Female Genital Mutilation as a cause of infertility

Female Genital Mutilation (FGM), also known as female circumcision, is the surgical removal or remodelling of the external female genitalia. It is practiced worldwide but is particularly prevalent in Northern Africa, parts of Arabia and South East Asia. Immigration into many other countries means it also takes place in the United States, the United Kingdom, France and the rest of Europe despite the procedure being illegal in those countries. It is thought that up to six thousand girls, some as young as three and up to the start of puberty, are put through this ritual mutilation every day. The World Health Organisation has called it a breach of the girls' human rights and a form of torture and states there is no valid medical reason for it to continue.

There are three forms of FGM commonly carried out. The first is the least severe this is the removal of the clitoral hood. The next is the removal of the clitoris and parts of the labia minora the remains of which are then sutured together to leave an opening. Finally there is the so called pharoanic procedure in which the removal of the clitoris, labia minora and part of the medial labia majora which is then sutured to leave a small opening.

While these procedures are now associated with the Muslim religion it can be seen from the name given to the most radical procedure that they pre-date Islam and evidence has been found of genital mutilation in Egyptian mummies from 200BCE. In fact the Koran speaks out against mutilation of any sort. The only procedure that could possibly meet the criteria of permissible, according to the Koran, is the first detailed above which is analogous to male circumcision, even then it is not considered essential to the religion.

In countries where this type of mutilation is an accepted part of life such as the Sudan a man will not marry a girl who has not been circumcised and uncircumcised females are often treated as harlots by other females. It is thought of as a way to ensure the girl is a virgin until her marriage as the first sexual penetration is extremely painful for a circumcised female.

The procedure itself is very painful and is frequently carried out in unsanitary conditions by a non-medical qualified person, often a female relative of the child, without the benefit of anaesthetics. Post operative infections are common and it is not unknown for the girl to lose her life from tetanus or other forms of septicaemia.

So how do these circumcised females become infertile? After recovery from the operation infections frequently recur and these can cause damage to the fallopian tubes. Damaged fallopian tubes may prevent the ova reaching the uterus leading to an increased risk of ectopic pregnancy. If the tubes become blocked by the damage the ova will not be fertilised and the girl is infertile unless aided by costly medical intervention.  A recent study in the Sudan has also shown another possible cause of infertility in circumcised women. When tissue is removed, in the radical procedure, some of the cells responsible for producing the natural fluids in the vagina, post-puberty, are also removed. These fluids help regulate the pH of the vagina and so maintain a healthy micro flora of beneficial bacteria. Without proper regulation of these fluids the vagina can become an environment which is toxic to sperm thus preventing the sperm reaching and fertilising the ova.

In the areas where FGM is common there is a huge stigma about being infertile. The argument that it induces infertility is a weapon that can be used to stop FGM continuing. While it was thought to be the post operative infections which were causing the problem the use of sterile conditions and medically qualified was put forward by proponents of allowing these procedures to continue. If however it is the procedure itself that can cause infertility then the possibility of a ban is much higher.

Finally there is the mans' point of view. It has been argued by many that the smaller vaginal opening left by the mutilation increased the husbands' enjoyment. Interviews with young men in the Sudan have shown that this is not always the case. Many of them find sex with a circumcised woman painful sometimes even leading to injury and occasionally impotence. Often they would prefer to wed an uncircumcised woman but family and social pressures maintain the practice.

Fighting a tradition, even a cruel one that has continued for thousands of years, is hard. A hundred years ago girls in China had their feet cruelly bound and disfigured to ensure a suitable marriage now they don't. With the argument of increased female infertility it may be possible for this barbaric mutilation to be ceased.

Reference - Primary infertility after genital mutilation in girlhood in Sudan: a case-control study.  The Lancet, Volume 366, Issue 9483, Pages 385 - 391 L. Almroth, S. Elmusharaf, N. El Hadi , A . Obeid, M. El Sheikh, S. Elfadil, S. Bergstrom