Presence of Chlamydia, Mycoplasma, Ureaplasma, and Other Bacteria in the Upper and Lower Genital Tracts of Fertile and Infertile Populations

Objective: The genital mycoplasmas (Mycoplasma hominis and Ureaplasma urealyticum) and Chlamydia trachomatis have been implicated as possible etiologic factors in infertility. Their role in patients with infertility needs to be further defined. Methods: Seventy-nine infertile patients underwent laparoscopy with cultures obtained for aerobic and anaerobic bacteria, Chlamydia, Mycoplasma, and Ureaplasma from the peritoneal fluid, fallopian tube, endometrium, and endocervix. Cultures for similar organisms were taken from the endocervix of 80 fertile women in their first trimester. Culture results were also compared according to ovulatory status and laparoscopic findings in the infertile group. Results: There were no differences in the recovery of Ureaplasma (29% vs. 28%) or Chlamydia (4% vs. 0%) positive cervical cultures in the fertile and infertile groups, respectively. However, a significantly higher number of Mycoplasma positive cervical cultures (14% vs. 5%, P = 0.05) were found in the fertile group. Only two upper genital tract cultures were found to be positive (Ureaplasma). Conclusions: Therefore, if these organisms play a role in infertility, they are present and eradicated prior to infertility work-up and thus do not supports the use of a routine trial of antibiotics prior to laparoscopy.

ver the past several decades, remarkable progress has been made in the treatment of infertility. There still, however, continues to be a subset of couples with reproductive failure in whom there is no demonstrable etiology. An association of the genital mycoplasmas (Mycoplasma hominis and Ureaplasma urealyticum), as well as Chlamydia trachomatis, with infertility has long been suspected. [1][2][3] However, neither epidemiologic evaluation nor treatment data from females in infertile partner-ships have offered consistent reproducible results to implicate any of these organisms as etiologic agents. Since all 3 of these organisms are sensitive to currently available antibiotics, routine empiric treatment of these organisms often occurs, despite the lack of substantial proof of its efficacy.
Overall, considerable controversy exists covering the role of all 3 of these organisms in human infertility. The major problem with previous studies is that infertility is a syndrome, not a specific entity, and that these organisms are likely to be related only to certain clinicopathological subsets.
Much of the data conflict, and the clinician or infertility specialist is left with several questions: 1) Do the genital mycoplasmas play a pathogenic role in infertility? 2) Are cultures for Mycoplasma and Ureaplasma a necessary part of the infertility workup? 3) Does cervical colonization correlate with upper genital tract involvement? 4) Will treatment result in increased fertility rates? Most of the studies include patients with "idiopathic infertility," of whom many have had inadequate diagnostic evaluations. If Mycoplasma, Ureaplasma, and Chlamydia are factors in infertility, they may only be contributing factors rather than primary ones.
Because effective therapy may require treatment for several interrelated factors or organisms, it seems reasonable to first identify which organisms place patients at risk before attempting trial of antibiotics which may not be specific for these organisms. Our particular study was designed to determine the incidence of the genital mycoplasmas and chlamydia colonization in a group of fertile and infertile patients and to possibly identify a clinical subset of patients at a higher risk of colonization.

SUBJECTS AND METHODS
This study consisted of a group of 80 private practice, infertile couples and a control group of 80 consecutive private practice couples with proven fertility in their first trimester of pregnancy. Information obtained for the investigation included: duration of infertility (at least year); significant past medical history and social history; age and race of each partner; oral contraceptive (OC) or intrauterine device (IUD) use; history of pelvic inflammatory disease (PID) or sexually transmitted disease (STD); evidence of ovulation; hysterosalpingogram (HSG); laparoscopic findings; semen analysis and other male factors; results of cultures for C. trachomatis, Mycoplasma, Ureaplasma, Neisseria gonorrhoeae, aerobes, and anaerobes from the endocervix, endometrium, and peritoneal fluid obtained at time of laparoscopy, as previously described. 1-z Information taken from the control (fertile) group included: age and race of each partner; OC or IUD use; history of STD or PID; history of previous infertility work-up. Similar cultures were collected from the endocervix for the previously mentioned organisms at time of initial examination for this group. Endometrial cultures utilized biopsy specimens obtained with Novak curette divided into 2 portions, for routine histological studies and another for culture. At time of laparoscopy, a collection of peritoneal fluid was obtained. If fluid in the cavity was inadequate, lavage with normal saline and aspiration were performed. The fluid was centrifuged to pellet cellular material and then transferred to tissue culture. Direct specimens using swabs of the right oviduct were obtained in 16 patients. Specimens collected for M. hominis and U. urealyticum were done in a similar fashion and placed in a Mycotrans Mycoplasma Transport System (Irvine Scientific, Irvine, CA). These were refrigerated for 25 h, inoculated into a biphasic Mycotrim (Irvine Scientific) GU system, incubated, and then interpreted.
N. gonorrhoeae, aerobic, and anaerobic cultures were obtained and evaluated by routine bacteriological techniques. 4 Chlamydia specimens were processed by tissue culture according to standard methodology. 5 For statistical analysis, Fisher's exact test or chi-square analysis was utilized. P < 0.05 was determined to be significant.

RESULTS
The infertile and control groups were comparable with respect to the demographic characteristics listed in Table (P > 0.05). None of the patients in either group related a history of PID and none of the patients in the fertile group related a history of infertility evaluation. The demographic data and laparoscopic results are listed in Table 2. At the time of laparoscopy, endometriosis was found in 33 (41%) of the patients. Adhesions were identified in 47 (70%) of all patients, but were present in only 31 (39%) of the patients without any evidence of endometriosis. Tubal occlusion, defined as distal occlusion as evidenced by hydrosalpinx, phimosis,  combined, no statistical differences in their culture results were noted. Thirteen of 17 patients with occlusion had histories of previous pelvic surgery. Of the 4 patients who had had no previous pelvic surgery, only had a positive culture (Ureaplasma). In the subpopulation of 53 ovulating patients (i.e., a group of patients in which anovulation cannot be considered to be a contributing factor to the etiology of their infertility), the demographic characteristics were similar to the control group and infertile groups.   evidence of endometriosis were compared to those with pelvic adhesions (without endometriosis). The findings did not demonstrate a statistical difference in cervical culture results for M. hominis or C. trachomatis, but a statistically higher incidence of ureaplasma colonization (P 0.04) was found in patients with endometriosis when compared to those with pelvic adhesions (36% vs. 12%). Sixteen of 25 patients with documented endometriosis in the ovulatory group also had concomitant adhesions. Furthermore, 18 10 studied 20 patients with infertility for longer than year and obtained cultures from the cervix and endometrium for Mycoplasma and Ureaplasma. They found no difference in the incidence of colonization with these organisms in patients with laparoscopic evidence of previous PID. They also found genital mycoplasma colonization in only 10 of 203 endometrial biopsy (EMB) specimens, and of these was associated with endometrial inflammation. During the same time, several investigators have attempted to demonstrate that treatment of these organisms would result in an increased pregnancy rate.Z, 11 Most regimens involve attempted eradication of the organisms by treatment of both partners with either doxycycline or tetracycline, usually in- 12,13 volving a 28-day course.
The role of C. trachomatis in infertility has long been suggested. [14][15][16][17][18] Several investigators have demonstrated an association between serum antichlamydial antibodies and infertility in patients with tubal factors as the source of their infertility. [14][15][16] Despite these implications, few studies have been  (27) 0 *The control group and the infertile groups were statistically different with respect to mycoplasma isolation (P 0.05). **The pelvic adhesion and the endometriosis groups were statistically different with respect to ureaplasma isolation (P 0.04). This study did not document a higher incidence of active colonization with any of these 3 organisms in patients with infertility, tubal occlusion, or pelvic adhesions when compared to pregnant patients.
However, one cannot exclude the possibility that these patients were infected in the past, at which time fertility damage might have occurred, and/or the possibility that subsequent treatment with antibiotics for any number of reasons resulted in a lower incidence of positive cultures. There does not appear to be a high rate of isolation of the genital mycoplasmas or Chlamydia at the time of infertility work-up. Either C. trachomatis, M. hominis, and U. urealyticum do not have a role in infertility or they are factors which manifest themselves prior to the formal work-up of the individual for infertility. Therefore, routine antibiotic treatment without culture confirmation at the time of infertility work-up in a similar patient population is not indicated. It may also be stated that in this, and perhaps similar infertility settings, culture of the endocervix for these organisms is unwarranted. However, work-ups performed by a physician at an earlier stage or in a population with a higher rate of PID may necessitate the consideration of obtaining cultures. If previous infections are proven at some point to be a factor in infertility, diagnosis and treatment of infection need to occur prior to the point at which patients seek infertility care. This challenge then falls on the patient's earlier obstetric and gynecologic care providers, perhaps even in the patient's teenage and early adulthood years before conception is often considered.