Recovery of Chlamydia trachomatis from the endometrium of women at risk for chlamydial infection

Genital Chlamydia trachomatis Seroprevalence and Uterine Fibroid Development: Cohort Study of Young African-American Women

Few studies have investigated the 1930s hypothesis that reproductive tract infections are risk factors for fibroid development. In our 2017 cross-sectional analysis from the Study of Environment, Lifestyle, and Fibroids (2010–2018), a large Detroit community-based cohort of 23–35 year-old African-American women with ultrasound fibroid screening, we found an inverse association between seropositivity for genital Chlamydia trachomatis (gCT) infection and fibroids. With prospective data from the cohort (standardized ultrasounds every 20 months over 5 years), we examined gCT’s associations with fibroid incidence (among 1158 women fibroid-free at baseline) and growth. We computed adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for incidence by gCT serostatus using Cox proportional hazards models. GCT’s influence on growth was assessed by estimating the difference between fibroid size change for seropositive vs. seronegative between successive ultrasounds (1254 growth measures) using a linear mixed model. Growth was scaled to change over 18 months. GCT seropositivity was not associated with fibroid incidence (aHR, 1.0 95% CI: 0.79, 1.29) or growth (4.4%, 95% CI: −5.02, 14.64). The current evidence based on both biomarker gCT data, which can capture the common undiagnosed infections, and prospective ultrasound data for fibroids suggests that Chlamydia is unlikely to increase fibroid risk.

Effects of Hydrosalpinx on Endometrial Implantation Failures: Evaluating Salpingectomy in Women Undergoing in vitro fertilization

Hydrosalpinx is a disease characterized by the obstruction of the salpinx, with progressive accumulation in the shape of a fluid-filled sac at the distal part of the tuba uterina, and closed to the ovary. Women with hydrosalpinges have lower implantation and pregnancy rates due to a combination of mechanical and chemical factors thought to disrupt the endometrial environment. Evidence suggests that the presence of hydrosalpinx reduces the rate of pregnancy with assisted reproductive technology. The main aim of the present is review to make an overview of the possible effects of hydrosalpinx on in vitro fertilization (IVF). We conducted a literature search on the PubMed, Ovid MEDLINE, and Google Scholar data bases regarding hydrosalpinx and IVF outcomes. Hydrosalpinx probably has a direct toxic effect on sperm motility and on the embryos. In addition, the increasing liquid inside the salpinges could alter the mechanisms of endometrial receptivity. The window of endometrial receptivity is essential in the implantation of blastocysts, and it triggers multiple reactions arising from the endometrium as well as the blastocysts. Hydrosalpinx could influence the expression of homeobox A10 (HOXA10) gene, which plays an essential role in directing embryonic development and implantation. Salpingectomy restores the endometrial expression of HOXA10; therefore, it may be one mechanism by which tubal removal could result in improved implantation rates in IVF. In addition, salpingectomy does not affect the ovarian response, nor reduces the antral follicle count. Further studies are needed to establish the therapeutic value of fluid aspiration under ultrasonographic guidance, during or after oocyte retrieval, in terms of pregnancy rate and ongoing pregnancy.

Chlamydia trachomatis Seroprevalence and Ultrasound-Diagnosed Uterine Fibroids in a Large Population of Young African-American Women

Reproductive tract infections have long been hypothesized to increase the risk of uterine fibroids. Few studies have been conducted, even for the common infection genital Chlamydia trachomatis (gCT), and only with self-reported gCT data. Our investigation used micro-immunofluorescence serology for gCT to characterize past exposure. We used cross-sectional enrollment data from a prospective fibroid study carried out in the Detroit, Michigan, area; ultrasound examinations systematically screened for fibroids. Participants were African-American women aged 23-34 years (recruited in 2010-2012). Age- and multivariable-adjusted logistic regression models were used to estimate odds ratios. A total of 1,587 women (94% of participants) had unequivocal gCT serology results; 22% had fibroids. Those who were seropositive for gCT were less likely to have fibroids (age-adjusted odds ratio = 0.68, 95% confidence interval: 0.54, 0.87; multivariable-adjusted odds ratio = 0.80, 95% confidence interval: 0.62, 1.03). Inverse associations were similar across categories of fibroid size, number, and total volume. Participant groups likely to have had multiple or severe infections (multiple serovar groups, more sex partners, clinically diagnosed chlamydia) all showed statistically significantly reduced odds of fibroids. A protective association of gCT with fibroids was unexpected but plausible. gCT infection might increase immune surveillance and eliminate early lesions. Further investigation on the relationship between fibroid development and reproductive tract infections is needed.

Cost-effectiveness analysis of Chlamydia trachomatis screening via internet-based self-collected swabs compared with clinic-based sample collection

BACKGROUND

Although the Centers for Disease Control and Prevention have recommended population-wide Chlamydia trachomatis screening of sexually active women less than 26 years of age, more than half of sexually active young women are not routinely screened. A Website (IWTK, www.iwantthekit.org), was developed in 2004 to promote home-based sample collection.

METHODS

A decision tree was designed to model a hypothetical cohort of 10,000 women per year who order an internet-based C. trachomatis screening kit. We compared the incremental cost-effectiveness of 2 screening strategies: self-sampling via the IWTK website, and traditional, clinic-based screening by the same cohort of women who used IWTK. Probabilities and costs were estimated for each node in the decision tree. Estimates were derived from primary data, published data, and unpublished health data.

RESULTS

The internet-based screening strategy prevented 35.5 more cases of pelvic inflammatory disease and saved an additional $41,000 in direct medical costs as compared with the clinic-based screening strategy.

CONCLUSION

Our model estimates demonstrated that an internet-based, self-swab screening strategy was cost-effective compared with the traditional, clinic-based screening strategy. Assuming that the popularity of the use of the internet as a resource for information about healthcare and sexually transmitted infections leads to an increased use of IWTK, the public health benefit of this cost-effective strategy will be even greater.

Comparative effectiveness of a rapid point-of-care test for detection of Chlamydia trachomatis among women in a clinical setting

OBJECTIVES

To compare the effectiveness and cost-effectiveness of a promising new point-of-care (POC) chlamydia test with traditional nucleic acid amplification testing (NAAT), and to determine the characteristics that would make a POC test most cost-effective.

METHODS

A decision tree was constructed to model chlamydia screening visits to a sexually transmitted disease clinic by a hypothetical cohort of 10,000 women. The model incorporated programmatic screening costs, treatment costs and medical costs averted through prevention of pelvic inflammatory disease (PID) and its sequelae. Parameter values and costs were estimated for each node in the decision tree based on primary data, published data and unpublished health data.

RESULTS

For the base-case scenario (POC sensitivity 92.9%; 47.5% of women willing to wait 40 min for test results; test cost $33.48), POC was estimated to save US$5050 for each case of PID averted compared with NAAT. One-way sensitivity analyses indicated that POC would dominate NAAT if the POC test cost is <US$41.52 or if POC sensitivity is ≥ 87.1%. In a probabilistic sensitivity analysis (Monte Carlo simulations, 10 000 iterations), 10.8% of iterations indicated that the POC strategy dominated the NAAT strategy. The mean incremental cost-effectiveness ratio indicated that the POC strategy would save US$28 in total, and avert 14 PID cases.

CONCLUSIONS

A promising new chlamydia POC test is likely to be cost-effective compared with traditional NAAT. The POC test sensitivity, cost and proportion of women willing to wait for the POC test result are key elements to determining the cost-effectiveness of any new POC test strategy.

Cost effectiveness analysis of azithromycin and doxycycline for Chlamydia trachomatis infection in women: A Canadian perspective

OBJECTIVE

To assess the cost effectiveness of azithromycin versus doxycycline therapy for cervical Chlamydia trachomatis infections in Canada.

DESIGN

A predictive decision analytic model using previously published clinical and economic evaluations, expert opinion and costs of medical care in Canada.

POPULATION

A hypothetical cohort of 5000 women followed over 10 years.

INTERVENTIONS

Two diagnostic strategies were compared, laboratory confirmed diagnosis (LCD) and presumptive diagnosis (PD) of C trachomatis infection. Under each strategy, two treatment alternatives were analyzed, a single 1 g dose of azithromycin and a seven-day course of doxycycline as 100 mg twice daily.

RESULTS

Despite a fourfold higher acquisition cost, under base case conditions, for both diagnostic strategies, the azithromycin treatment alternative was more cost effective than the doxycycline alternative. For the LCD model, the cost per cure for patients receiving azithromycin was $184.76 compared with $240.59 for patients receiving doxycycline, resulting in an incremental cost of $55.83. For the PD model, the cost per cure for patients treated with azithromycin was $51.48 compared with $51.82, resulting in an incremental cost of $0.34. For the hypothetical cohort of 5000 women, the use of azithromycin translates into a projected annual cost savings of $279,150 and $1,700 for the LCD and PD models, respectively. In one-way sensitivity analyses for the LCD model, no clinically plausible changes in the base case estimates changed the results of the cost effectiveness outcome. In the PD model, clinically plausible changes in the probabilities of doxycycline cure, pelvic inflammatory disease, sequelae and chlamydia infection were found to alter the cost effectiveness outcome.

CONCLUSIONS

Based on the results from our model, the azithromycin strategy should be employed for the treatment of laboratory confirmed cases. However, for presumptive cases, azithromycin should be used only if the probabilities of C trachomatis and pelvic inflammatory disease are more than 19%, doxycycline effectiveness is less than 78%, or the cost of azithromycin is less than $19.00.

Cost-effectiveness of screening strategies for Chlamydia trachomatis using cervical swabs, urine, and self-obtained vaginal swabs in a sexually transmitted disease clinic setting

BACKGROUND

We evaluated the cost-effectiveness of Chlamydia screening strategies that use different methods of specimen collection: cervical swabs, urines, and self-obtained vaginal swabs.

METHODS

A decision analysis was modeled for a hypothetical cohort of 10,000 per year of women attending sexually transmitted disease (STD) clinics. Incremental cost-effectiveness of 4 screening strategies were compared: 1) Endocervical DNA probe test (PACE2, Gen-Probe), 2) Endocervical AC2 (Aptima Combo 2, Gen-Probe), 3) Self-Obtained Vaginal AC2, and 4) Urine AC2. Sensitivities of the vaginal, urine, and cervical AC2 tests were derived from 324 women attending STD clinics. The primary outcome was cases of pelvic inflammatory disease prevented. The model incorporated programmatic screening and treatment costs and medical cost savings from sequelae prevented.

RESULTS

Chlamydia prevalence in the sampled population was 11.1%. Sensitivities of vaginal, urine, and cervical AC2 were 97.2%, 91.7%, and 91.7%, respectively. The sensitivity of the DNA probe was derived from the literature and estimated at 68.8%. The self-obtained vaginal AC2 strategy was the least expensive and the most cost-effective, preventing 17 more cases of pelvic inflammatory disease than the next least expensive strategy.

CONCLUSIONS

Use of a vaginal swab to detect Chlamydia in this STD clinic population was cost-saving and cost-effective.

Should asymptomatic men be included in chlamydia screening programs? Cost-effectiveness of chlamydia screening among male and female entrants to a national job training program

OBJECTIVE

To compare the cost-effectiveness of various chlamydia screening strategies within a population of male and female youth entering a national job training program.

STUDY DESIGN

Cost-effectiveness analysis of various chlamydia screening strategies among a cohort of 4000 female and male New England job training students. Strategies for women include (a) no screening, (b) universal endocervical DNA probe screening, (c) universal urine based NAAT screening, and (d) universal endocervical NAAT screening. Strategies for men include (a) no screening, (b) selective urine NAAT screening of leukocyte esterase (LE)-positive urines, and (c) universal urine-based NAAT screening.

RESULTS

Universal endocervical NAAT screening of women and universal urine NAAT screening of men were the most effective and cost-effective strategies individually and in combination. Endocervical NAAT screening of women prevented 23 more cases of PID and saved $27,000 more than endocervical DNA probe screening. Likewise, universal urine NAAT screening of men prevented 21 more cases of PID in their female partners and saved $16,000 more than selective urine NAAT screening of LE positive men.

CONCLUSIONS

Use of a sensitive NAAT to screen both men and women for chlamydia upon entry to a National Job Training Program is cost-effective, cost-saving, and provides a public health opportunity to substantially reduce chlamydia infections among youth at risk for sexually transmitted diseases.

Chlamydia trachomatis-associated tubal factor subfertility: Immunogenetic aspects and serological screening

Chlamydia (C.) trachomatis female genital tract infections usually remain asymptomatic and untreated. Therefore, an adequate immune response, rather than antibiotic treatment, is essential to clear the pathogen. Most women will effectively clear C. trachomatis infections, but some will have persistent C. trachomatis infections, which may ascend to the upper genital tract and increase the risk of tubal factor subfertility. Pattern recognition receptors (PRRs) of the toll-like receptor (TLR) and nucleotide-binding oligomerization domain (NOD) families recognize C. trachomatis and initiate the immune response. Host immune factors are determinants of the course of C. trachomatis infections. Genetic variations in TLR and NOD genes may affect receptor function, leading to inadequate recognition of C. trachomatis, an inadequate immune response, and consequently an increased risk of persistence and late sequelae. For the risk assessment of tubal pathology in subfertile women, C. trachomatis immunoglobulin (Ig) G antibody testing (CAT) in serum is widely used. A positive CAT is indicative of a previous infection but not of a persistent infection. Measuring serological markers of persistence, of which C-reactive protein (CRP) seems promising, in CAT-positive women may identify a subgroup of subfertile women with persistent C. trachomatis infections and the highest risk of tubal pathology.

Comparison of endometrial and subendometrial blood flows among patients with and without hydrosalpinx shown on scanning during in vitro fertilization treatment

OBJECTIVE

To compare endometrial and subendometrial blood flows among patients with and without hydrosalpinx (HSP) during in vitro fertilization treatment as measured by a three-dimensional power Doppler ultrasound.

DESIGN

A prospective observational study.

SETTING

A tertiary assisted-reproduction unit.

PATIENT(S)

Twenty-one patients with HSP were compared with 42 matched controls without HSP.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Endometrial thickness, endometrial pattern, endometrial volume, pulsatility index (PI) and resistance index (RI) of uterine vessels, and the vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of endometrial and subendometrial regions were measured on the day of oocyte retrieval.

RESULT(S)

The proportion of the non-multilayered endometrial pattern was significantly higher in the HSP group than in the non-HSP group. Patients in the HSP group had significantly lower endometrial and subendometrial VI and VFI. Endometrial thickness, endometrial volume, uterine PI, uterine RI, and endometrial and subendometrial FI were similar between the two groups. No significant differences were observed in endometrial and subendometrial VI, FI, and VFI among patients with unilateral and bilateral HSP.

CONCLUSION(S)

A change in endometrial pattern and a decrease in endometrial and subendometrial blood flows may be the reasons for impaired implantation in patients with HSP.

Characterization of estrogen-responsive epithelial cell lines and their infectivity by genital Chlamydia trachomatis

Chlamydial attachment and infectivity in vitro and ascending disease and sequelae in vivo have been reported to be enhanced/modulated by estrogen. Endometrial carcinoma cell lines Ishikawa and HEC-1B and the breast cancer lines MCF-7 and HCC-1806 were examined for Chlamydia trachomatis E infectivity. Estrogen receptor (ER) presence was confirmed by Western blot and qRT-PCR analyses. FACS analysis was used to determine the percent of plasma membrane-localized ERs (mERs), and their activity was tested by estrogen binding and competitive estrogen antagonists assays. Chlamydiae grew in all cell lines with HEC (90%) >> MCF-7 (57%)>Ishikawa (51%) >> HCC-1806 (20%). The cell line ER isoform composition was re-defined as: ERalpha + ERbeta + for MCF-7, HCC-1806 and Ishikawa; and ERbeta only for HEC-1B. HeLa cells were also tested and found to express ERbeta, but not ERalpha. A small percentage of both ERs were surface-exposed and functionally active. The endometrium-predominant ERbeta isoform was found in all cell lines, including those most representative of the common sites of C. trachomatis infection. Thus, the role of chlamydial attachment/infectivity will now be analyzed in ERbeta+and-isogenic HEC-1B cells.

Cost-Effectiveness Analysis of Screening Adolescent Males for Chlamydia On Admission to Detention

BACKGROUND

Chlamydia trachomatis infections can lead to serious and costly sequelae. Because chlamydia is most often asymptomatic, many infected youth do not seek testing. Entry to a detention system provides an opportunity to screen and treat many at-risk youth. GOAL The goal of this study was to determine the cost-effectiveness of screening male youth for chlamydia on entry to detention.

STUDY DESIGN

Incremental cost-effectiveness of 3 chlamydia screening strategies was compared for a hypothetical cohort of 4000 male youth per year: 1) universal chlamydia screening using a urine-based nucleic acid amplification test (NAAT), 2) selective NAAT screening of urine leukocyte esterase (LE)-positive urines, and 3) no screening. The model incorporated programmatic costs of screening and treatment and medical cost savings from sequelae prevented in infected males and female partners. The analysis was conducted from the healthcare system perspective.

RESULTS

Chlamydia prevalence in the sampled population of 594 was 4.8%, and the average number of female sexual partners/infected male was 1.6. Universal NAAT screening was the most cost-effective strategy, preventing 37 more cases of pelvic inflammatory disease (PID) and 3 more cases of epididymitis than selective screening and saving an additional 24,000 dollars. The analysis was sensitive to NAAT cost, LE sensitivity, rate of PID development, PID sequelae cost, and number of female partners. Universal screening remained the most cost saving for prevalence as low as 2.8% or higher.

CONCLUSIONS

Universal chlamydia screening of adolescent males on entry to detention was the most cost-effective strategy. Savings are primarily the result of the prevention of PID in recent and future partners of index males. Screening detained male youth using a urine-based NAAT provides a public health opportunity to significantly reduce chlamydia infections in youth at risk for sexually transmitted diseases.

The clinical and economic consequences of screening young men for genital chlamydial infection

BACKGROUND

Wide-scale application of urine-based screening of asymptomatic men for chlamydial infection has not been thoroughly assessed.

GOAL

The goal was to compare clinical and economic consequences of three strategies: (1). no screening, (2). screening with ligase chain reaction (LCR) assay of urine, and (3). prescreening urine with a leukocyte esterase test (LE) and confirming positives with LCR.

STUDY DESIGN

We used a decision analytic model.

RESULTS

At a chlamydia prevalence of 5%, the no screening cost was US dollars 7.44 per man screened, resulting in 522 cases of pelvic inflammatory disease (PID) per 100000 men. LE-LCR was most cost-effective, preventing 242 cases of PID over no screening at an additional cost of US dollars 29.14 per male screened. The LCR strategy prevented 104 more cases of PID than LE-LCR but cost US dollars 22.62 more per male screened. For this to be more efficient than LE-LCR, the LCR assay cost needed to decline to <or=US dollars 18.

CONCLUSION

At a chlamydia prevalence of 5%, LE-LCR is the most efficient use of resources. If LCR cost decreases or chlamydia prevalence increases, the LCR strategy is favored.

Should all sexually active young women in Hungary be screened for Chlamydia trachomatis?

OBJECTIVE

Cost-effectiveness analysis was carried out to develop screening strategy for Chlamydia trachomatis to assess the possibility of preventing pelvic inflammatory disease and its sequelae.

STUDY DESIGN

An 18 months epidemiological study of prevalence of chlamydial infection among pregnant women was carried out in Hungary.

RESULTS

The policy of testing and treating was less cost-effective than neither testing nor treating, unless the cost of the diagnostic test were less than or equal to US$ 10, or the prevalence of infection in women were greater than 8.3.

CONCLUSIONS

Since the prevalence of chlamydial infection amongst 15-24 years old women in this study was 8.0%, the cost of screening in Hungary only barely outweighs the benefit in economic terms. Given the undesirable potential consequences of the infection, it is thus recommended that Hungarian clinicians should screen all young, sexually active women for C. trachomatis at the same time as they perform routine pelvic examinations.

Detection of Neisseria gonorrhoeae and Chlamydia trachomatis colonization of the gravid cervix

OBJECTIVES

The aims of the study were to determine whether a Gram stain of cervical mucus can accurately rule out infection with Neisseria gonorrhoeae or Chlamydia trachomatis and to compare a diagnostic test that is based on the polymerase chain reaction with a deoxyribonucleic acid probe in the detection of these organisms.

STUDY DESIGN

Gravid patients were screened for N gonorrhoeae and C trachomatis with a deoxyribonucleic acid probe, Gram stain, and analysis with the polymerase chain reaction. A normal, noninfected sample was defined by <10 polymorphonuclear leukocytes per high-power field on the Gram stain. Standard statistical methods were used to compare results of the Gram stain and the deoxyribonucleic acid probe, as well as to compare results of deoxyribonucleic acid probe hybridization and polymerase chain reaction analysis. A P value of <.05 was considered statistically significant.

RESULTS

Patient enrollment totaled 519. The prevalence of infection as determined by deoxyribonucleic acid probe hybridization was 1.4% for N gonorrhoeae (7/518) and 6.8% for C trachomatis (35/518). The cervical Gram stain predicted the absence of infection in 17% (90/518) of patients, with a negative predictive value of 99% for N gonorrhoeae and 97% for C trachomatis. African American race, age <20 years, and unmarried status were all predictors of the presence of C trachomatis or N gonorrhoeae cervicitis. For the patients who lacked these risk factors (n = 74), the Gram stain had 100% negative predictive value. Analysis with the polymerase chain reaction detected 8 additional patients with C trachomatis and 105 additional patients with N gonorrhoeae, in comparison with deoxyribonucleic acid probe hybridization.

CONCLUSION

The cervical Gram stain can accurately predict the absence of N gonorrhoeae and C trachomatis in gravid women. Analysis with the polymerase chain reaction indicates that N gonorrhoeae and C trachomatis are significantly more prevalent in this population than previously reported.

Management of hydrosalpinx: reconstructive surgery or IVF?

Tubal disease remains the most important factor in female infertility. Many investigators reported that patients with hydrosalpinx had a decreased clinical pregnancy rate and an increased miscarriage rate, resulting in a decreased ongoing pregnancy rate when compared to that of patients with other types of tubal disease. Different studies showed a deleterious effect of the presence of hydrosalpinx on the outcome of in vitro fertilization-embryo transfer, because toxic agents flowing from the hydrosalpinx to the uterus impair the implantation rate. Operative laparoscopy is effective in the treatment of hydrosalpinges (Stage I or II). Fertility outcome is related to tubal damage. Patients with Stage III and IV disease should be managed from the beginning with in vitro fertilization. Excision of hydrosalpinx(-ges) improves the pregnancy potential after in vitro fertilization. We believe that assisted reproductive technology and reproductive surgery can be complementary. The development of laparoscopic surgery and in vitro fertilization improved the pregnancy rate in patients with tubal factor infertility.

Pelvic inflammatory disease in the adolescent population

Statistics suggest that the adolescents have a higher rate of diagnosis of pelvic inflammatory disease than any other age group. Early recognition improves the chances of preventing the long-term consequences of ectopic pregnancy and tubal infertility. For a significant number of teens, the symptoms are mild or vague, requiring a high index of suspicion by the physician to initiate treatment. The purpose of this article is to review the currently accepted guidelines for diagnosis and management of pelvic inflammatory disease in the adolescent patient.

Screening women for chlamydia trachomatis in family planning clinics: the cost-effectiveness of DNA amplification assays

BACKGROUND

Highly sensitive and specific DNA amplification assays are available for use on cervical and urine specimens. These new tests have the potential to identify more chlamydial infections than the commonly used enzyme immunoassay and DNA probe tests, yet they are more expensive. This study sought to assess the cost effectiveness of cell culture, enzyme immunoassay (EIA), DNA probe (Pace 2), polymerase chain reaction (PCR) of cervical and urine specimens, and ligase chain reaction (LCR) of cervical and urine specimens as screening tools for Chlamydia trachomatis in asymptomatic women younger than 30 years of age attending family planning clinics.

STUDY DESIGN

Program costs; medical cost savings of prevented sequelae in women, male sex partners, and infant; and number of prevented cases of pelvic inflammatory disease (PID), neonatal infections, and male sex partner urethritis and epididymitis were modeled in a decision analysis conducted from a health care system perspective. Results are expressed for a cohort of 18,000 women.

RESULTS

If no screening for C. trachomatis were conducted in Maryland, 497 cases of PID would develop, costing $2.2 million in future medical costs. Use of EIA to detect chlamydial infection would prevent 240 cases of PID and save $887,000 over no screening. Alternatively, use of DNA amplification assays on urine specimens would prevent up to an additional 66 cases and save $287,100 over EIA. Use of LCR on cervical specimens would prevent at least 13 additional cases of PID over the urine-based assays, but would cost $3,005 for each additional case prevented. In women receiving routine pelvic examinations, LCR of cervical specimens would prevent the most disease and provide the highest cost savings. In women not receiving routine pelvic examinations, use of LCR on cervical specimens would prevent the most disease but would cost approximately $28,000 per additional case of PID prevented over DNA amplification of urine.

CONCLUSIONS

Compared with EIA screening, the strategy with the lowest program costs, a screening strategy that combines use of DNA amplification on cervical specimens in women receiving pelvic examinations, and DNA amplification of urine in women with no medical indications necessitating a pelvic examination, prevents the most cases of PID and provides the highest cost savings. With enhanced sensitivity over the other diagnostic assays and with the use of noninvasive specimen collection, DNA amplification assays should be implemented as cost-effective components of a screening program for C. trachomatis.

The presence of hydrosalpinx may not adversely affect the implantation and pregnancy rates in in vitro fertilization treatment

PURPOSE

To evaluate the effects of hydrosalpinx on the outcome of in vitro fertilization (IVF) treatment, a retrospective study was undertaken at a tertiary referral center for infertility.

METHODS

Results of the first IVF treatment cycles in 144 patients from 1 January 1993 to 31 December 1995, who had tubal infertility only and were less than 38 years old, were reviewed. The duration/dosage of hMG used, serum estradiol level on the day of hCG, number of oocytes aspirated and fertilized, number of embryos replaced, implantation rate, clinical pregnancy rate, and pregnancy outcome were compared in patients with and without hydrosalpinx.

RESULTS

The mean implantation rate and clinical pregnancy rate were similar in patients with or without hydrosalpinx. Both groups had similar ovarian responses and fertilization rates. There was no increase in clinical abortion in the hydrosalpinx group but ectopic pregnancies were more common in patients with hydrosalpinx.

CONCLUSIONS

The presence of hydrosalpinx did not adversely affect the implantation and pregnancy rates in in vitro fertilization treatment when the results of the first cycle were compared. However, it can lead to a higher incidence of ectopic pregnancies.

Partner notification to prevent pelvic inflammatory disease in women. Cost-effectiveness of two strategies

BACKGROUND AND OBJECTIVES

Partner notification is an important strategy for prevention of Chlamydia trachomatis infection and pelvic inflammatory disease (PID). PID can be prevented by early diagnosis and treatment of the female sex partners of men infected with C. trachomatis (strategy 1) and by preventing reinfection in women through diagnosis and treatment of their male sex partners (strategy 2).

STUDY DESIGN

Using a decision model, the cost-effectiveness of strategies 1 and 2 was compared to no partner notification. Outcomes were measured by cases of PID prevented and net costs expended from a health care system perspective.

RESULTS

In a hypothetical cohort of 1,000 male and 1,000 female index patients, strategy 1 prevented 64 and strategy 2 prevented 20 cases of PID. Strategy 1 saved $247,000 and strategy 2 saved $33,000 over no partner notification. Sensitivity analysis showed that strategy 1 was cost-effective across a wide range of assumptions. Strategy 2 was cost-effective at baseline, but its cost-saving ability was subject to changes in the model.

CONCLUSION

Partner notification of both male and female index patients is a cost-effective public health strategy for prevention of PID. In most settings, both strategies can and should be implemented.

Drug therapies for sexually transmitted diseases. Clinical and economic considerations

Sexually transmitted diseases (STDs) are common, and result in immense social and economic costs. In some countries they have a major demographic impact. Because many STDs facilitate the transmission of HIV, the consequences of STDs are further increasing. At the same time, this association between STDs and HIV provides one of the ways in which drug therapy should be very cost effective. The perspective taken in this article is a societal one, and broader issues than those directly related to drug costs and benefits are discussed. However, it is the availability of drugs that has the potential to most quickly and most reliably make a major difference to overall health sector and societal costs as they relate to STDs. For those STDs for which curative therapy is available (particularly Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and Trichomonas vaginalis) there have been large decreases in prevalence in many parts of the world. In contrast, those STDs for which curative therapy is not available (particularly HIV, genital herpes and genital human papillomavirus infection) have had stable or increasing prevalence. For these latter infections, each new case increases the overall prevalence. Numerous features of STDs make clinical and economic evaluation difficult. These include the sensitive nature of the topic, the changing epidemiology and drug susceptibility of individual STDs, the fact that a large proportion of those infected are asymptomatic, difficulties in making specific diagnoses, the fact that often consequences are recognised late, sexual re-exposure and reinfection, and inadequate data on which to do clinical and economic evaluations. Furthermore, risk of acquiring an STD roughly correlates inversely with socioeconomic status, and countries or places with the highest rates of STDs may have the least ability to deal effectively with their diagnosis and management. Most of the direct and indirect costs are incurred by women, since they experience the vast majority of the complications of STDs. Many of these only become apparent years later, which makes it very hard to attribute costs and benefits to a specific episode of infection, and to its treatment. The late and indirect costs, plus the costs of prevention, are hard to quantify. That the major burden of STDs is in adolescents and young adults, socioeconomically disadvantaged groups and women has important implications, including for pharmacoeconomic studies.(ABSTRACT TRUNCATED AT 400 WORDS)

Proposed criteria for the selection of patients for ambulatory therapy of acute gonococcal salpingitis

No firm criteria have existed that delineate which patients with acute gonococcal salpingitis can be managed successfully on an outpatient basis and which patients would be best handled by hospitalization. This article describes one individual's rationale for selecting candidates for ambulatory therapy of acute salpingitis.

Chlamydial infection in the Amazon region of Brazil

The prevalence of antibodies to Chlamydia was determined in 9 population groups with different risk levels for sexually transmitted diseases in Belém, Pará state, Brazil. 583 serum samples were examined by the indirect immunofluorescence test. The prevalence rates varied from 33.3% in patients attending a sexually transmitted disease clinic to 97.1% in Parakana Indians. One or more pathogens were found in 55 of 86 patients presenting a clinical picture of urethritis; C. trachomatis was isolated from 11% (6/55) of these cases by inoculation to McCoy cell cultures, accounting for 30% (6/20) of the cases of non-gonococcal urethritis. C. trachomatis was isolated from one of 28 female patients (3.6%) attending gynaecology and obstetrics outpatient clinics. The positive patients had no symptom or complaint that would have suggested the diagnosis.

Prevalence of urogenital Chlamydia trachomatis infection in El Salvador. II. Gynaecology outpatients

The prevalence of urogenital infection caused by Chlamydia trachomatis was examined in 100 non-pregnant women with cervicitis, and 100 healthy women, in San Salvador City, El Salvador. Pharmacia Chlamydia EIA test was used for the detection of chlamydial antigen in urethral and cervical specimens from all the women. Direct immunofluorescence was used for confirmative tests on the EIA positive and the negative gray zone samples. C. trachomatis antigen was detected in 28% of the women with cervicitis compared with 5% in the group of healthy women (P < 0.001). The cervicitis group were also screened for Neisseria gonorrhoeae which was isolated from 12% of them. One strain out of 12 was beta-lactamase producing (PPNG). Five per cent of the women with cervicitis had simultaneous C. trachomatis and N. gonorrhoeae infections.

A randomized, comparative study of the efficacy and tolerance of roxithromycin and doxycycline in the treatment of women with positive endocervical cultures for Chlamydia trachomatis and Mycoplasma spp. in an in vitro fertilization program

A total of 45 patients wishing to enter an in vitro fertilization program had positive endocervical cultures for Chlamydia trachomatis, 86 had positive cultures for Ureaplasma urealyticum, and 11 had positive cultures for Mycoplasma hominis. These patients and their consorts were randomly allocated to treatment with either roxithromycin or doxycycline. Both antibiotics were completely effective against C. trachomatis. In patients with U. urealyticum infection, roxithromycin was successful in 73% and doxycycline in 87% of cases. Mycoplasma hominis was eradicated in 100% of cases by doxycycline and in 85% of cases by roxithromycin. Doxycycline caused significantly more side effects than did roxithromycin.

Chlamydia trachomatis: female pelvic infection

Chlamydia trachomatis is a bacterium that causes both symptomatic and asymptomatic infection. This infection has been associated with severe infections of the upper genital tract, such as salpingitis, which may be responsible for a significant number of cases of ectopic pregnancy and infertility. An unsettled question is the role of C. trachomatis in pregnant patients. In addition to causing cervicitis, it has been linked to chorioamnionitis, premature rupture of membranes, and premature delivery. However, chlamydial infection is an easily treatable disease. The main focus of prevention is appropriate prescreening of patients at risk.

Screening for cervical Chlamydia trachomatis infections in two Dutch populations

Endocervical cultures for Chlamydia trachomatis and Neisseria gonorrhoeae were taken from 492 women attending an outpatient clinic for sexually transmitted diseases (group I) and 560 women seeking legal abortion (group II). Possible risk factors for C trachomatis infection were evaluated by multivariate analysis. The prevalence rates for C trachomatis and N gonorrhoeae were 7.3% and 2.5% in group I and 9.4% and 0.4% in group II. From multivariate analysis it was found that age (p less than 0.01), number of sexual partners (p less than 0.01), abnormal vaginal discharge (p less than 0.01), and endocervical mucopus (p = 0.02) were independently associated with chlamydial infection in group I. In the abortion clinic age (p = 0.03) and endocervical mucopus (p = 0.03) were the only significant independent predictors of C trachomatis. In all women vaginal discharge was collected for Gram staining. A significant higher number of polymorphonuclear cells was seen in the smears of C trachomatis positive women (group I: p = 0.04; group II: p = 0.03). In group II there was also a significant association between C trachomatis and Gardnerella type bacterial flora (p = 0.02) and the presence of comma-shaped rods (p = 0.04). Screening for C trachomatis infection may help to decrease the incidence of (post-abortal) pelvic inflammatory disease. Because screening in abortion clinics is not always possible, decreasing the incidence of postabortal pelvic inflammatory disease could be achieved by using prophylactic antibiotics. Selective use of prophylaxis in high risk patients can minimise costs and the incidence of side effects.

Recovery of Chlamydia trachomatis from endometrial and fallopian tube biopsies in women with infertility of tubal origin

In order to examine the role of chronic active chlamydial infection in tubal infertility, cultures for Chlamydia trachomatis were performed on endometrial biopsies from 38, and fallopian tube biopsies from all, of 52 women undergoing tubal surgery for infertility. C. trachomatis was recovered from one or both sites in 8 of 52 (15%). Five of 6 women with positive fallopian tube cultures had endometrial cultures performed, and of these, 4 (80%) were positive. Three culture-positive women had been treated with tetracycline or doxycycline. Multiple blind passage in tissue culture was required for recovery of all six fallopian tube and four of the six endometrial isolates. No specific anatomic lesion was associated with documented infection. Chronic active chlamydial infection is frequently associated with tubal infertility, may persist despite therapy, and often can be detected by endometrial biopsy culture.

Abdominal pain. Chlamydia as culprit

Chlamydia trachomatis infection in the lower part of the genital tract of young girls and women may ascend to produce endometritis, salpingitis, perihepatitis, and other localized or generalized abdominal diseases. The resultant pain syndromes mimic a number of other common conditions that must be differentiated. A careful history and physical examination, with attention to historical and physical evidence of sexually transmitted disease, will alert the clinician to the possibility of chlamydial infection. Laboratory tests for C trachomatis may be helpful. However, tests of specimens from the lower genitourinary tract may yield negative results in patients with disease of the upper part of the genital tract and abdomen. Prompt recognition and treatment not only alleviate pain but also may help prevent inflammatory sequelae such as chronic painful adhesions, small-bowel obstruction, and tubal infertility. Costly workups and unnecessary surgery may also be avoided.

Screening for Chlamydia trachomatis at a university health service

Chlamydia trachomatis is the most common sexually transmitted infection in the United States. The aim of this study was to determine the prevalence of Chlamydia in college family planning patients and to identify diagnostic indicators associated with Chlamydia. A thorough history and physical examination was performed, including culture for gonorrhea, cancer (papanicolaou test), and Chlamydia trachomatis. Chlamydia occurred in 12.6% of 419 subjects. The lack of signs and symptoms and the possibility of inaccurate historical data limit the clinical predictability of chlamydial infections. Routine screening of college women is recommended.

Chlamydia trachomatis infections--the Royal Women's Hospital experience

During the 18-month period from December 1, 1985 to May 31, 1987 Chlamydia trachomatis was the most-common sexually-transmitted agent to be identified at the Royal Women's Hospital, Melbourne. It was isolated from 4% of all specimens for which such culture was requested and was found five-times more frequently than was Neisseria gonorrhoeae. A review of the clinical presentation and the management of the 100 public patient for this period whose cervical specimens were found to give positive results for the presence of chlamydiae revealed that 77% of the women were less than 25 years of age, 78% of the women were single and 65% of the women were nulliparous. Thirty-five women were asymptomatic carriers of chlamydiae. Of the remaining 65 patients with symptoms, 46% experienced pelvic pain, 39% experienced a vaginal discharge and 26% experienced irregular bleeding. The importance of abnormal bleeding is emphasized. In patients who presented for therapeutic abortions, morbidity occurred in 19% of those who were carriers of Chl. trachomatis; accordingly, screening for chlamydiae as routine is recommended in such patients. Furthermore, because of the risk of pelvic inflammatory disease and its consequences, it is important not only to treat female patients in whom chlamydiae have been isolated, but also to treat and to follow-up their sexual partners simultaneously.

Estrogen enhances attachment of Chlamydia trachomatis to human endometrial epithelial cells in vitro

Ultraviolet light-inactivated elementary bodies of Chlamydia trachomatis serovar E were fluorescently tagged with rhodamine isothiocyanate (5 micrograms/ml) and added to primary cultures of human endometrial gland epithelial cells. The elementary bodies, at a multiplicity of infection of 600:1, were allowed to adsorb to the cell monolayers for 1 hour at 35 degrees C in an atmosphere of 5% carbon dioxide. The monolayers were disaggregated by trypsinization and the individual cells were processed in the fluorescent activated cell sorter for chlamydial attachment. This method of analysis revealed attachment of C. trachomatis to approximately 50% of human endometrial gland epithelial cells. Addition of estrogen (10(-10) mol/L) to the culture medium enhanced chlamydial attachment to human endometrial gland epithelial cells to approximately 80% (p less than or equal to 0.005), and progesterone in combination with estrogen reduced chlamydial attachment in a dose-dependent fashion: 1 ng/ml progesterone, approximately 50%; 5 ng/ml, about 30%; 10 ng/ml, about 18%, respectively (p less than or equal to 0.025).

Ultrastructural study of endocytosis of Chlamydia trachomatis by McCoy cells

The entry of Chlamydia trachomatis into McCoy cells (fibroblasts) was studied by transmission electron microscopy. On adsorption of elementary bodies (EBs) to host cells at 37 degrees C, the EBs were bound primarily to preexisting cell-surface microvilli. They were also observed in coated pits located at the bases of the microvilli and along smooth surfaces of the host cells and were internalized within coated vesicles at this temperature. Postembedding immunogold labeling on Lowicryl thin sections with anti-clathrin antibody as the primary reagent revealed the gold marker localized in pits and vesicles containing chlamydiae. Some EBs were present in smooth-surfaced invaginations at or near the bases of microvilli and in vesicles devoid of distinguishable coat material. A similar entry process was observed with centrifugation-assisted inoculation of EBs onto the McCoy cells. Individual EBs were initially internalized into tightly bound endocytic vesicles. However, within 1 to 3 h postinfection, multiple C. trachomatis EBs were observed in large, loosely bound vesicles. Evidence suggests that vesicles containing C. trachomatis may have fused with one another early in the infectious process. These results indicate that chlamydiae can exploit the specific process of adsorptive endocytosis for entry into host cells and for translocation to a given intracellular destination, which may be different for each species.

Detection of Chlamydia trachomatis in adolescent females using direct immunofluorescence

Direct immunofluorescent slide tests for the detection of genital Chlamydia trachomatis have attracted considerable attention because of their speed and economy, but most evaluation trials have concentrated on adult, high-risk populations. Using 152 paired specimens, we compared the Syva Micro Trak direct specimen test with culture in a population of adolescent females attending a general adolescent medicine clinic. The direct slide test was 90 percent sensitive and 95 percent specific overall, with positive and negative predictive values of 74 percent and 98 percent, respectively. Prevalence by culture was 13 percent. Six of our 23 positive slide tests could not be confirmed by culture. A positive chlamydia culture was significantly associated with nonwhite race, a positive Gram's stain, and the presence of mucopurulent endocervical discharge, but not with oral contraceptive pill use, obstetrical history, Pap smear results, multiple sexual partners, coexisting vaginitis or gonorrhea, or a history of prior sexually transmitted diseases. The direct test appears to be an acceptable substitute for culture in higher prevalence adolescent settings and a useful screening adjunct in lower prevalence groups.

Tubal factor infertility: an association with prior chlamydial infection and asymptomatic salpingitis

In 265 Canadian women, with and without tubal factor infertility (TFI), we compared Chlamydia trachomatis cultures of endocervical swabs, endotubal swabs and biopsies, serology, and past history. A history of pelvic inflammatory disease (PID) was absent in 69.2% of TFI women, despite visual evidence of tubal damage. C. trachomatis was not isolated in any of 52 patients with TFI (TFI group), 114 having tubal ligation (STER group), or 99 patients having hysterectomy (HYST group). However, chlamydial antigen was detected with an immunochemical method in 1 of 16 tubal biopsy specimens from TFI women. The prevalence of chlamydial IgM or IgG antibody in serum was significantly higher (P less than 0.0001) in the TFI group (79.1%) than in the other two groups (relative odds, 6.3; 95% confidence interval: 2.5, 16.8). In seropositive (IgG or IgM) subjects, there was a significant (P = 0.003) and strong (relative odds, 5.1; 95% confidence interval: 1.5, 18.1) association between chlamydial IgA antibody and TFI. In women with TFI, there was no significant association between IgM or IgG seropositivity (P = 0.56). or IgA seropositivity (P = 0.53), and a negative history for PID. These findings are consistent with the hypothesis that C. trachomatis is a major cause of TFI following PID, which may or may not be asymptomatic.

Effect of blind passage and multiple sampling on recovery of Chlamydia trachomatis from urogenital specimens

Detection of chlamydial infections depends on the sensitivity of the techniques used. Variables include the number of body sites sampled, the number of samples obtained, and the number of passages in tissue culture. To assess these factors, microdilution plate cultures with a single blind passage were performed on specimens from 10,291 men and women attending a sexually transmitted disease clinic. Overall, 21% of the men and 30% of the women were culture positive. However, 18% of endocervical, 28% of female urethral, and 29% of male urethral cultures that were positive became so only after a single passage. Of culture-positive women, 23% were positive at the urethra only. Pooled urethral and endocervical specimens were positive more often than an endocervical specimen alone but less often than separately cultured endocervical and urethral specimens. A total of 221 specimens from 92 men and 66 women were subjected to five serial blind passages. Of 83 positive specimens, 29 (35%) were positive only after two or more passages. A total of 37 (46%) women were culture-positive, but only 12 (33%) of those who were positive and had an endocervical culture would have been detected by a single endocervical culture that was not passaged. The sensitivity of chlamydial culture is substantially less than 100% but can be improved by culturing samples from both the urethra and endocervix in women and by serial passage in tissue culture.