title: Primary infertility after genital mutilation in girlhood in Sudan: a case-control study.
abstract: BACKGROUND
  In theory, infections that arise after female genital mutilation (FGM) in childhood might ascend to the internal genitalia, causing inflammation and scarring and subsequent tubal-factor infertility. Our aim was to investigate this possible association between FGM and primary infertility.
  
  
  METHODS
  We did a hospital-based case-control study in Khartoum, Sudan, to which we enrolled women (n=99) with primary infertility not caused by hormonal or iatrogenic factors (previous abdominal surgery), or the result of male-factor infertility. These women underwent diagnostic laparoscopy. Our controls were primigravidae women (n=180) recruited from antenatal care. We used exact conditional logistic regression, stratifying for age and controlling for socioeconomic status, level of education, gonorrhoea, and chlamydia, to compare these groups with respect to FGM.
  
  
  RESULTS
  Of the 99 infertile women examined, 48 had adnexal pathology indicative of previous inflammation. After controlling for covariates, these women had a significantly higher risk than controls of having undergone the most extensive form of FGM, involving the labia majora (odds ratio 4.69, 95% CI 1.49-19.7). Among women with primary infertility, both those with tubal pathology and those with normal laparoscopy findings were at a higher risk than controls of extensive FGM, both with borderline significance (p=0.054 and p=0.055, respectively). The anatomical extent of FGM, rather than whether or not the vulva had been sutured or closed, was associated with primary infertility.
  
  
  CONCLUSIONS
  Our findings indicate a positive association between the anatomical extent of FGM and primary infertility. Laparoscopic postinflammatory adnexal changes are not the only explanation for this association, since cases without such pathology were also affected. The association between FGM and primary infertility is highly relevant for preventive work against this ancient practice.
authors.affiliation: Division of International Health, Karolinska Institutet, Stockholm SE-17176, Sweden. L.Almroth@telia.com
authors.forename: Lars
authors.initials: L
authors.lastname: Almroth
authors.forename: Susan
authors.initials: S
authors.lastname: Elmusharaf
authors.forename: Nagla
authors.initials: N
authors.lastname: El Hadi
authors.forename: Abdelrahim
authors.initials: A
authors.lastname: Obeid
authors.forename: Mohamed A A
authors.initials: MA
authors.lastname: El Sheikh
authors.forename: Saad M
authors.initials: SM
authors.lastname: Elfadil
authors.forename: Staffan
authors.initials: S
authors.lastname: Bergström
mesh_terms: D000328:Adult; D016022:Case-Control Studies; D019093:Circumcision, Female / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D007247:Infertility, Female / Q000209:etiology*; D013397:Sudan