eye to microscope11 Infection Screening

Infection Testing- The Importance of Uterine Microbiota In Female Fertility

The uterine microenvironment is unique from other mucosal sites in that it serves as the starting point for embryo implantation and placentation.

For almost a century, consensus was that a healthy uterine cavity is sterile. This sterility was hypothesized to be maintained by the cervical plug, which was supposed to be an impermeable barrier to bacterial ascension from the vagina. This assumption was challenged by multiple reports in the mid to late 1980s, using culture-dependent methods, of uterine-dwelling bacteria even in healthy asymptomatic women. Furthermore, the cervical mucus plug has been shown to not be entirely impermeable to bacterial ascension from vaginal bacteria. It was also shown that in a non-pregnant state, particles can translocate from the vagina to the uterus through the cervical canal within minutes during the follicular and luteal phases of the cycle. The position of the uterus in such close proximity to a consistently colonized site such as the vagina and the naturally occurring uterine peristaltic contractions in aids of sperm transport from the cervical canal to the uterus, would make some movement of bacteria to the uterine cavity inevitable.

Hematogenous (through the bloodstream) spread of bacteria through either oral  or the gut route  allows bacteria from mucosal sites such as the oral cavity and the gastrointestinal tract to colonize distal mucosal sites and occurs during epithelial barrier breach (e.g., gingivitis and leaky gut). However, other sources of uterine microbiota seeding may include inadvertent bacterial transmission of vaginal bacteria into the uterus through assisted reproductive technology (ART)-related procedures or during placement of intrauterine contraceptive devices.

A healthy endometrium is the foundation for successful implantation and intrauterine infection has been deemed the cause of many reproductive complications

The uterine microbiota as defined by Microbiome Molecular Analysis (MbMA) varies greatly throughout healthy subjects.With little consistency, it is currently difficult to define a consensus “healthy” or “core” uterine microbiota. However, certain generalizations can be made from the existing data with the most abundant bacteria consistently belong toLactobacillus.

The genus Lactobacillus is a very prominent component in the majority of the uterine microbiome studies and is a consistent finding among reports. High levels of Lactobacillus (>90%) are significantly associated with increased reproductive success in women undergoing IVF. The source of Lactobacillus in the uterus is easily explained by the abundance of this bacterial genus in the nearby vagina (although again the Lactobacillus species could differ).

The presence of other bacteria in the uterus has been associated with poor reproductive outcomes and endometritis.

Uterine microbiota composition has been shown to be significantly different in women with unexplained infertility. Furthermore, endometritis patients treated with antibiotics before implantation have significantly better reproductive outcomes compared with those not treated with antibiotics, suggesting that the negative impact of endometritis on reproductive outcomes may be in part attributable to the presence of uterine bacteria. The above groups of patients have been shown to exhibit a uterine bacterial composition with low levels of Lactobacillaceae species and enrichment of Streptococcaceae, Staphylococcaceae, and Enterobacteriaceae species relative to healthy controls. Inflammation in the uterus due to the presence of bacteria may influence the balance of cytokines needed for successful blastocyst development and implantation as correlations exist between various pro-inflammatory cytokines such as IL-6 and anti-inflammatory cytokines andinfertility of unknown origin.

Microbiome Molecular Analysis can be used to determine whether uterine microenvironment is normal or whether pretreatment (antibiotics and probiotics) should be suggested, for a specific time of period, in order to try to influence the microbiome towards a more healthy population, a great benefit not only for women undergoing IVF, but for every woman wishing to conceive.

An initial analysis can be performed on a menstrual fluid sample.  This represents a combined uterine and vaginal sample.

 

Gene Diagnosis Microbiome Molecular Analysis (MbMA) test – €300:

We now run a panel of tests run by Gene Diagnosis lab in Athens, which comprises:

  • Lactobacillus spp.
  • Enterobacteriaceae
  • Streptococcus spp.
  • Staphylococcus
  • Enterococcus spp.
  • Gardnerella vaginalis+ Prevotella bivia + Porphyromonas spp.
  • Eubacterium spp.
  • Sneathia spp. + Leptotrichia spp. + Fusobacterium spp.
  • Megasphaera spp. + Veillonella spp. + Dialister spp.
  • Lachnobacterium spp. + Clostridium spp.
  • Mobiluncus spp. + Corynebacterium spp.
  • Peptostreptococcus spp.
  • Atopodium vaginae
  • Mycoplasma hominis
  • Mycoplasma genitalium
  • Ureaplasma (urealyticum + parvum)
  • Chlamydia trachomatis
  • Neisseria gonorrhoeae
  • Candida spp.
  • HSV1
  • HSV2
  • HHV6

 

Can I have these tests at home, or Do I have to come to Athens for the tests?

Since posting is becoming difficult you can collect the sample and bring it with you on your first visit. If there is no possibility of collecting the sample we can easily take a biopsy at Serum on your first visit.

 

 

How to collect a menstrual sample

In order to perform the test we need a few drops of your menstrual fluid in a clean container, the kind used to collect urine for culture, which you can generally buy very cheaply from your local pharmacy.

IMPORTANT: Please use a clean container with a SCREW top-the safest option is Sterilin Polystyrene 7ml containers-, to prevent the sample from being spilled and contaminated during transfer.

 

  1. Collect a few drops of your menstrual blood in a small, clean container.  You will probably find this easiest during times of heavy flow i.e. on day 2 or 3 of your period, but only a small amount of blood is needed.

There are several ways you can do it:

  1. Use a Mooncup (available from Boots);
  2. Use a boiled teaspoon;
  3. Squeeze a few drops of blood from a tampon;

Or simply hold the container up to your vagina after lying down for a while.

  1. Add a little normal saline solution e.g. contact lens saline, or COLD boiled water (5-10 ml).  Do not fill the container – the extra liquid is only needed to prevent the sample from drying out before it reaches the lab.

You know you have sufficient when you can shake all the contents down to the bottom of the bottle, and the blood mixes with the saline turning it pink/red.

  1. Screw the cap on tightly, and ensure the container is labelled with your name and date-of-birth.
  2. Put the container in a sealed plastic bag, then in a strong cardboard box with some soft, absorbent packaging material, bubble wrap or cotton wool to protect the container from breaking.
  3. Add a cover letter, containing:
  4. contact details (name and email);
  5. your date-of-birth

 

You can store the sample, if needed in the fridge (NOT the freezer) for several weeks if necessary. A sample can be valid for about a month. Please bring it with you on the first visit. In case you cannot collect we will easily take a biopsy here.

You may want to keep a back up sample in the fridge at home until your sample has been successfully tested just in case of loss or breakage.

 

If you do not have natural periods

If you do not have natural periods, you should be able to generate a bleed by taking 21/28 days of Cyclacur (any cyclical HRT).

You should start to bleed 3-5 days after the last pill in the packet.

You may be able to get a prescription for cyclical HRT from your GP.  Alternatively, we can post you the pills, or send you a prescription you can use in the UK or anywhere in the EU.

Alternatively you can have a biopsy here easily on your first visit.

 

Infection testing in men

Where the male partner has symptoms, or the semen analysis is suggestive of infection, we may recommend doing a culture on a fresh sample of semen in order to identify the species of infection present, and, by testing with samples of antibiotics, determine which antibiotics are capable of killing the specific species.

We’ve had a lot of success in improving sperm parameters and pregnancy rates after giving antibiotics where a positive result was detected. But we would generally tend to suggest only testing the female partner unless the male partner has symptoms of infection.

If either partner tests positive on any of our tests, it is prudent to assume that the other is also at risk of having the infection.  So we would always suggest that both partners take the antibiotic treatment simultaneously, and use condoms until the antibiotic course is completed.

Where sperm parameters improve very markedly after antibiotic treatment, we recommend that men repeat the course every 2 years, as protection from potential urinary and prostate problems caused by recurrent infection.

 

Your results

Your results will usually be ready within 8- 10 working days after we receive your sample.

Once we receive your test results and we have proof of your payment, we will send you a copy of your results by email.

If your results are positive, we will recommend suitable antibiotics to treat any infection detected, and post or email you a prescription for them if you need it.  (If you are not a patient of our clinic, we reserve the right to make a charge of €100 for arranging your prescription).

Please note that we liaise with the laboratory and advise on the antibiotics purely to help your treatment and we do not make a mark-up offering these tests.

Although some women will have no scarring in the uterus as a result of an infection (only inflammation, which will reduce after antibiotic treatment), a positive result tends to indicate a higher risk of significant uterine scarring and adhesions.  So we are more likely to recommend a hysteroscopy if your test result is positive.

We’ve also noticed that women whose progesterone level is unusually low have tended to test positive for pathogenic species, which has led us to suspect that bacteria may be interfering with progesterone metabolism.  Antibiotic treatment can address this, as can monitoring with blood tests, and, where necessary, increasing the dose of progesterone we use during an IVF or natural cycle.

 

Please note

Some couples will find it upsetting to discover they have an infection, particularly if they have been together for many years.

It can be helpful to remember that once an infection passes above the cervix or down to the testicles, it can be resident for decades.  Other evidence shows that such infections can be transmitted during birth, from mother to child (sometimes called ‘vertical transmission’).

So there is no shame in finding you have an infection.  These infections are common, and widespread.  Some of them have been shown to be present in high proportion of women who have never had sexual intercourse or who have only had intercourse with women.

We usually find that discovering an infection is a positive step, as detecting and treating it is often easy, and can result in your long-awaited pregnancy.