Janet M. Allan

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.

Ureaplasma parvum and Ureaplasma urealyticum are detected in semen after washing before assisted reproductive technology procedures

OBJECTIVE To investigate the prevalence of ureaplasmas in semen and washed semen and to explore their effect on semen andrology variables. DESIGN Prospective study. SETTING In vitro fertilization (IVF) unit of a private hospital. PATIENT(S) Three hundred forty-three men participating in an assisted reproductive technology (ART) treatment cycle. MAIN OUTCOME MEASURE(S) The prevalence of ureaplasmas in semen and washed semen tested by culture, polymerase chain reaction assays, and indirect immunofluorescent antibody assays. RESULT(S) Ureaplasmas were detected in 73 of 343 (22%) semen samples and 29 of 343 (8.5%) washed semen samples. Ureaplasmas adherent to the surface of spermatozoa were demonstrated by indirect immunofluorescent antibody testing. Ureplasma parvum serovar 6 (36.6%) and U. urealyticum (30%) were the most prevalent isolates in washed semen. A comparison of the semen andrology variables of washed semen ureaplasma positive and negative groups demonstrated a lower proportion of nonmotile sperm in men ureaplasma positive for washed semen. CONCLUSION(S) Ureaplasmas are not always removed from semen by a standard ART washing procedure and can remain adherent to the surface of spermatozoa.

Reduced levels of gamma-interferon secretion in response to chlamydial 60 kDa heat shock protein amongst women with pelvic inflammatory disease and a history of repeated Chlamydia trachomatis infections.

Peripheral lymphocytes in uninfected fertile controls, women with various histories of Chlamydia trachomatis infection, pelvic inflammatory disease (PID) and infertility not due to C. trachomatis infection (endometriosis) were cultured overnight with PHA mitogen and the 60 kDa chlamydial heat shock protein. Plasma samples were then assayed for levels of gamma-interferon and IL-10 using a commercial ELISA system. Women with PID and those with a history of multiple C. trachomatis infections showed reduced gamma-interferon production in response to cHSP60, not seen in women infected only once and those with infertility due to other causes (endometriosis). Secretion of IL-10 in response to cHSP60 did not vary significantly across the various patient groups, though all patients showed elevated levels of total IL-10 compared with uninfected controls.

Microbial colonization of follicular fluid: alterations in cytokine expression and adverse assisted reproduction technology outcomes

BACKGROUND Previous studies have measured cytokines expressed within follicular fluid and compared the profiles with the aetiology of infertility and/or successful or unsuccessful assisted reproduction technology (ART) outcomes. METHODS In this study, 71 paired follicular fluid and vaginal secretions collected from ART patients were cultured to detect microorganisms and tested for the presence of cytokines. Patient specimens were selected for assay based on two criteria: whether the follicular fluid specimen was colonized (with microorganisms prior to oocyte retrieval) or contaminated by vaginal flora and; the aetiology of infertility. Patients included fertile women (with infertile male partners; n = 18), women with endometriosis (n = 16) or polycystic ovary syndrome (PCOS, n = 14), or couples with a history of genital tract infection (n = 9) or idiopathic infertility (n = 14). RESULTS Microorganisms and cytokines were detected within all tested specimens. Colonizing microorganisms in follicular fluid were associated with: decreased fertilization rates for fertile women (P = 0.005), women with endometriosis (P = 0.0002) or PCOS (P = 0.002) compared with women whose follicular fluid was contaminated at the time of oocyte retrieval and with decreased pregnancy rates for couples with idiopathic infertility (P = 0.001). A single cytokine was discriminatory for women with an idiopathic aetiology of infertility (follicular fluid interleukin (IL)-18). Unique cytokine profiles were also associated with successful fertilization (IL-1α, IL-1β, IL-18 and vascular endothelial growth factor). CONCLUSIONS Follicular fluid is not sterile. Microorganisms colonizing follicular fluid and the ensuing cytokine response could be a further as yet unrecognized cause and/or predictor of adverse ART outcomes and infertility.

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.

Use of a commercial assay for detecting the 60 kDa chlamydial heat shock protein in a range of patient groups.

EVIDENCE IMPLICATING THE 60 kDa chlamydial heat shock protein (cHSP60) as the critical antigen responsible for stimulating immune-mediated inflammation and disease is quite considerable, mainly through studies reporting an increasing prevalence of cHSP60 antibodies among women with increasing severity of genital Chlamydia trachomatis disease. Women with visually observed chlamydial pelvic inflammatory disease showed a direct correlation between high cHSP60 antibody titers and severe inflammatory manifestations.1 A number of studies investigating serologic responses of infertile women to cHSP60 have demonstrated a correlation between cHSP60 antibodies and tubal infertility.2–5 This has led to the development of various commercial and in-house assays for detecting anticHSP60 antibodies as a research and potential diagnostic tool for investigations of infertility and tubal pathology. A recently published letter by Bax et al6 further suggested the value of a new commercially available cHSP60 assay as a diagnostic tool for predicting pathologic sequelae to urogenital chlamydial infections. This particular study compared women with tubal disease and C. trachomatis serology with control groups of pregnant women (unknown tubal status) and women without tubal pathology. We report on a similar evaluation of the same assay as applied to a wider range of female patient groups presenting with varying histories of C. trachomatis infection, sequelae, and uninfected controls. Four groups of women were sampled in our study: those with a previous history of C. trachomatis infection, those with endometriosis (infertility not resulting from C. trachomatis), uninfected adult females, and uninfected female children. Group 1: Women With a History of Chlamydia trachomatis Infection