Archives of Medicine and Health Sciences

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 9  |  Issue : 1  |  Page : 39--43

A comparative study of prevalence of Chlamydia trachomatis infection among infertile and fertile women at a tertiary care center


Moushmi Balwant Parpillewar, Shweta Singh 
 Department of Obstetrics and Gynaecology, Government Medical College and Hospital, Nagpur, Maharashtra, India

Correspondence Address:
Dr. Moushmi Balwant Parpillewar
Associate Professor, Department of Obstetrics and Gynaecology, Government Medical College, Medical Square, Hanuman Nagar, Nagpur
India

Abstract

Background and Aim: Chlamydia trachomatis is an obligate intracellular Gram-negative bacterium causing sexually transmitted infection leading to urogenital infections which are asymptomatic. If untreated, leads to complications such as chronic pelvic pain, inflammation, and occlusion of the fallopian tubes, resulting in infertility and ectopic pregnancy. The association is found between C. trachomatis infection and female infertility with a prevalence rate of 15%–30%. The aim was to determine the prevalence of C. trachomatis infection in women with infertility. Materials and Methods: This was a hospital-based cross-sectional study of patients presenting with or without infertility. Group A (75 cases) cases with infertility with or without symptoms of pelvic inflammatory disease. Group B (75 cases) with no infertility matching age, symptoms with Group A. After history, physical examination cervical swab for chlamydial antigen and serology sample was taken and processed. Positive cases were followed by hysterosalpingography (HSG) and laparoscopy. Results: Out of 150 patients, 14 were positive for chlamydia in cases and 4 in the control group. Chlamydial prevalence was four times more in cases as compared to the control group, which is significant. The mean age was 27.97 + 4.520 years. Out of 14 positive cases, 8 (57.14%) had symptoms, whereas 6 (42.85%) were asymptomatic; in controls, 2 were symptomatic, whereas 2 were asymptomatic. HSG and laparoscopy were positive in chlamydia positive cases. Conclusion: It can be presumed that there is a significant role of C. trachomatis in infertility and also there is an association between chlamydia antigen detection and tubal factor infertility.



How to cite this article:
Parpillewar MB, Singh S. A comparative study of prevalence of Chlamydia trachomatis infection among infertile and fertile women at a tertiary care center.Arch Med Health Sci 2021;9:39-43


How to cite this URL:
Parpillewar MB, Singh S. A comparative study of prevalence of Chlamydia trachomatis infection among infertile and fertile women at a tertiary care center. Arch Med Health Sci [serial online] 2021 [cited 2021 Sep 18 ];9:39-43
Available from: https://www.amhsjournal.org/text.asp?2021/9/1/39/319376


Full Text



 Introduction



Chlamydia trachomatis is an obligate intracellular Gram-negative bacterium and is one of the most common bacterial sexually transmitted infections throughout the world.[1] It is estimated that every year, 92 million new cases of C. trachomatis infection occur worldwide. More than two-thirds of these cases occur in the developing world.[2] The majority of urogenital infections due to C. trachomatis infections are asymptomatic.[3] Thus, most infected people remain undetected and untreated as they do not seek medical attention, in contrast to other sexually transmitted infections.[2]

C. trachomatis infection is very common with prevalence ranging from 3.0% to 5.3% among women 18–26 years old and 2.4%–7.3% among men 18–26 years old.[4] C. trachomatis causes infection in the lower genital tract which if untreated suffers from ascending infection of the genital tract, which can lead to complications such as chronic pain, inflammation, and occlusion of the fallopian tubes, which may result in infertility and ectopic pregnancy.[5],[6] The infection is asymptomatic in up to 50% of women and 80% of men or may only display mild symptoms; therefore, infection often remains unnoticed and undiagnosed, and thus untreated.[7]

Female infertility may be attributed to a number of factors, typically divided into endocrine, vaginal, cervical, uterine, tubal, and pelvic-peritoneal factors, and approximately 15%–30% of cases still remain unexplained.[8] Tubal factor infertility (TFI) ranks among the most common causes of infertility, accounting for 30% of female infertility, and is even more prevalent in certain communities.[9] TFI is disproportionately common in women in developing countries; it accounts for over 85% of female infertility cases in regions of sub-Saharan Africa compared to 33% of cases worldwide.[3] Most cases of TFI are due to salpingitis, an inflammation of the epithelial surfaces of the fallopian tubes, and subsequent pelvic-peritoneal adhesions, both of which are mostly caused by previous or persistent infections[10],[11] Bacteria ascend along mucosal surfaces from the cervix to the endometrium and ultimately to the fallopian tubes. This causal pathway presents itself clinically as acute pelvic inflammatory disease (PID), which, in turn, is strongly associated with subsequent TFI. However, the majority of women with TFI do not have a history of acute PID, but rather develop asymptomatic or minimally symptomatic salpingitis as a result of upper genital tract infection.[10],[12] Various studies conducted suggested the significant association between C. trachomatis infection and female infertility with a prevalence rate of 15%–30% and that positive serology screening result for C. trachomatis is predictive for both tubal damage and a reduced pregnancy rate. Our study, thus, aims at finding the impact of chlamydial infection and its sequelae in TFI through chlamydia antigen detection.

Aims and objectives

To determine the prevalence of C. trachomatis infection in reproductive age women attending gynecology outpatient department and comparing the association in patient with infertilityTo determine the symptom and sign and correlate with the chlamydia test resultTo determine its association with the type of infertility if any.

 Materials and Methods



A hospital-based cross-sectional study of the patient population presenting with or without complaint of infertility was undertaken at the Department of Obstetrics and Gynaecology, Government Medical College, Nagpur, which is a tertiary care center in central India. A proper informed consent was obtained from the patient after approval from the institutional ethics committee.

Sample size estimation

The sample size was determined considering the prevalence of infertility; therefore, 150 patients were included in the study.

Study duration

The study was conducted between January 2018 and July 2019.

Study cases

A total of 150 patients coming to the outpatient department with symptoms of burning micturition, vaginal discharge, lower abdominal pain, and signs of PID or those who are asymptomatic were enrolled in the study. The cases were divided into two groupsGroup A (75 cases) included cases with a history of infertility with or without the above symptomsGroup B (75 cases) included cases with no history of infertility matching age and symptoms with Group A.

Inclusion criteria

Women coming to the gynecology outpatient department were divided into two groupsGroup A – women with infertility who were asymptomatic or with complaints of burning micturition, vaginal discharge, lower abdominal pain, and signs of PID, cervicitis, and mucopurulent discharge attending infertility clinic between 19 and 40 years were includedGroup B – symptomatic or asymptomatic women without infertility matched with age and symptom of women in Group A.

Exclusion criteria

Women in the nonreproductive age groupWomen had a history of significant medical or surgical diseasePregnant femalesPatients taken antibiotic within 30 days of studyWomen who did not give consent.

After detailed history taking, a thorough physical examination was done. At the time of physical examination, Pap smear (Papanicolaou) was taken and sent for liquid-based cytology. A cervical swab for chlamydial antigen and serology sample was taken and processed further as detailed below. In case of vaginal discharge, a vaginal swab for culture and sensitivity was sent. Semen analysis of the male partner was done; abnormal semen analysis was designated as male factor infertility. Irrespective of the presence or absence of male factor infertility, the female patient was thoroughly evaluated for other factors. Transabdominal/transvaginal ultrasound was obtained to see the presence/absence of structural abnormalities of the genital tract.

Relevant history included the following

The duration of infertility and results of any previous evaluation and treatment, previous methods of contraception if any used, past medical and surgical illness, history of previous hospital admissions and any history of PIDs, and exposure to any sexually transmitted infections.

Physical examination documented

After the general examination, the following points were specifically noted:

Per speculum examination – evidence of vaginitis, cervicitis, mucopurulent discharge, or foul-smelling dischargePer vaginal examination – for tenderness, organ enlargement, or masses if any, adnexal masses, uterus size, position and mobility, and cul-de-sac masses, tenderness, or nodularity if any.

Procedure of cervical samples (swab)

Exocervix was swabbed to remove excess mucus and the swab was disposed. Second swab was inserted into the endocervix canal until most of the tip not visible and rotated for 5–10 s and withdrawn without touching any vaginal surfaces and sent for antigen detection in Microbiology department. The study was done by detection of antigen in cervical swab by Trinity Biotech antigen detection kitAfter collecting the report, positive cases were followed up by hysterosalpingography (HSG) and laparoscopy. Positive controls were also subjected to HSG after consent for study purpose. The finding of HSG and laparoscopy was included in the study to assess its relationship with tubal factor in cases positive for chlamydial antigen.

 Results



In our study, we recruited 150 patients, 75 cases of infertility in the study group and 75 patients attending the gynecology outpatient department for other complaints in the control group. Out of the 75 cases, 14 (18.6%) were positive for chlamydia in cases and 4 (5.6%) in the control group. [Table 1] shows that chlamydia prevalence is four times more in the case group when compared to the control group, which is significant.{Table 1}

In our study, the majority of patients were in the range of 26–30 years, amounting to 50% of the study group. The mean age of cases was 27.97 + 4.520 years. About 88% of our patients belonged to the urban background, whereas only 12% of them were from the rural background.

When symptoms suggestive of PID such as white discharge per vaginum and pain in the lower abdomen were studied; it was seen that in cases out of 14 positive cases, 8 (57.14%) had symptoms, whereas 6 (42.85%) were asymptomatic [Table 2].{Table 2}

There was a statistically nonsignificant difference seen for the frequencies between the groups (P > 0.05). Asymptomatic patients with chlamydia test positive(2) are same when compared to symptomatic patients in controls (2), which correlates well with the quiescent course of disease [Table 3].{Table 3}

When signs of pelvic infection like cervicitis were studied, it was seen that there is a statistically significant difference seen in the frequencies between the cases (P < 0.01, 0.05) with higher frequency for positive in cases [Table 4] and [Table 5]. Thus, in our study, we can conclude that even though the patients of infertility have no complaints, signs of cervicitis may be detected on per speculum examination and thus is must in the evaluation of infertility even in asymptomatic patients.{Table 4}{Table 5}

HSG changes were considered to be significant if there was bilateral tubal occlusion with or without hydrosalpinx. There was a statistically significant correlation between chlamydia test positive cases and positive changes in the fallopian tube on HSG in cases and controls. Out of 14 positive cases, 9 (64.28%) had tubal changes on HSG [Table 6].{Table 6}

Four controls that tested positive were subjected to HSG with their consent for study purpose, and 50% had tubal changes.

Laparoscopic findings were considered to be significant if there was peritubal adhesion with or without hydrosalpinx with no spillage on chromopertubation. [Table 7] shows that there is a significant correlation between pathological tubal changes seen on laparoscopy and cases that screened chlamydia test positive. About 60% of patients with chlamydia test positive had abnormal findings on HSG and laparoscopy. This was statistically significant with P < 0.0001 in either case. This indicates that the chlamydia antigen test correlates well with HSG and laparoscopy and has a good sensitivity, specificity, and diagnostic accuracy for detecting tubal factors of female infertility.{Table 7}

 Discussion



The increasing incidence of C. trachomatis infection is a global concern due to its potentially detrimental effects on reproductive health. The risk of long-term sequelae increases, especially with recurrent chlamydial infections, and in some women, C. trachomatis represents a major threat to fertility.

The aim of this study was to elucidate the impact of C. trachomatis infection on fertility and to analyze the prevalence of C. trachomatis in such patients. Another aim was to correlate it with TFI.

In our study, majority of patients were in the age group of 26–30 years (49.3%). Only 5.3% of patients belonged to the age group above 36 years. About 95% of women in our study were aged 20–35 years, thus supporting the fact of early marriage and childbearing in developing countries. This is in contrast to the current trend in developed as well in developing countries to some extent to defer childbearing until the mid-30s, which results in the diminished time frame available both for conception and for infertility evaluation.[13]

The mean age was 27.9, standard deviation 4.50 years, which were almost similar to some other reports from developing countries. The mean age of female patients at the time of the first presentation much depends on the socioeconomic structure, literacy level, and cultural belief of the population under study, but we still found a great concordance between our study and various other studies conducted in various developing countries.

In a study by Rahim and Majeed,[14] to assess the frequency and etiological factors of infertility, they observed that a majority of 94% of patients belonged to the age group of 18–34 years. Zargar et al.[15] in their study on etiological aspects of infertility in India observed the mean age of patients in their study as 28.3 years. Studies from developed countries have reported that about 25% of the women seeking infertility services are <24 years, whereas the percentage for the same age group in developing countries is 22%–42%.[12],[16]

On analyzing the prevalence of chlamydia infection in patients of infertility in our study, out of 75 couples, 18% were screened chlamydia test positive by ELISA chlamydia antigen detection test on slides prepared by a cervical swab of infertile patient, which was very similar to the study done by Ghosh et al.[17] in 2015, where they observed 15% prevalence of chlamydia among patients with infertility. Various studies[6],[18] show a wide range of prevalence of 9%–55% among infertile patients which can be explained by the prevalence of chlamydial infection in the respective area.

On analyzing the symptomatology in our study, out of 150 couples, only 30% were symptomatic, which was very similar to the study done by Gupta et al. in 2009.[19] This signifies asymptomatic and quiescent course of disease.

The test of association between chlamydia seropositivity and TFI was statistically significant in our study (P < 0.05). This finding lends credence to the strong association between chlamydia seropositivity and TFI as had been demonstrated by several other studies.[20],[21]

 Conclusion



This study was performed to determine the prevalence of C. trachomatis infection among women attending gynecology and infertility centers in a tertiary care center. This is the study using the ELISA test for the detection of C. trachomatis in endocervical swab specimens. The overall prevalence of C. trachomatis in the study population was 12% (18% in case group and 5% in control). In conclusion, it can be presumed that there is a significant role of C. trachomatis in infertility and also there is an association between chlamydia antigen detection and TFI, in this part of the country. If the chlamydia antibody test is applied as a screening tool early in evaluation, treatment initiation will prevent further damage to the fallopian tubes. A positive chlamydia antibody test might alert one to the possibility of tubal factors relating to previous chlamydial infection that would not be suspected, otherwise and it will help to determine whether HSG or laparoscopy will provide better information needed for planning the treatment. Hence, there is a scope for further study of this causative aspect of infertility with larger number of case studies, in a longer duration of time with well-equipped confirmatory diagnostic procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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