. WHO/MCH/91.9 Page 7 Constraints related to Data Collection Comparison of data collected at different times and places has to be done with particular care because of the different standards and techniques used in data collection and in their presenta tion. Differences in standards of population registration. methods of sampling, questionnaire construction, interviewing standards, definitions of target groups. recognition and definition of concepts such as martied/cohabiting, and calculation of rates in different segments of the female population, {.¢, all, currently married or ever-married, ete. are common and may be misleading An important effort to standardise the Information and process has been carried out in the framework of the World Fertility Survey (WFS) in 42 countries between 1972 and 1982,’ The Demographic and Health Survey (DHS) 1s continuing the effort in a large number of countries, ‘These studies are providing an opportunity for comparisons giving due consideration to different timings and soclal settings. 6 - CONCEPTS AND THEIR CONSTRAINTS ‘There is a lack of global agreement on pragmatic definitions for important indicators or concepts related to infertility that further limit the comparability of data. Particularly in the case of demographic data, in addition to voluntary infertility (contraception), such factors as postpar- tum sexual abstinence. breast-feeding customs, adaptation and acceptance by a secondarily infertile couple of their infertile state, long-term separation of husband and wife need to be taken into consideration. The examples below will also further highlight the need for specific, preferably epidemiological. research to measure prevalence. Primary Infertility and Childlessness When based on demographic data, primary infertility and childlessness may be indicated by any of the following: never pregnant, no live birth, no child born, and even no child surviving first year or no child alive. A actor to bear in mind is the custom in some societies for an infertile woman toadopta child or several children, These are naturally reported as her own offspring and can lead to lowering the reported rate of infertility. Also, in the case of women who are divorced or when marriage never takes effect because of childlessness, the actual extent of infertility will be underestimated if only married women are considered in the study. ‘Secondary Infertility and “Only one child” Estimating secondary infertility through demographic data is difficult as secondary infertility may occur at any time in a woman's Ife after the first pregnancy, Only through direct questioning in the context of a community based study can it be established whether a woman had attempted to have more children or not. “Only one child” must be seen as a very rough approximation and can be both an under or over estimation, depending primarily on contraceptive behaviour and the desired number of children, Survey data on indirect indicators for the prevalence of secondary infertility can be obtained from some fertility surveys that have categorized women who have fewer children than desired. Some inference on secondary infertility may also be made by examining data from countries characterized by traditional cultures in which the norms for family size are well above two. Age Cohorts Different age cohorts (45-49, 50+) have been used to describe the “end of reproductive life”. It is assumed that universally menopause in a female population occurs by the age of 50 years. However, arguments can be raised in favour of studying earlier age groups as only a fraction of births (particularly first births) take place after the age of 40, memory also tends to fade regarding reproductive history and with fewer older women, they presumably are a less representative group, A lower prevalence of childlessness in increasingly older age cohorts after 40 may reflect one or several of these factors. WHO/MCH/91.9 Page 8 Other Factors to Consider It should be noted that only exceptionally do demographical sources take account of voluntary and involuntary infertility even though it 1s an important factor to consider when making comparisons between countries or even between rural and urban areas. In urban areas stmay be particularly dificult to draw comparisons since there may be higher us¢ of contraception and there may also be true differences in, for example. childlessness, because of an increased spread of sexually transmitted diseases (STD). Seasonal migration disrupts family units and decreases the opportunity for impregnation, as do polygamous marriages, Delayed marriage because of educational opportunities, 1s becoming a factor that affects the age of the first birth in some countries . These and other factors may increase the number of women with no children or fewer children than could be expected, 7 - EXPLANATION OF THE TABULATIONS 7.1 Data Search ‘The baste resource for the data search has been publications and periodicals available at the WHO library, Medline and Popline searches and research being conducted, coordinated or monitored by other technical agencies /organizations and groups. Added to this were WHO coordinated country studies as well as informal, unpublished papers by experts working tn the field, Data from various demographic reports were also used tn this tabulation as were a range of national and regional reports and papers on recent developments, progress and related problems of primary and secondary infertility. 7.2 Data Collection All available reports relevant to the issue of infertility have been examined, and data systematically extracted. Every effort has been made to ensure uniformity and consistency in reporting, Responsibility for the accuracy of the data, however. rests with the authors of the reports. Despite the paucity and shortcomings of the data, as much information as possible has been included in this first edition of these tabulations. in order to provide a global picture of situation, The database will be revised and updated periodically. as more recent and more reliable studies become available, Readers are invited and encouraged to share their knowledge and materials and assist WHO in maintaining the database as up-to-date and comprehensive as possible. Any information and references should be sent to the Family Planning and Population Unit, Division of Family Health, World Health Organization, 1211 Geneva 27, Switzerland, 7.3 Sources of Data ‘The data were extracted from sources that are Usted in the final column of the tabulation by means of 4-digit numbers which corresponds to the accession number assigned to cach piece of information on the WHO/INF bibliographic database. A list of all references used in the tabulations ts attached. Not all references related to infertility that were examined could be used. Those not included elther duplicate data or contain information that could not be computed in the present format. 7.4 Data Sets Each line of the tabulations represents one set of data. As far as possible, repetition of the same data from different sources has been avoided. It must, however, be pointed out that different researchers may have used the same basic raw data and classified them differently and/or obtained slightly differing results during processing. WHO/MCH/91.9 Page 9 7.8 Conclusions from Data Basic information was not always provided in articles and reports, particularly the year of study, sample size and methods of data collection. Evidently the comparability and usefulness of data increase when they are presented with such relevant information. Some cautious comparisons and conclusions can nevertheless be drawn from the data presented, but the tabulations are not sultable for statistical manipulations nor should they be interpreted vertically without due consideration to the information given in the first, seven columns. The constraints discussed in Sections 5 and 6 should also be kept in mind. 7.6 Organisation of Tabulations Countries are arranged by WHO regions. Within the countries each sub-area or ethnic group for which data were obtained is listed alphabetically. Information on each sub-area is arranged in an ascending timescale. ‘7.7 Infertility Indicators In these tabulations the age cohorts 25-29 and 40-44 have been chosen as groups indicative of the level of infertility in the population. The cohort 25-29 corresponds to the age of highest fertility, when, in large parts of the world a woman has normally married and conceived at least ‘once, The cohort 40-44 1s chosen to represent the end of reproductive age, and may reflect both primary (no child ever born) and secondary infertility (only one child). Childlessness at 25-29 and 40-44 may be considered an approximation of primary infértility. Interpreted cautiously these two sets of data may indicate a time trend. “Only one child” at the end of reproductive life (40-44) may indicate the level of secondary infertility. The information for the age group 25-29 has been maintained for comparative purposes but cannot in itself be considered as an indicator. 7.8 Note Column ‘The note column contains additional information and explanations. It is also used to draw attention to data that help interpret the results or call for further study, 7.9 Abbreviations ‘The essential abbreviations are found at the bottom of each page of the tabulations. Section 9 contains an alphabetical list of all abbreviations and symbols used in the note column, 8 - EXPLANATION OF THE COLUMNS AND TERMINOLOGY Column 1: Region, Country, Area or Ethnic Group As fluctuations in infertility may be substantial in adjacent geographic areas or ethnic groups. detailed information has been presented. Efforts have been made for a coherent naming of places, Sometimes ethnic groups or data related to ethnic groups have been mentioned for an area, which has been registered in the note section. Column 2: Year ‘The year to which the data refers or the period during which the study took place. An “E™ following the year indicates that a likely year of study has been established through another source. A *D* indicates date of publication as the only possibilty of identification in time. WHO/MCH/91.9 Page 10 Column 3: Sample Size The sample size is mentioned if the information has been provided. However, frequently the sample size of a particular age cohort was not indicated in the report. Column 4; Type of Study It should be noted that the distinction between the different surveys identified below is not firm, but is intended to indicate the quality and validity of the data as well as any other information that may be available in the survey. The type of study colurnn distinguishes between € clinical study of prevalence of infertility: EP epidemiological infertility study: SE extended community study of fertility including medical and/or social aspects; SF fertiltty survey: S__ other or unspecified community survey. usually census or demographic surveys. Column 5: Sex of Subjects ‘The following identifications are made: female (F), male (H), couples (Co) and household units wo. Column 6: Age ‘When sequences of cohorts were available the age cohorts 25-29 and 40-44 were selected (see Section 7.7), In all other cases the cohorts or ages selected by the authors are given, Data for several age cohorts are tabulated for the same area when given in different reports, reflecting the authors’ choices, Column 7: Marital Status ‘The categories are all women (A), ever married (EM), married (M), married monogamously (MM) and married polygamously (MP). The figure after the M is an indication of the minimum number of married years. Data on cohabitation has been classified as married. Ifthe author has indicated “women” this has been taken to mean “all women”. Data for both A, EM and M have been Included in the tabulations if provided by different sources to allow comparisons between these groups and between corresponding groups in other areas and at other times. In some parts of the world, however, practically all women eventually marry and A may equal EM, particularly in the older age cohorts. Columns 8-12: Infertility Infertility has been registered as indicated by the author: primary infertility, secondary infertility, infertile (sterile) unspecified. childless and “only one child”, Data not fitting these categories have been classified, registering the definition in the note column, This has also been frequently done as specified by the reports. All data are expressed as percent. Column 13: The Note Column This column has been used to give additional information regarding the description and interpretation of data. This information may be an indication that further data is available (Data:), religion (Rel.:), ethnic group (Ethn.:), definition/s (Def. / Def.) or noted as a nota bene (N.b.). WHO/MCH/91.9 Page 11 9 - ALPHABETICAL LIST OF ABBREVIATIONS USED IN THE NOTE COLUMN . see note column + and 30-39 figure indicates the age range in years ecep contraception chi. childless Data _additfonal data (as indicated) available in report Def. definition used Def.s used definitions used, separated with a backstroke () Ethn. ethnicity, ethnic group Ethn.gr. data refers to an ethnic group excl. excluding fert. fertile; fertiity gyn.dept. gynaecological department incl, including inf, infertility Nb. nota bene oth. other PID Pelvic Inflammatory Disease pregn. pregnancy: pregnant pi. primary infertility rel, dominant religion sec, secondary infertility ster. _ sterile surg. surgical underest. underestimation w. with w/o without a8 years oavéien = m *ajun pjoyssnoy « 9 "Aone Aaj iai04 = 4S fansns popunaxa = 35+ » ‘sua)ieg = 4 ‘snows6hjed pelasen = ei “enauebovcu poaiey 2 ai doris yea 60) ontop 83 = ‘Sul siqeyoo 40 potion =H” ran essay oy rs o 5 sie esd" s0al mL smeas | ty | x05 ors, saies rary beg anjacysoeeg KLEITIGUPAINTI AXYYGNODTS GNY AUYHINEG WHO/MCH/91.9 Page 13 WHO/MCH/91.9 8 ia " Youn; 8:Asv09¥ ues pur e120" Taesea 107 Bae BR te FS ss % b $ 52 s ® $ s s s s 8 st suso.d site| subasd’n 6§-DEsK £°298"326| ¥ a omnis 8 pw] ss | ona | a ous ‘240 | crit | sou ras Avo req ontady 9590 RLITIG#@S ANI KRUVYGNODTS GNY AUVHIUE WHO/MCH/91.9 “aauak 42 pa] ueH = eg = "ea ycen = ‘00 ‘Agmas i if ui ‘| bE £ & 7 veanaksoiow HERES onnnnnnandt eouyaoia $706H TaNnung ¥ 591 PINE Ate ‘smieas sea ontadisoseg RGITIG@aane AYYadNOOgS a Page 15 samyen posusion =m '34un p1oyasnoy = 9 ‘homuns 434113384 = 18 ‘ensns popuaixg = 38 “pajyjzedsun Jo seuss ‘ojudestouep rhanuns = ‘siussiug = 4) “maueGkjed PolsseH = di “snOsgBOvou Po|J0K = ia seas j9b4 a3 *pojdate 330g = ye 1219 ‘Saeed 4z BOLsIOM = ZW “200K 41 *Baravaewo> 40 poqsem = W ‘O10 = yeiog es “9geujaea = 3 “OL es) \apd 42 ateg = 9 “sayaneg = 00 “AomIs nou 40 8413 ;aeyo9) uau/oowon FY = ¥ PECL TPIARLaRY WHO/MCH/91.9 re | so. bar] ou lexzy-ne “sus? seoue spo 301g vo 309908 ~ vobbbobootbo bbe sas sh anes x sop sma Arius -beses | ois ‘20 "esa ach, | syates *kaquno "u0yB04 preg 9nj34)29890 ay REIVIGUIANI KUYGNODTS GN AUVHIMA revorso1anuqey RRMSERES 4s}9 -Uboud 5s42| srubesdon 66-08: *s3¢| eupitye 2-14) sve} reise evoibes “ah ¥ Pu a 0 40 wo AGITIGagane WHO/MCH/91.9 Page 17 ssuoyeinsugne WHO/MCH/91.9 wunsog‘s3sip nossvsen | aah NWOTNAY TIGNES equa sumpe :23e supe tie “PHD. x Ass. pu | 330) suoses |S hove sy au wea enjsdose0 RLITIGUIANI AUYYGNODES aN ¥ 4 ¥ a ¥ a ¥ a ¥ i} a ¥ | 4 v | oe a |S w | ees] a] s e | os] a |S ¥ | esl a] s ¥ | ero] a | s v | es] a] s ¥ | eo] a] 5 ore v | “sos| a | as | gy 9 w] soe a | as | on ie ¥ | to a | as | ze se v | sol a | as | ae “usod sonou 20°400. et vfe ost a fas | oe eszai “usead vonou 28"490 ovr we fa esl a as | ase ensue ‘noua, # 608 eszo} suBed sanou 28°390 ze v fa asl a fas | a ipuegBn‘rowoaie ses eczo} Ly Usead sons 2e"300 {s8-uDy ze wv fa os) a | as leszal bad sonou = a3 a vf aos) | as sussud Janeu Jog ay v | see] ag | as subeud denau 390 ore v | tes) a | as su vfs os) a | as ee vf sos) a | as = v | sos) a | as ve vi fa ost] a | as | aot pucqsn‘newoa,W Soe woe w fa asi] a | as | soe uoyezn‘nouog, seg 37 v | srs] a | as | six rowon,4 see £ v | sos] ¢ | as | ge ue vy fz ssi] a | as | oe ze wf sa) a | as | sor [s2,24N"PewogsM SOE aR WVOTESY THING ¥ 7 ¥ xz Asp | Kieu | sms | 26y | as owuipa sou ars | tome | ta fo veaiy “heal ‘108 shu oh 4994 *aazuneg ‘U01 694 Asonbos4 moeg onsad}i9s00 Any egut ALITIGUGAINI AXYAGNODAS GN AUYWHIUXA WHO/MCH/91.9 Page 19 oo) 3B4Aa.gEy WHO/MCH/91.9 sont Seay Jou \ -ubad ou 22420 eaereny Jou \ -uBa.d ou 25-400 eseyery BER9R y BR BRRROSSROSENSK HananouneKREEH Boon sangegs Be v ¥ « k ‘ K 4 ¥ v ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ v ¥ ¥ ¥ ¥ v v v y ¥ ¥ ¥ ¥ ’ MLL ¥ mers v5 seer | ona pine | =e eo s18q eAtsd} 2620 Ane KLIQVIGUZaNI AUYAGNODES a WHO/MCH/91.9 samyen paauien = A ‘31un proyssnay skied ‘ei “snouesouc ¥ ¥ ¥ ¥ ¥ ¥ ¥ x ¥ ¥ ¥ x ¥ Ro nnneth8tton syueo “ame NOTEY WALID x= kup | Aaeu | seas swoses | Sue x5 feusrbass | 2380 2A;2¢1s9800 soy 2s934 oats. ores, Asiana fe teay sAagineg “8504 KGLITIG#SaANT RUVGNOOgS ane AUWHIEE WHO/MCH/91.9 Iqeye> 40 POLIIEN = W 160) 31eve9) use ation J2sson snusoa ¥ ¥ ¥ ¥ a a 7 Y ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ‘ ¥ ¥ ¥ ¥ ¥ ¥ ¥ 3 $961] 5961 uoybsy re snosuogy Pesnobusdy ue 1Boy hoanobusdy BUIOAT,d 4L00 a ju Tx Asp | Ave | savas -voaes | pa founebeis | 910g 2nj2d420500 Aan nep oyaues tAsqunen "01604 ALITIGuUg@ant AUWaNOODGS x KRawHiud saayen parysien = n "234m pio4asnoH = A "AanINS 42: ‘syuntieg = g)“snoueséjed pe 1sey = gh “snowesouce 148M » 2H “51994 BU) 319e409 20 ptseK =H yeneg = 09 ‘Aenys JesIus 13 = 3 *CaoU 20 euyayqeyos) unt uaoon 62-591 60) by-09) 9 2964 9 2861 62-42 ors] 6-07) 63-04) @-a 62-42 ¥ ¥ 8 a ‘4 ost sow | ow ‘@ a 3 a % ¥ 399-92 “yu1) s204e “po (99-92 “44)) seave “430 ontorevoannnn voi69y swv21po, swe2 SATOAL @ 3100 omg x05 ozs yates Avo eieg ontadiose¢ RLITI“GQYAANI AXYGNODTS ANY AUVHIMA WRO/MCH/91,9 semen powdsion =n 24uR proyesnon = 4. ‘hoauns £9) 12095 = 45 axa = 35 “paygioedeun 30 snzuao 12) rod pose = eh "snoueSou pa] sI6M = Hi 143 = 3306 29K = 18 ‘sanok 92 pasion = 2k N3}Q=uo2 10 Po|JOW =H “9TRH = H He seg = “seydn09 © 09 “ABMS ‘caou' 30 Buy3saeyeo) uaa/Geoen IV = ¥ 'SUO;e;AGSCIAY WHO/MCH/91.9 seauyng Jedén pg Jaden s 8 8 $ 8 3s 8 3 8 3 3 : s 5 s 5 s $ 8 8 8 8 8 s 3 $ $ 5 5 ¥ xx Autp | teu | smeas | o8y | ves eno stoses | Aha uo | BIND ao foverbosg | 910g aAjrdis2800 ate KLITIGUZanNrT AUYGNOoTS ANY WHO/MCH/91.9 Page 24 SSEES ERSTE eb. excl. surg. ster. lbefis: no pregn.\ only INFERTILITY creed 2+ years, et rudy, Co = Couples, D = Date of px <2 E88 cece ceed eSeEebeeebebccccccae’ » % « a a ° 8 a o Descriptive data ND a Smpte | Type PRIMARY He mate, wa = Mars Abbreviations: A= ALL wosen/nen (cohabiting oF Page 25, 1ovuep Aa: SIU 32K = 3 Soyoumy = 4 “B3mej303 = 3 “UOLIDIIand 40 935% WHO/MCR/91.9 es s1u9p 4 Atuo \-uBoud ou 23-400 wns 2] sans "Bins “O10 “4H eH oHLOsa'T uoysay worsen saya :ereq cuna Zeaeq singe zez0q saa 2eieq sue 280d nape 2 onde Gidnnddadddddaa id - yo}u"u6oud SuK5-n "140 SH Sr-omay 28404! 2494 | Aywo \-uBoud ou 25°409] BERL 2 Jo pa; J00M =| 2 = 9 "G30u 0 Bula sqeyen) ubalazon | a] oo BERIT FSLRS AVR! 62, 6s oe smeis | 28 | ves Pine oe Avo eg aatidiissag AUTH RLIGIGDaginI KUVaGNODAS a WHO/MCH/91.9 Page 30 Page 31 3 = 35. ‘poypsoedaun Jo snouss ‘oyifeuBouap téoAung = 3 '93U2}284 42 polsaby = 2m. "Sa00k 4) ered jo S3eq = a "seyéneg = 69 “Apmis | WHO/MCH/91.9 oul re RIPGRERIRRR ASLIRANSROR: S28 gy ¥ z r & ¥ & y ° ° t sasnsgenegencags ssu00 vINv2Mys “30°71 xT, Asp | Abea | smeas Agua luooss | -136 ous ‘so "easy odaes ‘daring: "W184 Aouonbosy | eyed aajady 9800 Aa 309u1 KLITIGUIANI AUXYGNODZS ANY AYVWHINA em paruBian = A fonuns popuoix = 35 ‘pat; toedsun Jo soueo ‘ojudetouap thanns 2 § ‘siusied 2 2 "ence fens 1091919100183 = “aia ‘ss00k 42 Palast = 2H "S189K v4 poLIeM = 2 40 pot lseK = t gpd ge 36g ="a “eaydnog = 09 “apmas Tesiui}g = "3 "{aou 20 Suisigayea) Uauamon TY = Y severe LANUeRY Seenes 0 8 ia on oe vs oral 7 Q a rs ease yeuns “9° sywoo vINZAYL “a3 "A z sep aman ws Anata stezes | ans, oa easy orduns *anaineg “U2480y Aerbesy | ere aafadiioseq Pree AGITIGUGINI LUYAGNODAS ANY AUYHIUA WHO/MCH/91.9 Page 32 Page 33 WHO/MCH/91.9 suyss :83eq REFGRRSSSRRRAIIRRLSORGT BIG TSESTFFRGS SA RIST TE 2 SRRRSSRNRSSANARS SRR suas sexed ‘sah "oH BEBBoBookedoen' ¥ x % ¥ x ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ¥ ase | 3 test] ¥ sng Pua 3 ors, m3 yates | se04 iv ‘ang onjadyosog Aouorbo1s Anneiui RGITIGUGGNI AUYGNOOTS ANY AUVWINE WHO/MCH/91.9 Page 34 INFERTILITY » m « a z ° ° 2 a Descriptive Date 5 PRIMARY Page 35 Aonurs poping = 35 deni e280 \oqmep a3 “ayenes WHO/MCH/91.9 Ebb YO> JO pol tueM = ‘9 Neaou' 20 Baja igeyes) uae/taaon revo 2 ARIE Dy1anasa NWOINTHOG oust yev0}20H u 2001208 Tevet en yuo} 20% sus4 1 Atvo \ruBoad ov :8°40q x. kee | smamis x5 sd 40 Amvenbes | ereg antadiuoseq Petrenyirg AGITILUSHNI AUYGNRODHS ANY AUYKHIUA WHO/MCH/91.9 WHO/MCH/91.9 UasPLEN 2-44) ubosd "1494 | Aque \susaud ou #840q) saays “Buns “1900 -4°4 sans Bune -y910 “9*4] fom » a & zeBBchaxce SSSSSRsRess ‘auo> arenes i ¥ aya spur seaeg anjady9s0q RITIAUTANT kRUYVaNODaS a ys grubaad 8k5'n cogs ve sarnscone oo OUP IHW Zh “aba saaap | Aue 436) saais "Bans “948 “A =aurig 4 Nn’ an TSA SA TS RBRRRRARR! agg saare ‘Bune “1249 -9°a] ‘uespl ND 2-44] “ny five utd a ruBoud Sic" escotmn Wwe ew'sy-onde #95900 amas | aty | xs Asuna aus fe aedy stains *Aup0) "160% maeg 9Aj36js9s00 RGEITILYAANI AAUYGNOOTS ANY AUWHIVA WHO/MCH/91.9 Page 43 semyen paaysi3n = WHO/MCH/91.9 Jase, 1 Aue \ruttsd ov fs ¥ $ygensaeass Heeeeeese s1u84 1 Avo \" smers | sty | x25 ais adees ‘reg aA12d}3980q eg RLITQISYFANT KRUYGNOOTZS ANY AUVHIME Aeasns popuowxs = 33 ‘porjszedaun Jo enais> ‘2iylosBousp :honsng = § ‘51021 ‘210 *Sue0h +2 BoLdeH = 2H sau9y 1 Atwo \ruBead ou 25°499 stats "Buns ~ 1330 -2"H 22 BEQ2 © Bhe}80101U—p13 = ea Jan3 Wa" joao) = 4 “oieuyasg = 3 “Uo}2e9} yard Jo o1eq = a “sDydnea'= 09 “ABMs TeoqWtTa sa WHO/MCH/91.9 “ye Astrum jon) revo} 20n euo1 20% qeuoh am youn} 209 yeucy2en yeuoy san meee eee ee 8 BBL « * ® « ” ¥« * ” " * ® « K 4“ susp | Atue \*usoud ou fad = ye ruBoad 6a J6s-obsx\- 14> 2sU0}3R\ARIRRY sez | oeei| va-scsi} sey | 92a] ry coy x2 Bree 2 say 4 Ayuo \susaue “sje tine “yao “ay 1 yeve}3eH LaXoa oung yww0} 20, ywu03398 you0y 30H sues WTENZaNA smieis x05 Argun otis ores see enjadiss0g anaes KLITI“GUPANI LUVGNOOTS GNY AUVHIUA :ouos28A3.0R ZT, Auge | Siow | emress vas suooss | 44 Asvoobosy | exeg oatadisosog ESTOS ALITIGUGGNI AUYGNODES aN WHO/MCH/91.9 Page 49 Aotune pepuenia = 35 ‘petpioadsun 10 seuss ‘2jutesbaump chaning = § ' ‘Apne Yw2(Boyowopias = a} epolsied 4ony = Wa *°290 "6IUOK 42 Dole = 2 es tqoye> 30. poLseH = *eqouns =} ‘2yeuiae3 = 3 “UD42e9/\opd Jo 93Uq = “saycHO] « Cy ‘APMIS TeD!U}TD = 3 “C3OU JO BULr{qaYOD) URUVAOION IY = Yt WHO/MCH/91.9 a0 1 Aye \-upesd ou & § baud sop 1 A1u0 \ruboad ou 8°5aq o © § ° ERRERRRRR 5 FE e SSSEBSESEESEE222 Aayqiwas Ayo Aouarbosy | sang onjadyce0q Ano RLITIGUTANI AUYGNODAS a suo ae Aaa yeuo} 10K sya wolotgaa saers “Buns “2x0 “47H caga °W NYTURS opus sssuiorsen apg eA} a so500 KGITIGHGINI AUYGNOORS a WHO/MCH/91,9 Page 51 r9u0) 26149009 WHO/MCH/91.9 12001204 swe eyaq 1143828 29sea1qoqo-d | Aa 1asae Judea qeqoud 28°429] z - youoy aa 1 jeuoja04 yeu0} 309, 309 wna ¥ = dave | anaes 705 3 cise. Ao fovonbssy | exeq eA}2dyso800 ay a3yL KLITIGUAANI KUYGNODAS Ga Jonins pepusnra = Apes yeoiBojouuepia = 4379] JI0U 983 = 1G ye 4 f3a0u 1983 = 3 TU} 30% sanyo “tans “y2x2 -9°y} 7 7 aes ses Bans *y0%9 *Aquo M3841) “a°A 7 : a ered - ywpe9 “Bans ~yoxe "quo K 39415 “OH z z iepen sess jewoyaen sessg VeuoteH sven dose xe “9°N Saaie Bins “ove "Awe W3U1E “OH 996) S198 “daa2 x99 “a1 Beet Suan “do0 ABS “ar 1W> 17499} 3003 Sans smiers Agape axis fo teed edt, | sas *Asiuneg weiBoy req aaiad}.9899 ESTE RELTIGUTANI AAVYGNOSAS ANY AUYHIXA WHO/MCH/91.9 Page 59 fons popuayea = 25 Apr 991 80}0,u9P 133 “oyauas= WHO/MCH/91.9 xeze zx sso) Pit AN Ss0y0 ALITIGU@GanI KuUVaNODAS rsuopeyanueny r2u0322H, WISUNOGNI yosug 1590, saoae “Buns “yoK0 -a°4] voupie 2-14] u-si64 yevoy 28H HSgqVIONYE ouvas ans x5 sraies | 00, hua rea aasdisose0 KLIGIGUGANT AYYGNODTS ANY AUYHIUE WHO/MCH/91.9 sO J9A3 = 1 ‘ewok 42 Polisew = 24 IqeyOO 0 PALAION © HOTTY =H yeued = 4 ‘9i0u4 363 « 3 Ua;IDF Ia 40 e1Eq = G '48)¢N09 = 69 ‘Konis *(a0u Jo Basa iqeWo3) Val Uaton YY = ¥ FsUO}ae;ACIRRY WHO/MCH/91.9 se-uina| ze oy esp ine z-46| ee® 25809 © 285Sc0202 4 7 f 0 4 fe royeues’ouoaus Bie4 qed go 9986 = a “e2TN0) val os “1s95 4 Alu yrusaud oo ‘yppsreseod seis | oy | vos siders Aoverbeis | ving onyadis280¢ sayeese KEITIGUTGRI RUYGNOOAS ANY AUVYHIUA WHO/MCH/91.9 Page $7 Aanine popuens3 = 35 | Apne yo0}60 01m0p 1d “oyeuoy = 4 "ai0ul WHO/MCH/91.9 oun 9} 1 Aywo \ruBesd ou 73 voupisus 2-14] Subasd) 4 que \-us0ud ou 25°39) ysis -usaud 6142] suboud'n 65-05% *°308"}09] aceqeBecEs®

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