Schistosomiasis and Infertility: What Do We Know?

Neglected Tropical Diseases and Female Infertility: Possible Pathophysiological Mechanisms

Battling female infertility has posed a global challenge, where neglected tropical diseases (NTDs) are nonetheless a notable contributing factor. NTDs affect a variety of diseases, often of a chronic nature, which are often cited as some of the most lethal diseases operating against the most economically disadvantaged populations across the globe. The various causative agents for NTDs have been documented and could originate from a myriad of sources-from bacteria, fungi and viruses to ecto- and endoparasitic species-including but not limited to helminths and protozoa. This paper will seek to describe how NTDs influence female reproductive health, together with likely mediators. While these diseases have curable forms, their effects have gone well beyond female infertility, to major pain, disability and even mortality, particularly in poorer countries, thus causing economic hardship, reduced productivity and a pool of social stigma. NTDs adversely affect female reproductive functions through multiple mechanisms, including ROS-sensitive signalling, depression of steroidogenic markers and promotion of apoptosis. The effects also may reflect their influence on ovarian histomorphology, consequently resulting in female infertility. Current-directed studies, however, suggest a potential benefit in combining drugs for the most common NTDs as a deterrent to possible female infertility endowed by NTD infection. Nonetheless, further clinical investigations will be instrumental in elucidating the probable preventive value of combination drugs as adjuvant therapy to NTDs infections. This will provide comprehensive insight into the pathophysiological and molecular basis for the impairment of female fertility brought about by NTDs, leading to the development of preventive models to curb the adverse effects of NTDs on female reproductive health. Therefore, attention should be given to providing the right, timely and effective mode of treatment for NTDs-related female infertility.

The burden of visually diagnosed female genital schistosomiasis among women with infertility in the Volta Region of Ghana

BACKGROUND

Female genital schistosomiasis (FGS) is the outcome of the deposition of Schistosoma haematobium egg in the ovaries, fallopian tubes, uterus or cervix of women in schistosomiasis endemic areas. Chronic and untreated FGS can result in an increased risk of human immunodeficiency virus (HIV) acquisition and infertility. This study aimed to evaluate the burden of visual FGS among women with infertility in the Volta region of Ghana.

METHODS

This study was a comparative cross-sectional study involving women with infertility defined as women with inability to achieve pregnancy after 12 months or more of frequent (3-4 times a week) unprotected sexual intercourse and nursing mothers (fertile women) from selected districts in the Volta Region. Questionnaire administration was used to obtain sociodemographic information including recent and childhood contact with water bodies as well as the practice of open defecation and clinical information such as the presence of genital symptoms. Urine samples were collected for detection of eggs of S. haematobium, and the women's lower genital tracts were examined using a handheld colposcope by two gynecologists and a third to resolve discrepancies. Data were analyzed using SPSS version 23 with frequency distribution done for the sociodemographic variables and the prevalence of FGS in the women. Pearson Chi-square analysis was performed to find any significant difference between the prevalence of FGS among infertile and fertile women and any significant association between any socioeconomic and clinical variables with FGS. Logistics regression analysis was performed to investigate sociodemographic and other risk factors for FGS among women.

RESULTS

Of the 265 sampled women 132 (49.8%) were infertile and 133 (50.2%) were nursing mothers (fertile women). More women had visual FGS (155, 58.5%) and most with FGS were fertile [96, 76.1%; infertile, 59(45.3%); p < 0.001], with infertile women having lower odds of FGS in this study (AOR, 0.29 [95% CI 0.17-0.50]; p < 0.001); adjusted for childhood and current contact with rivers and streams, availability of toilets facility, practice of open defecation and age. More women with FGS had childhood contact with rivers and streams (68.4%, p = 0.007) with lower odds of FGS seen in women without childhood contact with rivers and streams (AOR, 0.52 [95% CI 0.31-0.88]; p = 0.015).

CONCLUSION

In this study, infertile women unexpectedly had lower odds of FGS suggesting the need for more rigorous research on this topic to elucidate the true contribution of FGS on infertility.

Viruses, bacteria and parasites: infection of the male genital tract and fertility

BACKGROUND

Infertility affects one couple out of six worldwide. Male infertilty can result from congenital or acquired factors, of which pathogens that reach the genital tract through sexual contact or blood dissemination. The impact of major viral, bacterial and parasitic infections on the male genital tract and fertility has been summarized.

RESULTS AND CONCLUSIONS

A systematic review of articles published in the Google Scholar and PubMed databases was conducted. It turns out that viruses, as well as bacteria and parasites are major inducers of male genital tract infections and ensuing infertility through damage to the organs and subsequent loss of function and/or through direct damage to the sperm cells. Moreover, not only male infertility results from such infections but these can also be transmitted to women and even to the offspring, thus highlighting the need to efficiently detect, treat and prevent them.

Behaviour change interventions for the control and elimination of schistosomiasis: A systematic review of evidence from low- and middle-income countries

BACKGROUND

For the last two decades, schistosomiasis control efforts have focussed on preventive treatment. The disease, however, still affects over 200 million people worldwide. Behaviour change (BC) interventions can strengthen control by interrupting transmission through modifying exposure behaviour (water contact) or transmission practices (open urination/defaecation); or through fostering treatment seeking or acceptance. This review examines these interventions to assess their effectiveness in modifying risk practices and affecting epidemiological trends.

METHODOLOGY/PRINCIPAL FINDINGS

A systematic multi-database literature search (PROSPERO CRD42021252368) was conducted for peer-reviewed publications released at any time before June 2021 assessing BC interventions for schistosomiasis control in low- and middle-income countries. 2,593 unique abstracts were identified, 66 were assigned to full text review, and 32 met all inclusion criteria. A typology of intervention models was outlined according to their use of behaviour change techniques and overarching rationale: health education (HEIs), social-environmental (SEIs), physical-environmental (PEIs), and incentives-centred interventions (ICIs). Available evidence does not allow to identify which BC approach is most effective in controlling risk behaviour to prevent schistosomiasis transmission. HEIs' impacts were observed to be limited by structural considerations, like infrastructure underdevelopment, economic obligations, socio-cultural traditions, and the natural environment. SEIs may address those challenges through participatory planning and implementation activities, which enable social structures, like governance and norms, to support BC. Their effects, however, appear context-sensitive. The importance of infrastructure investments was highlighted by intervention models. To adequately support BC, however, they require users' inputs and complementary services. Whilst ICIs reported positive impacts on treatment uptake, there are cost-effectiveness and sustainability concerns. Evaluation studies yielded limited evidence of independent epidemiological impacts from BC, due to limited use of suitable indicators and comparators. There was indicative evidence, however, that BC projects could sustain gains through treatment campaigns.

CONCLUSIONS/SIGNIFICANCE

There is a need for integrated interventions combining information provision, community-based planning, and infrastructure investments to support BC for schistosomiasis control. Programmes should carefully assess local conditions before implementation and consider that long-term support is likely needed. Available evidence indicates that BC interventions may contribute towards schistosomiasis control when accompanied by treatment activities. Further methodologically robust evidence is needed to ascertain the direct epidemiological benefits of BC.

Identification of Putative Neuropeptides That Alter the Behaviour of Schistosoma mansoni Cercariae

Elucidating the infectivity of Schistosoma mansoni, one of the main etiological agents of human schistosomiasis, requires an improved understanding of the behavioural mechanisms of cercariae, the non-feeding mammalian infective stage. This study investigated the presence and effect of cercariae-derived putative neuropeptides on cercarial behaviour when applied externally. Cercariae were peptidomically analysed and 11 neuropeptide precursor proteins, all of which were specific to the Schistosoma genus and most of which highly expressed in the cercarial stage, were identified in cercariae for the first time. Protein–protein interaction analysis predicted the interaction of various neuropeptide precursors (e.g., Sm-npp-30, Sm-npp-33, Sm-npp-35) with cercarial structural proteins (e.g., myosin heavy chain and titin). In total, nine putative neuropeptides, selected based on their high hydrophobicity and small size (~1 kilodalton), were tested on cercariae (3 mg/mL) in acute exposure (1 min) and prolonged exposure (360 min) behavioural bioassays. The peptides AAYMDLPW-NH2, NRKIDQSFYSYY-NH2, FLLALPSP-OH, and NYLWDTRL-NH2 stimulated acute increases in cercarial spinning, stopping, and directional change during active states. However, only NRKIDQSFYSYY-NH2 caused the same behavioural changes at a lower concentration (0.1 mg/mL). After prolonged exposure, AAYMDLPW-NH2 and NYLWDTRL-NH2 caused increasing passive behaviour and NRKIDQSFYSYY-NH2 caused increasing body-first and head-pulling movements. These findings characterise behaviour-altering novel putative neuropeptides, which may inform future biocontrol innovations to prevent human schistosomiasis.

Absence of lower genital tract lesions among women of reproductive age infected with Schistosoma mansoni: A cross-sectional study using a colposcope in Western Kenya

BACKGROUND

Female genital schistosomiasis (FGS) constitutes four different lesions known to be caused by Schistosoma haematobium ova deposited in the genital tract. Schistosoma mansoni ova may also be found in the genital tract. However, it is not known if S. mansoni causes lower genital tract lesions characteristic of FGS.

METHODOLOGY

This study was conducted in 8 villages along the shores of Lake Victoria, western Kenya. Stool and urine samples, collected from women of reproductive age on three consecutive days, were analysed for S. mansoni and S. haematobium infection. S. mansoni positive and S. haematobium negative willing participants, aged 18-50 years were invited to answer a questionnaire (demographics, symptoms), undergo a gynaecological examination and cytology specimen collection by an FGS expert.

PRINCIPAL FINDINGS

Gynaecologic investigations were conducted in 147 S. mansoni-positive women who had a mean infection intensity of 253.3 epg (95% CI: 194.8-311.9 epg). Nearly 90% of them used Lake Victoria as their main water source. None were found to have cervicovaginal grainy sandy patches or rubbery papules. Homogenous yellow patches were found in 12/147 (8.2%) women. Women with homogenous yellow patches were significantly older (47 years) than the rest (34 years, p = 0.001). No association was found between intensity of S. mansoni infection and homogenous yellow patches (p = 0.70) or abnormal blood vessels (p = 0.14). S. mansoni infection intensity was not associated with genital itch, bloody or malodorous vaginal discharge.

CONCLUSION

S. mansoni infection was neither associated with lower genital tract lesions nor symptoms typically found in women with FGS.

Reduction of testosterone levels in Schistosoma haematobium- or Schistosoma mansoni-infected men: a cross-sectional study in two schistosomiasis-endemic areas of the Adamawa region of Cameroon

BACKGROUND

The incidence of schistosomiasis-induced male reproductive dysfunction and infertility is probably underestimated compared to female genital schistosomiasis. This study aimed to investigate the impact of Schistosoma haematobium or S. mansoni infection on the reproductive function of men of reproductive age in Tibati and Wouldé, two endemic schistosomiasis areas in the Adamawa region of Cameroon.

METHODS

A total of 89 men of reproductive age (range 14-56 years) from two localities were enrolled in the study, with 51 in Tibati and 38 in Wouldé. Each participant was submitted to a questionnaire to document data on sociodemographic and stream contact behaviors. A medical examination was performed to measure the testes' circumference and evaluate genital tract pathologies. Stool and urine samples were collected and screened for the presence of S. haematobium or S. mansoni ova. Blood serum was used to assess the levels of transaminases and testosterone.

RESULTS

Schistosoma haematobium was present only in Tibati, with a prevalence of 31.37%. The S. mansoni prevalence was 3.92% at Tibati and 44.71% at Wouldé. The intensity of infection was 22.12 ± 9.57 eggs/10 mL for S. haematobium and 128.10 ± 3.76 epg for S. mansoni. Serum transaminase activity and the mean testicular circumference of Schistosoma-positive individuals were close to Schistosoma-negative individuals. However, the testes size was more prominent in S. mansoni-positive individuals than in S. haematobium-positive individuals (P < 0.05). The serum testosterone levels of S. haematobium- and S. mansoni-positive men were significantly reduced by 56.07% (P < 0.001) and 51.94% (P < 0.01), respectively, in comparison to those of Schistosoma-negative men. A significant and negative correlation was established between schistosomiasis and the low serum testosterone level. Male genital tract pathologies such as scrotal abnormalities, varicocele, nodular epididymis, inguinal hernia, and hydrocele were recorded in both Schistosoma-positive and Schistosoma-negative men. However, no significant link was established between schistosomiasis infection and these pathologies.

CONCLUSION

These results demonstrated that infection with S. haematobium or S. mansoni is associated with low production of the reproductive hormone testosterone and may be a significant cause of male infertility.

Prevalence of urinary schistosomiasis in women: a systematic review and meta-analysis of recently published literature (2016-2020)

BACKGROUND

Urinary schistosomiasis is a serious threat in endemic territories of Africa and the Middle East. The status of female urinary schistosomiasis (FUS) in published literature between 2016 and 2020 was investigated.

METHODS

A systematic search in PubMed, Scopus, Google Scholar, and Web of Science, based on the 'Preferred Reporting Items for Systematic Reviews and Meta-analyses' checklist, and a meta-analysis using random-effects model to calculate the weighted estimates and 95% confidence intervals (95% CIs) were done.

RESULTS

Totally, 113 datasets reported data on 40,531 women from 21 African countries, showing a pooled prevalence of 17.5% (95% CI: 14.8-20.5%). Most studies (73) were performed in Nigeria, while highest prevalence was detected in Mozambique 58% (95% CI: 56.9-59.1%) (one study). By sample type and symptoms, vaginal lavage [25.0% (95% CI: 11.4-46.1%)] and hematuria 19.4% (95% CI: 12.2-29.4%) showed higher FUS frequency. Studies using direct microscopy diagnosed a 17.1% (95% CI: 14.5-20.1%) prevalence rate, higher than PCR-based studies 15.3% (95% CI: 6.1-33.2%). Except for sample type, all other variables had significant association with the overall prevalence of FUS.

CONCLUSIONS

More studies are needed to evaluate the true epidemiology of FUS throughout endemic regions.

Evidence of autochthonous transmission of urinary schistosomiasis in Almeria (southeast Spain): An outbreak analysis

BACKGROUND

Schistosomiasis is endemic in 78 countries belonging to tropical and subtropical areas. However, autochthonous transmission of urogenital schistosomiasis was reported in Corsica (France) in 2013. We present evidence of autochthonous transmission of urogenital schistosomiasis in Almería (Spain) in 2003.

METHODS

Description of the outbreak in farmers and subsequent epidemiological studies aimed at searching for Bulinus snails and their genotypic characteristics.

RESULTS

The outbreak affected 4 farmers out of a group of 5 people who repeatedly bathed that summer in an irrigation pool in the area. Two of them presented macroscopic hematuria with bilharziomas, showing the presence of Schistosoma eggs in bladder biopsies. Two others were asymptomatic but the serology for schistosomiasis was positive. In 2015, the presence of the vector Bulinus truncatus was demonstrated in Almería in water collections of appropriate characteristics. DNA sequencing proving that local B. truncatus species were base-to-base identical to B. truncatus from Senegal.

CONCLUSIONS

We present a new outbreak of autochthonous transmission of urogenital schistosomiasis in Europe. Although no new cases of autochthonous transmission have been reported, some other cases may have occurred at that time or later on and be unnoticed as many cases of schistosomiasis are asymptomatic or present mild and unspecific symptoms.

Effect of Lymphatic Filariasis and Hookworm Infection on Pregnancy Course and Outcome in Women Living in the Democratic Republic of the Congo

Little is known about the effect of helminth infections on the natural gynecological and pregnancy course. Our goal was to assess the relationship between Wuchereria bancrofti and hookworm (HW) infections with pregnancy course and outcome in a group of 82 women living in a rural area of the Democratic Republic of the Congo. Demographics and information on gynecological and obstetrical histories were collected retrospectively with standardized questionnaires. Wuchereria bancrofti and HW infections were diagnosed using a filarial antigen-detection test and the Kato-Katz method, respectively. Analyses consisted of multivariable logistic regressions adjusting for age, number of deliveries, and history of anthelmintic treatment (HAHT). The median age of study participants was 35 (interquartile range [IQR]: 30-44) years, and the median number of deliveries was five (IQR: 3-7). Wuchereria bancrofti and HW infection rates were 44.5% and 43.3%, respectively. Filarial antigenemia and HW infection were not significantly associated with the number of deliveries. The proportions of women with a history of pregnancy resulting in neonatal death, miscarriage, premature birth, and postpartum hemorrhage were 56%, 44%, 23%, and 36%, respectively. History of pregnancy associated with neonatal death was less frequent in women with HAHT, tended to be more frequent in women with filarial antigenemia, and was not associated with HW infection. None of the three other pregnancy events studied (miscarriage, premature birth, and postpartum hemorrhage) were associated with filarial antigenemia or HW infection. The positive association found between HAHT and lower risk of neonatal death warrants investigation in larger groups of women.