The effect of chlamydial infection on tubal patency

The study was carried out on 162 infertile women (110 with primary and 52 with secondary infertility), patients of the University Clinic of Gynecologic Endocrinology and Infertility, Sofia. The present study was designed to estimate the effect of chlamydial infection as a cause of tubal pathology in infertile women. Evidence of past chlamydial infection was determined by the presence of antichlamydial IgG antibodies by commercial ELISA test. 101 of the patients examined were positive for antichlamydial IgG antibodies (62.3%). 76 women were examined for tubal patience by means of hysterosalpingography and/or laparoscopy. 38 women had patient tubes and 38 women had tubal occlusion (20 had bilateral and 18 unilateral occlusion). 29 of the women with unilateral or bilateral tubal occlusion had a presence of IgG antichlamydial antibodies in their sera (76.3%) compared to 17 of the women with patient tubes (44.7%). The risk for tubal obstruction in women with positive serology for Chlamydia is 3.22 compared to 0.85 risk in the women with negative serology for chlamydia. The results of the present study indicate that women with evidence of past chlamydial infection are 4 times more likely to have obstructed fallopian tubes compared to women who had no such evidence. It is mandatory to examine the patient for chlamydial serology at the beginning of the diagnostic protocol in order to ensure adequate management prior to more invasive procedures such as hysterosalpingography or laparoscopy.     

Preferred strategies of men and women for managing chlamydial infection

Objectives  To determine men and women's preferred strategies for managing chlamydial infection: partner notification (patient referral), postal testing kit (PTK) or patient-delivered partner medication (PDPM).
Design  Interviewer-conducted questionnaires (women) and anonymous, self-administered questionnaires (men).
Population  Women infected with chlamydia who were participating in a randomised study assigning partners to patient referral, PTK or PDPM. Men attending genitourinary medicine, family planning and fracture clinics in Edinburgh.
Methods  Men and women were asked their preferred strategy for testing/treating sexual partners (patient referral, PTK or PDPM) if they or their partner had a positive chlamydia test. Women were also asked the reasons for their choice and whether partners were satisfied with the intervention received.
Main outcome measures  Reported preferences of men and women for testing/treating partners.
Results  Response rates were 97 and 81% for the women's questionnaires at study entry and 6 months, respectively, and 81% for the men's questionnaires. Of 174 women responding, 67% preferred PDPM for partners and 57% would prefer PDPM for themselves. The main reasons were that PDPM allows simpler, more convenient and faster treatment. Women reported that 65% of partners were satisfied with whichever intervention they received. Of 293 men responding, 70% would choose patient referral for partners and 53% would prefer patient referral for themselves. Men previously tested for chlamydia were significantly more likely to choose PDPM ( n = 22) than those never tested ( n = 7); P < 0.001. Only 3% of women and 9% of men preferred PTKs for partners.
Conclusion  The results suggest that women prefer PDPM and men, at least hypothetically, prefer patient referral. PTK appears unpopular with both sexes.     

Fetal death from chlamydial infection across intact amniotic membranes

We report a case of a fetal death at 34 weeks' gestation with intact membranes. An autopsy confirmed intrauterine pneumonia as a result of Chlamydia trachomatis. Staining of the lung tissue with a direct fluorescein-conjugated Chlamydia-specific monoclonal antibody assay revealed a pattern typical of a Chlamydia trachomatis infection. This case supports the thesis that Chlamydia crosses fetal membranes and produces disease.     

Treatment of cervical chlamydial infection with amoxicillin/clavulanate potassium

Objective: To determine if amoxicillin/clavulanate potassium is effective in the treatment of Chlamydia trachomatis endocervicitis.Methods: Thirty-two patients with culture-proven endocervical infection were treated with amoxicillin/clavulanate potassium, 500 mg orally 3 times a day for 10 days. Post-treatment endocervical specimens were obtained at 2, 4, and 6 weeks for culture of C. trachomatis. Male partners were treated with doxycycline, 100 mg orally twice daily for 10 days. The couples were provided condoms and asked to use them throughout the duration of the study.Results: All patients treated with amoxicillin/clavulanate potassium were cured of signs of cervicitis. All were found to be free of C. trachomatis at their follow-up visits.Conclusions: Amoxicillin/clavulanate potassium is effective in eradicating C. trachomatis.     

Localizing chlamydial infection in cervical biopsies with the immunoperoxidase technique

One hundred and two cervical biopsy specimens containing varying degrees of chronic inflammation were stained for chlamydial antigens with the immunoperoxidase technique. Seven cases (6.9%) were positive. Histologically, six (84%) of the Chlamydia-positive cases contained severe chronic inflammation, all contained reparative atypia, and two (28%), follicular cervicitis. When evaluated separately, 22% (six of 27) of the specimens with severe inflammation were positive in contrast to 0% (0 of 45) of cases with mild inflammation. Positively staining cells were located primarily in columnar epithelium and reparative atypia and occasionally in areas of immature squamous metaplasia. The cytological finding which correlated with positive staining was cytoplasmic vacuolation; however, cytoplasmic vacuoles were common in cells which did not stain positively, and it was impossible to predict on histological grounds which cells/specimens would stain positively by immunoperoxidase. Because of these findings, the presence of chlamydial infection should be strongly suspected whenever the cervical biopsy specimen contains severe inflammation and repair. Although tissue staining may not be as sensitive as culture for diagnostic purposes, it can be performed rapidly and simply and may be a useful special stain in cases where the diagnosis of chlamydial infection is not suspected clinically or cultures are not immediately available.     

Effective sampling device and mucopurulent cervicitis in women with chlamydial cervical infection

Brushes (Cytobrush, Medscand) are superior to swabs for the collection of endocervical cells for cytologic examination. In the present randomized study, Cytobrush was compared with ENT-swabs and with white, cotton-tipped swabs to obtain samples for the diagnosis of chlamydial cervicitis. The women were examined for the presence of mucopurulent cervicitis (MPC). The subjects comprised 126 women, most of whom had been referred because of asymptomatic chlamydial infection. Specimens obtained with brushes were culture-positive in 83 women and positive in a direct fluorescent antibody test (FA-test) in 78 women. The corresponding figures for samples obtained with swabs were 80 and 74, respectively. The mean number of inclusions was significantly higher in samples obtained with brushes (4,999), compared with swabs (3,155), as was the mean number of elementary bodies (3,000 vs 2,481). MPC was detected in 65% of the women with asymptomatic chlamydial cervicitis, and in 93% of those with symptomatic infection. The corresponding figures for a pathologic wet smear were 62% and 80%, respectively. The specificity and predictive values of a positive and negative MPC-test was 21%, 39%, and 86%, respectively, and for a pathologic wet smear 53%, 44%, and 85%, respectively. We conclude that brushes are superior to swabs for sampling material, both for culture and for direct FA-tests. The MPC and the wet smear tests could be of value in the diagnosis of chlamydial cervicitis, providing confirmatory laboratory tests are used.     

Predicting chlamydial and gonococcal cervical infection: implications for management of cervicitis

OBJECTIVE: To define utility of age and cervical findings in predicting infection with Chlamydia trachomatis and Neisseria gonorrhoeae among women universally tested for both infections, and to assess the independent contribution of Gram stain (GS) smear of endocervical secretions. METHODS: Visits by women to Seattle sexually transmitted diseases clinics from 1995 through 1999 were retrospectively reviewed. All women had endocervical GS and cultures for C trachomatis and N gonorrhoeae performed. Predictive values of age, cervical signs, and inflammation on GS (more than 30 polymorphonuclear leukocytes per 1000x field) were calculated. RESULTS: Among 6230 women, prevalence of C trachomatis and N gonorrhoeae was 6.9% and 2.1%, respectively; 520 women (8.3%) had either organism detected. Age, cervical signs (mucopus, induced bleeding), and inflammation on endocervical GS were independently associated with infection. However, the positive predictive value (PPV) of any cervical finding for infection was less than 19% in women 25 years and older. Inflammation on endocervical GS was the sole indicator of infection in 79 of 520 (15%) infections, but was insensitive in the absence of mucopurulent cervicitis (sensitivity, 26%; PPV, 21%). CONCLUSION: Cervical signs suggesting chlamydial or gonococcal infection have higher positive predictive value (PPV) in younger women. The PPV of inflammation on endocervical GS is too low to recommend its use to direct empiric treatment in the absence of mucopurulent cervicitis, especially in women 25 years and older. Further, its low sensitivity in detecting infection in women without mucopurulent cervicitis does not justify routine use. Signs suggesting mucopurulent cervicitis should be interpreted in the context of age, and empiric treatment may not be indicated in women aged 25 years and older.     

Infertility in Central Africa: infection is the cause

Determinants of infertility were studied in 340 women in Eastern Gabon, an area situated in the "infertility belt" of Central Africa. Fallopian tube occlusion was diagnosed in 82.8% of cases, showing the importance of infection-related causes. Women with tubal occlusion did not differ significantly from women with normal tubes in obstetrical history or prevalence of Neisseria gonorrhoeae or Chlamydia trachomatis on endocervical culture. Antecedents of pelvic inflammatory disease or a pelvic mass were significantly more common in the group with tubal occlusion. This group also had a significantly higher prevalence of serum chlamydial antibodies at a titer of 1/64 or higher. Hormonal factors were found in 31.7% of women, a cervical factor in 29.0% and mechanical factors in 5.6%. No diagnosis could be made in 12.2% of cases. During the investigation, 4.4% of women became pregnant. The predominance of infectious related causes of infertility makes it imperative to focus resources on prevention programs of upper genital tract infections in women.     

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.     

输卵管阻塞患者宫颈和输卵管衣原体、支原体的检测分析

目的 研究输卵管阻塞患者输卵管分泌物衣原体(CT)、支原体(UU)阳性率。方法39例经腹腔镜诊断为输卵管阻塞、要求行输卵管再通手术患者为实验组,26例因其他病因行手术治疗、输卵管正常患者为对照组,采用多聚酶链反应技术(PCR) 对实验组和对照组患者宫颈分泌物和输卵管分泌物CT和UU进行检测。结果 实验组宫颈分泌物CT、UU的检出阳性率分别为35.9%(14/39)、38.5% (15/39),输卵管分泌物的CT、UU检出阳性率分别为25.6％(10/39)、5.1％(2/39);与对照组比较,宫颈分泌物CT、UU感染无明显差异P>0.05);输卵管分泌物CT阳性检出率差异有显著性(P<0.05)。实验组CT阳性检出率高于UU检出率,差异有显著性(P<0.05)。39例术中输卵管不同程度增粗、管壁增厚,其中19条输卵管管壁增厚,僵硬,管壁纤维化,管腔消失。结论 宫颈和输卵管是CT、UU感染的好发部位,CT、UU能损害输卵管粘膜,造成输卵管阻塞,引起输卵管性不孕。     

The most suitable tests for studying chlamydial infection in women with sterility

The study was carried out on 280 infertile women (185 with primary and 95 with secondary infertility), patients of the University Clinic of Gynecologic Endocrinology and Infertility, Sofia. The present study was designed to estimate which is the most suitable test for detection of chlamydial infection in women with infertility. Evidence of past chlamydial infection was determined by the presence of antichlamydial IgG antibodies by commercial ELISA test. From 196 of the patients examined, 101 were positive for antichlamydial IgG antibodies (62.7%). 84 women were examined by means of direct antigen test for Chlamydia trachomatis from the endocervix (DIF. ELISA). Tubal patient was examined by means of hysterosalpingography and/or laparoscopy. In 34 women with unilateral or bilateral tubal occlusion the endocervical direct antigen test was positive in 4 (11.8%) and in 30 women with patient tubes 2 were positive by this test (6.7) In 38 women with tubal occlusion 29 of the women with unilateral or bilateral tubal occlusion had a presence of IgG antichlamydial antibodies in their sera (76.3%) compared to 17 of 38 women with patient tubes (44.7%). The results of the present study indicate that the examination antichlamydial IgG antibodies in the sera of women with infertility has a better predictive value with regard to tubal pathology compared to the direct antigen test for detection Chlamydia trachomatis in the endocervix. Examination for latent infection or reinfection has to be carried out before the administration of more invasive methods for the management of infertility.     

Periappendicitis and chlamydial salpingitis

Periappendicitis seems to be a novel manifestation of infections with Chlamydia trachomatis. In seven of 112 women with laparoscopically verified acute salpingitis, secondary appendicitis was diagnosed and histologically confirmed. The genital tract in all seven patients harbored Chlamydia trachomatis but not Neisseria gonorrhoeae. The fallopian tubes should be scrutinized when an inflamed appendix is removed from a sexually active woman. Signs of salpingitis should then lead to appropriate microbiologic, therapeutic and epidemiologic measures, including contact tracing.     

A study of Chlamydia trachomatis infection in gynecological outpatients--direct specimen test and chlamydial IgG antibodies

Among 226 outpatients, 30(13.3%) harboured Chlamydia trachomatis in the cervix. C. trachomatis was found in 15.1% of the patients with lower genital tract infection, 8.0% of pregnant women, 0.0% of sterile women, 14.3% of patients with pelvic inflammation and 88.9% of sexual partners respectively. The frequency of C.trachomatis infection in those 50 years old or more was 0.0%. One hundred and sixty-six women were also found to have titers of serum antibody to C.trachomatis. Serum IgG antibodies were found in 64 of 166(38.6%). Serum IgG antibodies were positive in 66.7% of the Chlamydia-positive women (20/30 subjects), whereas the positive rate was 31.0% in the Chlamydia-negative women (39/126 cases). In 40.0% of chlamydia positive patients, there was seen a significant rise in the number of paired sera. For C. trachomatis infection treatment with minocycline 100mg p.o. twice a day was effective (100%).