http://www.newscientist.com/article.ns?id=dn7752

Female genital mutilation can cause infertility
29 July 2005
NewScientist.com news service
Gaia Vince

Children undergoing female genital mutilation risk infertility years
later due to recurrent infections, a study in Sudan has found. The
researchers hope their evidence will add valuable weight to those campaigning for a
ban on the practice which affects millions of women and girls in Africa.

More than 132 million women and girls in Africa have undergone
circumcision, the World Health Organization estimates – about two million per year –
but until now, few scientific studies have examined the health effects of
the procedure, which is often advocated locally on with the claim that it
improves fertility.

Girls as young as 6 years old often suffer persistent recurring
infections as a result of the traumatic procedure. This can leave many women
infertile due to damage to the fallopian tubes, the joint team of scientists from
Sweden and Sudan found.

Paediatrician Lars Almroth, from the Karolinska Institute in Stockholm,
and colleagues studied 99 infertile women and 180 women who were pregnant
for the first time, at two hospitals in Khartoum in Sudan. Women in the
infertile group were included if their condition was not caused by
hormonal factors, previous abdominal surgery or the result of their partner’s
infertility.

All the women in the study had undergone female genital mutilation
(FGM) as girls, and they were examined to discover the extent of the mutilation.
This ranged from partial clitoridectomy to full excision of the clitoris,
inner labia and external genitalia with the two cut sides then stitched
together to close the vaginal opening to varying degrees.

The researchers found that the infertile women were significantly more
likely to have undergone the most extensive form of FGM, involving the
removal of the outer labia. The risk of infertility was related to the
extent of anatomical mutilation and not simply the extent to which the
vulva had been sutured or closed.

Immediate complications
“Children are bedridden for at least a week following mutilation and
suffer immediate complications and infections of the reproductive system, and
repeated urinary tract infections that often lead to kidney failure.
But very, very few make it to hospital. As a result, the untreated
infections of childhood ascend to the uterus and fallopian tubes causing scarring,
inflammation and infertility,” says Almroth.

Infection is rife not only a result of the unsanitary conditions in
which the surgery is performed, but also because the young age of the
children lays them particularly open to infection. “A pre-pubescent girl’s
vaginal [tract] is a low protective-oestrogenic environment, and the lack of
vaginal acidity in these young girls allows the bacteria to thrive,” Almroth
adds.

But it is not just blocked fallopian tubes that causes problems, he
told New Scientist. The removal of genital tissue involves removing necessary
glands. “Changes in the microfauna that result, means the vaginal environment
may become unfavourable to sperm, and also less able to guard against
constant infection leading to further inflammation – all of which reduces
fertility.”

Social disaster
Almroth and his team hope their results can be used effectively by
Non-Government Organisations to persuade influential leaders in Africa
to speak out against FGM. “The message until now has been: It’s dangerous
and causes complications. But villagers know that life is generally
dangerous and complicated so, at most, they will try to medicalise the procedure
and have it carried out by a doctor.

“But to say: ‘It could make you infertile,’ is a big thing. Fertility
is so highly valued in Sudan that infertility is social disaster for a woman
and for her family. This information could be a big tool.”

In a commentary accompanying the research in The Lancet, Layla Shaaban
and Sarah Harbison, from the Bureau for Global Health in Washington, DC,
US, write: “The importance of future fertility is deeply embedded in
traditional social fabric. Legitimate concern about impairment of fertility can
certainly weigh in heavily and help achieve the attainable goal of
ending female genital mutilation.”

And Almroth hopes that greater awareness will encourage paediatricians
in the West to look for signs of hidden morbidity in children of African
descent who have had FGM, so that their infections can be recognised
and treated early on.

Journal reference: The Lancet (vol 366, p 385)

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