Infertile women in Khartoum, Sudan, are significantly more likely than fertile women to have undergone the most extensive form of genital cutting.1 According to a clinical case-control study conducted in 2003-2004, the odds of primary infertility were significantly higher for women who had undergone cutting in which all or most of the external genitalia had been removed (odds ratio, 4.7), whether or not the cut sides of the vulva had been stitched together (a practice called infibulation).
Study participants included 99 women seeking medical treatment for primary infertility and a control group of 180 women who were expecting their first child and had become pregnant within two years of having unprotected sexual intercourse on a regular basis. To be included in the study, infertile women had to be aged 35 or younger, to have had intercourse regularly for the last two years and to lack known risk factors for infertility. To avoid bias due to age differences between infertile women and controls, 89 of the 180 fertile participants were selected to match, within one year, the age of infertile participants; all others were recruited consecutively from outpatient clinics.
All participants provided, via an interview-administered questionnaire, social and demographic data and information on the age at which genital cutting was performed, if applicable, as well as on any subsequent health outcomes. A gynecologist performed a genital examination on each participant to determine the extent of genital cutting, and blood samples were taken to detect the presence of STIs that could cause primary infertility. The gynecologist also examined the internal reproductive organs of women with primary infertility for tubal blockage, an indicator of previous inflammation. The majority of participants (80%) had experienced extensive genital cutting; only seven (3%) had not undergone any cutting. Slightly fewer than half of infertile participants (48%) had tubal blockage.
Both univariate and multivariate regression analyses revealed a strong correlation between extensive genital cutting and infertility. In the univariate model, the odds of having undergone extensive cutting were 3.6 times as high among infertile women as among controls; the odds were 4.7 times as high in the multivariate analysis. Further analyses showed that, whether or not women had tubal blockage, it was only the extent of cutting—not infibulation—that was associated with infertility.
Analysis of participants'social and demographic characteristics indicated that infertile participants who had tubal blockage were generally older, more socioeconomically disadvantaged and less educated than infertile women with no tubal blockage or women in the control group. However, these differences were not statistically significant in the multivariate analysis. Furthermore, the multivariate analysis controlled for the influence of STIs on the results.
In the univariate analysis, the odds of having undergone extensive cutting were higher among infertile women with and without tubal blockage than among fertile women (odds ratios of 5.7 and 3.4, respectively); in the multivariate model, these associations were only marginally significant (6.9 and 3.7).
This last finding, the researchers point out, indicates that tubal blockage is not the only factor contributing to infertility in this sample. Therefore, they hypothesize, female genital cutting may promote reproductive tract infections that, while leading to infertility, may or may not lead to tubal pathology.
The researchers suggest that, given the premium set on fertility in Sudan, the main finding of this study—that female genital cutting is a likely cause of primary infertility—could help eradicate the practice by challenging widespread beliefs that genital cutting prepares a girl to become a wife and even increases fertility. In counterpoint to such beliefs, the researchers posit that "any alteration of the normal anatomy of the girl's vulva could lead to structural and physiological changes, which in turn have negative effects on her reproductive health."—H. Ball
1. Almroth L et al., Primary infertility after genital mutilation in girlhood in Sudan: a case-control study, Lancet, 2005, 366(9483):385-391.