The question can be posed by an interviewer or asked in a written survey.  The method of questioning will depend on the literacy level of the population of women surveyed.

It is useful if data can be disaggregated by women’s age group, by “ever been pregnant” and by “length of time trying for pregnancy”.

Also, some experts prefer the “five or more years” timeframe for assessing infertility.

The prevalence of infertility as a measure of reproductive morbidity is a useful marker of progress towards improved reproductive health, defined by the ICPD as “the capability to reproduce and the freedom to decide if, when and how often to do so.”

Infertility, or the inability to produce a live birth after adequate sexual exposure without contraception, can affect both the man and the woman. To date, there has not been widespread attention on infertility, except in isolated cases or on a small scale, due to limited resources, policies aimed at reducing population growth, and the expense of modern infertility treatment (Dhont, et. al, 2010). Current estimates of infertility in developing countries are primarily based on Demographic and Health Survey (DHS) birth history data and do not include the self reported time to pregnancy question.  However, these estimates show that primary infertility, or childlessness, remains relatively rare, with rates between 1-10% in women aged 25-49. In contrast, the percentage of women experiencing secondary infertility, or an inability to produce a live birth after at least one previous birth, ranges from 9-38% (Rutstein and Shah, 2004). Prevalence is often highest in centrally located African countries, but estimated rates can vary from region to region even within the same country.

In many parts of the developing world, where having children constitutes the main purpose of marriage, infertility is considered a curse and a tragedy for the couple, entire family and community.  There are several factors that can affect the prevalence of infertility including:

1. Prevalence of sexually transmitted infections (STIs), e.g. gonorrhea;
2. Incidence of postpartum and postabortion infections;
3. Socio-cultural factors such as the practice of female genital cutting; and
4. Age of the partners.

There is conclusive evidence that much of the infertility in Africa is attributable to infections that produce irreversible reproductive tract damage in men and women, suggesting a need for public health programs to reduce these causes, including STI control and education programs to raise awareness about the link between high-risk sexual behavior and infertility (Okonofua, 2003).  Curative treatment of infertility is inaccessible for most couples in developing countries due to its very high cost and low success rate (Dhont, 2010). However, if a country-wide program implements a prevention strategy involving the effective control of STIs, appropriate postpartum care, and safe abortion techniques, this indicator may be one way of measuring the long-term impact of such initiatives.

In regions where infertility is high, there will be more demand for treatment services, both in the traditional and formal health sectors.  Until effective fertility treatments become more affordable and accessible, health authorities can in the meantime determine the extent of the problem and invest in improving information, education and counseling on causes and treatments of infertility, which have proven to reduce the stigmatization and suffering of infertile clients (Dhont, 2010).

The indicator measures the extent of difficulty or failure to become pregnant, rather than inability to produce a live birth.  As a consequence, the indicator may fail to capture infertile women who have achieved conception but experienced one or more spontaneous abortions. In addition, it should be noted that some women reporting a waiting time until pregnancy of two or more years may in fact become pregnant in the future without intervention.

This indicator does not differentiate between primary and secondary infertility.  However, if birth histories are also collected in the survey, this distinction can be made.  The differentiation can be important as often secondary infertility is more prevalent in a population and suggests poor access or quality of health care during the previous pregnancy, delivery, or postpartum period, and/or ineffective treatment of gynecological infections, including STIs.

A significant issue is that this indicator addresses only a woman’s failure to conceive. Nevertheless, this failure of conception is used as a measure of a couple’s infertility, which comprises inability to conceive by both the male and the female partner. The cause of the couple’s infertility could be female, male or both. Using this indicator, and therefore failing to address the male factor in infertility, may contribute to a further stigmatization of women (WHO, 2006).

Rutstein, S.O., Shah, I.H. 2004. Infecundity, Infertility, and Childlessness in Developing Countries.  DHS Comparative Reports No. 9. Calverton, MD, USA: ORC Macro and the World Health Organization.

Okonofua, F.E.  2003.  “New Reproductive Technologies and Infertility Treatment in Africa.” African Journal of Reproductive Health 7: 7-8.

“Reproductive Health Indicators: Guidelines for their generation, interpretation and analysis for global monitoring”.  WHO, 2006.

Okonofua, F.E., D. Harris, A. Zerai, A. Odebiyi, and R.C. Snow. 1997. “The Social Meaning of Infertility in Southwest Nigeria.” Health Trans Rev 7: 205–220.

Okonofua, F.E. 2002. “What about us? Bringing infertility into reproductive health care.” Quality/Calidad/Qualite 13: 1–2.