Positive Chlamydia trachomatis Serology Result in Women Seeking Care for Infertility Is a Negative Prognosticator for Intrauterine Pregnancy

No impact of a positive Chlamydia trachomatis serology on live-birth rate after intra-uterine insemination

OBJECTIVE

To study the impact of a CT serology on intrauterine insemination (IUI) cumulative live-birth rate (cLBR) in women with documented bilateral tubal patency.

DESIGN

Cohort study SUBJECTS: Infertile women with documented bilateral tubal patency and medical indication of IUI matched on the following criteria: woman's age, number of cycles completed and number of motile sperm inseminated (NMSI).

EXPOSURE

This retrospective, observational and monocentric cohort study compared women with positive CT serology matched 1:1 to control women with negative CT serology.

MAIN OUTCOME MEASURES

Cumulative LBR, rates of clinical pregnancy, spontaneous abortion, biochemical pregnancy.

RESULTS

A total of 71 women in the CT positive group were matched to 71 women in the negative CT group, leading to compare 136 cycles per group. No statistically significant difference was observed between groups regarding the demographic and medical characteristics of couples. Cumulative LBR per woman was similar in both groups with 32.4% (n = 23) in the negative serology group Vs 25.4% (n = 18) in the positive CT group (NS). The rates of clinical pregnancy, spontaneous abortion, biochemical pregnancy were comparable between the two groups.

CONCLUSION

In a population of infertile women with patent tubes, our study suggests that the serological status for CT has no impact on the IIU cLBR.

Female urogenital chlamydia: Epidemiology, chlamydia on pregnancy, current diagnosis, and treatment

Female urogenital chlamydia is a disease caused by Chlamydia trachomatis infection in the female urogenital tract. It is a common bacterial sexually transmitted disease. The bacteria is transmitted through sexual contact with an infected partner or from mother to newborn during vaginal delivery. The prevalence varies among studies and the number is possibly higher due to the lack of massive screening. Many patients were asymptomatic and still be able to transmit the disease. The undiagnosed and untreated disease could cause pelvic inflammatory disease, which leads to infertility, ectopic pregnancy, and chronic pelvic pain. The prevalence among pregnant women is similar to non-pregnant women, therefore chlamydia screening in pregnant women is highly recommended. The nucleic acid amplification test is the most reliable method for the diagnosis due to high sensitivity. The current treatment is given by prescribing antibiotics.

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Female urogenital chlamydia is caused by Chlamydia trachomatis.

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Urogenital chlamydia affects young and sexually active women.

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Female urogenital chlamydia is diagnosed through indirect methods (serology-based tests) and direct methods (culture).

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Treatment of chlamydia consists of antibiotics with doxycycline being the first-line choice.

[Update of Chlamydia trachomatis infection]

Chlamydia trachomatis (CT) is the most common sexually transmitted bacterial infection worldwide. It is asymptomatic in most cases and mainly affects young women, with potential long term sequelae (pelvic inflammatory disease, tubal infertility, obstetric complications). The impact on male fertility is controversial. Screening methods as well as antibiotics use have recently been reassessed due to resistance phenomena and the negative effect on the urogenital microbiota. Positive CT serology may be indicative of tuboperitoneal pathology, which may not be noticed on hysterosalpingography. New research on single-nucleotide polymorphisms (SNPs) aims to establish a patient profile at higher risk of infectious tubal damage due to CT. CT seropositivity is also associated with decreased spontaneous pregnancy rates and is a predictive factor for obstetrical complications.

C-reactive protein as a marker of persistent Chlamydia trachomatis infection is not associated with tubal factor infertility-an independent clinical validation study

STUDY QUESTION

Does C-reactive protein (CRP), as a marker of persisting low-grade inflammation, identify Chlamydia trachomatis IgG antibody test (CAT)-positive women who are at the highest risk for tubal factor infertility (TFI)?

SUMMARY ANSWER

No association was found between slightly elevated CRP (seCRP) levels and TFI in our CAT-positive patient population.

WHAT IS KNOWN ALREADY

In the fertility work-up, CAT is used to estimate the risk for TFI and to select high-risk patients for additional invasive diagnostic procedures (e.g. hysterosalpingography and laparoscopy). However, a high number of false positives exist among CAT-positive patients. In a previous study, it has been suggested that women with TFI may be identified more accurately when combining CAT with CRP, a marker for persistent low-grade inflammation.

STUDY DESIGN, SIZE, DURATION

Our original retrospective cohort consisted of 887 consecutive female patients who visited the fertility clinic of a tertiary care centre between 2007 and 2015. All CAT-positive women who underwent laparoscopy (as the reference test for evaluation of tubal function) and who had not undergone previous pelvic surgery were included in the study. CRP was determined in spare serum samples, and medical data was obtained by chart review.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 101 women (11.4%) were CAT-positive, and 64 of these 101 women (7.2%) met all inclusion criteria. CAT was performed with an ELISA. TFI was assessed by laparoscopy and strictly defined as extensive peri-adnexal adhesions and/or distal occlusion of at least one tube. In spare sera, CRP was performed with a high-sensitivity CRP ELISA, and CRP levels between 3 and 10 mg/L were defined as positive. Analyses were corrected for BMI, endometriosis and smoking.

MAIN RESULTS AND THE ROLE OF CHANCE

There was no statistically significant association between seCRP level and TFI after adjusting for BMI, endometriosis and smoking (odds ratio 1.0; 95% CI 0.3–3.3; n = 64).

LIMITATIONS, REASONS FOR CAUTION

Our retrospective study had a small sample size due to a low CAT-positivity rate and a conservative clinical policy with regard to invasive diagnostic testing. Additionally, CRP levels were only measured once, while they may change throughout the menstrual cycle and in time.

WIDER IMPLICATIONS OF THE FINDINGS

Contrary to previous findings, our results show CRP is not suitable as a marker of persistent low-grade inflammation in CAT-positive women. Other inflammatory markers and immunogenetic host factors should be studied on their clinical validity and utility to improve non-invasive risk assessment for TFI in the fertility work-up.

STUDY FUNDING/COMPETING INTEREST(S)

This work was partially supported by the European EuroTrans-Bio Grant [Reference number 110012 ETB] and the Eurostars grant (E!9372). S.A.M., a full-time employee of Amsterdam University Medical Centres location VUMC (0.56 fte) and the Maastricht University Medical Center (0.44 fte), is the founder (2011) and CEO of TubaScan Ltd, a spin-off company, Dept. of Medical Microbiology and Infection Prevention, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands. S.O. and E.F.v.E. at the time of conducting this research had a partial appointment at TubaScan Ltd.

Predicting tubal factor infertility by using markers of humoral and cell-mediated immune response against Chlamydia trachomatis

PROBLEM

The accuracy of Chlamydia trachomatis antibody test in predicting tubal factor infertility (TFI) is limited, and more accurate methods are needed. Cell-mediated immune response (CMI) is crucial in the resolution of pathogen, but it may play an important role in the pathogenesis of C trachomatis-associated tubal damage. We studied whether combining the markers of C trachomatis-induced CMI to humoral immune response improves the accuracy of serology in TFI prediction.

METHOD OF STUDY

Our prospective study consists of 258 subfertile women, of whom 22 (8.5%) had TFI. Women with other causes for subfertility served as a reference group. Serum C trachomatis major outer membrane protein (MOMP) and chlamydial heat-shock protein 60 (cHSP60) IgG antibodies were measured by ELISA. CMI was studied by lymphocyte proliferation assay in vitro.

RESULTS

Serological markers were more prevalent in women with TFI than in other subfertile women (40.9% vs 12.3% for MOMP IgG and 27.3% vs 10.2% for cHSP60 IgG). The best test combination for TFI was C. trachomatis MOMP and cHSP60 antibody with an accuracy of 90.3%, sensitivity of 22.7% and specificity of 96.6%. Positive post-test probability of this combination was 54.2%, and negative post-test probability was 12.4%. Adding of the markers of CMI did not significantly improve the accuracy of serology in TFI prediction.

CONCLUSION

The accuracy of TFI prediction increases when the combination of C trachomatis MOMP and cHSP60 antibody tests is used. C trachomatis-induced CMI was common in our study population, but the markers of CMI did not predict TFI.

Performance of the multitarget Mikrogen Chlamydia trachomatis IgG ELISA in the prediction of tubal factor infertility (TFI) in subfertile women: comparison with the Medac MOMP IgG ELISA plus

There is a need for more accurate Chlamydia trachomatis (CT) IgG antibody tests for tubal factor infertility (TFI) diagnostics. We evaluated the predictive value for TFI of Medac ELISA plus (MOMP) and multitarget Mikrogen ELISA (MOMP-CPAF-TARP). Based on Medac ELISA plus results, 183 subfertile women underwent either hysterosalpingography or laparoscopy to diagnose TFI. TFI was defined as extensive adhesions and/or distal occlusion of at least one tube. Women not fulfilling the definition of TFI served as controls. Serum was subsequently tested with Mikrogen ELISA and results were compared. 48 patients had TFI, 135 were controls. Mikrogen ELISA tested 125 patients positive/borderline of which 32% had TFI. Medac ELISA plus tested 77 patients positive/borderline of which 29.9% had TFI. Mikrogen tested 40 out of 48 TFI patients positive/borderline, Medac 23 out of 48. Kappa value was 0.34. PPV of Mikrogen ELISA and Medac ELISA plus were respectively 32% (95% CI 26%-39%) and 30% (95% CI 24%-37%), and NPV 86% (95% CI 81%-91%) and 76% (95% CI 70%-82%). Both tests were comparable in the prediction of TFI. However, Mikrogen ELISA had a higher NPV and might be more reliable in identifying patients without TFI. Kappa-value showed limited concordance between both tests.

Chlamydia trachomatis-induced cell-mediated and humoral immune response in women with unexplained infertility

PROBLEM

What is the role of past Chlamydia trachomatis infection in unexplained infertility?

METHOD OF STUDY

This is a prospective study of the impact of past C. trachomatis infection on pregnancy rates in 96 women with unexplained infertility. Both humoral and cell-mediated immune responses (CMI) against C. trachomatis were studied. Serum C. trachomatis IgG antibodies were analyzed using major outer membrane protein (MOMP) peptide-based ELISA. CMI was studied by lymphocyte proliferation (LP) assay in vitro. Data on given fertility treatment, time to pregnancy, and pregnancy outcome were collected.

RESULTS

Altogether, 11.5% of the 96 women had C. trachomatis IgG antibodies. LP response to C. trachomatis was positive in 62.9% women. The overall pregnancy rate or live birth rate did not differ by the presence of antichlamydial antibodies or CMI against C. trachomatis. Time to spontaneous pregnancy was longer among C. trachomatis sero-positive women than among sero-negative women (2.9 years vs 2.0 years, P = .03).

CONCLUSION

Past chlamydial infection does not play a major role in unexplained infertility. Women with unexplained infertility and positive immune response to C. trachomatis do not have reduced pregnancy rates, but time to spontaneous pregnancy is longer among C. trachomatis IgG sero-positive women than among sero-negative women.

Prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium and Ureaplasma urealyticum infections using a novel isothermal simultaneous RNA amplification testing method in infertile males

Background

The purpose of this study was to evaluate the prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium and Ureaplasma urealyticum infections in infertile men that consulted our outpatient departments using a novel simultaneous amplification testing (SAT) that is RNA-detection based. The possible impact of C. trachomatis, N. gonorrhoeae, M. genitalium and U. urealyticum infections on semen parameters was also noted in the present study.

Methods

A total of 2607 males that were diagnosed with infertility were included in this study. C. trachomatis, N. gonorrhoeae, M. genitalium and U. urealyticum infections were detected in the urine samples using SAT method. Related data, including semen parameters and age as well as C. trachomatis, N. gonorrhoeae, M. genitalium and U. urealyticum infections were collected and analyzed.

Results

A total of 51 and 1418 urine samples were found positive for M. genitalium RNA and U. urealyticum RNA, respectively, while the prevalence of C. trachomatis and N. gonorrhoeae was relatively lower. Men with positive M. genitalium RNA and U. urealyticum RNA had higher sperm DNA fragmentation index (DFI) while the comparisons of other semen parameters yielded nonsignificant results between the RNA positive and negative group. A multivariate linear regression analysis revealed that U. urealyticum and M. genitalium infections posed significant factors of DFI (adjusted R² = 46.2%).

Conclusions

Our study suggested a relative high prevalence of U. urealyticum and M. genitalium infection based on this novel SAT detection method. U. urealyticum and M. genitalium infection could possibly impair male fertility potential through promoting sperm DNA damage.

The prevalence of Chlamydia trachomatis infection among Saudi women attending the infertility clinic in Central Saudi Arabia

Objectives:

To determine the prevalence of Chlamydia trachomatis (C. trachomatis) infection among Saudi women, its clinical presentation, and its association to infertility.

Methods:

This study was conducted between October 2012 and July 2013 at King Khalid University Hospital and King Abdulaziz University Hospital, Riyadh, Kingdom of Saudi Arabia. Female patients aged between 19 and 46 years old with infertility problems seen at both hospitals were recruited to join the study. A separate group of female patients without infertility problems was also recruited from both hospitals to serve as controls for the study. Endocervical swabs were collected from both groups of patients, and samples were analyzed using real time polymerase chain reaction.

Results:

There was a statistically significantly greater prevalence of C. trachomatis infection in infertile women (n=8, 8.0%) compared with the fertile group of women (n=1, 1.0%). The C. trachomatis infection was significantly correlated to infertility.

Conclusion:

A significant association between infertility and increased prevalence of C. trachomatis infection is shown in this study, thus, we suggest that screening for Chlamydial infection to be part of the routine investigation for infertility.

Sero-epidemiological assessment of Chlamydia trachomatis infection and sub-fertility in Samoan women

Background

In our recent village-based cross-sectional study, the prevalence of nucleic acid amplification technique (NAAT) diagnosed Chlamydia trachomatis (CT) in sexually active Samoan women was very high (36 %), and test positivity was associated with sub-fertility. We conducted a serological and epidemiological analysis in these participants to identify if serological data can provide further insight into the potential contribution of CT to sub-fertility in this population.

Methods

Serological prediction of CT associated sub-fertility was conducted using a series of commercial tests. The correlation between fertility or sub-fertility, behavioral factors, and serologically predicted CT associated sub-fertility was determined.

Results

A positive antibody reaction against the Chlamydia Major Outer Membrane Protein (MOMP) was significantly associated with sub-fertility, with 50 % of infertile women being positive. Serum IgG and IgA antibodies against MOMP correlated with current infection measured by urine NAAT, suggesting longer term infections are common in this population. Chlamydia pneumoniae antibodies were frequently detected in this population (84 %), and unexpectedly, were significantly associated with sub-fertility.

Conclusions

The high prevalence of chlamydial infection and of positive chlamydial sub-fertility results suggests that CT is an important and frequent contributory factor to sub-fertility in this population.

Human and Pathogen Factors Associated with Chlamydia trachomatis-Related Infertility in Women

Chlamydia trachomatis is the most common bacterial sexually transmitted pathogen worldwide. Infection can result in serious reproductive pathologies, including pelvic inflammatory disease, ectopic pregnancy, and infertility, in women. However, the processes that result in these reproductive pathologies have not been well defined. Here we review the evidence for the human disease burden of these chlamydial reproductive pathologies. We then review human-based evidence that links Chlamydia with reproductive pathologies in women. We present data supporting the idea that host, immunological, epidemiological, and pathogen factors may all contribute to the development of infertility. Specifically, we review the existing evidence that host and pathogen genotypes, host hormone status, age of sexual debut, sexual behavior, coinfections, and repeat infections are all likely to be contributory factors in development of infertility. Pathogen factors such as infectious burden, treatment failure, and tissue tropisms or ascension capacity are also potential contributory factors. We present four possible processes of pathology development and how these processes are supported by the published data. We highlight the limitations of the evidence and propose future studies that could improve our understanding of how chlamydial infertility in women occurs and possible future interventions to reduce this disease burden.

CXCL10, CXCL11, HLA-A and IL-1β are induced in peripheral blood mononuclear cells from women with Chlamydia trachomatis related infertility

Chlamydia trachomatis infections can result in the development of serious sequelae such as pelvic inflammatory disease and tubal infertility. In this study, peripheral blood mononuclear cells from women who were undergoing or had recently undergone IVF treatment were cultured ex vivo with C. trachomatis to identify the immune responses associated with women who had serological evidence of a history of Chlamydia infection. Cytokines secreted into the supernatant from the cultures were measured using ELISA, and the level of IL-1β was found to be significantly higher in Chlamydia positive women than Chlamydia negative women. qRT-PCR analysis of the expression of 88 immune-related genes showed trends towards an upregulation of CXCL10, CXCL11 and HLA-A in Chlamydia positive women compared with Chlamydia negative women. These findings support that some women launch a more marked proinflammatory response upon infection with C. trachomatis and this may be associated with why C. trachomatis induces infertility in some infected women.