Three Experts Explain Why We Need to be Concerned about Obstetric Fistula

WORDS ASSOCIATE PROFESSOR DR KHINE PWINT PHYU, ASSOCIATE PROFESSOR DR GANESH RAMACHANDRAN & ASSOCIATE PROFESSOR DR ANITHA PONNUPILLAI

The International Day to End Obstetric Fistula, observed annually on 23 May, serves as a reminder of the silent suffering endured by women around the world.

FEATURED EXPERT
ASSOCIATE PROFESSOR DR KHINE PWINT PHYU
School of Medicine
Faculty of Health and Medical Sciences
Taylor’s University
OBSTETRIC FISTULA EXPLAINED IN 5 KEY POINTS

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  1. Obstetric fistula is an excruciating childbirth injury resulting in an abnormal connection between a woman’s birth canal and bladder or rectum.
  2. The cause of obstetric fistulas lies in traumatic childbirth experiences. Prolonged and difficult labours subject women to prolonged pressure on the birth canal, resulting in inflammation, tissue damage, and death of cells.
  3. This can lead to the formation of fistulas, creating distressing symptoms such as urinary or faecal leakage, foul-smelling vaginal discharge, chronic vaginal infections, or painful sexual intercourse.
  4. Globally, 65% of obstetric fistula cases occur in girls under the age of 18, affecting impoverished and vulnerable girls and women.
  5. Despite its profound impact, obstetric fistula remains largely hidden in the shadows of societal taboos and healthcare disparities. However, empirically, because of the access most women in Malaysia have to good healthcare facilities, obstetric fistulas are exceedingly uncommon in our country.
FEATURED EXPERT
ASSOCIATE PROFESSOR DR GANESH RAMACHANDRAN
School of Medicine
Faculty of Health and Medical Sciences
Taylor’s University
3 FACTORS THAT INCREASE THE RISK OF OBSTETRIC FISTULA

Limited Access to Skilled Healthcare

Inadequate access to skilled birth attendants and emergency obstetric care can lead to prolonged labour without proper medical intervention. This is the leading cause of severe birth trauma and fistula formation.

Poor Socioeconomic Conditions

Due to poverty and lack of education, young women in underprivileged environments can be subjected to childhood marriages, teenage pregnancies, and associated complications that include fistula formation.

Social Stigma and Cultural Barriers

Some cultural beliefs and societal stigma surrounding childbirth-related injuries impede timely medical interventions. Misconceptions and shame prevent women from seeking the necessary healthcare, thus exacerbating the severity of obstetric fistulas.

FEATURED EXPERT
ASSOCIATE PROFESSOR DR ANITHA PONNUPILLAI
School of Medicine
Faculty of Health and Medical Sciences
Taylor’s University
INITIATIVES THAT MUST BE TAKEN TO REDUCE THE INCIDENCE OF OBSTETRIC FISTULAS

Promote Access to Quality Maternal Healthcare
  • Strengthen maternal healthcare services, especially in remote areas, is crucial.
  • Ensure healthcare for all, with emphasis on accessible care during pregnancy, labour, and after childbirth.
Health Education Initiatives
  • Public awareness campaigns and access to education are instrumental in dispelling myths and fostering early recognition of birth injuries.
  • Empower women with knowledge about childbirth complications.
  • Encourage proactive seeking of medical assistance and reduces the stigma surrounding fistulas.
Enhance Healthcare Infrastructure
  • Invest in healthcare infrastructure, including skilled birth attendants, surgical facilities, and postoperative rehabilitation services, play a crucial role.
  • Provide adequate resources and training for healthcare professionals to assist in ensuring timely diagnosis, treatment, and rehabilitation of obstetric fistula patients.
Conduct Population Studies and Research
  • Conduct comprehensive population studies on the prevalence and incidence of obstetric fistula to establish accurate regional data.
  • Use the data from these studies to dentify causative factors to shed light on the root causes and also to curtail and eliminate the factors responsible for obstetric fistulas.
WHAT ARE WE DOING IN MALAYSIA TO ADDRESS THE PROBLEM?

In Malaysia, extensive measures are taken to ensure that both urban and rural areas receive adequate care during pregnancy, labour, and childbirth.

Intensive training programs for midwives are conducted to ensure the delivery of babies with safe techniques and the timely diagnosis of serious postpartum complications, including obstetric fistulas.

Furthermore, urogynaecology departments have been established in both private and public sectors, staffed with trained urogynaecologists to effectively treat obstetric fistulas efficiently if at all they occur and provide comprehensive rehabilitation services.

You Aren’t Alone When It Comes to Infertility, Experts Say, So Here’s What You Can Do About It

WORDS DR KHINE PWINT PHYU & ASSOCIATE PROFESSOR DR GANESH RAMACHANDRAN

FEATURED EXPERTS

DR KHINE PWINT PHYU
Senior Lecturer in Obstetrics and Gynaecology
School of Medicine
Faculty of Health and Medical Sciences
Taylor’s University
ASSOCIATE PROFESSOR DR GANESH RAMACHANDRAN
Head of School
School of Medicine
Faculty of Health and Medical Sciences
Taylor’s University
THE INCIDENCE OF INFERTILITY IS ON AN UPWARD TREND WORLDWIDE
  • Infertility is defined as not being able to conceive after 1 year of unprotected sexual intercourse.
  • In women above 35, this duration is sometimes shortened to 6 months.
  • The World Health Organization estimates that 1 in 6 people are affected by infertility.
  • In Malaysia, there is a drop in fertility rates from 4.9 children per woman of childbearing age in 1970 to 1.7 in 2021.
CAUSES ARE VARIED, INVOLVING ISSUES IN EITHER PARTNER OR BOTH AND IN SOME CASES, THE CAUSES ARE DIFFICULT TO IDENTIFY

Female factors of infertility

  • Anovulation, or ovulation disorders, are situations where no eggs are released from the ovaries during the menstrual cycle. These disorders can be caused by:
    • Hormonal imbalances such as seen in polycystic ovary syndrome (PCOS) and excessive prolactin secretion.
    • Eating disorders.
    • Extremes of body weight.
    • Strenuous exercises.
    • Stress.
    • Chronic illnesses.
  • Blockage of fallopian tubes, caused by previous pelvic infections, inflammation of tubes, and pelvic adhesions which may be related to past surgery at the abdomen and pelvis. When the tubes are blocked, it will affect the transport of sperm to meet the eggs to achieve successful implantation and pregnancy.
  • Endometriosis, which is the presence of tissue that is normally found in the inner lining of the uterus, outside the uterine cavity, which may affect the function of the ovaries, uterus, and fallopian tubes.
  • Congenital abnormalities (malformations that develop before birth) of the uterus.
  • Uterine fibroids (non-cancerous growths which develop in and around the womb).

Male factors of infertility

  • Low sperm count, which can be seen in men with genetic defects, chronic health problems such as diabetes, liver or kidney diseases, or sexually transmitted infections like gonorrhoea. Abnormalities such as undescended testis and varicoceles (swollen veins within the scrotum) can also be causes.
  • Premature ejaculation.
  • Blockage or injury to the reproductive organs.
  • Usage of certain medications can affect sperm movement, quality, or lead to coital dysfunction.
  • Environmental and lifestyle factors such as use of tobacco, heavy alcohol, marijuana or steroids, exposure to toxins and exposure of the external genitalia to high temperatures.
BOTH PARTNERS NEED TO BE INVOLVED WHEN IT COMES TO FERTILITY TREATMENT

To support health education and increase awareness regarding numerous infertility issues faced by couples across the globe, World Infertility Awareness Month is observed every year in June. Many couples are not even aware they are infertile; hence this month serves to alert them of issues that may affect them as well as their available solutions.

While the causes of infertility are varied and can affect both partners, the burden and stigma are often shouldered by the female partner. In our part of the world, both issues are particularly pronounced.

Couples with fertility issues should therefore see a doctor in a timely manner to receive a proper assessment and effective treatment. As age is an important factor in conceiving, early medical intervention often leads to positive outcomes in a couple’s fertility journey.

Both partners should be involved in fertility consultation and management. The primary issues to address include if the woman is ovulating regularly, if the sperm cells in semen are healthy, if there are coital issues and any problems with fertilization and implantation, and if the woman is able to maintain the pregnancy.

To answer these questions, thorough evaluation should be done through taking a detailed medical and personal history, sexual history and performing a physical examination for both partners. The next steps would then be to test the couple with baseline investigations as well as specific evaluations.

Some common assessments include tests to ensure the fallopian tubes are patent (open and lacking blockage), tests to confirm ovulation, sperm counts, and ultrasound to look for abnormalities in the uterus, fallopian tubes, and ovaries.

MANAGING & TREATING INFERTILITY

Sometimes, simple lifestyle modification measures such as weight management, adequate exercise, cessation of smoking, and the limitation on alcohol consumption can solve infertility.

As for natural methods, frequency of sexual intercourse can be an issue and it is recommended that at least 3 times a week increases the probability of conceiving.

Timed intercourse during a women’s fertile period may be a strategy as well. Women usually ovulate about 12 to 14 days before the start of a next menstrual cycle and the fertile period is the five days before ovulation, the day of ovulation, and the day after ovulation.

The treatment for fertility issues depends on the cause. For women who experience problems with ovulation, medications to induce ovulation may be employed. As for women with endometriosis, fibroids, or other tubal diseases, surgery may also improve outcomes. For men, prescribing medications to improve sperm quality may help and surgery may be employed for men with structural abnormalities in their reproductive system.

When more simple methods are not successful, more complex procedures may be employed such as intra-uterine insemination (IUI), gamete intra-fallopian transfer (GIFT), and intracytoplasmic sperm injection (ICSI). For couples with unexplained infertility, increasing coital frequency in combination with IUI often results in successful pregnancies.


References:

  1. Ferlin, A., Raicu, F., Gatta, V., Zuccarello, D., Palka, G., & Foresta, C. (2007). Male infertility: role of genetic background. Reproductive biomedicine online, 14(6), 734–745. https://doi.org/10.1016/s1472-6483(10)60677-3
  2. Lipshultz, L. I., Howards, S. S., & Niederberger, C. (2009). Infertility in the male (4th ed.). Cambridge University Press. http://dlib.sbmu.ac.ir/site/catalogue/134959
  3. Krausz C. (2011). Male infertility: pathogenesis and clinical diagnosis. Best practice & research. Clinical endocrinology & metabolism, 25(2), 271–285. https://doi.org/10.1016/j.beem.2010.08.006
  4. Poongothai, J., Gopenath, T. S., & Manonayaki, S. (2009). Genetics of human male infertility. Singapore medical journal, 50(4), 336–347.