Discussing Some Risk Factors In Obstetric and Gynecological History That May Affect Tubal Infertility

When women are childless, not only do people blame the woman, but they also think that it is due to bad luck and bad morality that they lose the ability to give birth (37-year-old woman, farmer, mountainous area). Moreover, the woman’s fault can also be due to causal relationships, that she has had a bad time and got ectopic pregnancy due to blocked fallopian tubes. “…people say that I was bad in the past so I got blocked fallopian tubes…” (29-year-old woman, teacher, rural area).

Or women without children are a disaster that everyone needs to avoid when going out, especially during Tet and festivals, for fear that these people will bring disaster and misfortune to their families. “…I am still young, like a tree without fruit, afraid that going to someone else’s house will bring disaster, especially during Tet weddings…” (woman, 23 years old, housewife, rural area).

Therefore, many women have sought spiritual help to pray, beg, hoping for a miracle to help them have children. Most people, whether in rural or urban areas, with high or low educational levels, have sought help from this spiritual factor.

Maybe you are interested!

Chapter 4 DISCUSSION

4.1. DISCUSSION ON SOME RISK FACTORS IN GYNECOLOGICAL HISTORY THAT MAY AFFECT INFERTILITY DUE TO TUBE CAUSES

As stated in the theoretical framework in the overview section 1.5, VS due to VTC is a pathology with many risk factors that are difficult to fully evaluate within the framework of a study. This study focuses on analyzing 4 main risk factors that have been mentioned in the medical literature in the obstetrics and gynecology history of women:

(1) history of IUD use; (2) history of pelvic surgery; (3) history of NPT; and (4) history of genital tract infection (VSD).

4.1.1. Brief discussion of the demographic characteristics of the study participants

According to the data described in Table 3.1, in general, there is no difference in place of residence, occupation, education level and economic conditions between the two groups of subjects participating in the study with a p value ≥0.05 not statistically significant. This proves the compatibility between the patient group and the control group, confirming that the sampling results are appropriate. Particularly for the ethnic variable, there is a statistically significant difference between Kinh people and ethnic minorities coming to Thanh Hoa Obstetrics Hospital due to the accessibility conditions of ethnic people (usually living in remote areas) and often having economic difficulties, so accessing medical treatment services at the provincial level is also difficult and is also a limitation of the study in the complex geographical and social conditions in Thanh Hoa.

4.1.2. Discussion on the relationship between history of IUD placement and risk of VS due to VTC

The results of univariate analysis in Table 3.2 show that IUD is a contraceptive method chosen by many women in Thanh Hoa. About one-third of women have a history of IUD placement (33.7% of women in the case group and 36.8% of women in the control group). The univariate analysis shows that there is no strong association between the risk of VS due to VTC and

Using BPTT by placing IUD with OR = 0.9 and p value>0.05 is not statistically significant (Table 3.2).

However, according to the multivariate analysis model in Table 3.3, the risk of VS due to VTC is related to the number of times of IUD insertion. Women who only have IUD insertion once have no association with VS due to VTC, but if IUD insertion is 2 times or more, the risk of VS due to VTC is 2.2 times higher than that of women who do not have IUD insertion (95% CI = 1.13-4.62, p < 0.05). However, after using a multivariate logistic regression model that controls for confounding factors, the number of IUD insertions is not closely related to VS due to VTC (Table 3.9). Thus, IUD insertion is not a risk factor for VS due to VTC. However, women with IUD insertion who live in urban areas have a nearly 2 times higher risk than women with the same IUD insertion who live in other areas (95% CI = 1.03-3.38, p < 0.05).

The results of the study on the association between IUD placement and VS due to VTC are consistent with some studies, especially when this association is closely related to the group of women living in urban areas. It is still assumed that women living in urban areas will have better access to health services, however, STDs are often higher in subjects living in this area [12]. It is possible that age of sexual activity, number of sexual partners and STDs are related to the difference in the association with risk factors between areas of residence. The following analysis related to infection will further address this issue.

According to a review of world literature, previously, some authors still believed that DCTC could increase the risk of VS due to VTC [59], [86].

However, to explain why not all women with IUDs have VTC-related VS, these authors explain this difference in risk by explaining the mechanism of pelvic inflammatory disease leading to VTC damage of IUDs, in which IUDs act as a foreign object that reduces the body's resistance to bacteria causing inflammation, and this inflammation is completely different depending on each person's resistance [59], [86].

Some other authors believe that if IUDs are placed in women with inflammatory diseases, especially in some diseases such as gonorrhea with mild symptoms, or Chlamydia infection, if IUDs are placed, there will be a very high risk of retrograde infection leading to VTC obstruction much higher than in the group of women without infection [81], [80]. However, this risk is equal to that of women with the above infection but do not place IUDs. Thus, according to this author, IUDs are not a risk factor for increased VTC-induced VS, but it is the infection in women with IUDs that increases the risk of VTC-induced VS [81].

This is also consistent with the results of the thesis analysis, when the analysis results showed that the history of IUD placement was not a risk factor for VS due to VTC, however, women living in urban areas with IUD placement had a risk of VS due to VTC higher than women living in other areas with IUD placement nearly 2 times higher. The results seem paradoxical, but can also be explained by factors that may be related to infection because the time of IUD placement did not increase this risk.

Grimes et al. also showed that IUDs do not increase the risk of VTC-related VS, but infections with silent progression of symptoms such as gonorrhea and Chlamydia increase the rate of VTC-related VS. For women with these diseases that are not treated, the risk of VTC-related VS is the same in both groups with or without IUDs [79].

Author Doll and colleagues also believe that IUDs distract women from preventing STDs because they no longer have to worry about unwanted pregnancy compared to other contraceptive methods such as condoms or birth control pills. The risk of infection also increases, leading to a link between IUDs and STDs [59].

The factor of time of IUD placement is not closely related to the cause of VTC, which is also consistent with many studies in the world when scientists said that infection leading to VTC inflammation only occurs in the first 4 months, after that the risk of infection almost does not increase [80], [81], [128].

Similarly, the results of the study by author Khalaf showed that the risk of infection threatening to damage the VTC only occurred within the first 20 days after IUD placement, then in the first month the risk of damaging the VTC was small, and this risk almost did not increase until the IUD was removed [91].

Thus, the status of genital infections in women at the time of IUD insertion is still the most concerning issue, especially the high-risk group is the group of women living in urban areas, where sexual relationships are relatively complicated and the rate of infection due to STDs is also high [12]. However, it is difficult to assess the status of genital infections in women with the naked eye, requiring certain clinical skills and the simplest tests. During the interview with the research participants, it was learned that the assessment of the status of infection depends entirely on the observation and subjective experience of the medical staff, which means that very few people have had tests to assess their status of infection at the grassroots level. This is also an issue of concern in Thanh Hoa, because the professional qualifications of medical staff at the grassroots level are relatively limited and very few grassroots medical facilities support diagnosis with tests, even the simplest fresh smear tests to find pathogenic bacteria [29].

Considering the significant increase in secondary VS rates, especially VS due to VTC in recent decades, we need to pay attention to many factors related to IUDs, especially when wired IUDs have been completely replaced by wireless IUDs in recent decades, when all women in this study group had T-shaped or Multiload wired IUDs.

Although a meta-analysis by Gareen et al. reviewing 36 other studies concluded that any type of IUD use may be associated with an increased risk of pelvic inflammatory disease [73], the recent rapid increase in secondary IUD rates requires that researchers not overlook any detail to reduce the risk of IUD-related IUDs.

Many authors believe that if the IUD is placed by a professionally trained health worker, the IUD placement environment is hygienic, and the woman has no previous infection and is in a stable sexual relationship with a partner, this is a safe contraceptive method and does not pose a risk of VTE [91]. However, in this study, there was no association between the level of IUD placement person and the risk of VTE (Table 3.3).

From the results obtained in the study and comparison with other studies by domestic and foreign authors, the results of the study are consistent with the hypothesis that IUD is a risk factor for VTC-induced VS if IUD is placed at a time when the woman is infected, especially due to sexually transmitted diseases, and the IUD placement procedure is not sterile. If IUD is placed correctly, the woman has been screened for gynecological infections, then IUD is not a factor that increases the risk of VTC-induced VS.

Although the results of the multivariate logistic regression model did not find a strong association between IUD insertion 2 or more times as in the multivariate regression models (Table 3.9 and Table 3.13), it is still necessary to warn young women who still want to have more children not to insert IUDs many times. And perhaps further studies related to age of sexual intercourse, number of sexual partners and sexually transmitted diseases will shed more light on the association between IUD insertion and groups of women living in different geographical areas.

Another factor that should probably be considered given the recent increase in secondary VS rates, including among many rural women with IUDs, is whether there is a difference in the types of IUDs (wired and wireless).

In 2002, several authors studying the effectiveness and safety of the Tcu 380A IUD also commented that the rates of fungal and bacterial infections increased after placing the wired IUD, but there was no study comparing it with the wireless IUD [35]. Up to now, there have been very few studies that have delved into these issues in Vietnam, perhaps due to the sensitivity of issues related to population policy and family planning. Some authors such as TH Dung said that

9.3% of VS cases due to VTC obstruction are related to IUD placement [6]. However, the author's assessment is based only on history taking, mainly statistical description, without in-depth analysis to find the relationship between factors.

4.1.3. Discussion of the relationship between history of pelvic surgery and risk of VTC-induced VS

Data from Table 3.4 show that surgery for appendicitis, surgery for a tumor, and cesarean section are not risk factors for VTC-related VS. Women who have had a cesarean section even have a 0.3-fold reduced risk of VTC-related VS (OR=0.3 with p<0.001). The causes of VS are often complex, so it is possible that women who have had a cesarean section have demonstrated that their ability to conceive is normal and that the cesarean section scar on the uterus does not affect the condition of VTC.

In particular, women with a history of ectopic NMTC surgery increased the risk of VS due to VTC 4.6 times compared to women without ectopic NMTC surgery (Table 3.4). After being included in the multivariate logistic model to control for confounding factors, women with ectopic NMTC surgery still increased the risk of VS due to VTC 4.8 times compared to women without ectopic NMTC surgery with the same place of residence (Table 3.10).

In the final multivariate regression model in relation to other risk factors, ectopic pregnancy remained a risk factor for VS due to VTC. Women with ectopic pregnancy had a 4.6-fold increased risk of VS due to VTC compared to women without ectopic pregnancy in the same place of residence (Table 3.13).

Women who had undergone pelvic surgery living in urban areas had a 2.2-fold increased risk of VTC-related VS compared with women living in other geographic areas (Table 3.10). In the final multivariate regression model controlling for confounders, women living in urban areas still had a 2.8-fold increased risk of VTC-related VS compared with women living in other regions (Table 3.13).

Thus, the research results have some similarities and some differences with some other studies in the world and in Vietnam.

Although according to the literature review and basic theory, pelvic surgery can cause adhesions and contractures that lead to VTC adhesions [17], [140], some studies in the world and Vietnam have different opinions.

According to Saraswat et al. in a case-control study comparing women with VS due to VTC and women with TS cesarean section showed that TS cesarean section was not a risk factor for secondary VS due to VTC (OR=1.27; 95% CI= 0.9-1.78; p

>0.05) [116]. The author Saraswat's comments are consistent with the conclusion drawn from this study that women with cesarean section have a reduced risk of VS due to VTC compared with women without cesarean section (tables 3.4, 3.10, 3.13).

However, a study by Saraswat et al. showed that cesarean section in patients with pelvic inflammatory disease was strongly associated with VTC-related VS. Women who had cesarean section with pelvic inflammatory disease had a 17-fold increased risk of VTC-related VS compared to women who had cesarean section but did not have pelvic inflammatory disease (OR=17.3; 95% CI=10.9-27.6) [116].

In Vietnam, regarding pelvic surgery, some authors have presented different evidence compared to the results of this study. TH Dung and colleagues believe that pelvic surgery, including cesarean section, contributes to about 7.4% of cases of VS due to VTC obstruction [6]. However, this is only a descriptive study, so it is difficult to assess the reliability of these results.

Particularly for women with TS who have had surgery for ectopic NMTC, the conclusion from the study coincides with most other studies [23], [20]. Ectopic NMTC is the cause or consequence of VS has not been proven through many studies, people only see that Ectopic NMTC is often associated with VS-infertility. However, the important issue of how to avoid this risk is still under research because the pathological mechanism of Ectopic NMTC is unclear [20], [33], [64].

Thus, although TS of NMTC surgery is considered a risk factor in the research results and is closely related to VS, especially VS caused by VTC in all analyzed models, but due to unclear pathological mechanism,

Comment