1 Reproductive Medicine Unit, Liverpool Women's Hospital, Crown Street, Liverpool L8 7SS, 2 Department of Obstetrics and Gynaecology and 3 Public Health Laboratory, Countess of Chester Hospital, Chester CH2 1UL, UK
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Abstract |
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Key words: antibody/Chlamydia trachomatis/hysterosalpingography/laparoscopy/tubal damage
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Introduction |
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The two most commonly used methods of assessment for tubal disease are still hysterosalpingography (HSG) and laparoscopy (Dabekausen et al., 1994). HSG has been routine in many fertility centres as an initial investigation as it is cheaper and less invasive than laparoscopy. It is sometimes painful, however, and has a low sensitivity (Swart et al., 1995
). Laparoscopy is considered the gold standard and has been shown to be better than HSG in tubal assessment, particularly in detecting peritoneal adhesions and endometriosis (Corson, 1977
). Laparoscopy is however an invasive procedure and carries with it specific complications. The use of a non-invasive test in conjunction with, or as an alternative to, these would therefore be useful in the initial investigation.
Moore et al. (1982) showed that between 7379% of infertile women with tubal abnormalities as seen on HSG or direct inspection were positive for C. trachomatis antibody (Moore et al., 1982). Serology has since been shown to be more accurate than HSG in predicting the presence of tubal disease (Dabekausen et al., 1994
), and when used in conjunction with an HSG it significantly lowers the false-positive rate (Meikle et al., 1994
).
When patients present for infertility investigations, C. trachomatis infection will have been present for many years. Serological investigation for C. trachomatis is more likely to be positive than using antigen detection tests. Traditionally micro-immunofluorescence (MIF) testing has been used to test serologically for chlamydial infection. Depending on how this test is performed, it can be used to differentiate C. trachomatis, C. pneumoniae and C. psittaci infection but there is also a level of cross-reaction due to shared antigens (Mannion et al., 1991). The MIF test is also technically demanding and labour intensive and as a result is being replaced in some centres by enzyme-linked immunosorbent assay (ELISA) based antibody tests.
The aim of this study was to look at the relationship, if any, between the MIF titre and the degree of tubal damage. The intention was to consider if the MIF titre could be used to determine which patients required a laparoscopy and which patients could have a less invasive procedure, i.e. a HSG or hydrosalpingo-contrast sonography (HyCoSy).
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Materials and methods |
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The serological test used during this period was an indirect MIF technique for C. trachomatis IgG antibodies based on the method previously described (Treharne et al., 1977; Dave Ellis, personal communication). After March 1997 the ELISA technique was used and analysis was therefore not continued.
Tubal patency was tested by HSG or, if there was any indication of pelvic pathology, by laparoscopy and dye test. Tubal disease seen on HSG was defined as obstruction to dye or abnormal dye patterns as defined by the viewer. At laparoscopy it was determined by the presence of adhesions involving the tube, clubbing of the tube or obstruction to the dye. All HSG tests were done in the proliferative phase of the cycle with oil-soluble contrast medium. For laparoscopy tubal testing was done with methylene blue dye.
The case sheets were reviewed for those patients with positive titres (i.e. 1 in 32 or greater) with particular reference to parity, previous gynaecological history, symptoms on presentation, past history of PID, swab results (high vaginal and endocervical), transvaginal ultrasound scan findings, results of HSG and/or laparoscopy, fertility treatment received and the outcome of the treatment.
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Results |
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Transvaginal scan was done in 105 cases, with 36 (34.3%) showing an abnormality. These were polycystic ovaries (n = 19), endometrioma (n = 6), hydrosalpinx (n = 5), fibroid (n = 4) and endometrial polyp (n = 2).
Three patients received prophylactic antibiotics in view of high titres even though there was no evidence of active disease. The use of antibiotics and their value is not known in these patients but it was felt that they may be of value in patients with high titres.
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Discussion |
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Laparoscopy and dye test is considered the gold standard for the evaluation of tubal function but is an invasive and expensive procedure, making it unsuitable for screening purposes. HSG is a less invasive test but is of limited use for detecting tubal patency because of its low sensitivity, although its high specificity makes it a useful test in confirming the presence of tubal obstruction (Swart et al., 1995). Its high false-positive outcome is thought to result from tubal spasm, dissimilar tubal filling pressure, too high viscosity of the contrast medium and faulty technique (Dabekausen et al., 1994
). When HSG is combined with C. trachomatis titres, the false-positive rate is significantly lowered (Meikle et al., 1994
). HyCoSy has a similar accuracy in detecting the tubal patency as HSG, although it has other benefits (e.g. better visualization of the uterine cavity, no radiation exposure) which may make it a more popular test in the future (Reis et al., 1998
). A problem with HSG is that Chlamydia causes adnexal adhesions as well as tubal obstruction and these are best picked up by laparoscopy (Swart et al., 1995
). Adnexal adhesions are much more common in women with positive Chlamydia titres (Walters et al., 1988
; Tanikawa et al., 1996
) showing that those women with high titres should therefore have a laparoscopy. High titres of chlamydial IgG antibody are associated with inflammatory tubal damage, pelvic adhesions and increased risk of tubal pregnancy (Sheffield et al., 1993
; Land et al., 1998
). The presence of peritubular adhesions may also limit tubal motility and interfere with ovum capture (Tanikawa et al., 1996
). These findings are in keeping with the results of this study and show the usefulness of C. trachomatis antibody testing as a routine baseline investigation in the infertility clinic.
Chlamydia antibody titres cannot be used as the sole test of tubal patency. Patients may have an unrelated cause for adhesions (e.g. endometriosis or salpingitis due to another micro-organism). Also some patients who have had previous C. trachomatis infection have no detectable antibody (Puolakkainen et al., 1986). These authors also showed that the sensitivity of the antibody test is critical as IgG titres can decrease over time. During a follow-up period of 36 years there was a significant decline in IgG titres in 26 (43%) patients. Chaim et al. (1992) noted that in a 5 year interval antibody titres fell in 18 out of 25 patients but no patient became seronegative. False positive results can occur because of cross-reactivity in MIF tests due to antibodies to C. pneumoniae (Moss et al., 1993
), which is widely prevalent in Europe and the USA (Mol et al., 1997
).
Chlamydia infection can be detected by a variety of methods. No single test has total diagnostic accuracy. The MIF test, which was used in this study, has been evaluated extensively in the investigation of tubal factor infertility (Jones et al., 1982) and ectopic pregnancy (Chow et al., 1990
). The whole-inclusion immunofluorescence (WIF) test, which has limited published evaluation, and the ELISA are used but there has also been sharp focus on the heat shock protein-60 (HSP-60) test. Reaction to the 60 kDa antigen of C. trachomatis infection, a HSP analogue, has been suggested as a possible marker for the development of chronic sequelae after C. trachomatis infection. Several studies have shown this test to have a high sensitivity and high specificity (Wagar et al., 1990
; Toye et al., 1993
) and anti-HSP antibody rates in patients with complete tubal occlusion have been shown to be significantly higher than in those patients with normal Fallopian tubes (Freidank et al., 1995
). Chernesky et al. (1998) compared results of antibody assays with cervical culture and C. trachomatis plasmid DNA by polymerase chain reaction (PCR) on endometrial biopsies. They compared a combination of MIF, WIF, ELISA and HSP-60. No single serological assay combined 100% sensitivity and specificity in the study, although the HSP-60 enzyme immunoassay showed 100% specificity and 42.9% sensitivity. Routine availability of this test could perhaps further reduce the number of laparoscopies performed in our study group. Cervical IgG antibodies to C. trachomatis have also been shown to be strongly related to chlamydial infection (Witkin et al., 1997
) and may well prove to be a reliable method of detection.
In summary, our study showed a significant increase in the degree of tubal damage in women with C. trachomatis MIF titres 1 in 128. The higher the titre the more likely there would be tubal damage. In this study we only looked at those with positive serology to determine a cut-off level, although there will be a proportion of patients with negative titres who have tubal damage due to other causes (e.g. endometriosis). It has already been mentioned that seropositive patients do not seem to become seronegative (Puolakkainen et al., 1986
), making chlamydial damage very unlikely in this group. Previous work has shown that combination of HSG and C. trachomatis antibody titres will give a false negative rate of approximately 5% (Meikle et al., 1994
), and therefore are best used in those patients with a low titre (<1 in 128). In patients with a higher titre, a laparoscopy would be the better procedure as there is a significantly higher incidence of tubal disease. In our setting this would mean that a quarter (26.3%, 57/216) of new patients would initially have a laparoscopy based on their initial titre. Although other patients would undergo a laparoscopy for other reasons (e.g. assessment of endometriosis), the majority would undergo a less invasive investigation (HSG or HyCoSy). This treatment also has beneficial cost implications. The choice of method for tubal assessment should therefore be taken after the results of the C. trachomatis antibody titres are known.
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Acknowledgments |
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Notes |
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References |
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Submitted on November 19, 1999; accepted on February 9, 2000.