Friday, May 10, 2019

Sexually transmitted diseases and infertility

hiv-std-fertility
About 9% of reproductive-aged women, including nearly 1.5 million women in the USA are infertile[1]. Sexually transmitted diseases are the hidden cause of infertility that you do not hear about very often.




This emotional toll of infertility can be extremely difficult on the couple’s relationship. The physical, emotional and financial stress of infertility can, if you are not careful, hurt your relationship with your partner.
Sexually transmitted diseases are one of the causes of infertility. The reason it is called silent diseases is it can lie dormant in the body for years causing mild symptoms that you might not even notice, but weakening reproductive system. Keep reading to know more about STDs and their impact on fertility in a woman.




Causes and Risks of STDs: 
STDs are caused by almost every kind of organism. This includes bacterial infection like chlamydia, gonorrhea, and syphilis. Viral STDs include genital herpes, genital warts, HIV and hepatitis. Trichomoniasis is caused by a flagellated protozoan.
  1. You may have more than one sexual partner
  2. You may have sex with someone who has more than one sexual partners
  3. You do not use condoms while having sex
  4. You share needles when injecting intravenous drugs.
  5. You trade sex for money or drugs.
 The germs that cause STDs are hidden in semen, blood, vaginal secretions and sometimes saliva. Most of the organisms are caused by oral, anal sex but other conditions like genital warts and genital herpes may spread by skin contact.

Sexually transmitted organisms that can cause infertility:

1. Chlamydia:

Chlamydia is the most common sexually transmitted bacterial infection with women under 25 years of age are most commonly affected[2]. 10-15% of the women with chlamydia if left untreated can develop pelvic inflammatory diseases (PID) and subsequent complications[3].




PID is the recognized complication of chlamydia and less frequently of gonorrhea. Infection with chlamydia is often asymptomatic. Women with PID may exhibit scarring and adhesion formation between structures of the pelvis and in the upper genital tract and cause permanent damage to fallopian tubes, uterus and surrounding tissues, which can lead to infertility.

Since Chlamydia infection can be asymptomatic, most cases can go unnoticed[4]. Annual screening and testing are indicated in women with risk factors, including a new sexual partner and sex partner who has sexually transmitted diseases or those with symptoms that include altered vaginal discharge, intermenstrual or postcoital bleeding or abdominal pain.

2. Gonorrhea:

Gonorrhea is the second most reported STD in the United States, just after Chlamydia[2]. It can manifest as endocervical, rectal, or oral infections. Endocervical infection is asymptomatic in up to 50% of the cases[5], with altered vaginal discharge the most common symptom and lower abdominal pain in up to 25%.




Rectal infection occurs through receptive anal sex and pharyngeal infection through receptive oral sex, the latter is nearly always asymptomatic.

Ascending infection with Gonorrhea may result in PID and infertility[6]. Rarely hematogenous spread can cause disseminated gonococcal infection with purpuric non-blanching rash and arthralgia or arthritis.

3. Mycoplasma genitalium

M. genitalium is another sexually transmitted organism. The prevalence of M. genitalium infections in young adults is about 1% in the United States, whereas, in a sexually active woman, the prevalence rises to 15-20%[7].

M. genitalium first causes the infection of the cervix and can present as abnormal vaginal, intermenstrual or post-coital bleeding, and/or discomfort while urinating. The untreated M. genitalium infection can progress to involved and cause Salpingitis (inflammation of fallopian tubes) and PID.




Just like Chlamydia and Gonorrhea, the M. genitalium infection causes inflammation, scarring, and detachment of cilia in the tubes leading to infertility[8]. Another study showed that this organism can be transported by spermatozoa to the tubes and cause tubal obstruction there[9].

The damage to fallopian tubes caused M. genitalium alone is less severe than that caused by Chlamydia and Gonorrhea, yet a co-infection with these organism results in adverse outcomes.

4. Trichomonas vaginalis

T. vaginalis is the most common non-viral sexually transmitted organism and accounts for more than half of treatable STDs[10].

The T. vaginalis infection is asymptomatic in 50% of the woman and most of their male partners. For the remaining, the symptoms include vaginal discharge and soreness, itchiness, or discomfort in external genitalia.




The concrete evidence of T. vaginalis as the cause of PID and infertility is lacking. It causes inflammation of the uterus, fallopian tubes, and atypical PID[11], making it a suspect for upper genital tract damage.

Some studies have also indicated its role in decreasing sperm motility and killing spermatozoa[12], but these don’t directly affect the fertility of a woman.

5. Vaginal Microbiome and Other Potential Pathogens

Other vaginal microbiomes such as M. hominis and U. urealyticum have also been considered potential culprits for pelvic inflammatory disease and infertility[13][14]. More research is needed to be certain about their role in doing so.
Although Bacterial Vaginosis (BV) is more common in a woman with fertility problems, the evidence of BV as the cause of their infertility is still lacking[15][16].

Conclusion

Claymadia and Gonorhhea are the most common cause of STDs and lead to infertility in women. Other organisms that can affect female fertility include T. vaginalis and M. genitalium. If you’re having fertility problems and/or symptoms of PID, you should consult your gynecologist and get treatment as soon as possible.




Discuss the treatment options for PID and infertility due to PID with your doctor. Ignoring such symptoms can severely impact the ability to conceive and potential complications with pregnancy, such as ectopic pregnancies.
 References
  1. Lindsay, T. J., & Vitrikas, K. R. (2015, March 01). Evaluation and Treatment of Infertility. [Link]
  2. Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. (2018, September). Reported STDs in the United States, 2017[Press release]. [Link]
  3. Haggerty, C. L., Gottlieb, S. L., Taylor, B. D., Low, N., Xu, F., & Ness, R. B. (2010, June 15). Risk of sequelae after Chlamydia trachomatis genital infection in women. [Link]
  4. Haggerty, C. L., Gottlieb, S. L., Taylor, B. D., Low, N., Xu, F., & Ness, R. B. (2010, June 15). Risk of sequelae after Chlamydia trachomatis genital infection in women. [Link]
  5. Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. (2013, April). STD curriculum for clinical educators [Press release]. [Link]
  6. Tubal infertility: Serologic relationship to past chlamydial and gonococcal infection. World Health Organization Task Force on the Prevention and Management of Infertility. (1995). [Link]
  7. Huppert, J. S., Mortensen, J. E., Reed, J. L., Kahn, J. A., Rich, K. D., & Hobbs, M. M. (2008, March). Mycoplasma genitalium detected by transcription-mediated amplification is associated with Chlamydia trachomatis in adolescent women. [Link]
  8. McGowin, C. L., Ma, L., Martin, D. H., & Pyles, R. B. (2009, March). Mycoplasma genitalium-encoded MG309 activates NF-kappaB via Toll-like receptors 2 and 6 to elicit proinflammatory cytokine secretion from human genital epithelial cells. [Link]
  9. Svenstrup, H. F., Fedder, J., Abraham-Peskir, J., Birkelund, S., & Christiansen, G. (2003, October). Mycoplasma genitalium attaches to human spermatozoa. [Link]
  10. WORLD HEALTH ORGANIZATION. (2001). GLOBAL PREVALENCE AND INCIDENCE OF SELECTED CURABLE SEXUALLY TRANSMITTED INFECTIONS OVERVIEW AND ESTIMATES[Press release]. [Link]
  11. Cherpes, T. L., Wiesenfeld, H. C., Melan, M. A., Kant, J. A., Cosentino, L. A., Meyn, L. A., & Hillier, S. L. (2006, December). The associations between pelvic inflammatory disease, Trichomonas vaginalis infection, and positive herpes simplex virus type 2 serology. [Link]
  12. Hoosen, A. A., Quinlan, D. J., Moodley, J., Kharsany, A. B., & Van den Ende, J. (1989, September 16). Sexually transmitted pathogens in acute pelvic inflammatory disease. [Link]
  13. Sweet, R. L. (1986). Colonization of the endometrium and fallopian tubes with Ureaplasma urealyticum. [Link]
  14. Mårdh, P. A., & Weström, L. (1970, June). Tubal and cervical cultures in acute salpingitis with special reference to Mycoplasma hominis and T-strain mycoplasmas. [Link]
  15. Van Oostrum, N., De Sutter, P., Meys, J., & Verstraelen, H. (2013, July). Risks associated with bacterial vaginosis in infertility patients: A systematic review and meta-analysis. [Link]
  16. Taylor, B. D., Darville, T., & Haggerty, C. L. (2013, February). Does bacterial vaginosis cause pelvic inflammatory disease? [Link]
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