Cervical cancer remains the second most frequent malignancy among Indian women, accounting for 17% of global cervical cancer deaths, with rural regions like Rajasthan bearing a disproportionate burden1. Despite advances in screening technologies such as liquid-based cytology (LBC), only 2.6% of rural Rajasthani women undergo regular cervical screening, compounded by systemic barriers including healthcare inequity, cultural stigma around gynecological examinations, and low HPV vaccination rates (<5%).

Infertility affects 12–18% of Indian couples, yet cervical health assessments remain conspicuously absent from standard infertility workups in rural primary health centers. Emerging evidence suggests cervical dysplasia may impair fertility through altered cervical mucus properties and chronic inflammatory microenvironments. Rajasthan’s unique sociocultural landscape—where 68% of women marry before age 21 and multiparity rates exceed the national average—creates intersecting risks for cervical pathology and subfertility.

This study addresses critical gaps identified in Rajasthan’s 2021–2025 State Health Policy, which prioritizes reproductive health but lacks cervical screening integration. By analyzing cytological abnormalities in 650 infertile women across six rural districts, we aim to:

1. Quantify the prevalence of cervical dysplasia in this high-risk cohort
2. Identify modifiable risk factors linked to cytological anomalies
3. Propose culturally adapted screening protocols for resource-limited settings

LITERATURE REVIEW

Prior studies in urban India report a 10–20% prevalence of cervical abnormalities among infertile women, driven by HPV infections and delayed diagnoses. Rural populations, however, face unique challenges:

• Cultural stigma limits gynecological care access.
• Low literacy rates (57% in rural Rajasthan) reduce health awareness.
• Sparse screening infrastructure (1 cytology unit per 100,000 women).

Existing data highlight HSIL and ASCUS (atypical squamous cells of undetermined significance) as predominant abnormalities. This study builds on these insights while focusing on Rajasthan’s rural demographics.

Study Design

• Population: 650 infertile women (aged 20–44 years) attending rural primary health centers (PHCs) in 2023–2024.
• Inclusion Criteria: Married ≥1 year, no conception despite unprotected intercourse, no prior cervical screening.
• Exclusion Criteria: History of cervical cancer/treatment.

Data Collection

• Liquid-based cytology (LBC) for Pap smears.
• Structured questionnaires on demographics, reproductive history, and risk factors.

Statistical Analysis

• Chi-square tests for categorical variables.
• Logistic regression to identify risk factors (α = 0.05).

Demographics

• Mean age: 31.2 ± 6.5 years.
• Literacy rate: 58.3%.
• Average infertility duration: 4.2 ± 2.1 years

Prevalence of Abnormalities

Overall Prevalence: 95/650 (14.6%).

Key Risk Factors:

• Early sexual debut (<18 years): OR = 2.3 (95% CI: 1.6–3.4).
• Multiparity (≥3 children): OR = 1.8 (95% CI: 1.2–2.7).

Our findings reveal a 14.6% prevalence of cervical cytological abnormalities among rural infertile women, substantially higher than the 8.1% reported in urban Rajasthan. This disparity reflects systemic inequities: only 12% of participants had

prior Pap smear exposure, versus 34% in urban counterparts. The peak HSIL prevalence (7.5%) in women aged 30–39 aligns with Rajasthan’s median age of infertility presentation (31.2 years), suggesting prolonged HPV persistence due to delayed healthcare access.

Notably, multiparous women (≥3 children) showed 1.8× higher abnormality risk, contradicting urban studies where nulliparity was a risk factor. This paradox may stem from rural obstetrical practices: 62% of deliveries occur at home without sterile techniques, increasing trauma-associated HPV entry points. Furthermore, 78% of HSIL cases reported first sexual intercourse before age 18—a critical window for cervical metaplasia vulnerability.

Three key policy implications emerge:

1. Integration of LBC screening into Rajasthan’s Rashtriya Kishor Swasthya Karyakram (RKSK) program using existing ASHA worker networks
2. Task-shifting cytology interpretation to trained nurses, addressing Rajasthan’s 76% shortage of gynecologists
3. Community-based HPV vaccination drives leveraging Anganwadi centers

Limitations include recall bias in self-reported sexual histories and single-center sampling. However, our district-stratified sampling framework strengthens generalizability to Rajasthan’s 33 rural districts. Future studies should correlate cytology with HPV genotyping and fertility outcomes.

This study reveals a high burden of cervical abnormalities among infertile women in rural Rajasthan. We recommend:

1. Integrating LBC screening into infertility clinics.
2. Community HPV vaccination drives.
3. Awareness campaigns targeting stigma and misinformation.

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