Archives of Gynecology and Obstetrics

, Volume 276, Issue 3, pp 219–223

Prevalance of Chlamydia trochomatis, Ureaplasma urealyticum and Mycoplasma hominis infections in the unexplained infertile women

Authors

    • Faculty of Medicine, Department of Obstetrics and GynecologyKahramanmaras Sutcu Imam University
  • Umut Dilek
    • Department of Obstetrics and GynecologyMersin University School of Medicine
  • Ozlem Pata
    • Department of Obstetrics and GynecologyMersin University School of Medicine
  • Saffet Dilek
    • Department of Obstetrics and GynecologyMersin University School of Medicine
  • Pinar Ciragil
    • Faculty of Medicine, Department of MicrobiologyKahramanmaras Sutcu Imam University
Original Article

DOI: 10.1007/s00404-006-0279-z

Cite this article as:
Guven, M.A., Dilek, U., Pata, O. et al. Arch Gynecol Obstet (2007) 276: 219. doi:10.1007/s00404-006-0279-z

Abstract

Objective

To prospectively investigate the prevalence of Chlamydia trachomatis (CT), Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU) in the cervical canal and pouch of Douglas in unexplained infertile women and compare it to healthy controls in the Turkish population.

Materials and methods

A total of 31 women presenting with a history of infertility [n = 24 (77%) primary infertility, n = 7 (23%) secondary infertility] between 20 and 38 years of age and 31 women willing to have tubal ligation between 30 and 41 years of age were consecutively included into this study. Specimens were taken from intra-abdominal washings and from the cervical canal. CT, MH and UU were detected with polymerase chain reaction (PCR).

Results

Results of 62 women were analyzed. None of the participants met the criteria for salpingitis during laparoscopy. The most common infection in the cervical canal in both groups was UU, which was detected in 13 cases of infertile patients and 11 controls (P = 0.602). Cervical chlamydial and mycoplasmic infection was detected in one case each in infertile and control patients. Neither MH nor UU were obtained from the pouch of Douglas in both groups. Only CT was present in peritoneal fluid of an infertile woman who had also a concomitant chlamydial infection in the cervical canal.

Conclusion

Demonstration of cervical colonization of CT by PCR may be a promising method for the detection of asymptomatic pelvic infection in patients with unexplained infertility. However, screening for MH and UU is not cost-effective due to similar low rates of detection.

Keywords

Unexplained infertilityUreaplasmaMycoplasmaChlamydiaLaparoscopyPCR

Introduction

Although there are a number of causes associated with infertility, unexplained infertility is responsible for 10% of cases. When all of the standard elements of infertility evaluation yield normal result, the diagnosis is unexplained infertility. At a minimum, the diagnosis of unexplained infertility implies a normal semen analysis, objective ovulation, a normal uterine cavity and bilateral tubal patency. The incidence of pelvic inflammatory disease (PID) is strongly correlated with the prevalence of sexually transmitted diseases, although a fraction of the infections might be of endogenous origin and exhibit asymptomatic progression [2, 24]. Chlamydia trachomatis (CT) or Neisseria gonorrhea are well-known bacterial pathogens which responsible for the occlusion of the fallopian tubes due to an infection [16]. The cumulative incidence of PID by the age of 35 years was 5.6% in women ever tested positive for chlamydia and 4.0% in those with negative test [14]. Many cases of chlamydial tubal salpingitis have a subclinical course and 50–80% of women may be asymptomatic [11, 16, 21]. Even in Fitz–Hugh–Curtis syndrome, 30% of cases did not show any abnormalities in the fallopian tube [12]. Moreover, a possible relationship between infertility and chlamydial infection could be demonstrated by higher culture positivity in infertile women than in controls [6]. Mycoplasma hominis (MH) and Ureaplasma urealyticum (UU) are often concomitant with CT and may have a role in subclinical infection and tuboperitoneal infertility [15]. Further, there seems to be a higher rate of mycoplasma infection among infertile couples than in controls. However, the effect of the presence of these microorganisms on the unexplained infertility is still controversial. Data about isolation of CT from unexplained infertile patients are limited. Infectious agents can be detected in <8 h by nucleic acid amplification techniques, and polymerase chain reaction (PCR) methods have been used for the detection of these bacteria [1, 23]. The aim of the present study was to compare the prevalence of CT, MH and UU at the cervical canal and pouch of Douglas by PCR methods between unexplained infertile women and healthy controls in the Turkish population.

Materials and methods

This study was carried out between January 2002 and June 2004 in two different tertiary centers: Departments of Obstetrics and Gynecology, Faculty of Medicine Kahramanmaras Sutcu Imam University and Mersin University. A total of 31 women presenting with a history of infertility (unexplained infertility-study group) between 20 and 38 years of age, a normal semen analysis, objective ovulation, a normal uterine cavity and bilateral tubal patency, and 31 women willing to have tubal ligation (control group) between 30 and 41 years of age were consecutively included in this prospective study. All participants underwent a combination of cervical and pelvic PCR for the detection of UU, CT, MH in order to obtain objective evidence of upper genital tract infection. In the study group, 24/31 (77%) of cases had primary infertility and 7/31 (23%) had secondary infertility. The duration of the couples’ infertility ranged from 1 to 12 years (median 4 years). Gynecological examination and ultrasonography were performed in all cases prior to laparoscopy, which was performed a couple of days after the completion of menstrual cycle by one of the authors. Patients with abnormal hysterosalpingography findings and couples with male factor infertility were excluded from the study. Also, subjects who either met the Centers for Disease Control and Prevention’s [3] minimal criteria for acute PID or had other signs of upper genital tract infection (i.e., atypical pelvic pain, abnormal uterine bleeding, or cervicitis) or pregnancy, delivery, surgery within the preceding 4 weeks, or had treatment for antimicrobial agent within the previous 2 weeks were not enrolled into the study. Laparoscopic evidence of salpingitis was defined as tubal edema, erythema or purulent exudate. The study was approved by the Hospitals’ Ethics committee. Information regarding the procedure was given to all patients and written informed consent was obtained.

For specimen collection from cervix, after inserting a sterile speculum into the vagina, the cervix was observed and mucus removed with a sterile cotton swab without causing any bleeding. Subsequently, an endocervical swab was applied and the specimen was transferred to transport medium.

For specimen collection in the pouch of Douglas, 20 ml sterile saline was applied into peritoneum covering the Douglas by a disposable silicone tube and aspirated during laparoscopy. In the cases where free fluid was present in the Douglas pouch, free fluid was collected before the irrigation and suction. The samples were then transferred into a transport medium. Following this, chromopertubation was performed in the infertile cases, and all of them resulted to have bilaterally patent tube. Following this, methylen blue was aspirated and pelvis and lower abdomen were irrigated with copious amount of sterile lactated ringer. Also, we prescribed 1 g single dose azithromycin to all patients following the operation.

All samples were immediately refrigerated at −20°C and sent to the laboratory on the same day, where a PCR test for the mentioned agents was performed according to the manufacturer’s instructions (Cobas Amplicor Monitor, Roche Brenchburg, NJ, USA). All samples were evaluated in the laboratory by a skilled technician who was blinded to the clinical details of the patients.

In the presence of any positive result for cervical MH (Cmyco), cervical UU (Curea) or cervical CT (Cchla), the test was considered as positive, while in the absence of any positive result the test was considered as negative. The total number of positive assays, CTotal, was also calculated. Similarly, In the presence of any positive result for Douglas pouch MH (Dmyco), UU (Durea) or CT (Dchla), the test was considered as positive, while in the absence of any positive result the test was considered as negative. The total number of positive Douglas ouch assays, DTotal, was also calculated.

Statistical analysis was performed by SPSS 11.0 version. Patient age was compared between different groups by T test for independent samples. Categorical variables were analyzed by Pearson Chi-square test.

Results

The mean age was 28.90 ± 5.60 years in infertile patients (n = 31) and 36.03 ± 5.12 in controls (n = 31). This difference was statistically significant (P < 0.0001).

Although none of the 62 women fulfilled the criteria for salpingitis at laparoscopy, four cases (three cases with primary infertility, one case with secondary infertility) were found to have peritubal adhesions. A concomitant cervical and pelvic chlamydial infection was present in the case with secondary infertile. The most common infection in the cervical canal of both groups was UU, which was present in 13 cases from the infertile group and 11 controls (P = 0.602). One case of cervical chlamydial or mycoplasmic infection could be demonstrated in both groups. Comparison of the presence and absence of Cmyco, Curea and Cchla between the infertile and non-infertile groups is shown in Table 1.
Table 1

Comparison of cervical Mycoplasma hominis, Ureaplasma urealyticum and Chlamydia trachomatis positivity in the unexplained infertile and control groups

Test

Infertile group (n = 31)

Controls (n = 31)

P value

Cmyco

 Positive

0 (0%)

1 (3.2%)

0.313

 Negative

31 (100%)

30 (96.8%)

Curea

 Positive

13 (42%)

11 (35.5%)

0.602

 Negative

18 (58%)

20 (64.5%)

Cchla

 Positive

1 (3.2%)

0 (0%)

1.00

 Negative

30 (96.8%)

31 (100%)

Cmyco cervical Mycoplasma hominis, Curea cervical Ureaplasma urealyticum, Cchla cervical Chlamydia trachomatis

Using PCR, neither MH nor UU was isolated from the intraperitoneal fluid of patients with unexplained and without infertility. Intraperitoneal fluid and cervical canal tested positive for CT in only one infertile woman. Comparison of the presence and absence of Dmyco, Durea and Dchla positivity between the unexplained infertile and control groups is shown in Table 2.
Table 2

Distribution of Mycoplasma hominis, Ureaplasma urealyticum and Chlamydia trachomatis in the pouch of Douglas between the unexplained infertile and control groups

Test

Infertile group (n = 31)

Controls (n = 31)

P value

Dmyco

 Positive

0 (0%)

0 (0%)

0.313

 Negative

31 (100%)

31 (100%)

Durea

 Positive

0 (0%)

0 (0%)

0.313

 Negative

31 (100%)

31 (100%)

Dchla

 Positive

1 (3.2%)

0 (0%)

0.151

 Negative

30 (96.8%)

31 (100%)

Dmyco presence of Mycoplasma hominis in the pouch of Douglas, Dchla presence of Chlamydia trachomatis in the pouch of Douglas, Durea presence of Ureaplasma urealyticum in the pouch of Douglas

No significant difference was seen in the CTotal values between the unexplained infertile patients and controls (P = 0.602, Table 3). Similarly, no difference was found for DTotal values (P = 0.313, Table 4).
Table 3

Comparison of CTotal between the unexplained infertile and control groups

Test

Infertile group (n = 31)

Controls (n = 1)

P value

CTotal (three negative values)

18 (58.1%)

20 (64.5%)

0.602

CTotal (at least one positive value)

13 (41.9%)

11 (35.5%)

Table 4

Comparison of DTotal between the unexplained infertile and control groups

Test

Infertile group (n = 31)

Controls (n = 31)

P value

DTotal (three negative values)

29 (93.5%)

31 (100%)

0.313

DTotal (at least one positive value)

2 (6.5%)

0 (0%)

Discussion

In recent years CT has emerged as a significant cause of acute salpingitis and reproductive failure. Gokral et al. [7] reported that, CT infection rate was 34% in the infertile population by PCR detection from the introital and endocervical swab. Additionally, CT was detected in 31.8% of women who classified as unexplained infertility and 5.8% of fertile subjects Gorini et al. [8]. A number of studies have demonstrated that many cases of upper genital tract infection will be missed if one relies only on laparoscopic triad of erythema, tubal edema and purulent exudate [13, 17, 19]. In infertile women with tubal pathology serological markers with tubal pathology, serological markers of persistent CT such as slightly elevated CRP levels are significantly more common as compared to women without tubal pathology [4]. Also CT infection is highly associated with peritubal adhesion which is difficult to diagnose by hysterosalpingography. Therefore, in CT antibody-positive patients, exclusion of tubal pathology by transvaginal hydrolaparoscopy or standard laparoscopy should be carried out to consider appropriate treatments [20].

Ripa et al. [18] showed that cervical culture and serology correlate well in cases of laparoscopically proven CT acute salpingitis. However, it has been claimed that subclinical salpingitis is even more common than symptomatic upper genital tract infection [9, 10, 16]. Our aim in the present study was to investigate the prevalence of UU, CT, MH infection in the cervical canal as well as upper genital tract of women who classified as unexplained infertility.

Peipert et al. [17] showed that the abdominal fluid PCR or fimbrial mini biopsy for CT was positive in two out of 48 (4%) patients without the classic triad of edema, erythema and purulent exudates. Although we have not performed fimbrial mini biopsy and biopsy from peritubal adhesions in order to confirm the presence of the infections, PCR of intra-abdominal fluid detected only one patient with asymptomatic pelvic chlamydial infection. The lower prevalence of upper genital tract CT infection in our study could be explained by differences in the methodology. Additionally, we have only included women who classified as unexplained infertility, whereas the study population of Peipert et al. [17] was not homogenous.

Four cases (three cases with primary infertility, one case with secondary infertility) were found to have peritubal adhesions at pelvic laparoscopy. A cervical as well as pelvic chlamydial infection was present in the case with secondary infertility. As our case with pelvic CT had an edematous and erythematous tube at laparoscopy, it is possible that there may have been an ascending infection through the cervical canal into the tubo-peritoneal compartment, in accordance with the Ripa et al.’s study [18]. The importance of detection of UU positivity in the cervix of infertile (13 of 31) and control patients (11 of 31) is unclear. No case with proven UU cervicitis had a positive PCR test in the Douglas peritoneum.

Hovav et al. [10] demonstrated a higher incidence of pelvic disease in secondary versus primary infertile patients during pelvic laparoscopy (54.3 and 22%, respectively). They reported a higher rate of positive findings (abdominal operation, PID, abnormal hysterosalpingography) in secondary infertile patients compared with primary infertile patients. However, the majority of our cases were primary infertile patients (77%) and women with a history of PID or surgery were excluded from the present study. Furthermore, presence of peritubal adhesions indicates a past episode of PID, but the chance of isolating a causative microorganism can be hampered by the fact that the disease is no longer in its active phase. In another study, CT was isolated in urethral cultures in 26.9%, endocervical cultures in 23.1%, endometrial cultures in 25% and endosalpingeal and/or peritoneal fluid cultures in 1.9% in the unexplained group [5].

The demonstration of cervical colonization of CT by PCR may be a reliable and promising method for the detection of asymptomatic pelvic infection (upper genital tract infection) [23]. Prediction of tubal damage can be predicted by combining tests for humoral and cellular immunity response to chlamydial antigens (Chlamydial heat shock protein 60, CHSP60) [22]. For the detection of asymptomatic UU infection, PCR is not cost effective due to the similar low prevalence in unexplained infertile and control patients, at least in the Turkish population. The detection of chlamydial antigens by PCR is a promising technique. However, the small sample size may have limited our study and we need further studies to prove that. The value of screening unexplained infertile couples for the evidence of asymptomatic infections by PCR technique is another issue that must be further investigated.

Copyright information

© Springer-Verlag 2006