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Session on Vaginal Microbiome and Infertility with Dr. GirijaWagh

- 7 min read
written by Dr Prachi Ahire


A lot of patients visit different clinics due to infertility issues. It is important to ask these patients about sexual history but what is most important is to ask about the actual vital history.

Dr. Girija references an article titled: Evidence that the Endometrial Microbiota has an effect on Implantation Success or Failure.

This article addresses the vaginal microbiome and how it affects fertility in women.

Shield Healthcare has taken the cause to explain the vaginal issues that might even lead to infertility in females.

This is a very detailed but simple-to-understand presentation by the award-winning doctor Dr. GirijaWagh. There are lots of study references used in the video to buttress points made. Each topic is explained in a slide to make understanding easier.

The doctor begins by explaining how patients would visit her complaining of a burning sensation and itching. Upon delving further into the issue, she came across a published resource that shared evidence that the endometrial microbiotahas an effect on implantation success or failure.

The study revealed that individuals who had Lactobacilli in the endometrial cavity of the vagina showed better implantation rates. This could lead to a major breakthrough in the process of implantation in the cases of infertility.

Another review by Elsevier in RBM Online titled ‘What fertility specialists should know about vaginal microbiome’’ shares a lot of information and terminologies.

What is Bacterial vaginosis

The vagina is a fascinating organ with biotic and abiotic factors creating a completely different habitat that protects the female organ from infections. Unfortunately, it undergoes a chance

It is a persistent imbalance of microbiota in the vagina as a result of improper or incomplete treatment.

Bacterial vaginosis is defined as abnormal microflora in the vagina, characterized by an overgrowth of anaerobic bacteria and G.vaginalisis with a marked decrease in the presence of lactobacillus.

How to identify a case of Bacterial vaginosis

Sometimes bacterial vaginosis is mistaken for normal vaginal secretion because the whitish discharge might be mistaken for a normal secretion.

About 50 percent of patients with BV are asymptomatic.

The World Health Organisation estimates that there are 333 million new cases of curable Vulvovaginal infections per year. Of these, Bacterial vaginosis contributes 40-45%, while Vaginal candidiasis and Trichomoniasis contribute 20-25% and 15-25% respectively.

Regardless of the huge number of bacterial vaginosis cases reported by the World Health Organization, most cases still remain undiagnosed. About 7-72% of women with vaginitis may remain undiagnosed.

  • Strong or offensive smell
  • No pruritus
  • Whitish grey
  • Milky white as opposed to clear white of a normal secretion

A pH greater than 4.5 is an indication of infection. Oftentimes, the pH levels are elevated to more than 4.5 for patients with bacterial vaginosis.

Abnormal vaginal flora is identified to have adverse obstetrical and gynecological sequelae like pelvic inflammatory disease, cervical intraepithelial neoplasia, and cuff infection.

Risk factors of bacterial vaginosis

  • Age at first exposure
  • Change in sexual partners
  • Concurrent sexually transmitted diseases
  • Cigarette smoking
  • Intrauterine contraceptive device
  • Vaginal douching
  • Occurs normally in Asian women

Why Indian Women Are More Prone to Bacterial Vaginosis

Indian women’s attitude towards hygiene and cleanliness has changed over the years but there are still problems that need to be addressed.

  • Awareness– Women in rural and even urban areas are not made aware of the importance of maintaining menstrual hygiene. There is neglect and lack of awareness and transparency.
  • Basic sanitation exercise – A lot of Indian women cannot afford the basic sanitation exercise. So, affordability is a big reason linked to poverty.

A study conducted in South India by a group of researchers on a group of 898 women indicated that nearly 12% of the women diagnosed with bacterial vaginosis had vulvovaginal candidiasis. Further, approximately 10% of teenagers and young adults between 16-22 years in Tamil Nadu had bacterial vaginosis. The percentage spiked with age as 35% of 650 adult women in the rural parts of Maharashtra were diagnosed with the same.

Diabetes and intimate health is one key area that doesn’t get the required attention in India. Every fifth woman in India is suffering from diabetes and it further complicates their intimate health.

The pH value of the women’s vagina area varies during the different phases of their lives, including during pregnancy and menstruation.

Here’re a few facts:

  • Newborn babies have pH between 4-5
  • A girl has pH 7 before puberty
  • During puberty, the pH is between 5-7
  • During the childbearing age, the pH drops to between 4-5
  • Pregnant women will have a pH of 3.5-4.5
  • Postmenopause pH is between 6-7

Sexual activities have also been linked with bacterial vaginosis because;

  • The incidence of bacterial vaginosis increases with an increase in the number of recent and lifetime sexual partners.
  • A new partner can also be related to bacterial vaginosis
  • Male partners of women with bacterial vaginosis may have urethral colonization caused by the same organism that is responsible for bacterial vaginosis but the male is asymptomatic.

It is important to understand that due to the social taboos, a lot of young women in India won’t admit to being sexually active, which is why the incidences can often go unreported.

But in any way, while treating the woman for bacterial vaginosis, it is always a good practice to treat a man for sexually transmitted infections.

Clinical Features of Bacterial Vaginosis

In order to diagnose bacterial vaginosis, doctors would often observe the following:

  • If there a foul-smelling discharge
  • If there no pruritis
  • Whitish grey discharge from the vagina

If you do a history pathological test, you can deduce the presence of bacterial vaginosis.
Dr. Girija explains more ways in this video to tell if a patient has bacterial vaginosis.

Other diagnostic tools for bacterial vaginosis

Bacterial Vaginosis can be diagnosed by the following methods as well:

  • Vaginal Gram Stain and you can carry out the Nugent or Speigel criteria
  • Culture test
  • DNA probe
  • Newer diagnostic modalities are: PIP activity and Sialidase

Bacterial Vaginosis and Pre-term Birth

40% of Pre-Term Births are attributed to infection which is why It is a good practice to screen pregnant women for BV when they are up to 12 weeks into the pregnancy.

Bacterial vaginosis is also linked with CP. To understand this, please watch the videoto understand Dr. Girija’s scientific explanation.

Effects of abnormal microbiota on ART

  • Contamination is possible from vaginal-cervical microorganisms by needle puncture of the vagina.
  • Microorganisms that enter the endometrium from the cervix during embryo transfer could cause damage to the developing embryo and prevent pregnancy.

Bacterial vaginosis has been known to affect the placenta during pregnancy.

A study titled Potential Influence of Microbiome on Infertility and Assisted Reproductive Technology shows that

  1. A meta-analysis demonstrated that bacterial vaginosis is significantly more prevalent in women with infertility. (Odd ratio of 3.32; 95% Confidence Interval [CI], 1.53-7.20).
  2. Women with tubal factors also had a significantly higher prevalence of bacterial vaginosis (Odd ratio of, 2.77; 95% Confidence Interval, 1.62-4.57) compared to women with other causes of infertility.

The role of probiotics in ART
Probiotics can be of great help in the process of ART especially the ones that contain lactobacillus.

Probiotics can be used over a long period and can also be an alternative to antibiotics. To find out more about the uses of probiotics, please watch the video to view the particular slide shown by Dr. Girija.

During early pregnancy, bacterial vaginosis increases the risk of PID. It could also lead to late miscarriages as part of other obstetric problems. The abnormal microbiome is also associated with PID, infertility, and first-trimester loss. It makes women more vulnerable to chlamydia infections during the rise of tubal disease. Men are also likely to be affected as it also causes an adverse effect on sperm.

Effects of ART on vaginal microbiota

Contamination can occur as a result of vaginal-cervical microorganisms by needle puncture of the vagina.

Microorganisms that find their way into the endometrium from the cervix during embryo transfer could prevent pregnancy by causing damage to the developing embryo.

A quick look at the pathophysiology of vaginal imbalance in female infertility shows that not only does it increase the concentration of IL-1B in the vaginal environment, but it also triggers the generation of reactive oxygen species. Not only that, but it may also affect the membrane integrity and flexibility.

Fertility is affected because this Impairs both tail motion and sperm-oocyte fusion. Lastly, it disrupts fertilization and implantation of the postulated pathophysiological mechanisms.

The local microbiota, especially the absence or presence of microbiomes within parts of the female reproductive tract seems to be associated with the outcome of ART.

Treatment of bacterial vaginosis

Studies have shown that the treatment of bacterial vaginosis doubles the success rates of ART.

All points discussed by Dr. Girija can be found in the video. The ReceptIVFity cohort study protocol to validate the urogenital microbiome as predictor for IVF or IVF/ICSI outcome shows that it is important that couples have knowledge of their vaginal microbiota to help make a more balanced decision regarding timing and continuation of their IVF or IVF-ICSI treatment cycles. Through predictive knowledge of the microbiome profile, couples can avoid the unnecessary physical and emotional burden of a failed IVF.

The presentation by Dr. Girija will improve the infertility outcome related to the vaginal microbiome. For more clarification on each topic, please refer to the video.

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