Original Article

Current Chlamydia trachomatis Infection, A Major Cause of Infertility

Jayanti Mania-Pramanik 1*, Shilpa Kerkar 1, Shobha Sonawane 1, Pratibha Mehta 1, Vinita Salvi 2,3

1- Department of Health Research, Indian Council of Medical Research, National Institute for Research in Reproductive Health,
Mumbai, India
2- Seth G S Medical College and KEM Hospital, Parel, Mumbai, India
3- Seven Hills Hospital, Mumbai, India

Abstract
Background: In India, the impact of current Chlamydia trachomatis (C. tracho-
matis) in reproductive health remains a neglected area of investigation. The present
study evaluates if current Chlamydia infection is associated with any clinical com-
plication that needs the attention of clinical investigators.
Methods: In this cross-sectional study, we enrolled 896 women attending the Gyne-
cology Out Patient for the detection of C. trachomatis infection. Polymerase chain
reaction was used to diagnose current C. trachomatis infection and ELISA for past
infections. Bacterial vaginosis, Candida and Trichomonas were screened. The results
of symptomatic and asymptomatic groups were compared. The data was analyzed
using Epi Info version 6 and "Z" test. A probability value of p≤0.05 was considered
as significant.
Results: Statistical analysis revealed significant association between current C. tra-
chomatis infection with infertility when comparing infected fertile (18.6% vs. 9.4%,
* Corresponding Author:
Jayanti Mania-Pramanik, odds ratio: 2.19, p<0.0005) and uninfected infertile women (45.6% vs. 27.3%, odds
Infectious Diseases Biolo- ratio: 2.24, p<0.0001). Average infection rate was 12.1%, highest in women with in-
gy, National Institute for fertility (18.6%) or with ectopic pregnancy (25%). Significant proportions of infect-
Research in Reproductive ed women with infertility (p<0.01) or with recent pregnancy (p<0.001) were asymp-
Health, Indian Council of
Medical Research, De-
tomatic. Follow up of infected women who became negative after treatment [28
partment of Health Re- women from infertility group and 9 women with recurrent spontaneous abortion
search, Mumbai, India (RSA)] revealed live birth in 8 (21.6%) women within one year, 4 with infertility
E-mail: and 4 with RSA.
jayantimania@rediffmail. Conclusion: Study findings suggest association between current C. trachomatis in-
com
fection and infertility. Absence of signs and symptoms associated with this infection
Received: Jun. 23, 2012 highlights its diagnosis in women with a history of infertility and RSA for their bet-
Accepted: Jul. 7, 2012 ter management, as revealed by live births with one year of follow up.

Keywords: Asymptomatic, Chlamydia infection, Current, Infertility.

To cite this article: Mania-Pramanik J, Kerkar S, Sonawane S, Mehta P, Salvi V. Current
Chlamydia trachomatis Infection, A Major Cause of Infertility. J Reprod Infertil.
2012;13(4):204-210.

Introduction
iagnosis, treatment and prevention of sexual- tions like mucopurulent endocervicites, endo-
ly transmitted Chlamydia infection has be- metritis or salpingitis have been attributed to this
come an important public health priority es- infection. The potentially serious sequelae of cer-
pecially, by strong evidence linking this infection vical infection with C. trachomatis includes infer-
with HIV transmission (1). Consequences of Chla- tility, ectopic pregnancy, pelvic pain and recurrent
mydia trachomatis (C. trachomatis) infection are pelvic inflammatory diseases (PID) (2−4). How-
more damaging to the reproductive health of ever, all the infected individuals do not develop
women than to men. A number of clinical condi- such complications or symptoms, as only a frac-

J Reprod Infertil. 2012;13(4):204-210

 Mania-Pramanik J, et al. JRI
tion get upper genital tract infection and a subset India) specimens were collected in a sterile con-
of them manifest complications leading to infertil- tainer with 1ml PBS (pH=7.5) for immediate pro-
ity and ectopic pregnancy (5, 6). Direct and indi- cessing to detect C. trachomatis infection, while
rect costs of chlamydial infections are substantial, second specimens were stored in dry sterile vials
justifying more attention and a stronger multidis- at -20°C for confirmatory tests, if required. Vagi-
ciplinary approach. Cates and Wasserheit re- nal specimens were also collected from the poste-
viewed a large number of studies showing statisti- rior fornix using a wooden spatula for the diagno-
cally significant association between tubal factor sis of bacterial vaginosis (BV) using Nugent's
infertility, spontaneous abortion (SA) and ectopic scoring system for Gram stain smears (11) and for
pregnancy with previous systemic chlamydial in- the detection of trichomonas and candida by wet
fection identified by the presence of C. tracho- mount. Blood specimens collected from the wom-
matis specific antibody (7). Reports are also avail- en were used for antibody test using commercially
able on the prevalence of current C. trachomatis available ELISA kit (Novatech Immuno-diag-
infection in women with different clinical condi- nostica, GMBH).
tions like infertility and genitourinary complaints Adequacy of specimens: In order to check speci-
(8-10); however, there is not much reports on its men adequacy, each cervical specimen in PBS
association with infertility or related clinical com- was vortexed for 30 s, the swab was squeezed and
plications. Evaluation of present infection with the 10 μl of specimen was examined under micro-
aforesaid types of manifestations could help in scope to see the presence of epithelial cells. Four
treatment. In India, the clinical manifestations or to five epithelial cells per high power field was
sequelae associated with current C. trachomatis considered as an adequately collected specimen
infection, is yet to be considered as a major health for further processing.
problem and clinician rarely refer any subject for Signs and symptoms of reproductive tract infections:
its diagnosis. Hence, the present study aims to Severely eroded cervix with hypertrophic cervical
assess whether current C. trachomatis infection is erosions and a mucopurulent endocervical dis-
associated with any complications in Indian wom- charge or leucorrhoea were recorded as signs
en that needs to be highlighted for its clinical in- while burning micturation and pain in the abdo-
vestigation. men reported by the women were recorded as
symptoms.
Methods Extraction of DNA: DNA was isolated from cer-
Subjects: In this cross-sectional study, we en- vical specimen using a rapid non-enzymatic
rolled women attending the Gynecology Out Pa- method. The cells were pelleted and resuspended
tient Department (OPD) of Seth G.S. Medical in Tris-MgCl2-KCl buffer (pH=7.4) and treated
College and King Edward Memorial (KEM) Hos- with 10% sodium dodecyl sulphate at 55 ºC for 10
pital, Parel, Mumbai, between 2003 to 2009. The min to lyse the cells. The proteins were precipitat-
group comprised of women with histories of re- ed using saturated sodium chloride solution. DNA
current spontaneous abortion (RSA, n=143), infer- was precipitated by 100% ethanol and eluted in
tility (n=264), symptoms and signs of lower geni- Tris EDTA buffer (12). The quantity and quality
tal tract infections (LGTI, n=213), pregnant wom- of DNA was estimated spectrophotometrically
en (n=174) attending the antenatal care (ANC) and by loading an aliquot of DNA on 0.8%
unit, as well as those who had no symptoms and agarose gel. As an internal control PCR for beta-
signs of any infection (asymptomatic controls, globin gene was also performed for each sample
n=102) but came for family planning advice. to rule out the presence of inhibitory factors in the
Ethics Committees of the institute, as well as of extracted specimens.
KEM Hospital approved the study. Each woman PCR for diagnosis of C. trachomatis: PCR was per-
was informed about the study and written consent formed on extracted DNA using primers designed
was obtained from all the women before enroll- from the conserved region of MOMP gene of C.
ment. trachomatis with sense primer: 5' GCC GCT TTG
Specimens: The clinician team did a routine gy- AGT TCT GCT TCC 3' and anti-sense primer: 5'
necological per speculum examination to record GTC GAA AAC AAA GTC ACC ATA GTA 3' to
signs of infection and collected endocervical and amplify a 180 bp DNA fragment common to all
vaginal swab specimens. First, endocervical swab serotypes (13). The reaction was carried out in a
(Hi-media Laboratories Pvt. Limited, Mumbai, volume of 50 μl. It contained primers (0.5 μm

J Reprod Infertil, Vol 13, No 4, Oct-Dec 2012 205

JRI C. Trachomatis Infection in Indian Women

each), 0.2 mM dNTP’s, PCR buffer (10 mM Tris this product is directly proportional to the amount
buffer; pH=9), 1.25 units of Taq polymerase, 10 of Chlamydia-specific IgG antibodies in the spec-
μl of DNA specimen and the volume was adjusted imen. The specimens with O.D. higher than the
with sterile distilled water. Positive and negative cut-off value (0.250−0.900) were considered posi-
controls were also run in each experiment. Reac- tive for Chlamydia-specific antibodies and used as
tion was performed in a thermal cycler (Perkin an indicator of past Chlamydia infection. Each
Elmer 2400) as per the following protocol: initial positive sample was again confirmed using anoth-
denaturation was done for 5 min at 94 °C. This er serum aliquot of the same participant. The re-
was followed by 35 cycles of 30 s each of dena- sults were found to be reproducible.
turation at 94 °C, annealing at 55 °C and exten- Follow up of C. trachomatis positive cases: Coun-
sion at 72 °C for 1 min. The final extension step seled each enrolled women to come back to take
was carried out at 72 °C for 5 min. The amplified the report. Those found to be infected with any of
products were run on 2% Agarose gel, observed these infections were treated by the clinician.
under a UV transilluminator while the results Statistical analysis: Statistical analysis using Epi
were being documented. Presence of 180 bp re- Info version 6 software for Chi-squares (χ2) test
peat sequences in positive control specimen and was applied to study the association between C.
its absence in the negative control indicated reac- trachomatis infection with the clinical manifesta-
tion had been completed satisfactorily. Presence tions. The test of significance for proportion be-
of 180 bp repeat sequences in other clinical spec- tween different groups was carried out using "Z"
imens indicated presence of C. trachomatis infec- test. A probability value of p≤0.05 was considered
tion. Further confirmation of these amplified as significant.
products was carried out using specific C. tra-
chomatis probe in Southern hybridization (14). Results
Probe was prepared using PCR dig-labeling kit Study subjects: Eight hundred and ninety-six
(Roche diagnostics). Standard protocol for South- women were tested for current C. trachomatis
ern blotting was followed for transfer of PCR infection by PCR. The participants were between
products to a nylon membrane, which was then 16 to 45 years old with a median age of 29 yrs,
processed for hybridization using a generic probe. and an interquartile range (IQR) value of 10. They
Instruction manual was followed to detect the belonged to middle socio-economic groups and
probe complex using Dig-luminescence detection their personal history did not reveal any high risk
kit (Roche diagnostics). behavior. The number of women in asymptomatic
Detection of C. trachomatis IgG antibody: Com- control group, as well as those in groups with dif-
mercially available enzyme-linked immunosorb- ferent clinical histories like RSA, infertility, with
ent assay (ELISA) kit was used to detect C. tra- lower genital tract infection (LGTI), pregnant
chomatis specific IgG antibody (NovaTec Im- women from antenatal care (ANC) centers, their
munodiagnostica, GMBH). In brief, microtitre age and the infection rate in each group is pre-
wells precoated with C. trachomatis antigens were sented in table 1.
incubated with serum specimen at a 1:100 dilution In the RSA group, there were 58 women with 2
so that any corresponding antibodies present in pregnancy losses (2SA), 77 women with more
the serum would bind to the antigen to form com- than 3 pregnancy losses (>3SA) and 8 with ectop-
plexes. After washing the wells to remove all un- ic pregnancy. In the ANC group, the gestational
bound sample material, horseradish peroxidase period of the pregnant women varied from 2 to 4
(HRP) labeled anti-human IgG conjugate was months. There were 108 (12.1%) women with cur-
added which would bind to captured Chlamydia rent C. trachomatis, indicating the prevalence of
specific antibodies. The immune complex formed this infection in the study population.
by the bound conjugate was visualized by adding Presence of other reproductive tract infections and
tetramethylbenzidine (TMB) substrate, which past C. trachomatis infection: Of the 108 C. tracho-
gives a blue colored reaction product. matis infected women, 4 (3.7%) had concomitant
After terminating the reaction using a stop solu- BV while 1 (0.9%) had concomitant Candida
tion (Sulphuric acid, 0.2 mol/l), the absorbance of albicans. In the rest of participants (n=788), C.
the end product, which is yellow in color, was trachomatis specific antibody was present in 14
read at 450 nm using an ELISA plate reader (μ women, one woman had both the antibody and the
Quant, Bio-Tek Instruments Inc.). The intensity of antigen. Eighty women had other infections such

206 J Reprod Infertil, Vol 13, No 4, Oct-Dec 2012

 Mania-Pramanik J, et al. JRI
Table 1. Defined groups of participant (count and age) and C. trachomatis infection rate
Participant C. trachomatis
Age in years Ag Other Infections
Clinical groups (n=896) Ab Ag+Ab
N (%) Range Median N (%) N (%) N (%) BV Candida Trichomonas
Asymptomatic 102 11.4 18-40 30 2 (1.96) 0 (0.00) 0 (0.00) 6 2 0
LGTI 213 23.8 18-40 30 20 (9.39) 0 (0.00) 0 (0.00) 6 15 5
RSA (n=143, 15.38%)
2 SA 58 6.5 20-43 26 3 (5.2*) -- -- 9 5 0
>2 SA 77 8.6 20-40 28 8 (10.4*) -- -- 3 1 0
Ectopic pregnancy 8 0.9 26-38 31.5 2 (25*) -- -- 0 0 0
Infertility 264 29.5 18-40 26 49 (18.6) 6 0 (0.00) 18 2 2
ANC 174 19.4 19-40 26 24 (13.8) 0 (0.00) 1 1 10 0
*p<0.001,
Notes: Asymptomatic=Healthy women without any sign or symptoms of any infection or disease; LGTI=Lower genital tract infections; RSA=Recurrent
spontaneous abortion; Infertility=Women unable to conceive after two years of cohabitation with husband; ANC=Antenatal cases or pregnant women;
SA=Spontaneous abortion

as BV, Candida or Trichomonas infections and the {9.4% (46 of 489); odds ratio: 2.19, p<0.0005)}
related infection rates were 14.5%, 4.3% and when compared to infected infertile women (18.6%,
0.9%, respectively. For further analysis, these 49 of 264). Comparison of clinical manifestation
women with C. trachomatis antibody (n=15), as of women with only current C. trachomatis infec-
well as those with other infections (n=80) were tion (n=103) with that of uninfected women
excluded. Hence, there were 693 women without (n=693) revealed significant association of C. tra-
any infection, who were taken into consideration chomatis infection with infertility (45.6% vs.
for comparative analysis (Table 2). 27.3%, p=0.0001; Table 2). Another significant
Sequelae, symptoms and signs associated with cur- observation was the absence of any symptoms or
rent C. trachomatis: Infection rate varied from signs on per speculum examination in infertile
1.96% to 25.0% among the different groups of (64% vs. 36%, p<0.01) and pregnant (79.2% vs.
participants (Table1). Among the RSA subgroup 22.8%, p≤0.001) infected women, indicating
a significant (p<0.001) proportion of women with asymptomatic nature of this infection (Figure 1).
ectopic pregnancy (25%) and with more than 2 Age associated with current C. trachomatis infec-
spontaneous abortions (10.4%) had this infection, tion: C. trachomatis infection was highest (21.8%)
compared to women with 2 spontaneous abortions among women 20 years old or younger, though
(5.2%). C. trachomatis infection rate was signifi- not statistically significant, and lowest in 21−25
cantly low in the group of women with children or year old age group. The infection rate again show-
expecting a child such as asymptomatic controls ed an increasing trend in women above 26−40
(n=102), LGTI (n=213) or in ANC (n=174) groups, years of age.

Table 2. Frequency of clinical manifestations with or without current C. trachomatis infection in women who did not have any other infec-
tion and their treatment outcome

C. trachomatis
Treatment outcome
Positive Negative
C. trachomatis
Treatment Live birth after Loss to
Women N=103 N=693 OR χ2 p
given treatment follow up
Negative Positive
N (%) (%)
Infertility 47 45.6 189 27.27 2.24 13.3 0.00014 42 28 2 4 12
RSA 11 10.7 106 15.29 0.66 1.63 0.217 11 9 2 4 -
not
ANC 24 23.3 138 19.91 1.22 4.47 0.425 8 8 -
known
LGTI 19 18.4 168 24.24 0.71 1.13 0.195 9 9 -- -- --
Asymptomatic control 2 1.9 92 13.28 - 9.67 0.0002 2 2 -- -- --
Total 103 - 693 -- -- -- -- 72 48 4 16 12

Notes: Infertility=Women unable to conceive after two years of cohabitation with husband; RSA=Recurrent spontaneous abortion; ANC=Antenatal cases or pregnant
women; LGTI=Lower genital tract infections; Asymptomatic controls=Healthy women without any sign or symptoms of any infection or disease

J Reprod Infertil, Vol 13, No 4, Oct-Dec 2012 207

JRI C. Trachomatis Infection in Indian Women

our study, we excluded women positive for C.

trachomatis antibody from analysis as presence of
C .trachomatis antibody is known to be associated
with tubal factor infertility, spontaneous abortion
and ectopic pregnancy (7). A recent report in
Ghanaian women, also highlighted the presence of
Chlamydia-specific IgG (39%) and IgA (14%)
antibodies indicating previous C. trachomatis in-
fections among women with primary or secondary
infertility compared to current infection (2.4%)
(15). Further, C. trachomatis infected women with
co-infections were also excluded from the study
so that a direct correlation could be made between
Figure 1. Sequelae associated with C. trachomatis infection, with or current C. trachomatis infection with its clinical
without symptoms and signs
*p>0.05; #p<0.01; †p<0.001, LGTI=Lower genital tract infection; manifestations. In the present study, comparative
RSA=Repeated spontaneous abortion; ANC= Antenatal case. Per- analysis between women with or without C. tra-
centage of subjects=Percentage of infected women in each group of chomatis with different types of clinical manifes-
women with different manifestations
tations, showed a statistically significant associa-
Association of current C. trachomatis infection with tion between current C. trachomatis infection with
vaginal pH/Microscopic analysis (>10PMNs)/Colour infertility.
of swab/Bleeds on touch: Among the C. tracho- The average infection rate was 12.1%. This high
matis infected women, (20.2%) had high pH (>5), rate of infection might be due to the inclusion of
(47.7%) had more than 10 polymorphonuclear women with specific clinical history like infertili-
leukocytes (PMNs) in their specimens, 2.7% had ty, ectopic pregnancy, as well as women with
yellow/grayish coloured discharge and 7.3% had more than two spontaneous abortions. Previous
blood on swab or bled during collection of speci- studies in the local population have shown a low
mens. infection rate among women with infertility
Follow up of C. trachomatis positive cases: Seven- (2.5%) which might have been due to the use of
ty-two women with C. trachomatis infection came less sensitive techniques like ELISA (16). Our
for the report, which were subsequently treated. previous study using the same method (ELISA)
Follow up record on 60 women was available only also showed a similar infection rate (1.7%) in
for one year. Thereafter, they could not be traced asymptomatic controls, while the present rate
due to several reasons. In ANC group, 8 of 24 C. (18.6%) of infection in women with infertility
trachomatis positive pregnant women came for using PCR was high compared to 14.3% of wom-
follow up and were treated. No further testing was en with infertility published earlier using ELISA
done in these pregnant women after completion of (17). Another study from Mumbai reported high
treatment in accordance with the clinician advice rates of infection (23.2%) in female sex workers
to avoid any risk during pregnancy. These eight using ELISA (18), indicating presence of this in-
women had live births. Result of follow up in oth- fection in the local population. Moreover, women
er groups revealed that four of the 52 infected in- with infertility and recurrent spontaneous abor-
dividuals were positive even after treatment. tions might be more sexually active to conceive
There were eight live births in these groups fol- leading to high infection rates. Other studies in
lowing treatment (Table 2). Women with other in- women from northern Indian also revealed similar
fections such as BV, Candida and Trichomonas high infection rates (27%, 20 of 74) in women
were also treated as per hospital routine procedure. with primary infertility as detected by culture or
antigen test (8). High prevalence rate (43.1%) of
Discussion C. trachomatis was also seen in women (n=430)
Results revealed statistically significant associa- with genitourinary complaints, even among the
tion between current C. trachomatis infection with slum dwellers (15.3%, n=53) compared to 9.39%
clinical manifestations or sequelae like infertility observed in our women with LGTI (10). Report
in women in Mumbai, India. Women with con- also revealed high rates of Chlamydia infection in
founding variables such as other abnormalities or women with infertility (36%, n=169), compared to
infections were excluded from comparisons. In our observation of 18.6% (9). Provision of free

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 Mania-Pramanik J, et al. JRI
treatment and access to health care system might In C. trachomatis negative women, the rate of
be responsible for the comparatively low infection other infections like BV, Candida and Tricho-
rate seen in this western region of the country. monas correlated well with a previous study con-
Significant proportion of women with ectopic ducted in Mumbai where the infection rate of BV,
pregnancy and more than two spontaneous abor- Candida and Trichomonas were, 13% (58/446),
tions had current C. trachomatis infection, which 0.9% (4/446) and 0.5% (2/446), respectively (26).
might be the etiology for the aforesaid disorders Infection such as candidiasis (4.3%) was expected
as reported earlier (7, 19). However, these reports to be more common in Mumbai in view of poor
suggest association of C. trachomatis antibody or and unsatisfactory housing conditions under
its past infections with these types of manifesta- which many of them lived but this condition was
tions, whereas our results showed its association, not observed. Even existence of common RTIs
i.e.; one fourth of ectopic pregnancies with current along with C. trachomatis infection was observed
C. trachomatis infection, supporting the recent re- to be low in this clinic based prevalence study.
view which attributes one- third of ectopic preg- These findings could suggest, statistically signif-
nancies to chlamydial infection (2). icant association between current C. trachomatis
Age-wise distribution of study population with infection with infertility and immunity to infection
C. trachomatis infection revealed that a high pro- which might be correlated to sperm rejection in
portion of women younger than 20 years of age women leading to infertility.
had this infection, which is in harmony with other The limitation of the study was follow up of en-
reports that Chlamydia infection rates are inverse- rolled women only up to one year. The enrolled
ly related to age (5−7, 20, 21). In the present study, a women could not be contacted due to frequent
unique trend between infection rate and age was change of their phone number.
observed. Absence of signs and symptoms in significant
This infection was mostly asymptomatic; women proportions of currently infected women, as well
only came to the clinics when they developed as high infection rate in the younger age group
complications such as signs and symptoms of emphasizes the need for C. trachomatis diagnosis.
lower genital tract infection, experienced repeated Current C. trachomatis infection could be in-
pregnancy loss, and had infertility at later age; volved in the etiology of infertility and its treat-
thus, present observation revealed an increasing ment will help in positive pregnancy outcomes.
rate of infection with age.
A year of follow up of the treated women was Conclusion
followed by the pregnancy and subsequent live Study findings suggest, statistically significant
birth in four women with infertility and four association between current C. trachomatis infec-
women with RSA indicating the association of tion with infertility. Absence of signs and symp-
this infection for such types of manifestations. toms associated with this infection highlights the
Asymptomatic nature of these manifestations al- need for its investigation in women with a history
so correlated with earlier reports (22, 23). Some of infertility and RSA for their better manage-
studies have shown that a count of <10 PMNs per ment, as revealed by live birth with one year of
high power field was defined as predicting ab- follow up.
sence of gonococci and C. trachomatis (24, 25)
but only 47.7% of the infected women from the Acknowledgement
study group had a count of >10 PMNs/hpf. Ab- We thank all the staff members who helped us in
sence of increased number of PMNs in the rest this work and the National Institute for Research
might be associated with asymptomatic nature of in Reproductive Health for their support. We
disease manifestations in these women. thank WHO for providing financial support
We could not establish the cause of high pH of through WHO-Country budget, as well as partial
vaginal secretion in 20% of the C. trachomatis support from ICMR Adhoc Research Grant5/7/
infected cases as only 3.7% had BV infection. 129/05-RHN to carry out the study.
Hence, our attempt to correlate C. trachomatis
infection with any changes in vaginal pH, any Conflict of Interest
changes in the colour of swab collected or bleed- There was no conflict of interest in this article.
ing while collecting specimen was futile.

J Reprod Infertil, Vol 13, No 4, Oct-Dec 2012 209

 JRI C. Trachomatis Infection in Indian Women

References 2006;20(1):8-14.
1. Grosskurth H, Mosha F, Todd J, Mwijarubi E, 15. Siemer J, Theile O, Larbi Y, Fasching PA, Danso
Klokke A, Senkoro K, et al. Impact of improved KA, Kreienberg R, et al. Chlamydia trachomatis
treatment of sexually transmitted diseases on HIV infection as a risk factor for infertility among
infection in rural Tanzania: randomised controlled women in Ghana, West Africa. Am J Trop Med
trial. Lancet. 1995;346(8974):530-6. Hyg. 2008;78(2):323-7.
2. Bébéar C, de Barbeyrac B. Genital Chlamydia tra- 16. Chandhok N, Datey S, Gaur LN, Saxena NC. Prev-
chomatis infections. Clin Microbiol Infect. 2009; 15 alence of chlamydia trachomatis in women attend-
(1):4-10. ing different clinics at tertiary hospitals. J Obstet
3. Darville T, Hiltke TJ. Pathogenesis of genital tract Gynecol India. 2003;53(5):463-7.
disease due to Chlamydia trachomatis. J Infect Dis. 17. Mania-Pramanik J, Meherji P, Gokral J, Donde U.
2010;201 Suppl 2:S114-25. Chlamydia trachomatis infection in an urban set-
4. Haggerty CL, Gottlieb SL, Taylor BD, Low N, Xu ting. Sex Transm Infect. 2001;77(2):141.
F, Ness RB. Risk of sequelae after Chlamydia tra- 18. Divekar AA, Gogate AS, Shivkar LK, Gogate S,
chomatis genital infection in women. J Infect Dis. Badhwar VR. Disease prevalence in women at-
2010;201 Suppl 2:S134-55. tending the STD clinic in Mumbai (formerly Bom-
bay), India. Int J STD AIDS. 2000;11(1):45-8.
5. Stamm WE. Chlamydia trachomatis infections of
the adult. In: Holmes KK, Sparling PF, Mardh PA, 19. Witkin SS, Ledger WJ. Antibodies to Chlamydia tra-
editors. Sexually transmitted diseases. New York: chomatis in sera of women with recurrent sponta-
McGraw-Hill; 1999. p. 407-22. neous abortions. Am J Obstet Gynecol. 1992;167
(1):135-9.
6. Schachter J, Stoner E, Moncada J. Screening for
chlamydial infections in women attending family 20. Schachter J. Infection and disease epidemiology.
planning clinics. West J Med. 1983;138(3):375-9. In: Stephens RS, editor. Chlamydia intracellular bi-
ology, pathogenesis, and immunity. Washington DC:
7. Cates W Jr, Wasserheit JN. Genital chlamydial in-
American Society for Microbiology; 1999. p. 139-69.
fections: epidemiology and reproductive sequelae.
Am J Obstet Gynecol. 1991;164(6 Pt 2):1771-81. 21. Thompson SE, Washington AE. Epidemiology of
sexually transmitted Chlamydia trachomatis infec-
8. Malik A, Jain S, Hakim S, Shukla I, Rizvi M.
tions. Epidemiol Rev. 1983;5:96-123.
Chlamydia trachomatis infection & female infertili-
ty. Indian J Med Res. 2006;123(6):770-5. 22. Sellors JW, Mahony JB, Chernesky MA, Rath DJ.
Tubal factor infertility: an association with prior
9. Mittal A, Kapur S, Gupta S. Screening for genital
chlamydial infection and asymptomatic salpingitis.
chlamydial infection in symptomatic women. Indi-
Fertil Steril. 1988;49(3):451-7.
an J Med Res. 1993;98:119-23.
23. Osser S, Persson K, Liedholm P. Tubal infertility
10. Singh V, Rastogi S, Garg S, Kapur S, Kumar A,
and silent chlamydial salpingitis. Hum Reprod.
Salhan S, et al. Polymerase chain reaction for detec-
1989;4(3):280-4.
tion of endocervical Chlamydia trachomatis infec-
tion in women attending a gynecology outpatient 24. Moscicki B, Shafer MA, Millstein SG, Irwin CE Jr,
department in India. Acta Cytol. 2002;46(3):540-4. Schachter J. The use and limitations of endocer-
vical Gram stains and mucopurulent cervicitis as
11. Nugent RP, Krohn MA, Hillier SL. Reliability of
predictors for Chlamydia trachomatis in female ad-
diagnosing bacterial vaginosis is improved by a
olescents. Am J Obstet Gynecol. 1987;157(1):65-71.
standardized method of gram stain interpretation. J
Clin Microbiol. 1991;29(2):297-301. 25. Eltabbakh GH, Eltabbakh GD, Broekhuizen FF,
Griner BT. Value of wet mount and cervical cul-
12. Lahiri DK, Nurnberger JI Jr. A rapid non-
tures at the time of cervical cytology in asympto-
enzymatic method for the preparation of HMW
matic women. Obstet Gynecol. 1995;85(4):499-
DNA from blood for RFLP studies. Nucleic Acids
503.
Res. 1991;19(19):5444.
26. Brabin L, Gogate A, Gogate S, Karande A, Khan-
13. Stephens RS, Mullenbach G, Sanchez-Pescador R,
na R, Dollimore N, et al. Reproductive tract infec-
Agabian N. Sequence analysis of the major outer
tions, gynaecological morbidity and HIV sero-
membrane protein gene from Chlamydia trachoma-
prevalence among women in Mumbai, India. Bull
tis serovar L2. J Bacteriol. 1986;168(3):1277-82.
World Health Organ. 1998;76(3):277-87.
14. Mania-Pramanik J, Potdar S, Kerkar S. Diagnosis of
Chlamydia trachomatis infection. J Clin Lab Anal.

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