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What is bacterial vaginosis and how does it impact fertility?

What is bacterial vaginosis and how does it impact fertility?

8 min read

Around 30% of people with vaginas get bacterial vaginosis (BV) during their lifetimes, sometimes more than once. If you happen to be one of the many people who get BV at some point, there are many solid treatment options available — and researchers are working hard to find new ways to combat this common infection.

Keep reading for the rundown of BV symptoms, its relationship to fertility, and what you need to know about BV and pregnancy.

What is bacterial vaginosis?

Bacterial vaginosis (BV) is a type of vaginal inflammation caused by an overgrowth of bacteria — a shift from healthy bacteria to unhealthy bacteria in the vaginal microbiome. It’s the most common vaginal infection in people with vaginas aged 14-49.

Dr. Jennifer Conti, OB-GYN and medical advisor to Modern Fertility, explains: “It's poorly understood why some people get BV and others do not.” But people who experience BV often have reduced levels of the amylase enzyme and antimicrobial peptides (AMPs). The amylase enzyme and AMPs both maintain a healthy vulvovaginal environment where acid-producing lactobacillus bacteria thrive and harmful bacteria is kept at bay.

Shifts in your vaginal microbiome cause a chaotic cycle of events in your body that makes it difficult to regain control of the bacteria in your vagina. Without the lactobacillus bacteria fighting off infections, the vagina is left defenseless to recurring BV, or other vaginal infections like a yeast infection. And until the vagina finds balance again, it remains highly susceptible to infection.

Is bacterial vaginosis a sexually transmitted infection?

No, BV isn’t a sexually transmitted infection (STI). Still, doctors are uncertain about how much of a role sexual activity plays in getting BV since there’s no definite explanation as to how BV spreads. Unfortunately, this makes it difficult to know exactly what to do to avoid the infection — but, as we’ll get more into a little later, it’s highly treatable.

What are some BV symptoms to look out for?

Most people with vaginas who get BV don’t actually experience symptoms. If they do, the symptoms are so subtle that they might not be super noticeable or pose much concern for the individual.

Here are the most common symptoms of BV:

  • Fishy vaginal odor
  • Gray vaginal discharge
  • Burning sensation when you pee
  • Itching in the vulvovaginal area
  • Pain during sex

If you experience any of the symptoms above, you may have a vaginal infection — but whether or not you have BV or a yeast infection depends on lab test results that identify your genital culture. Your doctor may also take a sample of your discharge to inspect under a microscope. Sometimes BV and yeast infections can be identified without waiting for a culture.

How is bacterial vaginosis treated?

Antibiotics like metronidazole (also known as Flagyl) and Clindamycin taken in pill form or placed vaginally in cream form are standard treatments for bacterial vaginosis. Still, only 65% to 85% of people with BV are completely cured after taking standard antibiotics. The thing is, while antibiotics work to kill off the harmful bacteria in your vaginal area, they also kill off the healthy bacteria — which is less than ideal.

Do you have to use antibiotics to treat bacterial vaginosis?

The treatments for bacterial vaginosis are limited. Dr. Conti says that while there may be treatments for BV that don’t include antibiotics, they aren’t effective ones.

She also doesn’t recommend using probiotics alongside any antibiotic treatment for BV because the data isn’t very good. According to UpToDate, a trusted resource for healthcare providers, there isn’t “sufficient evidence for or against efficacy” of probiotics for BV.

Because of the sensitive nature of the vaginal microbiome, the effort to discover an effective alternative treatment to BV (with an emphasis on the probiotic lactobacillus to supplement the imbalance in the vaginal flora) is ongoing.

Is bacterial vaginosis the same thing as a yeast infection?

Bacterial vaginosis and yeast infections are both vaginal infections that require medical intervention to heal, but they’re often mixed up by those experiencing symptoms. As similar as the symptoms can be, Dr. Conti says it’s important to figure out exactly what’s going on. Her patients “don't often realize that the treatment of one (BV with an antibiotic) can actually cause the other (yeast),” she explains. Although antibiotics are necessary to treat bacterial infections, they can also disrupt the good bacteria in your vagina and lead to yeast infections.

It’s easy to confuse BV and yeast infections because they share a lot of similar symptoms like “abnormal” vaginal discharge and a burning sensation in the vulvovaginal area. But understanding the differences in these infections is important for handling them when, and if, either of them occurs.

  Bacterial vaginosis:

  • BV is a bacterial infection that can increase the risk of getting STIs or HIV.
  • The “abnormal” vaginal discharge that indicates BV is generally gray or white in color and thin.
  • Treatment typically involves antibiotics.

  Yeast infections:

  • Yeast infections are fungal infections that don’t cause STIs.
  • The “abnormal” vaginal discharge that indicates a yeast infection generally resembles cottage cheese. 
  • Treatment typically involves antifungal cream (which you can find OTC!).

In the end, only your healthcare provider can tell you for sure which infection you have and recommend a proper treatment by testing your genital culture or vaginal fluid. A BV test is similar to getting a Pap smear: You go to your OB-GYN or preferred healthcare provider, and they use a cotton swab to collect a sample of your vaginal fluid to send for culture or to inspect under a microscope.

What’s the deal with bacterial vaginosis and fertility?

BV is known to be more common in people with infertility than people without fertility issues — three times more common. Dr. Eduardo Hariton, an OB-GYN and fertility fellow at the University of California in San Francisco, explains: "These [existing] studies show that bacterial vaginosis is more common in women with infertility, but not yet proven to be a cause of infertility. At this point, we should not assume causality."

And while the extent that BV directly affects fertility is still unclear, a 2016 study found a connection between the presence of BV and the presence of pelvic inflammatory disease (PID), an infection that causes fertility issues by spreading into the fallopian tubes.

Dr. Eva Luo, MD, an OB-GYN and one of Modern Fertility’s medical advisors, adds that “STDs, IUDs, pregnancy, and surgical procedures” can throw off the body’s vaginal flora, leaving the vagina more susceptible to BV. For some, even periods and sex seem to be correlated with BV. All of these various causes make studying the link between fertility and BV more difficult.

To recap: The occurrence of BV in people with fertility issues doesn’t mean the BV is causing fertility issues — but it’s difficult to know exactly what the connection between the two issues might be, or if there are any drivers of infertility that may increase the likelihood of BV.

However, Dr. Conti says that “PID doesn’t frequently develop [because of] BV.” The connection found within this study was a first and more research needs to be done before drawing any conclusions between PID, BV, and fertility.

What should you do if you get bacterial vaginosis during pregnancy?

Getting BV during pregnancy is related to pregnancy risks such as miscarriage, preterm birth, and low birth weight. According to a 2018 study, a connection between BV and miscarriage does exist, but more research is required before reaching a definitive conclusion.

Research shows that BV can be treated during pregnancy. If you think you have BV and you’re pregnant or trying to conceive, it’s important to consult with your healthcare provider.

What does it mean if you get recurrent bacterial vaginosis?

Unfortunately, once you’ve had BV, the odds of getting it again are pretty high. Despite how easy it is to receive initial treatment for BV, Dr. Conti says that 30% of “patients with initial responses to therapy have a recurrence of symptoms within three months.” 50% of people with vaginas end up getting BV again within one year of treating it.

A 2017 study found that when a person gets rid of BV, it’s important to recreate a healthy vaginal microbiome to avoid a layer of microorganisms from collecting onto your vaginal epithelial cells, the microscopic cells that make up your vagina.

Can you stop recurring bacterial vaginosis infections permanently?

There’s no matter-of-fact way to stop recurring BV infections permanently. The best (and the simplest) thing to do is to exercise healthy vaginal hygiene and to limit any risk factors by:

  • Wiping front to back after you go to the bathroom
  • Regularly changing menstrual products
  • Avoiding irritants around your vagina (like soaps, douches, restrictive clothing)
  • Practicing safe sex

What’s it *really* like to have BV?

Now that we’ve covered the research around BV, let’s talk about personal experiences. We spoke with three members of the Modern Community — Modern Fertility’s online space for anyone with ovaries to connect and have unfiltered conversations about reproductive health — to find out what having the infection was like for them.

Ronnie remembers her experience with BV as so distressing that it left her feeling depressed. “I had horrible itching, and no matter how many showers I took, I still smelled,” she explains. Identifying the cause of the discomfort gave her some relief — but after treating the BV with medication, it would come back when she had sex, got her period, or ovulated. While there isn’t a ton of research yet to support the treatment of BV with probiotics, Ronnie found that they worked well for her vaginal health and was eventually able to stop taking the antibiotics.

For Camille, approaching her doctor to talk about BV was embarrassing at first. “I didn’t like bringing it up to my doctor because it felt like it was something I wasn’t taking care of,” she says, “but she assured me that it was completely normal and nothing to be freaked out about or embarrassed by.” Camille’s doctor told her that the likely cause of her BV was the many hours she’d regularly spend wearing a uni-suit in the water — she was rowing on a crew team at the time. Camille was prescribed antibiotics to treat the infection, but her doctor left her a few refills in case it came back.

Tina* also felt a little embarrassed when she found out she had BV. “I thought I had done something wrong hygiene-wise,” she explains. But once Tina was aware of the diagnosis, she didn’t waste any time looking for treatment: “I went to Planned Parenthood right away to get it resolved, and they gave me an antibiotic that I had to apply inside my vagina.” She ended up getting BV again later on, but she caught it quickly and was able to treat it. It’s now been a decade since she’s last had the infection.

L. experiences recurring BV. “I’ve been with the same partner (male) for 10 years, but for some reason two years ago, intercourse triggered BV. Even after various treatments, intercourse will trigger it — even with a condom,” she explains. When L. was first diagnosed, she tried using natural remedies. They didn't resolve the issue, so she went to a doctor who prescribed oral antibiotics and then a more intensive course of care over a four-month period after the BV kept coming back. “Before the end of those four months, we started trying to conceive. I noticed the BV came back after unprotected intercourse and my doctor advised I do one gel treatment, so I did, and it cleared up,” L. says. Now, at the time of writing, she is seven weeks pregnant and continuing to have BV flare-ups — her doctor mentioned it could be due to the changes in pregnancy hormones. L. is working with her doctor on treatment options to reduce the risk of any complications.

The bottom line

As uncomfortable as BV may be, there are ways to take care of it. Check in with your OB-GYN or healthcare provider if you feel like something is off with your body or you begin to experience any of the aforementioned symptoms.

And because most people with vaginas who get BV don’t show symptoms, make it a habit to monitor things like odor and discharge regularly after having sex with a new partner or use a new product you think could interfere with your vaginal microbiome.

*This name has been changed to protect the privacy of the individual.

This article was medically reviewed by Dr. Eva Marie Luo, an OB-GYN at Beth Israel Deaconess Medical Center and a Health Policy and Management Fellow at Harvard Medical Faculty Physicians, the physicians organization affiliated with the Beth Israel-Lahey Health System.

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Alex Shea

Alex is a sexual wellness and relationship writer who has a love for sparking deep conversations about the awkward and uncomfortable topics in life.

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