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

Risk factors of tubal infertility in a tertiary hospital in a low-resource setting: a case-control study

BACKGROUND

Infertility is the inability to sustain a pregnancy in a woman with regular (2-3 times per week) unprotected sexual intercourse for a period of 1 year. This is a major public health problem that remains under-recognised in Cameroon and most countries in sub-Saharan Africa. This study aimed at identifying the risk factors associated with tubal infertility in a tertiary hospital in Douala, Cameroon.

METHODS

We conducted a case-control study at the Obstetrics, Gynaecology and Radiology Departments of the Douala Referral Hospital from October 1, 2016, to July 30, 2017. We recruited 77 women with tubal infertility diagnosed using hysterosalpingography and 154 unmatched pregnant women served as controls. Data on socio-demographic, reproductive and sexual health, and radiologic assessments were collected using a pretested questionnaire. The data were analysed using the Statistical Package for the Social Sciences (SPSS) software version 24.0. Logistic regression models were fitted to identify demographic, reproductive health factors, surgical, medical and toxicological factors associated with tubal infertility. The adjusted odds ratios (AOR) and their 95% confidence interval were interpreted. Statistical significance set at p < 0.05.

RESULTS

Sixty-one per cent of respondents had secondary infertility. Following multivariate logistic regression analysis, respondents who were housewives (AOR 10.7; 95% CI: 1.68-8.41, p = 0.012), self-employed (AOR 17.1; 95% CI: 2.52-115.8, p = 0.004), with a history of Chlamydia trachomatis infection (AOR 17.1; 95% CI: 3.4-85.5, p = 0.001), with Mycoplasma infection (AOR 5.1; 95% CI: 1.19-22.02, p = 0.03), with ovarian cyst (AOR 20.5; 95% CI: 2.5-168.7, p = 0.005), with uterine fibroid (AOR 62.4; 95% CI: 4.8-803.2, p = 0.002), have undergone pelvic surgery (AOR 2.3; 95% CI: 1.0-5.5, p = 0.05), have undergone other surgeries (AOR 49.8; 95% CI: 6.2-400, p = 0.000), diabetic patients (AOR 10.5; 95% CI 1.0-113.4, p = 0.05) and those with chronic pelvic pain (AOR 7.3; 95% CI: 3.2-17.1, p = 0.000) were significantly associated with tubal infertility while the young aged from 15 to 25 (AOR 0.07; 95% CI: 0.01-0.67, 0.021), those in monogamous marriages (AOR 0.05; 95% CI: 0.003-1.02, p = 0.05), as well as those with a history of barrier contraceptive methods (condom) (AOR 0.17; 95% CI: 0.03-1.1, p = 0.06) were less likely to have tubal infertility.

CONCLUSION

The following factors were independently associated with tubal infertility: being a housewife, self-employed, history of Chlamydia trachomatis, Mycoplasma infection, and uterine fibroid. Furthermore, a history of pelvic surgery and other surgeries, diabetes mellitus, and chronic pelvic pain were also associated with tubal infertility. Young age, persons in monogamous marriages and users of barrier methods of contraception (condom) were less likely to have tubal infertility. Identification of these factors will be a target of intervention to avoid tubal infertility.

Identifying a role for Toll-like receptor 3 in the innate immune response to Chlamydia muridarum infection in murine oviduct epithelial cells

Because epithelial cells are the major cell type productively infected with Chlamydia during genital tract infections, the overall goal of our research was to understand the contribution of infected epithelial cells to the host defense. We previously showed that Toll-like receptor 3 (TLR3) is the critical pattern recognition receptor in oviduct epithelial (OE) cells that is stimulated during Chlamydia infection, resulting in the synthesis of beta interferon (IFN-β). Here, we present data that implicates TLR3 in the expression of a multitude of other innate-inflammatory immune modulators including interleukin-6 (IL-6), CXCL10, CXCL16, and CCL5. We demonstrate that Chlamydia-induced expression of these cytokines is severely disrupted in TLR3-deficient OE cells, whereas Chlamydia replication in the TLR3-deficient cells is more efficient than in wild-type OE cells. Pretreatment of the TLR3-deficient OE cells with 50 U of IFN-β/ml prior to infection diminished Chlamydia replication and restored the ability of Chlamydia infection to induce IL-6, CXCL10, and CCL5 expression in TLR3-deficient OE cells; however, CXCL16 induction was not restored by IFN-β preincubation. Our findings were corroborated in pathway-focused PCR arrays, which demonstrated a multitude of different inflammatory genes that were defectively regulated during Chlamydia infection of the TLR3-deficient OE cells, and we found that some of these genes were induced only when IFN-β was added prior to infection. Our OE cell data implicate TLR3 as an essential inducer of IFN-β and other inflammatory mediators by epithelial cells during Chlamydia infection and highlight the contribution of TLR3 to the inflammatory cytokine response.

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.

Chlamydia trachomatis urogenital infection in women with infertility

PURPOSE

The study objective was to evaluate the prevalence of urogenital Chlamydia trachomatis (C.tr.) infection in women with diagnosed infertility.

MATERIAL AND METHODS

The study involved patients from the Department of Gynecological Endocrinology and from the Center for Reproductive Medicine "Kriobank" in Bialystok. Female patients (n=71), aged 23-41, were divided into two groups according to the main diagnosis: A--tubal infertility (23) and B--infertility of another origin (48). For direct testing, PCR method was used to detect C.tr. infection in cervical samples (Roche, Molecular Systems, N.J., USA). Specific IgA and IgG anti-chlamydial antibodies in the serum were determined by immunoenzymatic assay (medac, Hamburg, Germany). Diagnostic procedures were performed at the Centre for STD Research and Diagnostics in Bialystok.

RESULTS

In group A, C.tr. infection was detected in: 8.7% patients, in group B--8.3%. Specific anti-C.tr. antibodies IgA were detected in: 13.0% in group A and 6.3% in group B, IgG respectively in 39.1% and in 10.4%.

CONCLUSIONS

1. C.tr. infection is very important etiological factor of female infertility. 2. The detection of specific antichlamydial antibodies is a valuable, noninvasive diagnostic procedure. 3. Infertile women should be routinely tested for C.tr. infection.

Deoxyribonucleic acid of Chlamydia trachomatis in fresh tissue from the Fallopian tubes of patients with ectopic pregnancy

OBJECTIVES

The role of persistent chlamydial infection of the Fallopian tubes in ectopic pregnancy is still unresolved. Therefore, we examined tissue of the Fallopian tubes from patients with ectopic pregnancy for the presence of Chlamydia trachomatis. In addition, other markers of C. trachomatis infection implicated in the pathogenesis of tubal damage were studied including antibodies to heat shock protein 60 of chlamydial and human origin.

STUDY DESIGN

Fresh frozen tubal tissue from 55 patients with ectopic pregnancy in a hospital setting were examined for the presence of C. trachomatis DNA by polymerase chain reaction (PCR) and blood sample were analysed for antibodies to C. trachomatis including heat shock protein 60 (hsp60).

RESULTS

Chlamydial DNA was not detected in any of the 55 tubal specimens using a commercial test, Cobas Amplicor, Roche, and an in-house real time PCR able to detect a few copies of the organism. Logistic regression showed that chlamydial IgG antibodies were more common in a subgroup of patients with previous PID than in controls (OR=7.84, CI 1.78-34.6). Specific antibodies to hsp60 of chlamydial (OR=7.00, CI 1.50-32.6) but not of human origin (OR=2.13, CI 0.14-31.6) were associated with ectopic pregnancy in this group.

CONCLUSIONS

No evidence of persistent infection of C. trachomatis in the fallopian tubes at the time of ectopic pregnancy was found in this study.

Chlamydiae in oviducts and uteri of repeat breeder pigs

Chlamydial infections of the genital organs cause reproductive failure in female pigs, and the uterus is recognized a target tissue for an infection. In contrast, information on the effect of chlamydiae on the porcine oviduct is patchily and inconclusive, although the bacteria are known to cause severe tubal defects in humans and laboratory animals. The aim of this study was to examine the segments ampulla (A), isthmus (I) and utero-tubal junction of the left (n=20) or both (n=22) oviducts, and uteri (U) from 42 culled repeat breeder pigs for chlamydiae using ompA-PCR, partial ompA gene sequencing, immunohistochemistry (IHC) and microscopy of tissue specimens for histopathology. As revealed by PCR, among a total of 26 chlamydia-positive females, 19 were tested positive in one or more segments of one or both oviducts, 14 were found positive in the uterus, and concomitant infections of both organs were observed in 7 of them. Sequencing of 33 PCR products revealed the following chlamydial species: Chlamydophila (Cp.) psittaci (n=18), Cp. abortus (n=2), Chlamydia (C.) suis (n=10), and C. trachomatis (n=3). Immunopositive staining was observed within the surface epithelium (in A, I, U), stromal tissue (in I, U) and muscular layer (in A, I, U). A total of 24 females had inflamed oviductal segments (in A and/or I) and 36 inflamed uteri. However, there was no relationship between histopathology and results of PCR or IHC. In conclusion, chlamydiae were found to infect oviducts and uteri of pigs. Further studies are required to clarify whether chlamydial infection causes specific histopathology and alters tubal function.

Pattern recognition molecules activated by Chlamydia muridarum infection of cloned murine oviduct epithelial cell lines

Chlamydia trachomatis is the most common bacterial sexually transmitted disease in the United States and a major cause of female infertility due to infection-induced Fallopian tube scarring. Epithelial cells are likely central to host defense and pathophysiology as they are the principal cell type productively infected by C. trachomatis. We generated cloned murine oviduct epithelial cell lines without viral or chemical transformation to investigate the role of the TLRs and cytosolic nucleotide binding site/leucine-rich repeat proteins Nod1 and Nod2 in epithelial responses to Chlamydia muridarum infection. RT-PCR assays detected mRNA for TLR2 (TLRs 1 and 6), TLR3, and TLR5. No mRNA was detected for TLRs 4, 7, 8, and 9. Messenger RNAs for Nod1 and Nod2 were present in the epithelial cell lines. Oviduct epithelial cell lines infected with C. muridarum or exposed to the TLR2 agonist peptidoglycan secreted representative acute phase cytokines IL-6 and GM-CSF in a MyD88-dependent fashion. Infected epithelial cell lines secreted the immunomodulatory cytokine IFN-beta, even though C. muridarum does not have a clear pathogen-associated molecular pattern (PAMP) for triggering IFN-beta transcription. The oviduct epithelial lines did not secrete IFN-beta in response to the TLR2 agonist peptidoglycan or to the TLR3 agonist poly(I:C). Our data identify TLR2 as the principal TLR responsible for secretion of acute phase cytokines by C. muridarum-infected oviduct epithelial cell lines. The pattern recognition molecule responsible for infection-induced IFN-beta secretion by oviduct epithelial cells remains to be determined.

Interaction of microbiology and pathology in women undergoing investigations for infertility

BACKGROUND: Cases of endometriosis with no tubal damage are associated with infertility, suggesting an immunological rather than mechanical barrier to reproduction. Laparoscopy and falloposcopy results of clinically asymptomatic women undergoing investigation of infertility were correlated with the outcomes of microbiological screening for Chlamydia trachomatis, Mycoplasma pneumoniae, Mycoplasma hominis, ureaplasma species, Neisseria gonorrhoeae, Neisseria meningitidis and Chlamydia pneumoniae. METHODS: A total of 44 women presenting to a hospital IVF service for laparoscopic or laparoscopic/falloposcopic investigation of infertility provided endocervical swabs, fallopian tube washings, and peripheral whole blood for analysis. RESULTS: Of these 44 women, 15.9% (7) showed evidence of C. trachomatis infection as detected by either PCR or EIA serology. Of these 7 women, 5 (71%) had no or mild endometriosis and 2 (29%) had moderate or severe endometriosis. Of the remaining 37 women who showed no evidence of chlamydial infection, 15 (40.5%) had no or mild endometriosis. CONCLUSION: Women with infertility, but without severe endometriosis at laparoscopy, showed a trend towards tubal damage and a higher rate of previous C. trachomatis infection. Although not statistically significant, this trend would suggest that, where moderate to severe tubal damage is found to be the primary cause of infertility, C. trachomatis infection could be a likely cause for such tubal damage.

Murine oviduct epithelial cell cytokine responses to Chlamydia muridarum infection include interleukin-12-p70 secretion

Epithelial cells play an important role in host defense as sentinels for invading microbial pathogens. Chlamydia trachomatis is an intracellular bacterial pathogen that replicates in reproductive tract epithelium. Epithelial cells lining the reproductive tract likely play a key role in triggering inflammation and adaptive immunity during Chlamydia infections. For this report a murine oviduct epithelial cell line was derived in order to determine how epithelial cells influence innate and adaptive immune responses during Chlamydia infections. As expected, oviduct epithelial cells infected by Chlamydia muridarum produced a broad spectrum of chemokines, including CXCL16, and regulators of the acute-phase response, including interleukin-1alpha (IL-1alpha), IL-6, and tumor necrosis factor alpha. In addition, infected epithelial cells expressed cytokines that augment gamma interferon (IFN) production, including IFN-alpha/beta and IL-12-p70. To my knowledge this is the first report of a non-myeloid/lymphoid cell type making IL-12-p70 in response to an infection. Equally interesting, infected epithelial cells significantly upregulated transforming growth factor alpha precursor expression, suggesting a mechanism by which they might play a direct role in the pathological scarring seen as a consequence of Chlamydia infections. Data from these in vitro studies predict that infected oviduct epithelium contributes significantly to host innate and adaptive defenses but may also participate in the immunopathology seen with Chlamydia infections.

Update on the impact of Chlamydia trachomatis infection on male fertility

With approximately 90 million cases annually, infection with Chlamydia trachomatis is the most prevalent sexually transmitted bacterial disease in the world. Considering that these infections are often asymptomatic and cause major complications like acute pelvic inflammatory disease, ectopic pregnancy, infertility or infant pneumonia, the estimated costs for diagnosis and treatment in the USA amounts to 2.2 million US dollars for each 500 cases. Therefore, there is a high need for correct, quick and cost-effective diagnosis and treatment of this urogenital tract infection. New innovative therapies provide good results with regard to efficacy and patients' compliance. The success rates of treatments are at least 95%. However, the occurrence of antibiotic resistance should not be ignored and new treatment schemes must be developed. The state-of-the-art of diagnosis and treatment of chlamydial infections as well as the pathophysiology is discussed in this review. In conclusion, infections with C. trachomatis is an important public health problem, especially in third world and developing countries, and more socio-economic studies linking secondary prevention of chlamydial infections, infertility and adverse pregnancy outcome are needed to understand more of its aetiology. In addition, diagnosis and treatment should be improved. Data in men revealed that past infections but not present infections are more related to male infertility. There is still controversial results. In future studies, function of the seminal vesicles and evaluation of the antioxidant capacity should be taken into account when role of C. trachomatis infection on male fertility is assessed.

Immunopathogenesis of chlamydia trachomatis infections in women

OBJECTIVE

To develop a model of pathogenesis by which Chlamydia trachomatis progresses from acute to chronic infection, and finally serious disease (salpingitis, tubal occlusion).

DESIGN

Review of current literature located through web-based Medline searches using key words: Chlamydia trachomatis, immunology, cytokines, heat shock protein, infertility.

RESULT(S)

Cell-mediated immune mechanisms appear to be critical in determining whether acute infection is resolved or progresses into chronicity with pathological outcome. What determines the particular immune pathway depends on a range of determinants-HLA subtype and human genetics, cytokine profile, infectious load, route of infection, and endocrinology. A clearer picture of the natural history of chlamydial pathology may assist in providing better predictors of those women who may go on to develop significant sequelae after infection.

CONCLUSION(S)

Predicting those who may develop serious disease, including infertility, may contribute to improved management of such persons during earlier stages of infection and assist in prevention.

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.

Detection of Chlamydia trachomatis DNA in archival paraffinized specimens from chronic salpingitis cases using the polymerase chain reaction

OBJECTIVE

To identify Chlamydia trachomatis by the polymerase chain reaction (PCR) in fallopian tube tissues with chronic salpingitis.

DESIGN

Retrospective case-control study.

SETTING

Academic tertiary institution.

PATIENT(S)

Women with a pathological diagnosis of chronic salpingitis or normal fallopian tube hospitalized between September 1992 and November 1994. Initial identification of 248 specimens with final analysis of 154.

INTERVENTION(S)

Paraffin-embedded fallopian tube tissues were analyzed with use of PCR to detect C. trachomatis.

MAIN OUTCOME MEASURE(S)

Identification of C. trachomatis DNA; demographics of age, ethnicity, parity, history of sexually transmitted disease, and surgical procedure.

RESULT(S)

C. trachomatis DNA was detected in 9 of 77 chronic salpingitis cases. Seventy-seven controls were negative for C. trachomatis. No statistically significant difference in age or ethnicity between cases and controls was identified. Nulliparity was more frequent in cases (26 of 74) than controls (14 of 76). Sexually transmitted disease history was more prevalent in cases (24 of 74) than controls (6 of 76). Chlamydia infection was not associated with a particular surgical indication.

CONCLUSION(S)

Chronic salpingitis is highly associated with the presence of C. trachomatis infection as detected by PCR.

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.

Chlamydial infection in asymptomatic infertile men attending an andrology clinic

Urethral swabs, first-catch urine or urine collected at least 2 h after the previous micturition, and semen swabs were collected from 131 asymptomatic men during the routine workup for infertility at the andrology clinic at Ga-Rankuwa Hospital, Medunsa. The urethral and seminal swabs were used for enzyme immunoassay (EIA) (IDEIA III), tissue culture, and direct immunofluorescent antibody (DFA) test (IMAGEN) to detect Chlamydia trachomatis, and similarly the urine was tested by EIA. In 82/131 (62.6%) cases all tests for chlamydiae were negative and in 49/131 (37.4%) cases at least one test was positive. Tissue culture detected 24/131 (18.3%) as positive for C. trachomatis. Urethral swab EIA detected 33/131 (25.2%) and DFA 34/131 (26%) positive patients. Urine EIA was positive in 33/131 cases (25.2%). Semen EIA was positive in 35/131 (26.7%) of cases of whom 7/131 (5.3%) were positive in semen EIA only (all samples were conformed by PCR). It would seem, therefore, that testing for the presence of chlamydia was incomplete if semen samples were not included. The positivity in only semen samples raises the possibility that the organisms are harbored in the epididymis, seminal vesicles, or the prostate.

Can serology diagnose upper genital tract Chlamydia trachomatis infections? Studies on women with pelvic pain, with or without chlamydial plasmid DNA in endometrial biopsy tissue

BACKGROUND

Upper genital tract chlamydial infections in women are on the increase, and serology might be a convenient tool for diagnosis. Evaluations of this approach are needed in women with or without microbiologic evidence of organisms in the upper genital tract.

GOALS

To compare the results of antibody assays with cervical culture and upper genital tract histopathology in women with pelvic pain and chlamydial plasmid DNA in endometrial biopsies.

STUDY DESIGN

Chlamydia trachomatis plasmid DNA was detected by polymerase chain reaction (PCR) on extracted deparaffinized endometrial biopsy tissue. Five antichlamydial antibody assays were performed measuring total antibodies or immunoglobulin G (IgG), IgM, and IgA classes on sera from 14 women with plasmid DNA as well as 31 without plasmid DNA.

RESULTS

Accepting the presence of plasmid DNA as the gold standard, no single test had total diagnostic accuracy. The best sensitivity and specificity occurred with the following assays: whole inclusion fluorescence (WIF) (100% and 80.6%); microimmunofluorescence IgM (MIF IgM) (78.6% and 93.6%); and heatshock protein-60 enzyme immunoassay (42.9% and 100%). Although recombinant anti-lipopolysaccharide enzyme-linked immunosorbent assays measured anti-chlamydial antibodies in a large proportion of these women, specificity was low. The sensitivity and specificity of cervical culture was 28.6% and 100% and of endometrial histopathology was 71.4% and 48.4%. Analysis of patient serological profiles suggested that and 6 women without plasmid DNA may have been cases that were missed by PCR.

CONCLUSIONS

Evaluations of assays to diagnosis Chlamydia trachomatis upper genital tract infections could use the presence of organisms or their markers in the upper genital tract as a standard of comparison. Some of these serological assays, such as WIF or MIF IgM, may be helpful in diagnosis, but more studies are needed.

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.

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.

Post-therapeutic evolution of serum chlamydial antibody titers in women with acute salpingitis and tubal infertility

OBJECTIVE

To determine if serologic data and, more particularly, antichlamydial immunoglobulin (Ig) M can be used for diagnosis of current chlamydial intrapelvic gynecologic infection.

DESIGN

Forty-two women with acute salpingitis (group A), 131 women with tubal factor infertility (group B), and 98 pregnant women (control group C) were studied.

SETTING

Hôpital Jean Rostand, Sèvres (patients), Laboratories Magenta and Eylau, Paris (serology), Institut Pasteur, Paris (cultures).

INTERVENTIONS

Study groups: endocervical/urethral swabs, pelvic samples; serologic study before and after treatment.

CONTROL GROUP

Serologic study.

MAIN OUTCOME MEASURES

Serum samples were collected from each patient initially and 6 to 9 weeks later; additionally, two to five sequential sera were obtained from 22 (group A) and 25 (group B) patients with positive cultures, evolutive serology, or positive antichlamydial IgM. Sera were tested for antichlamydial IgG by a microimmunofluorescence assay using Chlamydia trachomatis elementary bodies and for IgA and IgM by whole inclusion-fluorescent assay.

RESULTS

Before treatment, there was a correlation between the presence of antichlamydial IgM and positive cervical and/or intrapelvic chlamydia cultures. After treatment, antichlamydial IgM, when initially positive, rapidly disappeared in most subjects; its persistence after 4 months was significantly associated with tubal sequelae in group A patients and persistence of positive intrapelvic chlamydial cultures in group B women.

CONCLUSION

Serologic analysis of women with acute salpingitis or tubal infertility, including antichlamydial IgM, may aid both in the before treatment diagnosis of chlamydial infection and in the follow-up evaluation.

Urine as an alternative to urethral swabs for the diagnosis of Chlamydia trachomatis in infertile males

Swabbing the urethrae of men has been the traditional approach for collecting specimens for detection of Chlamydia trachomatis. Recently, however, urine testing using enzyme immunoassay has yielded promising results. A total of 105 patients attending the Andrology Clinic at Ga Rankuwa Hospital, Medunsa were included in the study. These patients were asymptomatic and had no urethral discharge. Three endo-urethral swabs and first-catch urine were collected from each patient. The urethral swabs were used for enzyme immunoassay (EIA) (IDEIA III), tissue culture and direct immunofluorescent antibody (DFA) test (IMAGEN) to detect C. trachomatis. In addition about 15-30 ml of first-catch urine, or urine collected at least 2h after the previous micturition, was collected for each patient for EIA testing. Fifteen (14.3%) of 105 patients were positive on urethral swab EIA, in comparison with the DFA test in which 14 (13.3%) were positive. Eight (7.8%) were positive in tissue culture. Urine EIA was positive in 17 (16.2%) patients, of whom five (4.8%) were positive in urine EIA only. All EIA positive urines were confirmed by DFA. We recommend that first-catch urine or urine collected at least 2h after the previous micturition in infertile males may be considered a suitable alternative to urethral swab for chlamydial diagnosis because it is noninvasive and nontraumatic.

The role of Chlamydia trachomatis infection in female infertility

The incidence of positive Chlamydia cultures in females undergoing laparoscopy for tubal patency is high. We advocate routine screening for Chlamydia infection in females with infertility. Of seventy-five patients undergoing laparoscopy for infertility, 49 grew Chlamydia on tissue culture of material from the cervix, an incidence of 65.3%. of these 49 cases, 33 (67.3%) had tubal blockage. In asymptomatic patients, 22 out of 50 had positive cultures from the cervix, an incidence of 44%. Peritoneal fluid culture was negative in all infertile patients. When compared to populations studied elsewhere, the incidence of Chlamydia appears to be high in our population and significantly higher in the infertile patients. In the management of infertility, pelvic inflammatory disease, and neonatal conjunctivitis, Chlamydia should be routinely investigated and treated.

A controlled trial of a single dose of azithromycin for the treatment of chlamydial urethritis and cervicitis. The Azithromycin for Chlamydial Infections Study Group

BACKGROUND

Currently, there is no single-dose therapy that is effective in the treatment of urethral or endocervical infections with Chlamydia trachomatis. Azithromycin is a new azalide antibiotic that has substantial activity against C. trachomatis, is concentrated intracellularly, and has a long half-life in serum and tissue.

METHODS

We conducted a trial in which 299 female patients and 158 male patients with uncomplicated genital infection and a positive C. trachomatis antigen test were randomly assigned to receive either azithromycin (1 g once orally) or doxycycline (100 mg orally twice daily for seven days). Only patients subsequently determined to have a culture positive for C. trachomatis at base line were included in the evaluation of efficacy.

RESULTS

Among the patients who could be evaluated, 5 of the 141 patients (4 percent) treated with azithromycin did not respond to treatment, as compared with 3 of the 125 patients (2 percent) treated with doxycycline (difference between groups, 2 percent; 95 percent confidence interval, 0 to 6 percent). Of the patients evaluated 21 to 35 days after treatment, none of 112 treated with azithromycin and 1 of 102 treated with doxycycline had a positive culture. The rates of bacteriologic cure were similar for the 98 female patients (97 percent) and the 43 male patients (95 percent) treated with azithromycin. Seventeen percent of the patients who received azithromycin and 20 percent of those treated with doxycycline had mild-to-moderate drug-related side effects, mainly gastrointestinal symptoms.

CONCLUSIONS

A single 1-g dose of azithromycin is as effective for the treatment of uncomplicated genital chlamydial infections as a standard seven-day course of doxycycline.

The prevalence, risks, and management of Chlamydia trachomatis infections in fertile and infertile patients from the high socioeconomic bracket of the South African population

OBJECTIVE

The main objective of the study was to evaluate the prevalence of Chlamydia trachomatis endocervicitis in an infertile population.

DESIGN

Forty consecutive patients were enrolled in the study group and 41 in the control group.

SETTING

The study was undertaken in the Department of Obstetrics and Gynaecology of the University of the Orange Free State, Bloemfontein, Republic of South Africa.

PATIENTS

Infertile white females, visiting an infertility clinic in an academic hospital and fertile white female patients visiting an antenatal clinic.

INTERVENTIONS

Endocervical swabs were taken, and monoclonal direct immunofluorescence for C. Trachomatis were done on each.

MAIN OUTCOME MEASURES

A difference was expected between the prevalence of C. trachomatis infection in the fertile and infertile population.

RESULTS

In the study group, 14(35.9%) positive, 25(64.1%) negative, and 1 fallout were obtained. In the control group, 3 patients (7.32%) tested positive.

CONCLUSION

Although no correlation was found between C. trachomatis infection of the female genital tract and the clinical history, it showed a significant correlation with infertility. This justifies routine screening tests and antibiotic treatment of positive infertile couples. Analysis of cost-effectiveness showed that empirical treatment of new infertile couples is justified in some populations.

Recurrence of ectopic pregnancy: the role of salpingitis

We evaluated the role of salpingitis on the recurrence of ectopic pregnancy from a historical cohort of 2501 women who had undergone laparoscopic examination for acute salpingitis. We used pregnancy (N = 2899) as the unit of analysis and a modified conditional logistic regression to estimate a pairwise odds ratio as a measure of the recurrence of ectopic pregnancy. Among the second or higher order of pregnancy, the recurrence was 21.7%. For pregnancies with a prior uterine pregnancy, the ectopic pregnancy rate increased with prior salpingitis scores constructed from a combination of prior salpingitis episodes and severity (0 score, 2.7%; 1 to 2 scores, 4.8%; and greater than or equal to 3 scores, 12.1%). For those with a prior ectopic pregnancy, the rate did not increase with prior salpingitis scores (score 0, 20.0%; score 1 or 2, 19.2%; and score greater than or equal to 3, 26.9%). The adjusted pairwise odds ratio was 2.2 and was practically unchanged (2.1) after additional adjustment with prior salpingitis scores. These findings confirm salpingitis as a risk factor for first ectopic pregnancy, but once a woman had an ectopic pregnancy, previous salpingitis might not add any incremental risk.

Genital chlamydial infections: epidemiology and reproductive sequelae

Genital chlamydial infection is increasing and is now more common than gonorrhea. A sizable percentage of chlamydial infections of the lower genital tract in women progress to endometritis and salpingitis. Tubal infertility and ectopic pregnancy are important sequelae. Failure to control chlamydial infections reflects the following four factors: (1) Many cases are mild or asymptomatic; (2) diagnostic tests are expensive and technically demanding; (3) at least 7 days of multiple-dose therapy are currently required; and (4) partner notification is not routinely performed. Thus early identification of infected persons and compliance with curative therapy are less likely than with other sexually transmitted bacterial diseases.

New treatments for Chlamydia trachomatis

Standard regimens of tetracycline, doxycycline, or erythromycin, if compiled with, appear to be effective against Chlamydia trachomatis infections under most circumstances. However, the organism may sometimes persist despite what would seem to be adequate therapy. How often this occurs, to what extent noncompliance is the issue, and the role antibiotic resistance plays remain to be determined. Among newer antibiotics, azithromycin appears to be effective in the treatment of uncomplicated urogenital C. trachomatis infections. Single-dose therapy with azithromycin may be especially useful in overcoming compliance problems associated with the treatment of sexually transmitted disease.

Chlamydial infections and the quinolones

Some of the newer fluoroquinolones may be suitable agents for the treatment of Chlamydia trachomatis infections and non-gonococcal urethritis. To date, small studies with both ofloxacin and fleroxacin appear to achieve cure rates of 85-100% for urethritis and cervicitis due to Chlamydia trachomatis. However, large well-designed clinical trials are required to determine the efficacy and acceptance of these and other fluoroquinolones in the treatment of patients with genital or respiratory syndromes due to chlamydiae or other bacterial pathogens causing infections with similar manifestations.

Pelvic inflammatory disease

The costs of PID to both individuals and society are enormous. Although primary prevention of PID through control of lower genital tract infections is the most effective prevention strategy, early diagnosis and treatment of acute PID may minimize some of its serious sequelae. Although laparoscopy is helpful for establishing the diagnosis of salpingitis, other less invasive tests along with selected clinical criteria may also be useful. Treatment of PID, which is empiric and broad spectrum, is oriented toward polymicrobial PID. Whenever possible, women with PID should be hospitalized for parenteral therapy. The 1989 CDC STD treatment guidelines recommend two regimens for inpatient parenteral therapy: clindamycin/gentamicin and cefoxitin, or equivalent cephalosporin/doxycycline. Outpatient management of PID should be monitored closely; the CDC-recommended regimen includes use of intramuscular cephalosporins and oral doxycycline. Oral penicillins are no longer recommended.