Chlamydial Antibody Titers Research Articles

A concise infertility work-up results in fewer pregnancies.

STUDY QUESTIONIs pregnancy success rate after a concise infertility work-up the same as pregnancy success rate after the traditional extensive infertility work-up?SUMMARY ANSWERThe ongoing pregnancy rate within a follow-up of 1 year after a concise infertility work-up is significantly lower than the pregnancy success rate after the traditional and extensive infertility work-up.WHAT IS KNOWN ALREADYBased on cost-effectiveness studies, which have mainly focused on diagnosis, infertility work-up has become less comprehensive. Many centres have even adopted a one-stop approach to their infertility work-up.STUDY DESIGN, SIZE, DURATIONWe performed a historically controlled cohort study. In 2012 and 2013 all new infertile couples (n = 795) underwent an extensive infertility work-up (group A). In 2014 and 2015, all new infertile couples (n = 752) underwent a concise infertility work-up (group B). The follow-up period was 1 year for both groups. Complete follow-up was available for 99.0% of couples in group A and 97.5% in group B.PARTICIPANTS/MATERIALS, SETTING, METHODSThe extensive infertility work-up consisted of history taking, a gynaecological ultrasound scan, semen analysis, ultrasonographic cycle monitoring, a timed postcoital test, a timed progesterone and chlamydia antibody titre. A hysterosalpingography (HSG) was advised routinely. The concise infertility work-up was mainly based on history taking, a gynaecological ultrasound scan and semen analysis. A HSG was only performed if tubal pathology was suspected or before the start of IUI. Laparoscopy and hormonal tests were only performed if indicated. Couples were treated according to the diagnosis with either expectant management (if the Hunault prognostic score was >30%), ovulation induction (in case of ovulation disorders), IUI in natural cycles (in case of cervical factor), IUI in stimulated cycles (if the Hunault prognostic score was <30%) or IVF/ICSI (in case of tubal factor, advanced female age, severe male factor and if other treatments remained unsuccessful). The primary outcomes were time to pregnancy and the ongoing pregnancy rates in both groups. The secondary outcomes were the number of investigations, the distribution of diagnoses made, the first treatment (started) after infertility work-up and the mode of conception.MAIN RESULTS AND THE ROLE OF CHANCEThe descriptive data, such as age, duration of infertility, type of infertility and lifestyle habits, in both groups were comparable. In group A, more than twice the number of infertility investigations were performed, compared to group B. An HSG was made less frequently in group B (33% versus 42%) and at a later stage. A Kaplan–Meier curve shows a shorter time to pregnancy in group A. Also, a significantly higher overall ongoing pregnancy rate within a follow-up of 1 year was found in group A (58.7% versus 46.8%, respectively, P < 0.001). In group A, more couples conceived during the infertility work-up (14.7% versus 6.5%, respectively, P < 0.05). The diagnosis cervical infertility could only be made in group A (9.3%). The diagnosis unexplained infertility differed between groups, at 23.5% in group A and 32.2% in group B (P < 0.001).LIMITATIONS, REASONS FOR CAUTIONThis was a historically controlled cohort study; introduction of bias cannot be ruled out. The follow-up rate was similar in the two groups and therefore could not explain the differences in pregnancy rate.WIDER IMPLICATIONS OF THE FINDINGSRe-introduction of an extensive infertility work-up should be considered as it may lead to higher ongoing pregnancy rates within a year. The therapeutic effects of HSG and timing of intercourse may improve the fertility chance. This finding should be verified in a randomized controlled trial.STUDY FUNDING/COMPETING INTEREST(S)No funding was obtained for this study. No conflicts of interest were declared.TRIAL REGISTRATION NUMBERN/A.

Chlamydia antibody titre as a predictor of tubal factor infertility

BACKGROUND: Genital Chlamydia trachomatis is major cause of tubal factor infertility. Assessment of tubal patency by hysterosalpingography (HSG) and laparoscopy are invasive and expensive. In low resource setting, there may be a place for Chlamydia Antibody Titre (CAT) in infertility work up.Objective: To determine the predictive value of Chlamydia antibody titre in tubal factor infertility.Materials and Methods: This was a prospective cross-sectional study of women presenting with infertility at the Human Reproduction Research Programme unit of the University of Benin Teaching Hospital, Benin City, Nigeria. All the women had serum Chlamydia antibody titre and hysterosalpingography and where indicated, laparoscopy and dye test. The predictive value of Chlamydia Antibody was assessed using likelihood ratios.Results: The prevalence of Chlamydia antibody among women with infertility was 32.1%. This was significantly higher among women with HSG diagnosed tubal damage (72.1% vs 27.9%; P = 0.000). The sensitivity and specificity of Chlamydia Antibody were 84.6% and 66.7% respectively while the sensitivity and specificity of Hysterosalpingogram were 85.7% and 50% respectively. The positive likelihood ratio (LR+) and negative likelihood ratio (LR-) of CAT were 2.58 and 0.22 respectively while the LR+ and LR- of HSG were 1.72 and 0.28 respectively. Both tests showed comparable predictive value in screening for tubal damage.Conclusions: The predictive value of CAT was comparable to that of HSG. Chlamydia antibody titre determination is non-invasive and inexpensive and may be used in infertility screening to select patient for HSG and laparoscopy.

Anti-Müllerian hormone does not predict time to pregnancy: results of a prospective cohort study

In order to study whether ovarian reserve tests (ORTs) can predict time to ongoing pregnancy, we conducted a prospective cohort study in a cohort of healthy pregnancy planners. A total of 102 pregnancy planners were followed for 1 year, or until ongoing pregnancy occurred, after cessation of contraceptives). A baseline measurement of anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH) and antral follicle count (AFC) was conducted. At the end of follow-up, a semen analysis was performed and chlamydia antibody titres were assessed. A univariate prediction model demonstrated age and the AFC to be significantly capable of predicting time to pregnancy (hazard ratio 0.92, 95% CI 0.87–0.98, p = 0.01; 1.04, 95% CI 1.01–1.07, p = 0.02 respectively). In the multivariate model, however, correcting for female age, we found no predictive effect of AMH, basal FSH or the AFC for time to ongoing pregnancy (hazard ratios 1.43, 95% CI 0.84–2.46, p = 0.36; 0.96, 95% CI 0.86–1.06, p = 0.43; 1.03, 95% CI 1.00–1.07, p = 0.08, respectively). This was confirmed by the low C-statistic. We therefore concluded that baseline AMH, AFC or FSH levels do not predict time to ongoing pregnancy in a cohort of healthy pregnancy planners. These results limit the usability of these ORTs in the assessment of current fertility.

General practitioners' adherence to work-up and referral recommendations in fertility care.

What is the current guideline adherence by general practitioners (GPs) for work-up and subsequent referral from primary to secondary care for patients suffering from infertility? Guideline adherence by GPs concerning infertility was 9.2% in couples referred. Adherence to recommendations can decrease unnecessary referral, diagnostics and treatments, and consequently result in lower expenditures. Moreover, patients can be saved from unnecessary hospital visits, emotional burden and out of pocket costs. A retrospective cohort study among 306 patients referred for basic fertility work-up between January 2011 and June 2013 from primary care to a secondary care teaching hospital or a tertiary hospital with IVF facilities. Couples were eligible to participate when there was no previous referral for fertility problems and the duration of the child wish was <2 years. Data to assess guideline adherence were collected from the referral letter and the medical records. A patient questionnaire was used to determine patients' general and fertility-related characteristics. The GP performed a Chlamydia Antibody Titre (CAT) testing and semen analysis as recommended in 15.9% and 42.2% of the referred patients, respectively. According to the guideline, 39% of the couples were under referred (i.e. not immediately referred as recommended), 8.8% were unnecessarily referred and the CAT and semen analysis were unnecessarily repeated in secondary care in 80.0% and 57.1% of cases, respectively. We could not include non-referred patients with expectant management in primary care, an unknown number of whom became pregnant in this period. This may have resulted in an underestimation of primary care performance. Our findings show that guideline adherence concerning work-up and subsequent referral for fertility problems is low. The influence of patient demands for referral remains largely unknown. Barriers and facilitators for guideline adherence should be determined to develop interventions to improve guideline adherence in the areas of work-up and referral for fertility care and to diminish duplicate tests in secondary care. Funded by CZ, a Dutch healthcare insurer (grant number AFVV 11-232). CZ had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: None. Not applicable.

Evaluation of tubal and peritoneal factors in chlamydia positive infertile women by laparoscope

Background: Abnormalities or damage to the fallopian tube interferes with fertility and is responsible for abnormal implantation (eg, ectopic pregnancy). Obstruction of the distal end of the fallopian tubes results in accumulation of the normally secreted tubal fluid, creating distention of the tube with subsequent damage of the epithelial cilia (hydrosalpinx). Genital Chlamydia trachomatis infection has a worldwide distribution6 and is now recognized as the single most common cause of tubal peritoneal damage. The study explores the relationship between serum chlamydia antibody titres (CATs) and detection of tubal damage in infertile women.Objective: To Evaluation of tubal and peritonial factors in chlamydia positive infertile women by laparoscope.Methodology: The tubal status and pelvic findings in 138 women underwent laparoscopy for infertility were related to CAT, which was measured using the whole-cell inclusion immunofluorescence test. RESULTS: A total of 138 infertile women who underwent laparoscopic investigation for infertility were identified and they were divided in two groups, on the bsis of presence is absence Chlamydia positive (n=69) and Chlamydia Negative (n=69). Demographic status were almost similar between two groups, however service holder was found significantly higher in Chlamydia positive group (17 vs. 7). Tubal block was found in 44(63.7%) in Chlamydia positive and 37(53.6%) in Chlamydia negative. The difference was statistically significant (p&lt;0.01) between two groups. Site of block &amp; hydrosalpinges was almost similar between two groups. POD was completely obliterated in 10(14.5%) in Chlamydia positive and 3(4.3%) in Chlamydia negative. The difference was statistically significant (p&lt;0.05) between two groups.Conclusion: Chlamydia serology is useful mainly as a screening test for the likelihood of tubal damage in infertile women and may facilitate decisions on which women should proceed with further investigations without delay.J Shaheed Suhrawardy Med Coll, December 2015, Vol.7(2); 54-58

Clinical, diagnostic and pathologic features of presumptive cases of Chlamydia pecorum-associated arthritis in Australian sheep flocks.

BackgroundArthritis is an economically significant disease in lambs and is usually the result of a bacterial infection. One of the known agents of this disease is Chlamydia pecorum, a globally recognised livestock pathogen associated with several diseases in sheep, cattle and other hosts. Relatively little published information is available on the clinical, diagnostic and pathologic features of C. pecorum arthritis in sheep, hindering efforts to enhance our understanding of this economically significant disease. In this case series, a combination of standard diagnostic testing used routinely by veterinarians, such as the Chlamydia complement fixation text (CFT), veterinary clinical examinations, and additional screening via C. pecorum specific qPCR was used to describe putative chlamydial infections in five sheep flocks with suspected ovine arthritis.Case presentationFive separate cases involving multiple lambs (aged six to ten months) of different breeds with suspected C. pecorum arthritis are presented. In two of the five cases, arthritic lambs exhibited marked depression and lethargy. Arthritis with concurrent conjunctivitis was present in four out of five lamb flocks examined. Chlamydia CFT demonstrated medium to high positive antibody titres in all flocks examined. C. pecorum shedding was evident at multiple sites including the conjunctiva, rectum and vagina, as determined via qPCR. Two of the five flocks received antimicrobials and all flocks recovered uneventfully regardless of treatment.ConclusionThis case series highlights the features a field veterinarian may encounter in cases of suspected ovine chlamydial arthritis. Our analysis suggests a presumptive diagnosis of chlamydial arthritis in lambs can be made when there is evidence of joint stiffness with or without synovial effusion and elevated chlamydia antibody titres. C. pecorum-specific qPCR was found to be a useful ancillary diagnostic tool, detecting Chlamydia positivity in low or negative CFT titre animals. Variables such as symptom duration relative to sampling, sheep breed and farm management practices were all factors recorded that paint a complex epidemiological and diagnostic picture for this disease. These case studies serve to provide a platform for further research to improve diagnostic testing and new treatment and control strategies for C. pecorum infections in sheep.

P08.05 Chlamydia trachomatisandtrichomonas vaginalisco-infection in the macaque model

Introduction We have used the pigtailed macaque model to individually study chlamydia (bacteria) and trichomonal (parasite) infections. To increase utility of the model, we explored infection potential for both chlamydia and trichomoniasis, when delivered simultaneously to macaques. This co-infection model will be useful for testing the efficacy of developing multi-purpose technologies. Methods Twelve female Macaca nemestrina were challenged by cervical inoculation with C. trachomatis E (CT: 5E6 IFU in 0.5 mL volume), immediately followed by vaginal exposure to T. vaginalis ATCC 50148 (TV: 5E5 trichomonads in 0.5 mL volume). For five weeks, infection status, chlamydia-specific serum antibody, and tissue responses were followed. Nucleic acid amplification tests were employed to detect each organism; cervical swabs were also cultured for chlamydia detection. Cervicovaginal tissues were monitored by colposcopy. Each animal completed a five day regimen of oral azithromycin plus metronidazole followed by test of clearance. Results Nine of twelve macaques tested positive for infection with both pathogens on at least three weekly visits. One animal was positive for chlamydial infection only (TV negative) for two weeks. These ten animals developed chlamydial IgG antibody titers of at least 1:16. The two remaining animals had limited, self-clearing infections; CT positive for one week, plus TV positive for one or two weeks. Neither of these macaques developed serum antibody to CT. During five weeks of secretion sampling, chlamydia positivity ranged from 1 to 5 weeks (median 5 weeks) and TV positivity ranged 0–5 weeks (median 5 weeks) as well. Colposcopy revealed blisters on the cervix of three co-infected animals. Neither infection could be correlated to changes in vaginal pH, exudate or polymorphonuclear cell presence. Conclusion We have demonstrated that co-infection with Chlamydia trachomatis and Trichomonas vaginalis is achievable in the pigtailed macaque model. Infections are individually detectable and concurrent treatments are effective in clearing both organisms. Disclosure of interest statement This research was supported by NIH Contract HHSN272201000006I, Task Number HHSN27200008 and by the Office of Research Infrastructure Programs (ORIP) of the National Institutes of Health through Grant Number P51 OD010425 Washington National Primate Research Centre. No pharmaceutical grants were received in the development of this study.

P2.055 “P.I.D.” or Endometriosis? Laparoscopic Assessment, Chlamydial Antibodies and Dysmenorrhea Symptom Scoring in Women with Acute Pelvic Pain

BackgroundMost women with endometriosis receive unnecessary antibiotics for “P.I.D.” because both conditions present with pelvic pain and dyspareunia.We used negative chlamydial antibody titre and laparoscopy to confirm diagnoses in women...

P63 Treatment of pelvic inflammatory disease using short-course azithromycin

BackgroundIn our centre, a novel 5-day regimen of azithromycin (1 g stat then 500 mg daily for 4 days with or without metronidazole and/or ceftriaxone) is used and has been...

Should a hysterosalpingogram be a first-line investigation to diagnose female tubal subfertility in the modern subfertility workup?

Tubal assessment is an integral part of female fertility evaluation. While diagnostic laparoscopy is gold standard, it is not suitable to be used as a screening test. Hysterosalpingogram (HSG) has been advocated as first-line investigation historically. With advances in diagnostics, more tests are available, such as hysterosalpingo contrast sonography (HyCoSy) and Chlamydia antibody titre (CAT) are available. The CAT test is much cheaper, less invasive and can be performed at any time during the cycle. The CAT test can also be used as a means of identifying which patients need further evaluation. HyCoSy has same diagnostic accuracy as HSG, without exposing women to radiation. We argue that HSG is out of date and has no place in a modern infertility evaluation. We also suggest a pathway (based on history, clinical and ultrasound evaluation) for investigations to screen for and diagnose tubal pathology.

Significance of positive Chlamydia serology in women with normal-looking Fallopian tubes

Chlamydia trachomatis poses a potential threat to the fertility of women by causing tubal damage. Many women with serological evidence of past Chlamydia infection have normal tubal appearances on laparoscopic assessment. The aim of this study was to assess if serological evidence of past chlamydial infection affects the likelihood of conception in women with normal tubes. Infertile couples in which the female partner was under the age of 40 years, with normal ovulatory function and a male partner with normal sperm function were studied. All women had normal tubes as assessed by laparoscopy. Serum Chlamydia antibody titres were assayed using the immunofluorescence test. Pregnancy rates were related to grouped Chlamydia antibody titres (<64, 64-256 and > or =512). A total of 174 women were studied. The cumulative pregnancy rates (SE) according to these titres were 45.1% (6.2), 42.6% (9.3), 59.1% (11.8) and the risk ratios (95% confidence interval) were 1, 1.59 (0.82-3.07) and 1.04 (0.52-2.08) respectively. The differences were not statistically significant. Therefore, in women with normal-looking tubes, serological evidence of past chlamydial infection does not appear to have an adverse effect on pregnancy rates. These findings suggest that laparoscopic findings and not Chlamydia serological titres are the key to prognosis.

Further observations, mainly serological, on a cohort of women with or without pelvic inflammatory disease

An analysis was undertaken of data pertaining to over 100 women with lower abdominal pain who were laparoscoped. Prior to laparoscopy, 11 of the women were considered to almost certainly have salpingitis, of whom six (55%) had salpingitis at laparoscopy; 17 to probably have salpingitis, of whom six (35%) did; 28 to possibly have salpingitis, of whom five (18%) did; and 56 to be very unlikely to have salpingitis, of whom five (9%) did. Of the 22 women who had salpingitis at laparoscopy, 14 (64%) had a Chlamydia trachomatis IgG antibody titre of >or=1:128 and might reasonably be regarded as having chlamydial disease on this basis; six without such a titre probably did not have chlamydial disease as C. trachomatis could not be detected at any genital site. At laparoscopy, 18 women had adhesions without obvious tubal inflammation; clinically, 15 of them had been regarded as possibly having salpingitis or unlikely to have it, with 12 having chronic pelvic pain. Twelve (67%) of the 18 women had a chlamydial IgG antibody titre of >or=1:128. IgM antibody was also detected most often in the 'salpingitis' group. Of 49 women without any abnormality detected at laparoscopy, nine (18%) had a high chlamydial IgG antibody titre. Overall, a woman who had a high titre of chlamydial IgG antibody and acute pelvic pain, together with a clinical picture of pelvic inflammation, was more likely to have salpingitis than adhesions alone. Likewise, a woman who had a high titre of chlamydial IgG antibody and chronic pelvic pain, together with a clinical picture suggesting that salpingitis was unlikely, was more likely to have adhesions alone than acute chlamydial salpingitis. However, while antibody measurement and seeking cervical C. trachomatis may help in formulating a diagnosis, there seems no simple way of detecting the small proportion of women who are infected by C. trachomatis in the upper genital tract but whose laparoscopic findings indicate normality. So far as patient care is concerned, the only way of preventing damage to the upper genital tract is to treat early on the basis of suspicion.

The relationship between serum Chlamydia antibody levels and severity of disease in infertile women with tubal damage

The study explores the relationship between serum Chlamydia antibody titres (CAT) using the whole-cell inclusion immunofluorescence (WIF) test and severity of tubal damage in infertile women undergoing laparoscopy. Comparisons between the extent of specific lesions, including their severity found at laparoscopy, and CAT levels were analysed in 408 infertile women with tubal damage. CAT levels were assayed using the WIF test. There were significant differences in the severity of individual lesions (tubal occlusion, tubal pathology, fimbrial state, extent and type of tubal and ovarian adhesions, type of tubal and ovarian adhesions) for both left and right adnexa in relation to CAT (P < 0.0001). The presence and severity of lesions found in one adnexum significantly correlated with the findings on the contra-lateral side (r > 0.5; P < 0.01). The American Fertility Society grades for tubal occlusion and adhesions in the right adnexum did not correlate with CAT. CAT levels are quantitatively related to the severity of tubal damage in infertile women. Wide variations in the severity of lesions observed in relation to CAT were suggestive of broad individual differences in response to chlamydial infection.

The basic fertility work up in who class II anovulatory women; usefull or redundant? A systematic review

OBJECTIVE: The first line treatment in WHO class II anovulatory patients is clomiphene citrate (CC). Once women become ovulatory after previous anovulation, there is a tendency to start a basic fertility work-up. However, one could hypothesize that in the presence of anovulation, which is an explanation per se for infertility, the prevalence of other causes of subfertility, may be decreased in comparison to patients suffering from subfertility for more than a year. DESIGN: We performed a systematic review to summarize the best available evidence regarding the value of a basic fertility work-up in WHO class II women once ovulatory on CC. MATERIALS AND METHODS: A literature search in MEDLINE, Embase and Cochrane library was performed to assess the potential value of basic fertility work up, including a semen-analysis, postcoital test, Chlamydia antibody titre, hysterosalpingography and diagnostic laparoscopy. RESULTS: We could identify only four studies. A prospective cohort study described the Chlamydia antibody titre. The sensitivity of the test to detect bilateral tubal pathology was 9% and the specificity 96%. A second and third study from 1983 and 1984 reported about the semen analysis, post coital test and tubal tests. Only a part of the population of interest was tested, follow up for pregnancy rates were lacking or total performed tests was unknown and the group size was small which made it impossible to draw conclusions. A fourth prospective follow up study was performed to identify parameters which could predict conception, but no significant predictors in the fertility work up were found. CONCLUSIONS: The present review shows there is no evidence to perform a basic fertility work up the women described and does not allow us to give firm recommendations. Routine use of these tests in these women might lead to unnecessary treatment. Effort should be focussed on studies on this subject, in stead of performing non-validated tests on a non-research setting.

Clinical findings and chlamydia antibody titre as predictors of tubal factor infertility

Objective:To compare the predictive capacity of clinical scoring system and chlamydia antibody titre in predicting tubal disease.Methods:This study included 70 infertile women with normal ovarian and male factors. All women had detailed history taking, general examination, local examination, and vaginal and cervical swabs for culture and sensitivity. A clinical scoring system based on the following variables was used for prediction of tubal disease; age, infertility duration, previous abortion, previous delivery, dysmenorrhea, dyspareunia, evidence of bacterial vaginosis, and tender adnexa. IgG chlamydia antibody titre (CAT) and mid luteal phase serum progesterone were assessed using enzyme immunoassay (ELISA) technique. Tubal abnormality was assessed by hysterosalpingography (HSG) in the follicular phase. The clinical scoring and the CAT were compared by calculating the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio (+LR), negative likelihood ratio (-LR), the relative risk (RR), and the area under the curve (AUC) of the receiver operator curve.Results:CAT was positive in 20 patients (28.57%) out of the 70 studied women. Evidence of tubal disease identified by HSG was present in 34 patients (48.6%). Seropositive women had significantly higher incidence of tubal abnormality compared to seronegative women (p=0.0001). The CAT was significantly higher in women with tubal disease (11.63 ± 7.27) compared to women with normal tubes (6.76 ± 4.02) (z=3.126, p=0.002). The CAT achieved a low sensitivity of 50% and a high specificity of 91.67%. In comparison, the clinical scoring system achieved a balanced sensitivity and specificity of 82.35% and 86.11% respectively. The AUC of the clinical scoring system (0.891) was found to be significantly higher than that of the CAT (0.717).Conclusion:The clinical scoring system proved to be more accurate than the CAT in predicting tubal disease.

The predictive value of medical history taking and Chlamydia IgG ELISA antibody testing (CAT) in the selection of subfertile women for diagnostic laparoscopy: a clinical prediction model approach

Medical history taking as well as Chlamydia antibody titre (CAT) testing are currently used in the selection of patients for diagnostic laparoscopy with tubal patency testing. Most research has focused on the predictive value of CAT in isolation from medical history. We assessed therefore whether the combination of medical history and CAT improves the efficiency of selecting patients for laparoscopy as compared to the use of either medical history or CAT. Data of 207 consecutive subfertile women were used to create multivariable logistic regression models for the prediction of tubal disease as diagnosed by diagnostic laparoscopy. The model with data of medical history only had an area under the receiver operating characteristic curve (AUC) of 0.65 (95% CI 0.56-0.74). Addition of CAT increased the AUC to 0.70 (95% CI 0.62-0.78) (P = 0.065). CAT was positive in 40 women and showed a sensitivity of 0.37 (95% CI 0.26-0.49) for a specificity of 0.88 (95% CI 0.82-0.93). In CAT positive women, a blank medical history did not decrease the probability of tubal disease. Of the 167 women tested CAT negative, 23 (14%) still had a high probability of disease due to their medical history and 11 of them (48%) showed tubal abnormalities on diagnostic laparoscopy. CAT testing adds valuable information to a woman's risk profile based on her medical history. The combination of medical history taking and CAT testing has a better yield for diagnosing tubal disease than either of these alone.

Routine Chlamydia antibody testing is of limited use in subfertile women with anovulation

The Chlamydia antibody titre (CAT) is a test used to identify subfertile couples at increased risk for tubal pathology. The usefulness of the routine performance of CAT was evaluated in a multicentre prospective cohort study, in women without regular ovulation. Consecutive couples presenting with subfertility due to an irregular menstrual cycle or amenorrhoea were included. A total of 711 women were studied, all of whom underwent CAT. Tubal status was verified in 190 of these women. Two-sided tubal pathology was found in 5% of these women, and one-sided occlusion in 10%. Of all the women in the study group, 33 (4.6%) had an abnormal CAT, of which 21 underwent further tubal testing. Tubal pathology was found in two (10%) of these 21 patients. The sensitivity and specificity of CAT were respectively 20% and 89%. Correction for verification bias increased the specificity to 96% with a drop of the sensitivity to 9%. In subfertile couples with anovulation, the performance of CAT is not useful. It is proposed that testing for tubal disease in these women is delayed until treatment with clomiphene citrate has failed.

High titers of Chlamydia trachomatis antibodies in Brazilian women with tubal occlusion or previous ectopic pregnancy.

Objective. To evaluate serum chlamydia antibody titers (CATs) in tubal occlusion or previous ectopic pregnancy and the associated risk factors.Methods. The study population consisted of 55 women wih tubal damage and 55 parous women. CAT was measured using the whole-cell inclusion immunofluorescence test and cervical chlamydial DNA detected by PCR. Odds ratios were calculated to assess variables associated withC. trachomatis infection.Results. The prevalence of chlamydial antibodies and antibody titers in women with tubal occlusion or previous ectopic pregnancy was significantly higher (P < .01) than in parous women. Stepwise logistic regression analysis showed that chlamydia IgG antibodies were associated with tubal damage and with a larger number of lifetime sexual partners.Conclusions. Chlamydia antibody titers were associated with tubal occlusion, prior ectopic pregnancy, and with sexual behavior, suggesting that a chlamydia infection was the major contributor to the tubal damage in these women.

Do clinical prediction models improve concordance of treatment decisions in reproductive medicine?

To assess whether the use of clinical prediction models improves concordance between gynaecologists with respect to treatment decisions in reproductive medicine. We constructed 16 vignettes of subfertile couples by varying fertility history, postcoital test, sperm motility, follicle-stimulating hormone level and Chlamydia antibody titre. Thirty-five gynaecologists estimated three probabilities, i.e. the 1-year probability of spontaneous pregnancy, the pregnancy chance after intrauterine insemination (IUI) and the pregnancy chance after in vitro fertilisation (IVF). Subsequently they proposed therapeutic regimens for these 16 fictional couples, i.e. expectant management, IUI or IVF. Three months later, the participant gynaecologists again had to propose therapeutic regimes for the same 16 fictional cases but this time accompanied by pregnancy chances obtained from prediction models: predictions on spontaneous pregnancy, IUI and IVF. Thirty-five gynaecologists working in academic and nonacademic hospitals in the Netherlands. Setting section. Main outcome measures The concordance between gynaecologists of probability estimates, expressed as interclass correlation coefficient (ICC) and the concordance between gynaecologists of treatment decisions, analysed by calculating Cohen's kappa (kappa). The gynaecologists differed widely in estimating pregnancy chances (ICC: 0.34). Furthermore, there was a huge variation in the proposed therapeutic regimens (kappa: 0.21). The treatment decisions made by gynaecologists were consistent with the ranking of their probability estimates. When prediction models were used, the concordance (kappa) for treatment decisions increased from 0.21 to 0.38. The number of gynaecologists counselling for expectant management increased from 39 to 51%, whereas counselling for IVF dropped from 23 to 14%. Gynaecologists differed widely in their estimation of prognosis in 16 fictional cases of subfertile couples. Their therapeutic regimens showed likewise huge variation. After confrontation with prediction models in the same 16 fictional cases, the proposed therapeutic regimens showed only slightly better concordance. Therefore a simple introduction of validated prediction models is insufficient to introduce concordant management between doctors.

Which factors play a role in clinical decision-making in subfertility?

Sixteen vignettes of subfertile couples were constructed by varying fertility history, post-coital test, sperm motility, FSH concentration and Chlamydia antibody titre (CAT). Thirty-five gynaecologists estimated probabilities of treatment-independent pregnancy, intrauterine insemination (IUI) and IVF. Thereafter, they chose IUI, IVF or no treatment. The relative contribution of each factor to probability estimates and to subsequent treatment decisions was calculated. Duration of subfertility and maternal age were the most important contributors for gynaecologists’ estimates of treatment-independent pregnancy [relative contribution (RC) 41, 26%]. Maternal age and FSH concentration were the most important contributors in the estimates for IUI (RC: 51, 25%) and for IVF (RC: 64, 31%). The decision to start IVF was mainly determined by maternal age, duration of subfertility, FSH concentration and CAT. The relative contribution of maternal age and duration of subfertility was in concordance with existing prediction models, whereas previous pregnancy and FSH concentration were under- and overestimated respectively. In conclusion, maternal age, duration of subfertility and FSH concentration are the main factors in clinical decision-making in subfertility. Gynaecologists overestimate the importance of FSH concentration, but underestimate that of a previous pregnancy, as compared with their importance reported in prediction models and guidelines.