Female Infertility in Arab Countries: A Comprehensive Review

Abstract

Objective

To review and summarize the current state of knowledge with respect to female infertility in Arab countries.

Methods

Review and summarize eight articles retrieved from PubMed electronic database on female infertility in Arab Countries.

Results

1. There are a number of women infected by secondary infertility after a specific period from their last birth.
2. Infertility decreases steadily for women over 25 years of age.
3. Infertility decreases in urban areas and increases in rural areas.
4. Women cease reproduction after the age of 45 years.
5. Homologous insemination is allowed in Islam, whereas heterologous insemination is absolutely prohibited in Sunni Islam.
6. Women with infertility challenges have more epithelial abnormalities and lesions in the cervix uteri than productive women.
7. Infertile women exhibit higher psychological problems than fertile women. (viii) Chlamydia trachomatis infection is significantly correlated to women infertility.

Conclusion

Special attention should be focused on conducting a future study on female infertility in Arab countries because many women are infertile and waiting for effective treatments to address the infertility problems.

Background

Merriam-Webster dictionary defines the word “family” as a group of persons of common ancestry (Merriam-Webster dictionary, n.d.). Parenthood and making up a family is not an easy task. People do not seek it only for joy since it requires a deep commitment to raising and educating the members of the family. Moreover, people need to make families in order to continue their generations. Female infertility refers to the inability of a female to become pregnant after having regular sex. It can also be defined as a woman who cannot carry a baby to full term. In addition, some countries defined it as the failure of couples to conceive after 12 months of regular sexual intercourse without using contraception.

Most of the studies have evidenced that more than half of infertility cases are as a result of female problems, while the remaining are either idiopathic or caused by sperm disorders (Nordqvist, 2016). There are two types of infertility, that is, primary and secondary infertility. Basically, primary infertility occurs in a situation when a woman is unable to have a child due to the inability to become pregnant or to carry a pregnancy to live birth. Secondary female infertility is the inability of a woman to get pregnant or bear after a previous successful pregnancy or live birth. Examples of the secondary female infertility are cases of repeatedly spontaneously miscarriage or pregnancy that ended up with a stillbirth (World Health Organization, n.d.).

The prevalence of female infertility has been reviewed across the globe. In the U.S, the infertility rate was reported as 11.2% in 1965, followed by a gradual decrease until the year 2002, when the rate rose up to 7.4% (Stephen & Chandra, 2006). A review of infertility rates in developed and undeveloped countries for about 72.4-120.6 million women aged between 20-44 years from the year 1990 to 2006 indicated that 25% of this population were reported infertile.

The same review reported that these women received infertility treatment, and their number is estimated to be between 40 and 90.4 million (Boivin, 2007). In Sub-Saharan Africa, the prevalence was totally different as women infertility was estimated at11.8% in Ghana, 9% in the Gambia, 21.2% in Northwestern Ethiopia and 20% to 30% in Nigeria. In Asia and Latin America, the World Health Organization indicated values in the range of 8%–12% in 1991.12 (Adeniyi, et al., 2012).

The risk factors that can contribute either directly or indirectly to infertility are subdivided into factors related to disorders of the woman and factors related to the spouse /man as discussed below:

Factors Related to Disorders of the Woman’s Ovulation

General health condition

High BMI or overweight might result in chronic diseases such as diabetes, hyper or hypothyroidism, lupus, arthritis, hypertension, or asthma, hormonal imbalance, history of two or more miscarriages, and polycystic ovary syndrome in which the woman’s ovaries function abnormally.

Environmental factors

Cigarette smoking or alcohol consumption might interfere with ovulation.

Emotional factors

Depression and stress may have a direct effect on the hormones that regulate reproduction and affect ovulation.

Age

Female fertility begins to deteriorate at the age of 32 years and above. A 50-year-old man is usually less fertile than a man in his 20s (male fertility progressively drops after the age of 40).

Sexually Transmitted Diseases (STDs)

Diseases such as gonorrhoea, syphilis and chlamydia transmit more easily to women and can lead to pelvic inflammatory disease (PID) in women and epididymitis in men. Complications are more common in women, including subsequent scarring, miscarriage, adhesions, blocked tubes, and ectopic pregnancy. Ultimately, infertility can be a consequence of STDs (The National Infertility Association, n.d.).

Problems in the uterus or fallopian tubes, including

Tubal Disease

Accounts for about 20% of infertility cases treated.

Endometriosis

This condition occurs when the uterine tissue is found outside of the uterus; on the ovaries, fallopian tube, bladder and bowel. It can occur in menstruating women of all ages, including teenagers. While the connection between endometriosis and infertility is not clearly understood, early detection may result in successful control and preservation of fertility.

Surgery

Pelvic surgery may sometimes cause scarring or damage to the fallopian tubes. Cervical surgery can sometimes cause scarring or shortening of the cervix. The cervix is the neck of the uterus.

Medications

Some drugs can affect the fertility of a woman. These include:

NSAIDs (non-steroidal anti-inflammatory drugs)

Women who take aspirin or ibuprofen long-term may find it harder to conceive.

Chemotherapy

Some medications used in chemotherapy can result in ovarian failure. In some cases, the side effects of chemotherapy may be permanent.

Radiotherapy

When radiation therapy is aimed near a woman’s reproductive organs, there is a higher risk of fertility problems occurring after the treatment.

Factors Related to Infertility Disorders in Men

• Sperm problems: The most common causes of male infertility are related to sperm problems such as low sperm count, slow sperm movement meaning that they die before they reach the egg, sperms that are not formed correctly, and seminal fluid that is too thick; sperm cannot move around in it very easily. Sperm-related problems may result from too much or too little of some of the hormones that guide sperm making.
• Ejaculation problems: In some cases, tubes inside the male reproductive organs are blocked.
• Idiopathic /unexplained infertility: In the case when there is no known reason for someone’s infertility, which can be a very frustrating diagnosis (Nordqvist, 2016).

The golden chance of a woman to have a baby is always reflected by a good prognosis of her condition, which depends on many factors, including her age or any underlying cause for infertility. The earlier the causes are detected the better chances of conceding. Since just a few couples are unable to conceive genuinely, having regular intercourse without any medical intervention remains the most preferred method of conceiving (Hull, 1995).

In the event of failure to conceive, supplements might be prescribed to the patient. For instance, Clomiphene citrate is a highly successful substance that acts by inducing ovulation in patients with an intact hypothalamic ovarian axis. It is important to note that the respond to clomiphene citrate in patients with PCOS is approximated at 73% of the time. The probability of pregnancy is 36%. Among these pregnancies, approximately 10% will be twins (Homburg, 2005).

Besides, studies have evidenced that using injectable gonadotropin in the treatment of infertility may have an overall success rate of between 20% and 22% per cycle in the properly selected patient. Almost 30% of these kinds of pregnancies are multiple gestations, and higher order pregnancies occur if monitoring is suboptimal. However in patients over 35 years of age, the pregnancy rates are markedly decreased (Dickey, 2009).

Another alternative supplement is the IVF, which is the most successful treatment for infertility, regardless of diagnosis. In the year 2011, around 450 fertility clinics in the US performed 151,923 fresh IVF cycles (using the woman’s own eggs), resulting in the births of around 61,000 infants. For women under 35 years of age, the live-birth rate/transfer accounted to almost 41% (with 33% of pregnancies ending in multiples). However the live-birth rate/transfer decreased by age, that is, 38.4% for women aged 35 to 37 years; 27.3% for women aged 38 to 40 years; 16.5% for women aged 41 to 42 years; and notably only 7.6% in women aged over 42 years as was reported in the 2011 research findings. There are international variations in success rates for assisted reproductive techniques as summarized in figure 1 below.

Literature Review

Introduction

There are many studies on infertility conducted in the Arab countries. However, there are no reviews conducted to summarize the findings of these studies. Therefore, the literature appraisal will perform systematic review of the past research studies on fertility in Arab countries to summarize the findings with respect to the problem of female infertility in the Arab countries. This section briefly discusses and reviews eight previous articles that addressed the problem of infertility among the females in the Arab counties.

Articles Review

El-Shalakani and Suchindran (1993) article, Estimation of Fecundity and Secondary Sterility from Survey Data on Birth Intervals in Egypt, aimed to estimate the fecundity and secondary sterility among males and females based on age, residence, and educational subgroups. The authors assumed that after a specific period from the last birth, a certain proportion of women become secondarily sterile. The researchers proposed and applied a special model to approve their assumption. They collected the data of 5667 women from the Egyptian Fertility Survey conducted in 1980 and conducted survey data analysis statically.

The findings revealed that fecundity decreases steadily for women over 25 years of age. Besides, the findings indicated that fecundity decreases in large urban areas and increases in rural and semi-urban areas. In addition, the findings suggested that most of the women cease reproduction at age 45 (El-Shalakani & Suchindran, 1993). Apparently, the substance in this research article is valuable for the scholars who are interested in establishing infertility in women in Arab countries since the location of the study was in Egypt. Moreover, the article addressed fecundity problem that affected a big number of Arab women in an attempt to find its causes.

The article, Ethical Considerations in Syria Regarding Reproduction Techniques, by Arbach (2002) discussed the Islamic substantial ethical considerations regarding the reproduction techniques in the Arab countries in general and particularly in Syria. The author focused on the ethical consideration of homogenic insemination, heterogenic insemination, surrogate motherhood, embryonic sex selection. The results of the study included the following:

1. Homologous insemination by sperm of the husband is allowed in Islam.
2. Heterologous insemination is absolutely prohibited in Islam.
3. Semen storage is allowed for a husband’s semen and not from any donor.

This article is very important in understanding the acceptable insemination as a fertility treatment in the Arabic world and Islamic religion in general. The article provides knowledge to Arab population who are living in non-Muslim countries all over the world. Therefore, if they want to be treated for reproduction and fertility, they will go to foreign clinics and hospitals. These medical centers usually offer variety of operations that are incompatible with Sharia and Islamic law such as the heterogenic insemination and surrogate motherhood. The article discussed ethical issues in details in order to help the Arab families not fall into the haram ways of treatment. Therefore, the article is essential for all the Arab families who want to be treated for reproduction and fertility in non-Muslim countries.

The study, The Prevalence of Abnormal Cervical Cytology in Women with Infertility, by AbdullGaffar et al. (2010) aimed to compare the frequency of abnormal cervical cytology in women with infertility problems with that of fertile women by using ThinPrep® liquid-based Pap Tests™. The authors conducted a retrospective case-control study for a period of over 2 years. The cases included 490 women with infertility problems who had Pap tests during their infertility treatment period (infertility group) and 7150 women without infertility problems who had regular Pap test checkups as part of their routine screening (control group). The cases of the infertility group were divided into primary and secondary infertility groups. The researchers analyzed the data they had collected from the cases statically.

They found the following results:

1. Women with secondary infertility had more epithelial abnormalities and more high-grade lesions than women with primary infertility.
2. Women with infertility had statistically significant higher frequency of squamous intraepithelial lesions than women without infertility problems of similar age and demographic background.

This article recommended that women with infertility might benefit from more frequent cervical cytology screening, preferably with HPV DNA tests for detecting high-risk HPV infections. We believe that this article is very important for all scholars who are interested in this field of study. It includes valuable information about the abnormal cervical cytology in women. We recommend all the researchers to continue their work and conducted new studies in this topic.

Al-Jaroudi (2010), wrote an article entitled Beliefs of Subfertile Saudi Women. The article aimed to assess the beliefs of infertile Saudi women and acquire information on alternative medicine usage by infertility patients. The study tool was a cross-sectional survey. The survey was distributed to a random sample that consisted of sample of 51 patients in the period from February 2008 to January 2009. These patients were receiving treatment in the Reproductive Endocrinology and Infertility Medicine Department of Women’s Specialized Hospital, which is part of King Fahad Medical City in Riyadh, Kingdom of Saudi Arabia.

The survey included questions pertaining to their beliefs and alternative therapies used to treat their infertility. After collecting the survey, the researcher entered its data to an Excel sheet and then analyzed it statically after checking its validity and reliability. The main results of this article were as follows: (i) 35.3% of the sample believed that their infertility was the result of the evil eye curse.(ii) 25.5% of believed that it was due to envy.

The researcher pointed out that 45.1% of the sample immediately read and said supplications when they found that they had infertility problem. In addition, the researcher indicated that 43.1% of the sample immediately visited a doctor for treatment when they found that they had infertility problem. Moreover, the researcher found that 9.8% of sample immediately read the Holy Qur’an when they found that they had infertility problem.

Furthermore, 72.5%of the sample ultimately turned to the Holy Qur’an as a remedy for their infertility problem. On the other hand, 68.6% of the sample used herbal medicine as a remedy for their infertility problem. We believe that this article is very valuable in the field of infertility treatment, because it focuses on the beliefs of the infertile women as an attempt to evaluate them for seeking a suitable treatment for those patients with infertility problems. We recommend conducting future articles in this regards, because we believe that there is no doubt that religions and beliefs play an important role in infertility treatment.

The article, Coping with Infertility among Kuwaiti Women: Cultural Perspectives, by Fido and Zahid (2004) aimed to examine the psychological distress among Kuwaiti women with infertility problems and explore the perceived causes of infertility. The study tool used by the researchers was an Arabic version of the Hospital Anxiety and Depression Scale (HADS). It was used to examine the psychological status of a random sample that consisted of (120) Kuwaiti infertile women as experimental group and an age-matched sample of (125) Kuwaiti healthy pregnant women as a control group.

The study results showed that the infertile women exhibited significant higher psychological problems such as tension, hostility, anxiety, depression, self-blame and suicidal ideation than the control group. In addition, the results indicated that the illiterate infertile women attributed the causes of their infertility to supernatural causes such as evil spirits, witchcraft and God’s retribution, whereas the educated infertile women attributed the causes of their infertility to nutritional, marital and psychosexual factors. Moreover, the results showed that the illiterate infertile women considered faith and traditional healers as the first choice of infertility treatment, whereas the educated infertile women considered an infertility clinic for treatment. Furthermore, the results pointed out that the infertile women were subjected to serious social and emotional risks.

We believe that this article is very valuable in the field of women infertility treatment, because it studies the psychological side of women with infertility as an attempt to find a suitable treatment for them. In addition, we recommend conducting further studies in field, because as we have mentioned before, there is a close relationship between the woman psychology and the success of her infertility treatment. We believe that women with good psychology can be treated from their infertility much faster than women who have psychological problems.

Mehanna et al. (1995) wrote an article entitled Chlamydial Serology among Patients with Tubal Factor Infertility and Ectopic Pregnancy in Alexandria, Egypt. Their article aimed to assess the association between past chlamydial infection, tubal factor infertility, and ectopic pregnancy in an Egyptian population. The researchers followed the experimental approach to achieve the objectives of this study. The study tools are interview and medical reports.

This study sample consisted of two concurrent case-control groups. The first group consisted of 51 women with tubal factor infertility who were compared with 48 healthy women who did not have tubal factor infertility and 53 healthy pregnant women. The second group consisted of 66 women with ectopic pregnancy who were compared with 51 healthy pregnant women. The results of this study indicated that the geometric mean titers of chlamydia trachomatis of women with tubal factor infertility and ectopic pregnancy were higher than titers of chlamydia trachomatis of healthy pregnant women. In addition, the results pointed out that the serum titer was significantly correlated with histologic evidence of salpingitis among the patients with an ectopic pregnancy.

We believe that this study is important for those who are interested in finding suitable treatments for women with infertility. Since its valuable findings can lead to potential treatments for infertility through doing more experiments on finding permanent cares for the chlamydial infection. Moreover, we recommend doing more research on this topic, because such researches will help all doctors all over the world who are looking for new effective methods on treating interested women with chlamydial infection, tubal factor infertility, and ectopic pregnancy.

Almobarak et al. (2013) wrote an article entitled Frequency and Patterns of Abnormal Pap Smears in Sudanese Women with Infertility: What are the Perspectives? The article aimed to assess the prevalence and patterns of epithelial cell abnormalities in cervical smears in Sudanese infertile and fertile women. The researchers used the experimental approach to achieve the study objectives. The study tool was the cervical smear of all women with infertility who consulted the Department of Obstetrics and Gynecology in the period from February 2010 to June 2011. The sample consisted of two groups.

The experimental group consisted of 200 women with infertility, and the control group consisted of 700 fertile women who had a cervical smear in the same period of study. The study results indicated that 6.5% of infertile women reported as positive for epithelial cell abnormalities, whereas 3.4% of fertile women reported as positive for epithelial cell abnormalities. In means that the percentage of abnormal pap smears in the infertile women is significantly higher when compared with the control group.

We consider this study as one of the best studies that are interested in finding suitable treatment for women with infertility since it addresses one of the main problems that face nearly 6.5% of infertile women all over the world. In addition, we recommend women to do Pap smear as a routine practice for early detection of any infertility problems. Moreover, we recommend conducting more studies to evaluate the incidence of epithelial cell abnormalities in infertile women.

Alfarraj et al. (2015) wrote an article entitled The Prevalence of Chlamydia Trachomatis Infection among Saudi Women Attending the Infertility Clinic in Central Saudi Arabia. Their article aimed to determine the prevalence of chlamydia trachomatis infection among Saudi women, its clinical presentation, and its association to infertility. The researchers followed the experimental approach to achieve the study objectives. The study tool was a data collection sheet designed by the researchers. This study was conducted in the period from October 2012to July 2013 at King Khalid University Hospital and King Abdulaziz University Hospital, Riyadh, Kingdom of Saudi Arabia.

The sample of this study consisted of two groups. The experimental group consisted of 100 infertile women, whereas the control group consisted of 100 women who were not infertile but attending the gynecology clinic at same hospitals. The results of this study indicated that 8.0% of infertile women were infected with the chlamydia trachomatis, whereas, only 1% of fertile women were infected with the chlamydia trachomatis.

It meant that the chlamydia trachomatis infection was significantly correlated to infertility. We believe that this article is very valuable for all scholars, doctors and scientists who are interested in treating women with infertility in effective treating methods. This research can lead the way towards more future studies that highlight the importance of providing medical devices that can examine and detect the chlamydia trachomatis infection among women in all countries, including Kingdom of Saudi Arabia, because almost all countries lack this kind of devices.

The summary of the above research articles in terms of results, year of publication, author, research tools, and location is presented in the table below:

Table 1: It summarize the study design used, location of study population, year of publication and main results.

Discussion

Introduction

From the review of past literature conducted in the field of female infertility over the last two decades within Arab countries, that is, Egypt, Sudan, Syria, among others, valuable findings were established as discussed below:

Finding 1: A Number of Women Suffer from Secondarily Infertility after a Specific Period from their Last Birth

After reviewing and analyzing the literature, we have found that there is number of women infected by the secondarily infertility after a specific period from their last birth due to variety of reasons that are not explained fully, yet. According to Grzechocińska et al. (1998), the most frequent reasons of secondary infertility were unexplained infertility 55.3% and tubal pathology 19.1%. However, concerned researchers all over the world write valuable articles bases on their personal experience on treating women with the secondary infertility to be as references for those doctors who are interested in finding suitable treatment for such cases.

For instance, El-Shalakani and Suchindran (1993) pointed out that there were many Egyptian women infected by the secondary infertility. They assumed that fecundity decreases steadily for women over the age of 25 years. In addition, they believed that fecundity decreases in large urban areas and increases in rural and semi-urban areas. In addition El-Shalakani and Suchindran (1993) stated that most of the women cease reproduction at the age 45 years. Rahman et al., (2016) designed a technique of laparoscopic vaginal reconstruction in a rare case of mid-vaginal septum with secondary infertility.

The goal of his technique is to treat women with transverse vaginal septum and restore the fertility these women. According to Izhar et al. (2016) among the reasons that can causes the secondarily infertility is the prolonged intrauterine retention of any fetal bones. Greta et al. (2016) spotted the light on the method of using the laparoscopic repair of the uterine scar defect. The authors believed that it was an effective method of treatment of secondary infertility.

Moreover, the authors recommended that all women with a previous history of caesarean section who were infected by the secondary infertility to perform a detailed evaluation of the uterine scar before planning future pregnancies. Accordingly, we confirm there is number of women infected by the secondarily infertility after a specific period from their last birth. The causes of the secondary infertility are not specified fully, at the moment. Therefore, we recommend conducting new international studies that aims to specify fully all the causes of the secondary infertility among women. If we do that, we can bring the smile back for great number of families all over the world.

Finding 2: Infertility Decreases Steadily for Women Over 25 Years of Age

After reviewing and analyzing the literature, it is apparent that the infertility decreases steadily for women over 25 years of age. El-Shalakani and Suchindran (1993) mentioned that fecundity decreases steadily for women over 25 years of age. Aziz et al., (2015) carried four thousand one hundred eight x-ray examinations of women uterus and fallopian tubes to diagnose and treat medical conditions.

The researchers found that 1999 (48.6%) were primary infertility cases while the 2109 (51.3%) were of secondary infertility. Mean age of presentation for primary infertility was 30 years and 35 years for secondary infertility. On the other hand, Silber et al., (1997) indicated that women age has no affect on fertilization, but it dramatically affect the embryo implantation, pregnancy and delivery rates. They clarified that wives aged 20-29 have a 46% live delivery rate per cycle, wives aged 30-36 years have a 34% live delivery rate per cycle, and wives aged 37-39 years have a 13% live delivery rate per cycle, whereas, wives >or = 40 years have only a 4% live delivery rate per cycle.

They pointed out that the number of eggs retrieved also has affect on pregnancy and delivery rate, but it is lesser than the affect of age. We believe that age is considered as an essential factor, which has a direct affect on the female infertility. Therefore, we recommend all females all over the world to get married early. Otherwise, their chance to have babies will reduce as they grow older.

Finding 3: Infertility Decreases in Urban Areas and Increases in Rural Areas

After reviewing and analyzing the literature, it is apparent that infertility decreases in urban areas and increases in rural areas. El-Shalakani and Suchindran (1993) pointed out that infertility of women decreases in large urban areas and increases in rural and semi-rural areas. They linked this result with the fact that urban residence was associated with more use of contraceptives. White et al., (2008) conducted an event-history analysis of fertility in Ghana. They confirmed that urban women exhibit fertility rates that are 11% lower than those of rural women. They assumed that urbanization reduces fertility of women because urban residence would likely increase the costs of raising children.

Since that the urban housing was more expensive, and children were probably less valuable in household production in urban areas. In addition, they believed that contraceptives played an important role in reducing the fertility of urban women. Chimere-Dan (1990) linked the reduction of urban women fertility with the marital stability for all educational and religious groups. Moreover, Chimere-Dan mentioned that the main determining factors of the fertility in urban and rural areas were breast feeding and postpartum sexual abstinence, which accounted for 80% of all reductions in marital fertility in urban and rural areas.

The researcher assumed that urban fertility may be increased due to shorter breast-feeding and abstinence durations among young educated women. Accordingly, we believe that the fertility of women in urban areas is higher than the fertility of women in rural areas due to variety of reasons. Among the main reasons that make the fertility of women in urban areas higher than the fertility of women in rural areas are the following: (i) Urban women use contraceptives higher than rural women. (ii) Urban women do not spend a lot of time doing hard works like the rural women. Moreover, we believe that the lifestyle of urban women plays an important role in reducing their fertility.

Finding 4: Women Cease Reproduction over Age 45

After reviewing and analyzing the literature, it is apparent that women cease reproduction over the age of 45 years. According to El-Shalakani and Suchindran (1993), at age 45, almost all of the women cease reproduction, and the incidence of secondary sterility perhaps includes menopause. Towner et al. (2016) indicated that menopause typically occurs between 45 and 55 years of age. Moreover, they pointed out that across history and cultures, women often cease reproduction many years before menopause. Cheung et al. (2011) indicated that the only effective treatment for women who cease reproduction due to ovarian aging is the oocyte donation.

They assumed that a woman with decreased ovarian reserve should be offered oocyte donation as a suggestion. They supposed that pregnancy rates associated with this treatment are significantly higher than those associated with controlled ovarian hyperstimulation or in vitro fertilization with a woman’s own eggs. However, we disagree with Cheung and his followers, because their treatment method is against Islam culture. Moreover, their proposal may cause problems inside the Islamic families who may reject a child born through this means as being an outsider. In addition, such families may deprive that child from inheritance.

Furthermore, even if the child does not face family related troubles, he or she may face many problems from the society. Therefore, it is better to avoid this kind of treatment. Because we believe that its disadvantages outweighs the existing advantages.

Finding 5: Homologous Insemination is Allowed in Islam, Whereas Heterologous Insemination is Absolutely Prohibited in Sunni Islam

After reviewing and analyzing the literature, we established that the homologous insemination is allowed in Islam, whereas heterologous insemination is absolutely prohibited, especially in the Sunni Islam culture. According to Arbach (2002), homologous insemination (by sperm of the husband) is allowed in Islam. Since it helps married couple to create their own family in halal way. In contrast, heterologous insemination (by sperm of someone other than the husband) is absolutely prohibited in Islam. Inhorn et al. (2010) pointed out that heterologous insemination treatments are banned in Egypt as in the rest of the Sunni Islamic world.

In addition, they indicated that Italy banned the heterologous insemination treatments in 2004. However, Inhorn et al. (2010) assumed that nowadays the heterologous insemination treatments are provided to both Shi’ite Muslims and Christians who live in Lebanon. Demoulin (1984) indicated that the Protestant religion alone does not object to artificial insemination by donor. However, it is absolutely proscribed in the other religions such as the Sunni Islam, Catholic Christianity and Judaism.

We believe that the assisted reproductive technology is one of the fastest growing fields in medicine. Scientists and doctors always do their best to develop new methods and techniques to treat women with infertility. These developed methods and techniques may also increase the chances of an infertile couple towards achieving a pregnancy. However, the developed methods and techniques must not neglect the patients’ law, religion, ethics, and local moralities.

Finding 6: Women with Infertility have more Epithelial Abnormalities and Lesions in the Cervix Uteri than Productive Women

After reviewing and analyzing the literature, we have noticed that women with infertility have more epithelial abnormalities and lesions in the cervix uteri than fertile women. In addition, women with primary infertility have less epithelial abnormalities and lesions in the cervix uteri than women with secondary infertility. AbdullGaffar et al. (2010) stated that women with primary infertility have less epithelial abnormalities and high-grade lesions in the cervix uteri than women with secondary infertility of similar age and demographic background.

Van et al. (2006) indicated that women with infertility eligible for In vitro fertilization (IVF) are diagnosed with a high-grade cervical lesion, which is almost twice as high compared to the fertile women. Almobarak et al. (2013) confirmed that the epithelial cell abnormalities are significantly higher in women with infertility as compared with fertile women. They pointed out that the inflammatory smears were reported two times more than in the fertile women.

Accordingly, we conclude there is no doubt that women with infertility have more epithelial abnormalities and lesions in the cervix uteri than fertile women. Therefore, we recommend all women with fertility problems to take a cervical smear test as routine practice ASAP. In addition, we recommend conducting further studies to evaluate the epithelial abnormalities and lesions in the cervix uteri of women with fertility problems, because great segment of women all over the world are suffering from the epithelial abnormalities and lesions in the cervix uteri.

Finding 7: Infertile Women Exhibit Higher Psychological Problems than Fertile Women

After reviewing and analyzing the literature, we noticed that too many women with infertility exhibited significant higher psychological problems such as tension, hostility, anxiety, depression, self-blame and suicidal ideation than fertile women as stated in the study of Fido and Zahid (2004). The researchers pointed out that the infertile women were subjected to serious social and emotional risks.

Alhassan et al. (2014), indicated that the prevalence of depression among the infertile women was high, especially among infertile women age 26 and above, those who were less educated, those with primary infertility, as well as those who had been diagnosed as infertile for more than 3 years. Ozkan and Baysal (2006) stated that depression, anxiety and strength of psychological symptoms were significantly higher in the infertile women.

However, they pointed out that depression was decreased as the rate of employment, economic status and education increased. They added that infertility, infertility treatment, and marriage duration were positively correlated with depression and the strength of psychological symptoms. Accordingly, we conclude there is no doubt that infertile women exhibit higher psychological problems than fertile women.

Therefore, we recommend conducting further studies in this field, because as we have mentioned before, there is a close relationship between the woman psychology and the success of her infertility treatment. In addition, we believe that infertile women with good psychology can be treated from their infertility much faster than infertile women who have psychological problems. We recommend also that the infertile women who have psychological problems be treated by a psychiatrist in order to decrease and prevent the development of their psychological problems.

Finding 8: Chlamydia Trachomatis Infection is Significantly Correlated to Women Infertility

After reviewing and analyzing the literature, we noticed that the chlamydia trachomatis infection is significantly correlated to women infertility as stated in the study of Mehanna et al. (1995). Mehanna and his co-researchers indicated in their study that the titers of chlamydia trachomatis of women with tubal factor infertility were higher than titers of chlamydia trachomatis of fertile women. Malik et al. (2006) indicated that the chlamydia trachomatis was detected in 28.1% of the infertile women, whereas it was detected in 3.3% in of the fertile women.

Alfarraj et al. (2015) stated that 8.0% of the infertile women were infected with the chlamydia trachomatis, whereas, only 1% of fertile women were infected with the chlamydia trachomatis. Accordingly, we conclude there is no doubt that the chlamydia trachomatis infection is significantly correlated to women infertility. Moreover, we recommend all scholars who are interested in this field to conduct future studies in this regard. In addition, we hope that the Kingdom of Saudi Arabia provide medical devices to all medical centers and clinics, because almost all the medical centers in the Kingdom of Saudi Arabia lack this kind of devices.

Conclusion

In conclusion, we recommend and encourage all the Arab women with infertility problems to start a stress reduction program into their daily lives. For instance, these women may read The Holy Qur’an for two hours daily to help them in reducing anxiety. We recommend doctors to respect beliefs and choices of their patients and to guide them on the right way towards their infertility treatment journey. We recommend all the Arab countries to follow and track the newest and effective treatment methods, and to participate with the other foreign countries in finding suitable and permanent remedy for all the cases of infertility in women.

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