Infertility, as defined by the World Health Organization’s International Classification of Diseases, is the failure to achieve pregnancy after one year of regular, unprotected sexual intercourse among couples in a stable union. While this one-year benchmark is widely used, other definitions extend the duration to two to five years or broaden the scope altogether—capturing individuals who seek care regardless of marital status or time attempting conception.
Scholars have also approached infertility through different lenses: whether it is self-reported or clinically diagnosed; how long it takes to achieve pregnancy; and whether social circumstances—such as being single or in a same-sex relationship—should qualify individuals for infertility services. These variations underscore a central point: infertility is not merely a biological condition, but also a social and clinical construct shaped by context.
Clinically, infertility is categorized as primary (the inability to conceive at all) or secondary (the inability to conceive after a previous pregnancy). It may also be described as lifetime or periodic, and further classified by sex as male or female infertility.
Globally, infertility is far from rare. An estimated one in six people experience it at some point in their lives. Regional disparities are stark. Lifetime prevalence reaches as high as 23.2 percent in the Western Pacific and 13.1 percent in Africa. Periodic infertility—measured over shorter time frames—is also significant, particularly in Africa.
Male infertility accounts for a substantial share of cases. Roughly one in four men are affected, and male-related factors contribute to about half of all infertility cases among couples. Causes of male infertility range from hormonal imbalances to structural and genetic conditions. Female infertility, meanwhile, is associated with ovulatory disorders, endocrine dysfunction, infections, uterine abnormalities, and genetic factors.
In sub-Saharan Africa, primary and secondary infertility occur at nearly equal rates. Yet prevalence varies widely across countries, reflecting differences in health systems, social conditions, and data quality. Estimates suggest rates as high as 30 percent in Nigeria, 21.2 percent in northwest Ethiopia, and 9 percent in Gambia.
Ethiopia presents a similarly complex picture. Analysis of the 2016 Ethiopian Demographic and Health Survey indicates that as many as one in four Ethiopians may experience infertility, with the highest reported prevalence in the Afar region. More recent studies in Addis Ababa suggest that roughly 27.6 percent of individuals are affected.
The consequences extend well beyond the clinical. Infertility can strain marriages and relationships, often leading to psychological distress marked by anxiety, depression, social withdrawal, and, in severe cases, suicidal behavior. In many settings, it fuels stigma and blame—frequently directed at women—while contributing to marital instability and divorce. The financial burden is also significant, as couples pursue often costly and prolonged treatments.
Addressing infertility is therefore integral to broader health and development goals. Sustainable Development Goal 3 calls for ensuring healthy lives and promoting well-being, including access to reproductive health services and the ability to make informed decisions about family planning.
In Ethiopia, the Ministry of Health has taken steps to expand access to infertility diagnosis and treatment. Yet despite its prevalence and profound social impact, the national and subnational burden of infertility—particularly among women—has not been comprehensively documented over time.
This article draws on data from the Global Burden of Disease Study 2021, produced by the Institute for Health Metrics and Evaluation at the University of Washington in collaboration with Ethiopian health authorities. It seeks to shed light on the distribution and long-term trends of female infertility in Ethiopia from 1990 to 2021—an area that has remained underexamined for far too long.
Prevalence of Female Infertility
In Ethiopia, the age-standardized prevalence of female infertility among women ages 15 to 49 rose markedly between 1990 and 2021. Estimated cases increased from approximately 625,100 (95% uncertainty interval [UI]: 111,805 to 318,796) in 1990 to 992,154 (95% UI: 180,469 to 476,708) in 2021—an increase of roughly 367,000 cases over three decades.
Regional variation is pronounced. Oromia consistently recorded the highest burden, with an estimated 199,126 cases (95% UI: 101,218 to 358,468) in 1990, rising to 351,411 (95% UI: 169,027 to 624,058) in 2021. At the other end of the spectrum, Harari reported the lowest prevalence in 2021, with an estimated 1,298 cases (95% UI: 2,705 to 4,963), though the uncertainty bounds suggest potential underestimation.
In Addis Ababa, the trend is less linear but still indicative of a substantial burden. Estimates suggest a shift from approximately 32,038 cases (95% UI: 16,399 to 56,772) in 1990 to 49,551 (95% UI: 23,521 to 92,260) in 2021.
Overall, the age-standardized prevalence of female infertility increased by approximately 58 percent between 1990 and 2021, despite a modest decline during the 1990–2000 period. This trajectory broadly aligns with findings from the 2016 Ethiopian Demographic and Health Survey, which estimated national infertility prevalence at 24.2 percent—suggesting that roughly one in four individuals is affected. It is also consistent with global estimates indicating that one in six people experience infertility during their lifetime.
The higher prevalence observed in this analysis, compared with survey-based estimates, likely reflects methodological differences. This study draws on Global Burden of Disease data, which integrates multiple data sources over time, rather than relying solely on cross-sectional surveys. It also focuses exclusively on female infertility and reports absolute case numbers rather than percentages, capturing cumulative and longitudinal trends rather than a single point-in-time snapshot.
Regional disparities observed in this analysis differ somewhat from earlier findings. While prior studies based on survey data identified Afar as having the highest prevalence and Addis Ababa among the lowest, this study finds Oromia and Harari at the respective extremes. Population size may partly explain these differences, though variations in measurement approaches and data sources are also likely contributors.
Trends of Female Infertility
The trajectory of female infertility in Ethiopia over the past three decades reveals a brief period of decline followed by sustained growth. After a slight reduction between 1990 and 2000, prevalence increased sharply, resulting in an overall rise of more than one-third—approximately 37 percent—by 2021.
By 2021, the leading drivers of female infertility in the country reflected a complex interplay of infectious and noncommunicable conditions. The top contributors included noncommunicable diseases; communicable, maternal, neonatal, and nutritional disorders; HIV/AIDS and other sexually transmitted infections; polycystic ovarian syndrome (PCOS); chlamydial infections; and endometriosis.
Clinically, infertility is categorized into two types: primary and secondary. Both have increased substantially in Ethiopia over the past three decades, though their trajectories and underlying causes reveal important distinctions.
Primary infertility—defined as the inability to conceive at all—rose from an estimated 140,554 cases (95% uncertainty interval [UI]: 55,089 to 302,209) in 1990 to 201,723 (95% UI: 78,933 to 438,909) in 2021. Its causes are diverse, spanning communicable maternal and nutritional conditions, gynecological disorders, and a range of noncommunicable diseases. Specific contributors include sexually transmitted infections (excluding HIV), HIV/AIDS, Turner syndrome, chlamydial and gonococcal infections, congenital urogenital abnormalities, and endometriosis. Notably, all major categories of causes associated with primary infertility have shown an upward trend over time.
Secondary infertility—defined as the inability to conceive following a previous pregnancy—accounts for a larger share of the burden. Among women ages 15 to 49, estimated cases increased from 651,349 (95% UI: 370,532 to 1,136,098) in 1990 to 1,076,286 (95% UI: 617,883 to 1,809,989) in 2021. The causes of secondary infertility largely overlap with those of primary infertility but are more strongly associated with acquired conditions. These include noncommunicable diseases, maternal sepsis and other maternal complications, polycystic ovarian syndrome, chlamydial infections, and sexually transmitted infections excluding HIV.
The prominence of PCOS is particularly notable. Global estimates indicate that infertility associated with PCOS has more than doubled, rising from approximately 6 million cases in 1990 to 12.3 million in 2019. Ethiopia’s trajectory appears to mirror this broader pattern.
Health Losses
Female infertility in Ethiopia carries a measurable and often underappreciated burden of disease, captured through two key indicators: disability-adjusted life years (DALYs) and years lived with disability (YLDs). Together, these metrics reflect both the duration and severity of health loss associated with the condition.
Infertility imposes both immediate and long-term consequences. These impacts translate into significant health losses over time.
In 2021, the age-standardized DALYs attributable to female infertility among women ages 15 to 49 in Ethiopia were estimated at 5,082 (95% uncertainty interval [UI]: 1,703 to 12,481). This figure is lower than estimates reported in several other African countries, including Djibouti (8,540), Eritrea (7,366), the Central African Republic (9,177), and Comoros (7,255). These differences may reflect variations in data years, methodologies, or underlying health system conditions. They may also indicate relative differences in the burden itself, though such comparisons should be interpreted cautiously.
At the subnational level, disparities are again evident. Oromia recorded the highest burden, with 1,922 DALYs (95% UI: 635 to 4,616), while Harari reported the lowest, at just 15 DALYs (95% UI: 5 to 35). Addis Ababa accounted for an estimated 268 DALYs (95% UI: 87 to 666).
Years lived with disability present a different picture. In 2021, age-standardized YLDs due to female infertility reached 5,419 (95% UI: 1,812 to 12,945), marking an increase of nearly 2,000 cases from 1990, when YLDs stood at 3,433 (95% UI: 1,157 to 8,500). This upward trend suggests that while infertility may not be a leading cause of premature mortality, it contributes substantially to prolonged disability and reduced quality of life.
Compared with other African countries such as Cameroon, Guinea, and Senegal—where YLD estimates are significantly lower—Ethiopia’s higher burden may be driven by several factors. Population size is one: Ethiopia is the second most populous country in Africa, which amplifies absolute case numbers. Another likely factor is differential access to diagnosis and treatment. Limited availability of specialized infertility services may prolong untreated conditions, increasing years lived with disability.
Comparisons with higher-income settings further underscore these disparities. While studies from countries such as China report a substantial burden of infertility-related disability, the overall impact appears lower than in Ethiopia—likely reflecting more advanced treatment options and broader access to reproductive health services.
The findings underscore a clear and concerning trend: female infertility has risen steadily in Ethiopia over the past three decades. Both primary and secondary infertility have increased, driven by a mix of infectious diseases, noncommunicable conditions, and reproductive health complications.
Primary infertility is associated with a wide range of factors, including gynecological disorders, congenital anomalies, sexually transmitted infections, Turner syndrome, chlamydial and gonococcal infections, and endometriosis, as well as broader noncommunicable diseases. Secondary infertility, while overlapping in some respects, is more strongly linked to acquired conditions such as polycystic ovarian syndrome, maternal infections including sepsis, and other reproductive health complications.
The burden is unevenly distributed. Oromia accounts for the highest prevalence of age-standardized female infertility, while Harari reports the lowest. At the same time, the growing number of years lived with disability and disability-adjusted life years attributable to infertility highlights its profound, long-term impact—not only on physical health, but also on social and psychological well-being.
Recent efforts to expand infertility care—including the introduction of assisted reproductive technologies such as in vitro fertilization, advances in diagnostic techniques, and the emergence of specialized fertility centers—represent important progress. But these interventions remain limited in reach and accessibility.
A more comprehensive response is needed. Public health efforts must move beyond treatment alone to include prevention, early detection, and education. Expanding community awareness about the causes of infertility—and, critically, its potential reversibility—could encourage earlier care-seeking and improve outcomes. At the same time, addressing the underlying drivers of both primary and secondary infertility requires strengthening reproductive health services more broadly, including infection prevention, maternal care, and management of chronic diseases.
Policy responses should be grounded in robust, up-to-date evidence, with greater investment in national and subnational research. Equally important is the integration of psychosocial support into infertility care, recognizing the emotional and social toll borne by affected individuals and couples.
Evidence suggests that outcomes improve significantly when individuals seek care early, particularly at younger ages. Ensuring timely access to affordable and effective services, therefore, is not only a clinical priority but a public health imperative.
Bedilu Abebe is a public health lecturer, specialist, researcher, and PhD candidate at Jimma University.
Contributed by Bedilu Abebe
