By Kalinda D. Woods, M.D.
Those of us who study science may remember sitting in an introductory general biology lecture hall at some point in our academic past. An esteemed lecturer after formal introduction and orientation to the course may have opened the semester of study by insisting students internalize a single concept to begin to study biology: life persists. The desire to reproduce a version of ourselves is very human and innate to a sense of being for many people. It is estimated that approximately ten percent of couples will experience infertility, a diagnosis which can be emotionally and socially devastating for families desiring pregnancy. Preventable causes of infertility include environmental exposures, and certain sexually transmitted infections play a significant role. As physicians, it is imperative that we educate about, screen for and address these disease processes to maximize best outcomes for our patients.
The term “sexually transmitted infection” encompasses several disease entities some of which have little or no impact on fertility directly. In fact, the most common STI worldwide is high-risk human papilloma virus, which is the causative agent of cervical dysplasia and cervical carcinoma. Although high-risk HPV infection, which will typically resolve with no consequence, is almost ubiquitous in young sexually active individuals, it appears to have no impact on fertility. The infections which more significantly affect fertility are gonorrhea, chlamydia and HIV. Physicians can impact fertility in many ways with regard to the preceding three infections.
According to the CDC1, if untreated, about ten to fifteen percent of women with chlamydia will develop pelvic inflammatory disease, a condition determined by fever, pelvic pain and ascending infection associated with inflammation of the endometrium, fallopian tubes, and possibly peritonitis/tubo-ovarian abscess formation. Chlamydia can also cause fallopian tube infection without any symptoms. PID and “silent” infection in the upper genital tract can cause permanent tissue damage leading to infertility by way of tubal obstruction. An estimated 2.86 million cases of chlamydia and 820,000 cases of gonorrhea, which infects similarly, occur annually in the United States and most women are asymptomatic.2 For these reasons, the CDC recommends screening of all sexually active women younger than 25 years, as well as older women with risk factors. Risk factors are further determined as new or multiple sex partners, or a partner who has had a recent STI.
We know that infertility is determined as no conception after 12 months of unprotected sex. We also know that with heterosexual couples, the male factor represents a significant percentage of identifiable causes of infertility. In men, chlamydial infection is known to cause urethritis, epididymitis, and prostatitis. There has been recent evidence suggesting that there is molecular damage to chlamydia-exposed sperm, which is irreparable and seems to be associated with poor sperm parameters among infertile individuals.3 Given these data, it is prudent to screen asymptomatic men with the same scrutiny and the same criteria as their female counterparts above. Syphilis infection rates have been rising in the US since 2014. While there is no specific relationship between syphilis and fertility or the ability to spontaneously conceive per se, congenital syphilis can be a devastating diagnosis. CDC data tells us that among 458 mothers of infants with CS in 2014, 100 (21.8%) received no prenatal care, and no information about prenatal care was available for 44 mothers (9.6%). (Among the 314 mothers with one or more prenatal visit, 135 (43.0%) received no treatment for syphilis during the course of their pregnancy and 94 (30.0%) received inadequate treatment. The 135 mothers who received no treatment include 21 mothers who were never tested for syphilis during pregnancy and 52 mothers who tested negative for syphilis in early pregnancy and subsequently acquired syphilis before delivery. The remaining 62 mothers tested positive, but were not treated. Benzathine penicillin G is the only known effective treatment for preventing CS. Maternal treatment was considered inadequate if it was initiated too late (<30 days before delivery), if a non-penicillin therapy was administered, or if the dose of penicillin administered was inadequate for the mother’s stage of syphilis.4
Identifying this very treatable spirochete therefore offers physicians yet another opportunity for intervention and prevention. Screening guidelines for syphilis are similar to those for chlamydia and gonorrhea above: sexually active individuals up to age 25 and older individuals with risks factors (IV drug use, men having sex with men, sex industry workers, multiple partners) annually. Pregnant women are also screened at initiation of prenatal care and again in the third trimester. Patients are typically screened via rapid plasma reagin (RPR) serum testing which is widely available, and inexpensive. Positive screening RPR will prompt further treponemal antibody testing which is confirmatory when positive.
HIV infection poses a significant roadblock with regard to fertility when partners are sero-discordant. Typically, barrier forms of contraception will be necessary to prevent viral transmission from one partner to the other, which is in itself a hindrance to fertility. While transmission rates between discordant partners continue to fall largely due to the sophistication of antiviral therapy and low to un- detectable viral loads in compliant individuals; HIV infection is obviously an impediment to achieving pregnancy. Factors which are considered by HIV positive individuals when making pregnancy planning choices are understudied. Contradicting factors, such as higher risk of horizontal transmission with condomless sex, versus sperm washing and IVF for example, which is costly are real life tradeoffs for those affected by HIV.5 As providers, routine screening for early diagnosis and options counseling are most appropriate for these patients.
Fertility is certainly achievable without increasing risk of transmission, but may be costly and must be carefully planned for. The USPSTF recommends that clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at in- creased risk should also be screened. Screening intervals will vary based on the HIV frequency in the community, presence of high risk behaviors, homelessness. The task force also recommends screening at initiation of prenatal care for women and again in the third trimester of pregnancy.
As with all things in medicine, we will never have the answers to the questions we don’t or won’t ask. Family planning and fertility are essential parts of the human experience and integral to the happiness and feeling of wholeness and wellbeing for many people. Although uncomfortable at times, it is important for physicians to ask the hard questions, obtain a thorough sexual history and inquire about reproductive goals so we are able to offer important testing, counseling and referral when needed, for our patients as part of our goals of comprehensive evidence based and compassionate care.
1. Centers for Disease Control. Division of STD prevention, national center for HIV/ AIDS Prevention
2. CDC 2015 STD treatment Guidelines
3. Moazenchi et al. The impact of CT infection on sperm parameters and male fertility: a comprehensive study. International Journal of STD and AIDS 2017. 1-8.
4. CDC Morbidity and Mortality Weekly Report, November 2015
5. Loutfy, et al. Pregnancy planning preferences among people and couples affected by HIV: Piloting a discrete choice experiment. J of Obstetrics and Gynec Can 2012; 34: 575-590
6. Final Recommendation Statement: Human Immunodeficiency Virus (HIV) Infection: Screening. U.S. Preventive Services Task Force. December 2016. https://www.uspreventiveservicestaskforce.org/Page/Document/