Chlamydia trachomatis associated with chronic inflammation in abdominal specimens from women selected for tuboplasty

Nitric oxide synthases and tubal ectopic pregnancies induced by Chlamydia infection: basic and clinical insights

Human ectopic pregnancy (EP) remains a common cause of pregnancy-related first trimester death. Nitric oxide (NO) is synthesized from L-arginine by three NO synthases (NOS) in different tissues, including the Fallopian tube. Studies of knockout mouse models have improved our understanding of the function of NOS isoforms in reproduction, but their roles and specific mechanisms in infection-induced tubal dysfunction have not been fully elucidated. Here, we provide an overview of the expression, regulation and possible function of NOS isoforms in the Fallopian tube, highlighting the effects of infection-induced changes in the tubal cellular microenvironment (imbalance of NO production) on tubal dysfunction and the potential involvement of NOS isoforms in tubal EP after Chlamydia trachomatis genital infection. The non-equivalent regulation of tubal NOS isoforms during the menstrual cycle suggests that endogenous ovarian steroid hormones regulate NOS in an isoform-specific manner. The current literature suggests that infection with C. trachomatis induces an inflammatory response that eventually leads to tubal epithelial destruction and functional impairment, caused by a high NO output mediated by inducible NOS (iNOS). Therefore, tissue-specific therapeutic approaches to suppress iNOS expression may help to prevent ectopic implantation in patients with prior C. trachomatis infection of the Fallopian tube.

Postsurgical adhesion formation and prevention – recent developments with regard to the consecutive stages in adhesion formation

The formation of adhesions is a significant clinical problem. Complications like bowel obstruction and chronic pelvic pain are known to be related to adhesion formation. Besides these complications, adhesions do play an additional role in the gynaecological patient. Interference with the functioning of the fallopian tubes and ovaries disturbs ovum pickup and sperm transport and may compromise the fertility of patients.

Is the prevention of genital chlamydial infections by community involvement possible?

This chapter presents different means by which community initiatives have been undertaken to reduce the prevalence and incidence of genital and allied infections caused by Chlamydia trachomatis. As most of these infections in the majority of infected individuals do not produce symptoms that are likely to urge them to attend any health care unit, screening programmes are mandatory to be able to influence the epidemic of infections with this agent. In many societies there has been a skewed gender distribution in the number of chlamydia-positive persons; this probably indicates that diagnostic service activities have been directed more against one gender than the other. The important role of partner notification, as in the case of other sexually transmitted infections, has been documented. Different means of community initiative have included counselling of school children and groups of persons more likely to be infected. Counselling by the pharmacy has an important role in many societies. Selected cohorts have been offered - via the mass media, Internet, radio and television programmes - sampling kits which can be mailed to a laboratory for testing. The establishment of youth clinics has been found effective for detecting teenagers harbouring C. trachomatis, similarly to screening at antenatal clinics. The offer of free consultations, aetiological tests and therapy has been a part of community initiatives, mimicking the services offered for some of the classic sexually transmitted infections. This chapter considers the usefulness of different test methods and stresses the need to retest those found to be positive. Barriers to the successful introduction of screening activities and diagnostic services are also considered.

Detection of Chlamydia trachomatis infection with DNA extracted from formalin-fixed paraffin-embedded tissues

It is a well-known fact that tubal stenosis and/or peritubal adhesion are often associated with Chlamydia trachomatis infection. Although tubal pregnancy may be attributed to this infection, there are only extremely rare cases in which the presence of C. trachomatis has been confirmed by immumo-histochemical examination on tissues isolated from patients with tubal pregnancy. We thus tried to confirm the presence of C. trachomatis infection by detecting DNA of the organism in tissues surgically isolated from patients with tubal pregnancy. Two detection methods, a ligase chain reaction (LCR) method and an immuno-histochemical staining which detects an antigen of C. trachomatis, were compared using paraffin-embedded tissue samples which were surgically isolated from patients with tubal pregnancy or hydrosalpinx. The LCR method was capable of detecting DNA of C. trachomatis in tissue samples in which the C. trachomatis-specific antigen could not be detected using immuno-histochemical staining. This was due to the fact that immuno-histochemical staining methods are applicable to the analysis of sequences the length of which range from 200 to 400 bp (base pairs), while the LCR method used here allows the analysis of sequences as small as 48 bp. This fact makes the LCR method a very convenient tool, as compared with immuno-histochemical methods, for analysis of the paraffin embedded tissue samples where by effects of formalin--used for fixation for pathologic diagnosis--the risk of fragmenting the DNA samples is relatively high. Presence of C. trachomatis DNA as detected by LCR method in surgically isolated samples from patients with tubal pregnancy supports the involvement of Chlamydia trachomatis infection in the occurrence of tubal pregnancy. Accordingly the LCR method is capable of detecting DNA of C. trachomatis in paraffin-embedded samples of tubal tissue in which presence of C. trachomatis could not be confirmed by an immuno-histochemical staining method.

Tubal pelvic damage: prediction and prognosis

Tubal pelvic damage is a common cause of infertility, and laparoscopy is the accepted gold standard for its diagnosis. However, laparoscopy is both costly and invasive. Chlamydia is now recognized as the most common cause of tubal pelvic damage. In contrast to laparoscopy, evidence of past chlamydial infection using serology is readily available, and the test is simple and quick to perform. As such, serology can be used as a screening test in infertile women. It is accepted that screening tests may have higher margins of error and may be less accurate than diagnostic tests. Screening is most valuable when detecting a disease for which the treatment is more effective when undertaken at the earliest opportunity. Because there are justified constraints to the indiscriminate use of laparoscopy, there is a need to minimize the number of patients who do not have disease (false positives) who are subjected to this diagnostic investigation. An appropriate Chlamydia antibody titre that would distinguish women at risk of tubal pelvic damage should be determined using diagnostic test analysis and clinical judgement. Identification by serology of women who are likely to have damage would enable these women to undergo a diagnostic test such as laparoscopy sooner, allowing treatment to be provided earlier. However, the severity of tubal pelvic damage varies, and the need to distinguish women with a favourable or unfavourable prognosis after treatment using a simple classification system is discussed.

Duration of untreated genital infections with chlamydia trachomatis: a review of the literature

BACKGROUND

Estimates of the duration of untreated genital infections with Chlamydia trachomatis vary. Accurately estimating the distribution of the duration of infection would be useful in the counseling patients, and is essential when modeling the burden of chlamydial disease and the potential impact of prevention programs.

GOAL

The authors review the scientific literature to summarize what is known about the duration of genital chlamydial infection and the factors that affect it.

STUDY DESIGN

Literature review of animal and human studies.

RESULTS

Animal studies document a longer duration of infection in primates than in mice or guinea pigs. Although animals spontaneously become culture negative over time, numerous studies document persistent nonculture evidence of chlamydiae in the upper genital tract. Studies in which women have been serially cultured suggest that most untreated infections remain culture positive for more than 60 days. Small series report that some infections may persist for years. Most infections eventually become culture negative; however, non-culture evidence of chlamydiae often persist in women with negative cultures. The duration of chlamydial infection is reduced in animals previously exposed to chlamydiae and in older humans, suggesting that partial immunity may result from exposure. Data are inadequate to define the median duration of untreated infection or to derive a curve that describes the natural history of untreated genital chlamydial infections.

CONCLUSION

Current data do not allow one to reliably estimate the duration of genital infections with C trachomatis. Systematic retesting could help to better define the duration of infection in patients who, against medical advice, delay treatment for genital chlamydial infections.

PID: clinical and laparoscopic aspects

Clinical signs of pelvic inflammatory disease (PID) are not constant and are often limited to slight pelvic pain. Laparoscopy can lead to a rapid and correct diagnosis of PID. Intrapelvic bacteriologic samples can be obtained so as to administer the proper antibiotic. The exact nature of the lesions can be evaluated, and in severe cases, recent abscesses can be treated with good results for fecundity. Because the results in cases of long-standing abscess are not so good, laparoscopy should be performed at the onset of infection and not be reserved until after some weeks of inefficient medical treatment, especially in young women who have not completed their family. In primary chronic salpingitis, the lack of any clinical signs usually leads to a delay in diagnosis until women consult for fertility problems. The ideal point would be to detect some biologic or clinical change that may lead to diagnosis such as a positive anti-Chlamydia trachomatis (CT) serology or, in the future, positive anti-CT Hsp 60 antibody could be the key to detecting and treating silent salpingitis in young women, CT being the main microorganism involved in chronic salpingitis. Screening for C. trachomatis low genital tract infection is mandatory in young people in order to control the epidemic.

Effect of immunoglobulin G isotype on the infectivity of Chlamydia trachomatis in a mouse model of intravaginal infection

It has been previously shown with an in vitro neutralization system that monoclonal antibodies (MAbs) to the major outer membrane protein (MOMP) of Chlamydia trachomatis, depending on the isotype of the MAb and the host cell used, can either neutralize or enhance the infectivity of this organism. MAbs to variable domain 4 (VD 4) of MOMP have been described that neutralize the infectivity of C. trachomatis when tested in a system in which either the host cell does not have detectable Fc gammaRIII receptors or complement is added to block the interaction of the MAb with the receptor. However, if Fc gammaRIII receptors are available, immunoglobulin G2b (IgG2b) MAbs to the VD 4 are able to enhance the infectivity of this pathogen. Two MAbs that recognize the sequence TLNPTIA in VD 4 of the MOMP but differ in isotype, E4 (IgG2b) and E21 (IgG1), were used to test whether in vivo the isotype of the MAb modulates the outcome of a vaginal infection in a murine model. A third MAb, CP33 (IgG2b), that recognizes the chlamydial lipopolysaccharide but does not neutralize infectivity of C. trachomatis, was also tested. Elementary bodies (EBs) of C. trachomatis, serovar E (BOUR), were pretreated with the three MAbs and were used to inoculate the vaginas of C3H/HeJ mice which had been pretreated with progesterone. Subsequently mice were monitored over a 5-week period with vaginal cultures. In the groups that were inoculated with EBs pretreated with MAbs directed to VD 4 of MOMP, there was a significant decrease (P < 0.05) in the number of mice infected. Only 30% of the mice were infected in the MAb E4-treated group, and 10% were infected in the MAb E21 group. This was in contrast to the groups inoculated with EBs pretreated with MAb CP33 and control untreated EBs, which resulted in 100 and 79% of the mice infected, respectively. Therefore, in this setting in which EBs were introduced in vivo coated with MAb, there was no enhancement of infection by IgG2b MAbs; rather, the results paralled the in vitro neutralization results, in which cells lacking Fc gammaRIII receptors were employed. Mice were also given the MAbs, as well as purified IgG as a control, by intraperitoneal injection before and after intravaginal inoculation with C. trachomatis. Despite relatively high levels of MAbs in serum and detectable levels of MAbs in the vagina at the time of infection, there was only modest protection in animals receiving MAb E21, with 60% of the mice infected in contrast to 90% of the mice receiving MAb E4, MAb CP33, and IgG. However, by the second week of infection compared to controls, there was a significant increase (P < 0.05) in the amount of chlamydiae recovered from the vaginas of mice that had received the two IgG2b MAbs, E4 and CP33. In summary, the presence of IgG2b MAbs directed to surface components of C. trachomatis at certain times during the course of infection may play a role in enhancing the infectivity of this pathogen.

The accuracy of serum chlamydial antibodies in the diagnosis of tubal pathology: a meta-analysis

OBJECTIVE

To assess the discriminative capacity of Chlamydia antibody titers in the diagnosis of tubed pathology in subfertile patients.

DESIGN

Meta-analysis of studies comparing Chlamydia antibody titers and laparoscopy for tubal patency and peritubal adhesions.

PATIENTS

A total of 2,729 patients with subfertility in 23 studies.

INTERVENTION(S)

Chlamydia antibody titer and laparoscopy as part of subfertility work-up.

MAIN OUTCOME MEASURE

Sensitivity and specificity of Chlamydia antibody titers in the diagnosis of tubal pathology using laparoscopy with chromopertubation as the reference standard.

RESULT(S)

The discriminative capacity of Chlamydia antibody titers depended on the type of assay that was used. Summary receiver operating characteristic (ROC) curves of studies using ELISA or (micro)immunofluorescence revealed a better discrimination than the summary ROC-curve of studies using immunoperoxidase assay.

CONCLUSION(S)

The discriminative capacity of Chlamydia antibody titers by means of ELISA, microimmunofluorescence, or immunofluorescence in the diagnosis of any tubal pathology is comparable to that of hysterosalpingography (HSG) in the diagnosis of tubal occlusion. Chlamydia antibody testing involves little burden but provides no details on the anatomy of uterus and tubes. Whether or not Chlamydia antibody testing can replace HSG depends on the perspective taken in the diagnostic work-up of subfertility.

Reproducibility problems with the AMPLICOR PCR Chlamydia trachomatis test

In an attempt to use an expanded "gold standard" in an evaluation of an antigen detection test for Chlamydia trachomatis, the AMPLICOR (Roche Diagnostics Systems, Inc., Branchburg, N.J.) PCR Chlamydia trachomatis test and culture were used with 591 sets of cervical specimens. Of the 591 specimens assayed, 35 were retested due to either an equivocal result by the PCR (19 samples) or a discrepancy between the results of culture, PCR, and the antigen detection method. During the repeat testing of the samples with equivocal and discrepant results, all but one interpretation change was due to the PCR result. In addition, upon repeat testing the PCR assay value measured in optical density units varied widely for 13 of these specimens. These 13 specimens were then tested in triplicate by the manufacturer with primers to the chlamydia plasmid and in duplicate with primers to the major outer membrane protein. Only 3 of the 13 specimens gave the same interpretation with these five replicates. In summary, reproducibility problems with the AMPLICOR test should be considered before it is incorporated as part of routine testing or used as an expanded gold standard for chlamydia testing.

Serologic responses of infertile women to the 60-kd chlamydial heat shock protein (hsp60)

OBJECTIVE

To determine whether women with Chlamydia trachomatis-associated tubal infertility are more likely than other infertile women to have antibodies to a particular region of the 60-kd chlamydial heat shock protein, hsp60.

DESIGN

Serologic responses to the chlamydial hsp60 were examined in 43 infertile women seropositive for Chlamydia trachomatis, including 21 women with tubal infertility, 13 women with endometriosis, and 9 women with other causes of infertility. Antibody responses were localized to regions of hsp60 using five nonoverlapping recombinant polypeptides.

RESULTS

Sixteen women with tubal infertility had anti-hsp60 antibodies compared with seven women with endometriosis and two women with other causes of infertility. Antibodies of 11 women with tubal infertility reacted predominantly with a region of hsp60 containing amino acids (201 to 300) compared with 1 women without tubal infertility. In contrast, antibodies that localized to the carboxyl terminus, amino acids (401 to 544), were seen equally in all groups.

CONCLUSIONS

Among seropositive infertile women, antibodies that localized to amino acids (201 to 300) were immunodominant in those with tubal infertility but not in those with infertility due to other causes.

Persistent chlamydiae: from cell culture to a paradigm for chlamydial pathogenesis

Chlamydiae are medically important bacteria responsible for a wide range of human infections and diseases. Repeated episodes of infection promote chronic inflammation associated with detrimental immune system-mediated pathologic changes. However, the true nature of chlamydial pathogenesis may encompass repeated infection superimposed upon persistent infection, which would allow for heightened immune reactivity. During the course of chlamydial infection, numerous host elaborated factors with inhibitory or modifying effects may cause alterations in the chlamydia-host cell relationship such that the organism is maintained in a nonproductive stage of growth. Abnormal or persistent chlamydiae have been recognized under a variety of cell culture systems. The numerous factors associated with altered growth suggest an innate flexibility in the developmental cycle of chlamydiae. This review evaluates in vitro studies of chlamydial persistence and correlates these model systems to features of natural chlamydial disease.

Unsuspected Chlamydia trachomatis infection and in vitro fertilization outcome

OBJECTIVE

Chlamydia trachomatis infections of the female genital tract, although a major cause of infertility, are often asymptomatic and undetected. Since many infertile women now seek in vitro fertilization, a procedure whereby fertilization and embryo implantation are precisely timed, we sought to determine the relation between an unsuspected C. trachomatis infection and the ability of embryos to implant and develop after their transfer to the uterus.

STUDY DESIGN

At the time of oocyte aspiration, endocervical samples were obtained from 216 women and assayed by enzyme-linked immunoassay for immunoglobulin A antibodies to C. trachomatis structural membrane components and to recombinant C. trachomatis heat shock protein. The presence of C. trachomatis in the cervices was assessed by the polymerase chain reaction. The outcome of each in vitro fertilization cycle was then ascertained.

RESULTS

Oocytes from 198 (91.7%) of the women were fertilized in vitro and subsequently transferred to the uterus. Term deliveries of healthy infants occurred after 68 (34.3%) of these transfers. Cervical immunoglobulin A antibodies to chlamydial heat shock protein were detected in 5 (7.3%) of the women with term births, and 1 (1.5%) also had immunoglobulin A antibody to chlamydial structural components; 3 (4.4%) were positive by the polymerase chain reaction for C. trachomatis. In contrast, among the 130 women whose embryo transfers did not result in an ongoing pregnancy, 36 (27.7%) had cervical antiheat shock protein immunoglobulin A (p = 0.0007) and 24 (18.5%) had antichlamydial structural component immunoglobulin A (p = 0.0002); 15 (11.5%) of these women had positive results of polymerase chain reaction for C. trachomatis. The majority of women with cervical antibodies to chlamydial structural antigens were also positive for antibody to heat shock protein. However, only 35% of the women with antibodies to heat shock protein were also positive for the other chlamydial antibodies. C. trachomatis was detected by polymerase chain reaction in 29.2% of women with anti-C. trachomatis antibodies and 7.8% of women with anti-heat shock protein antibodies. Women positive for antichlamydial immunoglobulin A were more likely to be undergoing a repeat in vitro fertilization cycle than were women who were antibody negative (p = 0.007).

CONCLUSION

Unsuspected C. trachomatis infection or reactivation of an immune response to the C. trachomatis heat shock protein may induce an inflammatory reaction in the uterus that impairs embryo implantation and/or facilitates immune rejection after uterine transfer of in vitro fertilized embryos.

Chlamydia trachomatis-specific antibodies in patients with pelvic inflammatory disease: comparison with isolation in tissue culture or detection with polymerase chain reaction

OBJECTIVE

The detection of acute phase antibodies against C trachomatis and its comparison with tissue culture or polymerase chain reaction (PCR) on samples of cervix and urethra obtained from patients with pelvic inflammatory disease (PID).

METHODS

In the academic hospital Dijkzigt, Rotterdam, The Netherlands, prospective investigations were performed on 49 consecutive patients who were admitted with the diagnosis of PID. Infections with C trachomatis were traced using tissue culture, PCR or by determining acute phase IgG and IgM antibodies. Differences between the sensitivities of serology and tissue culture or PCR were calculated using the Fisher exact test.

RESULTS

C trachomatis infection was detected more often in PID patients using serology in comparison with PCR (p < 0.05) or tissue culture (p < 0.05). All patients who were positive in tissue culture also had acute phase antibodies.

CONCLUSION

The establishing of acute C trachomatis infections in PID patients on the basis of serology was superior to either tissue culture or PCR on samples obtained from cervix and urethra.

Detection of Chlamydia trachomatis deoxyribonucleic acid in monkey models (Macaca nemestrina) of salpingitis by in situ hybridization: implications for pathogenesis

OBJECTIVE

Our purpose was to determine whether Chlamydia trachomatis persists in tubal tissues from monkey pocket models of chlamydial salpingitis and tubal infertility and to relate its presence to disease progression and histopathologic mechanisms.

STUDY DESIGN

In situ hybridization was used to detect Chlamydia deoxyribonucleic acid in a monkey pocket model of salpingitis and in the direct tubal inoculation monkey model of tubal infertility. Results were correlated with culture and immunocytochemistry results and histopathologic characteristics.

RESULTS

Chlamydia deoxyribonucleic acid was detected in the mucosa, submucosa, and deep tissues in the pocket model. In addition, it was present in peritubal adhesions from the direct inoculation model. Deoxyribonucleic acid was found at sites of inflammation and when culture and immunocytochemistry studies were negative.

CONCLUSION

The presence of Chlamydia trachomatis deoxyribonucleic acid at sites of inflammation and tissue damage in monkey models of chlamydial salpingitis and tubal infertility suggests that Chlamydia persists and may be directly involved in the stimulation of the immune-mediated tissue destruction associated with Chlamydia trachomatis infections.

Detection of Chlamydia trachomatis in fallopian tube tissue in women with postinfectious tubal infertility

OBJECTIVE

Biopsy tissues from women with postinfectious tubal infertility were studied for the presence of Chlamydia trachomatis.

STUDY DESIGN

Tubal biopsy specimens from 25 women with postinfectious tubal infertility undergoing laparoscopy for repair of fallopian tubes were evaluated by culture, in situ hybridization. Immunocytochemistry, and transmission electron microscopy for the presence of Chlamydia trachomatis. Serum was also tested for Chlamydia trachomatis antibodies.

RESULTS

Chlamydia trachomatis was detected in postinfectious tubal biopsy specimens in three of 25 patients by culture, 12 of 24 by in situ hybridization, 15 of 22 by immunoperoxidase stain, and two of 10 by transmission electron microscopy. Serum antibody against Chlamydia trachomatis was detected in 15 of 21 patients.

CONCLUSION

Chlamydia trachomatis deoxyribonucleic acid or antigens were detected at a high percentage (19/24 women) in the biopsy tissues of the fimbrial and peritubal adhesions by in situ hybridization or immunoperoxidase stain, suggesting a persistent infection in these women even after antibiotic treatment.

Characteristics of women under fertility investigation with IgA/IgG seropositivity for Chlamydia trachomatis

Chlamydial serology was performed in a group of 100 consecutive women and their partners under fertility investigation. Over one-quarter of the women had evidence of an ongoing, asymptomatic chlamydial infection. A significantly higher incidence of IgA-positivity was associated with women with evidence of tubal pathology, verified by hysterosalpingography and/or laparoscopy and with previous users of intrauterine devices. The male partners of IgA-positive women had a significantly higher incidence of IgA-positivity than the other men. However, this was not associated with an increase in sperm pathology relative to the controls. The study indicates that chlamydial serology should be integrated into the routine screening of women under fertility investigation regardless of previous history and that IgA serology provides more information about tubal pathology than IgG serology.

Chlamydia trachomatis in infertile Greek women. A serologic and laparoscopic study

This study investigates the prevalence of antichlamydial antibodies in infertile women, who underwent diagnostic laparoscopy. The patients were divided into two groups based on the presence or absence of damage of the fallopian tubes. Antichlamydial IgG antibodies were found in 22 of 27 (81.5%) infertile women with damaged fallopian tubes and 10 of 23 (43.5%) women with normal tubes. Mean geometric IgG titres for C. trachomatis were significantly higher in the patients with damaged tubes (187.4 vs. 39.39). C. trachomatis was not isolated from the peritoneal fluids. Only two chlamydial cultures of cervical specimens were positive, one in each group. These findings confirm that C. trachomatis may be a major cause of tubal damage with resultant infertility.

Chlamydial antibodies and deoxyribonucleic acid in patients with ectopic pregnancy

OBJECTIVE

To evaluate the importance of previous and persisting chlamydial infection for ectopic pregnancy (EP).

DESIGN

A prospective study of women with EP.

SETTING

Hospitalized patients.

PATIENTS AND CONTROLS

Eighty-six women with EP with (group I; n = 35) or without (group II; n = 51) risk factors for EP and chlamydial infection. Age-matched normally pregnant women served as controls.

INTERVENTIONS

Blood samples were drawn from patients and controls for antibody determination.

MAIN OUTCOME MEASURES

The frequency of immunoglobulin G antibodies was compared between patients and controls, and the polymerase chain reaction (PCR) was used to detect chlamydial deoxyribonucleic acid (DNA) in tubal tissue from 33 patients (70 specimens).

RESULTS

Immunoglobulin G antibodies (titer greater than or equal to 32) were significantly more common among patients than in controls (51% versus 31%, P less than 0.025). The difference was more pronounced between group I and controls (69% versus 31%, P less than 0.005). Chlamydial DNA was not detected in any tubal specimen.

CONCLUSIONS

An association was found between previous chlamydial infection (serologically) and EP, especially in women with risk factors, but no evidence of persisting chlamydial infection in the tubes could be demonstrated using PCR.

Increased inducibility of inflammatory mediators from peripheral blood mononuclear cells of women with salpingitis

To investigate whether immune system activation may contribute to the tissue damage observed in salpingitis, we isolated peripheral blood mononuclear cells and quantitated production of the monocyte activation products tumor necrosis factor-alpha, interleukin-1, and interleukin-6. Unstimulated cells from 7 of 20 women with salpingitis spontaneously released tumor necrosis factor at a concentration greater than 2 SD above the mean value produced by cells from 29 healthy donors. Interferon gamma (200 U/ml) further induced production of tumor necrosis factor from mononuclear cells of 11 women with salpingitis. In contrast, production of tumor necrosis factor by each of 23 other patients who lacked laparoscopic or clinical evidence of salpingitis was similar to that of the controls. In a subset of women whose cells were tested for production of other monokines, three of nine women with salpingitis spontaneously released interleukin-1 but none of the others did so. Four of nine patients with salpingitis also produced interleukin-6, but none of the others did so. None of the monokines were detected in serum from any subject. The results suggest that monocytes from women with salpingitis are primed in vivo and produce inflammatory mediators under conditions where monocytes from other women are poorly responsive. This increased monokine inducibility may contribute to the tubal damage that is the hallmark of salpingitis.

Chlamydial IgG and IgA in serum and follicular fluid among patients undergoing in vitro fertilisation

The point prevalence of IgG and IgA antibodies to Chlamydia was analyzed in serum and follicular fluid in 63 patients undergoing in vitro fertilisation (IVF) in comparison to sera of 298 healthy women by the single serovar (L2) inclusion immunoperoxidase assay (IPA). The presence of specific IgG and IgA to Chlamydia in follicular fluid was demonstrated. No statistical association was found between the presence of specific Chlamydia IgG and IgA in serum and follicular fluid to oocyte fertilization. The positive predictive value for mechanical infertility of Chlamydia IgG at titers of greater than or equal to 128 and IgA titers at greater than or equal to 16 was 91 and 92%, respectively, in this high-risk group for mechanical infertility. Multiple regression analysis singled out Chlamydia IgG levels as a major contributor to the variance between the groups of infertile patients.

Chlamydia trachomatis: the prevalence, trend and importance in initial infertility management

One thousand and five women, and 354 of their partners, attending an infertility clinic have been assessed for the presence of Chlamydia trachomatis antibodies in their serum. The overall prevalence in women was 12.4% (125/1,005) but appeared to have increased over a 2-year period. A similar trend was not apparent for men and the prevalence was only 4.2% (15/354). Of the 125 seropositive women 81 had their pelvis examined for the first time by laparoscopy. Fifty seven had tubal disease of varying severity, but only 16 had had an ectopic pregnancy or admitted to a previous history of pelvic inflammatory disease or nonspecific urethritis. These findings suggest that laboratory testing for chlamydial antibodies should be routine in the initial investigation of an infertile couple and that early laparoscopy is indicated in seropositive women.

The correlation between Chlamydia antigen, antibody, vaginal colonization and contraceptive method in young unmarried women

In a group of 55 unmarried women, mean age 25 years, attending a family planning clinic and having minor gynecological complaints, the correlation between Chlamydia trachomatis (CT) antigen, CT antibodies, vaginal colonization by Candida or bacteria and the method of contraception was investigated. The correlation between CT antigen and CT antibodies (IgG) was significant in oral contraceptive users (p = 0.003), as was the correlation with vaginal colonization by Candida and potential pathologic bacteria. In the group using the natural family planning method, a statistically significant correlation was found between CT antigen, IgG (p = 0.002), IgA (p = 0.02) antibodies, and vaginal candidiasis (p = 0.002), but not with bacterial colonization (p = 0.90). The discrepancy between CT antigen and antibodies is discussed. Differences in the prevalence of Chlamydia trachomatis infection were found among groups using different birth control methods, indicating an association between Chlamydia infection and the contraceptive method used.

Dose previous Chlamydia trachomatis infection influence the pregnancy rate of in vitro fertilization and embryo replacement?

The association between previous chlamydial infection, as reflected by the presence of chlamydial antibodies (specific serum immunoglobulin G antibodies with a titer greater than or equal to 32) and pregnancy outcome after in vitro fertilization and embryo replacement was studied in 121 infertile women with tubal damage. The antibody prevalence was 74.4%; the overall pregnancy rate was 26.4%. No difference in seropositivity was detected between those who became pregnant and those who did not (71.9% versus 75.3%). The geometric mean titers were also similar in the two groups. Even after subdivision of the cases into primary or repeated in vitro fertilization attempts, or after stratification of the material according to the number of embryos used for replacement, there was no correlation between chlamydial antibodies and pregnancy rate. Thus, past infection with Chlamydia trachomatis did not influence the outcome of in vitro fertilization and embryo replacement treatment in this study.

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.

The incidence of urogenital Chlamydia trachomatis infections among patients in Kumasi, Ghana

The incidence of urogenital chlamydia infections among selected patients in Kumasi, Ghana was evaluated using an immunofluorescent monoclonal antibody technique. Chlamydia trachomatis was identified in 4 of 110 patients presenting for prenatal care, 2 of 55 female patients with infertility and 6 of 15 males with acute urethritis. The findings demonstrate that C. trachomatis is a frequently identified pathogen among male patients presenting with symptoms of acute urethritis; however, the incidence of chlamydia infections among asymptomatic patients is relatively low.

Chlamydia specific IgG and IgA antibodies in women with obstructive infertility as determined by immunoblotting and immunoperoxidase assays

The prevalence rate of IgG and IgA antibodies to Chlamydia was analyzed in 50 women with laparoscopy-verified tubal infertility and in 50 age-matched control women by single serovar (L2) inclusion immunoperoxidase assay (IPA) and by immunoblotting technique (IB). Women with tubal infertility had significantly (p less than 0.001) elevated IPA Chlamydia IgG antibody titer greater than or equal to 128 and greater than or equal to 256 than controls (64% vs 16%. Odds ratios = 9.3 and 50% vs 10%, Odds ratio = 9 respectively). The prevalence rate of IPA IgA antibody titer (greater than or equal to 16) to Chlamydia was also significantly higher (p less than 0.001) in women with tubal infertility than controls (48% vs 8%, Odds ratio = 10.6). Antibodies to at least 19 chlamydial structural polypeptides ranging in molecular weight from 30 kD to 204 kD, were detected by the IB technique in the IPA seropositive sera. Antibodies to 57-60 kD were detectable in almost all the IPA IgG and IgA seropositive sera. The prevalence rate of IgG antibody to 57 kD-60 kD was significantly higher in women with obstructive infertility than healthy woman (84% vs. 56% p less than 0.01; Odds ratio = 3.8). More significantly, higher differences to 57-60 kD polypeptide were found in the case of IgA between the infertile women and controls (52% vs. 10%, p less than 0.001; Odds ratio = 9.7). The significance of IPA and IB technique for screening of infertile women is discussed.

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.

Infertility and chlamydial infection

The prevalence of humoral IgG and IgM antibodies to Chlamydia trachomatis was determined in 105 infertile women who underwent laparoscopy and/or laparatomy, and 90 pregnant women without any known fertility problems (control group). For chlamydial culture, cervical and urethral specimens were collected both from the infertile and the pregnant women, whereas specimens from the fallopian tubes were collected from the infertile women only. Among infertile subjects with abnormal fallopian tube findings, the prevalence of IgG as well as IgM antibodies to C. trachomatis was significantly higher than in the control group (P less than or equal to 0.001). Similar statistically significant differences in antichlamydial geometric mean titer (GMT) also were observed in sera from infertile subjects with fallopian tube abnormalities and the controls. The chlamydial isolation rate from lower genital samples was low both among the infertile and pregnant women. All tubal samples were culture negative. The present study indicates a close connection between infertility of tubal etiology and an immune response to C. trachomatis. The possibility of active or recent chlamydial activity in at least some of these infertile subjects is discussed.

Microbiologic study of chronic inflammation associated with tubal factor infertility: role of Chlamydia trachomatis

One hundred sixty-one women undergoing laparoscopy for infertility of obstructive origin (fallopian tube stenosis or obstruction and periadnexal adhesions) had thorough bacteriologic studies, including Chlamydia trachomatis cultures, of their lower and upper genital tracts. Peritoneal or tubal fluid cytologic features and biopsies of fallopian tubes or adhesions were also studied after each laparoscopy. The serum of each woman was titrated for evidence of C. trachomatis infection. The sera of a control group of 51 women with ovarian infertility but normal fallopian tubes according to laparoscopy and hysterosalpingogram were titrated in an identical manner. The current study confirms previous studies that showed a strong correlation between infertility due to fallopian tube factors and positive C. trachomatis cultures or serologic studies. The current study suggests that C. trachomatis infection does not correlate with a past history of salpingitis or pelvic pain, but that current C. trachomatis infection, as assessed by positive culture, does correlate with gross and histologic evidence of chronic inflammation.

Serologic evidence of prior chlamydial infection in patients with tubal ectopic pregnancy and contralateral tubal disease

Oviductal damage from infectious salpingitis is a principle cause of ectopic pregnancy. To examine the role of Chlamydia trachomatis in patients with ectopic pregnancy, 24 patients undergoing laparotomy for ectopic pregnancy were evaluated by assessment of chlamydial serology and chlamydial cultures of tubal biopsy specimens. The patients were divided into two groups based on the presence or absence of gross abnormalities in the fallopian tube contralateral to the ectopic gestation. Ten patients in group I showed gross evidence of chronic salpingitis in the contralateral tube; 14 patients in group II had normal-appearing contralateral tubes. Chlamydial cultures were negative in both groups. Chlamydial immunoglobulin M antibodies assayed by indirect microimmunofluorescence were negative in both groups (less than or equal to 1:32). Mean geometric immunoglobulin G titers for C. trachomatis were significantly higher in the patients with evidence of contralateral chronic salpingitis (78.9 versus 13.1). These findings suggest that C. trachomatis may be a major cause of oviductal damage, which predisposes to ectopic pregnancy.

Fallopian tube obstruction as a sequela to Chlamydia trachomatis infection

The association of tubal infertility and ectopic pregnancy with Chlamydia trachomatis infection was investigated using a case-control study design. Although culture methods failed to document active chlamydial infection in the majority of cases, serology revealed a significant association of Chlamydia trachomatis antibody with tubal infertility and ectopic pregnancy. Thirteen of 18 (72%) women with tubal factor infertility and 18 of 32 (56%) women with ectopic pregnancy had antibodies to Chlamydia trachomatis as compared to 11 of 49 (22%) normal pregnant controls. Interestingly, only 7 of 18 (39%) infertile women and 5 of 36 (14%) women with ectopic pregnancy recalled a history of pelvic inflammatory disease. These results suggest that chlamydia-associated salpingitis, whether clinically evident or subclinical, is a major contributor to diseases of tubal dysfunction.

Infection control considerations for in vitro fertilization and embryo transfer programs

In vitro fertilization and embryo transfer (IVF-ET) is a process in which human ova are obtained by laparoscopic ovarian follicular puncture, fertilized in vitro by capacitated donor sperm, and introduced transcervically into the uterus. The prospective mother's ovarian cycle is usually stimulated with either clomiphene citrate, human menopausal gonadotropin, or both, so that multiple aspiratable follicles are produced. Follicular development is monitored by ultrasound and by serial serum or urine estrogen determinations. When adequate follicular development has been achieved, a pre-ovulatory dose of human chorionic gonadotropin is administered.

Residues of pelvic inflammatory disease in intrauterine device users: a result of the intrauterine device or Chlamydia trachomatis infection?

It is currently believed that intrauterine devices cause pelvic inflammatory disease and tubal infertility. To investigate this concept further, we evaluated 245 infertile patients for inflammatory residues by laparoscopy or laparotomy; 176 patients had not used an intrauterine device and 69 had used one. Chlamydial antibody titers were performed on all patients. Although users had a higher overall prevalence of inflammatory residues than nonusers, there was no difference in residue prevalence for either group at the same titer level. No specific type of device appeared to be associated with either an increased or decreased residue frequency. "Silent" chlamydial infections occurred with equal frequency in both users and nonusers. We conclude that inflammatory residues and tubal infertility in intrauterine device users are not caused by the intrauterine device but by both overt and silent chlamydial infections.

Failure of in vitro fertilization and embryo replacement following infection with Chlamydia trachomatis

Antibodies to Chlamydia trachomatis were detected in 54 (47.4%) of 114 infertile women attending Bourn Hall Clinic. Antibodies were solely of the IgG class and mainly of a low titer, suggesting past infection. Antibodies were found in significantly more patients with tubal damage (54.4%) than in women whose infertility was due to other causes (16.6%). Seventy-two women completed in vitro fertilization, with 52 having three embryos replaced. We found that this treatment offered the optimum chance of a pregnancy being established, and 20 (38.5%) of these women became pregnant. Antibodies to C. trachomatis were present in only six (30.0%) of the women becoming pregnant, whereas antibodies were found in 21 (65.6%) of those who failed to become pregnant. Thus past infection with C. trachomatis halved the success rate of in vitro fertilization in these patients. The implications of these findings are relevant to all aspects of infertility from prevention to in vitro fertilization treatment.

Recovery of Chlamydia trachomatis from the endometrium in infertile women with serum antichlamydial antibodies

Upper genital tract infection with Chlamydia trachomatis appears to be a frequent cause of salpingitis and tubal infertility. However, the prevalence of active infection in women with infertility has not been well-defined. To examine this question, endocervical and endometrial cultures for C. trachomatis were obtained from infertile women with serum antibodies to C. trachomatis. The first 19 consecutive patients with titers greater than or equal to 1/32 were cultured. C. trachomatis was recovered from the endometrium or endocervix in six (32%) of the women examined and from the endometrium in five (26%). These findings indicate that a significant portion of infertile women with serum antichlamydial antibodies may have active upper genital tract infection with C. trachomatis at the time of presentation.

Prophylactic antibiotics in obstetrics and gynecology

Studies throughout the world demonstrate the effectiveness of prophylactic antibiotics in vaginal hysterectomy and cesarean section. Febrile morbidity is reduced by more than one half, and pelvic infections are reduced one third to one fifth, respectively. Prophylactic antibiotics are most beneficial in high-risk cesarean section, such as in patients in labor and with ruptured membranes. In abdominal hysterectomy, the effect of prophylactic antibiotics is less pronounced, and the results of the individual studies are more controversial. Prophylactic antibiotics are commonly used in extensive oncologic surgery, infertility surgery, and in other procedures, but data for adequate evaluation are lacking. First- and second-generation cephalosporins are the antibiotics most frequently used. In vaginal hysterectomies, a single preoperative dose, and in cesarean section, three perioperative doses seem to be adequate. Infections occurring despite prophylactic antibiotics are often caused by resistant organisms.

Inhibition of growth of Chlamydia trachomatis by human gamma interferon

Treatment of HEp-2 cell cultures with highly purified human gamma interferon before infection resulted in the reduction of Chlamydia trachomatis (L2/434/Bu) infectious particle yield. Electron microscope studies showed that interferon did not affect chlamydial conversion to reticulate bodies but influenced the extent of maturation to elementary bodies. High interferon concentrations (greater than 350 IU/ml) inhibited inclusion body formation and resulted in the appearance of aberrant reticulate bodies.

Lack of association between genital mycoplasmas and infertility

We studied the relation between colonization with Mycoplasma hominis and Ureaplasma urealyticum, and the results of infertility studies in 205 women with involuntary infertility of at least one year's duration. Isolation of M. hominis (but not of U. urealyticum) was significantly (P = 0.002) more common in patients with a history of pelvic inflammatory disease. However, no relation could be shown between these genital mycoplasmas and any of the following: evidence of prior pelvic inflammatory disease as determined by hysterosalpingography and laparoscopy; cervical inflammation; numbers and motility of spermatozoa on postcoital test; pyosemia; quality of cervical mucus; whether the cause of infertility was related to male or female factors, both, or neither; and occurrence and outcome of subsequent pregnancy. Mycoplasmas were cultured from only 10 of 203 endometrial biopsy specimens (4.9 per cent), and in no instance was inflammation associated with this finding. Out studies do not support a role for genital mycoplasmas in the cause of infertility.

Patterns of adnexal inflammatory damage: Chlamydia, the intrauterine device, and history of pelvic inflammatory disease

In a study of 204 consecutive infertile couples, 58 women with adnexal abnormalities consistent with prior pelvic infection were identified. The status of those 58 subjects with respect to prior pelvic infection, prior intrauterine device use, and serologic evidence of past chlamydial infection was correlated with the types of adnexal abnormalities identified. Women with serologic evidence of past chlamydial infection were more likely to exhibit severe adhesions and hydrosalpinx formation, and hydrosalpinx formation was related to a history of clinically detected pelvic infection.

Infertility after acute salpingitis with special reference to Chlamydia trachomatis

Of 552 women with laparoscopically verified acute salpingitis (AS), 299 were reviewed 2.5 to 7.5 years later. Cervical secretions from these women had been cultured for the presence of Chlamydia trachomatis and Neisseria gonorrhoeae. For 49 of 82 women with visually normal pelvic organs, such cultures were also performed; these women served as control subjects. In women exposing themselves to pregnancy, 50 (23.3%) of 197 AS patients and 2 (6.7%) of 30 control women were infertile for at least 1 year (P less than 0.02). After one episode of AS, women harboring chlamydiae, gonococci, both, or neither of these microorganisms in the cervix on admission seemed to have the same fertility prognosis. Infertility was correlated with the number of AS episodes, the erythrocyte sedimentation rate (millimeters per hour) at admission, and the severity of the inflammatory reactions of the tubes. The use of oral contraceptives at admission was found to be a positive prognostic factor regarding fertility. Oral contraceptives might protect the patient from severe tubal inflammatory reactions.

Evidence of prior pelvic inflammatory disease and its relationship to Chlamydia trachomatis antibody and intrauterine contraceptive device use in infertile women

A total of 204 infertile women attending the Infertility Clinic of the Medical Center Hospital of Vermont were studied for the possible role of Chlamydia trachomatis and intrauterine contraceptive device (IUCD) use as factors related to their infertility. All patients had had at least 1 year of involuntary infertility. All but one woman had negative cultures for C. trachomatis, but a highly significant correlation (p less than 0.001) was evident between evidence of prior pelvic inflammatory disease (PPID) as documented by hysterosalpingograms and/or laparoscopy and the prevalence of chlamydial antibody. Furthermore, a significant (p = 0.01) correlation could be shown between the prevalence of the antibodies and adnexal adhesions. IUCD use could also be shown between the prevalence of the antibodies and adnexal adhesions. IUCD use could also be shown to correlate significantly (p less than 0.001) with PPID, and a detailed statistical analysis indicated that the two factors, antibody to C. trachomatis and a history of IUCD use, were independently related to PPID. Only about one third of the patients with PPID could ever recall having had an illness consistent with PID. Subsequent to the infertility workup, 76 of these women became pregnant and there was a significant (p less than 0.001) correlation between the occurrence of ectopic pregnancy and antibody to C. trachomatis. A significant (p = 0.01) correlation was also noted between a history of IUCD use and subsequent ectopic pregnancy. From these data it appears that antecedent infection with C. trachomatis, as measured by antibody prevalence, and a history of IUCD use are important factors in infertility of tubal origin and are also related to ectopic pregnancy.