|Year : 2014 | Volume
| Issue : 2 | Page : 59-63
Pre-HSG microbial isolates from endocervical swabs in infertile women in Ilorin, Nigeria
Adewale E Oguntoyinbo1, Kikelomo T Adesina2, Adebunmi O Olarinoye2, Abiodun P Aboyeji2, Waheed I Olanrewaju3, Muritala Oniyangi4
1 Department of Radiology, University of Ilorin, Ilorin, Nigeria
2 Department of Obstetrics and Gynaecology, University of Ilorin, Ilorin, Nigeria
3 Department of Radiology, Olanrewaju Hospital, University of Ilorin Teaching Hospital, Ilorin, Nigeria
4 Department of Radiology, University of Ilorin Teaching Hospital, Ilorin, Nigeria
|Date of Web Publication||17-Jun-2014|
Dr. Adewale E Oguntoyinbo
Department of Radiology, Faculty of Clinical Sciences, College of Health Sciences, University Ilorin, P.M.B.1515, Ilorin, Kwara State
Background: Genital infections contribute significantly to infertility by causing tubal disease in our environment. This can be worsened by any instrumentation of the genital tract such as hysterosalpingography (HSG), which is the most common and affordable investigation by infertile couples for tubal factor. Materials and Methods: A prospective study of 53 women who presented for HSG on account of infertility was done in a radio-diagnostic centre In Ilorin, Nigeria. Endo-cervical swabs were taken aseptically prior to standardized HSG in all clients. The swabs were sent for microscopy, culture, and antibiotic sensitivity and the HSG findings of patients were documented. Results: The age ranged between 25 and 52 years with a mean of 34.26 + 5.762 years. Both fallopian tubes were patent in 10 patients and blocked in 14 cases. There were 14 cases of unilateral hydrosalpinx and 10 (18.9) bilateral hydrosalpinges. Either pelvic or cervico-uterine cavity adhesions were observed in 35 (66.0%) of the cases. Mild to heavy growth occurred in 67.9% of the cases. Gram stain was positive in 54.7% of cases. The most common organism was Staphylococcus spp (28.3%). Forty-five percent of yields were sensitive to more than two antimicrobials. There was statistical significant relationship between the presence of pathogens in the endo-cervix and the frequency of tubal disease (x 2 = 2.71, P ≤ 0.05). Conclusion: There was a positive or significant statistical relationship between presence of pathogens in the cervix and tubal disease. Pre-HSG endo-cervical swab for microscopy, culture and sensitivity is advisable to prevent genital infections after HSG.
Keywords: Endo-cervical swabs; genital tract infection; hysterosalpingogram; infertility; pathogens microbes
|How to cite this article:|
Oguntoyinbo AE, Adesina KT, Olarinoye AO, Aboyeji AP, Olanrewaju WI, Oniyangi M. Pre-HSG microbial isolates from endocervical swabs in infertile women in Ilorin, Nigeria. West Afr J Radiol 2014;21:59-63
|How to cite this URL:|
Oguntoyinbo AE, Adesina KT, Olarinoye AO, Aboyeji AP, Olanrewaju WI, Oniyangi M. Pre-HSG microbial isolates from endocervical swabs in infertile women in Ilorin, Nigeria. West Afr J Radiol [serial online] 2014 [cited 2019 Sep 22];21:59-63. Available from: http://www.wajradiology.org/text.asp?2014/21/2/59/134604
| Introduction|| |
Genital infections in women play a pivotal role in the development of tubal disease, which results in infertility. Approximately, 35% of women with infertility suffered from postinfectious sequelae affecting the fallopian tubes and/or the surrounding peritoneum.  Genital infections involving the cervix and endometrium may contribute to infertility in other ways; for example, an endo-cervical infection may lead to abnormalities of sperm function and immobilization in the cervix due to the direct effect of the microbes on the sperm and alteration of the cervical pH. These infections may be symptomatic or even go unnoticed. 
Upper genital infections are often due to Chlamydialtrachomatis, gonococcal infections, and mixed infections that cause pelvic inflammatory disease (PID). , It is estimated that 10-20% of women with endo-cervical gonorrhoea or chlamydial infections develop salpingitis if untreated, thereby contributing significantly to tubal infertility. 
Upper genital infections following sexually transmitted infections (STIs) with resultant PID are more common in our environment  and others may follow postabortal and postpartum infections. ,,
Tubal patency is usually demonstrable by hysterosalpingography (HSG) as part of evaluation in infertile women. Earlier studies have suggested a higher risk of pelvic infections either from ascending endo-cervical infections or from the reactivation of microorganisms persisting in the genital tract after previous ones (infections) such as Chlamydia, following the procedure. ,
Hence authors have suggested that prophylactic antibiotics should be considered in all sub fertile women before any instrumentation.  A Cochrane review of antibiotic prophylaxis for transcervical procedures in 2010 showed insufficient evidence to accept or reject the routine use of antibiotics in such procedures.  Either to offer prophylactic antibiotics or endo-cervical screening and treat positive cases only, remains debatable. ,,
HSG remains the most common method of ascertaining tubal patency in our environment and perhaps the most common form of uterine instrumentation in infertile women. Although, bacterial isolates before HSG may not represent the actual causative organism of the tubal damage, there is the risk of a new ascending infection if the organism is pathogenic or there is an on-going asymptomatic infection prior to the procedure. 
This study was undertaken to determine the pattern of microbial isolates from endo-cervical swabs taken in infertile women prior to HSG study with the aim of suggesting routine antimicrobial prophylaxis or routine endo-cervical screening before the procedure.
| Materials and Methods|| |
The study design was a prospective study starting from June 2011 to June 2012. It was conducted in a private radiological centre under the supervision of a consultant radiologist. All prospective patients were either self-directed or referred from medical centers in Ilorin. All patients referred for HSG due to primary or secondary infertility were recruited into the study by nonprobability purposive sampling till the sample size of 53 was obtained. The exclusions criteria were: Abnormal uterine/vaginal bleeding less than 5 days before the procedure or on-going menstruation, suspected pregnancy, purulent discharge on inspection of cervix, diagnosed PID in the preceding 6 months and previous history of contrast hypersensitivity. The informed consent of each patient was sought concerning the nature of the study and the likely benefits. The sociodemographic data, type, and duration of infertility were obtained at recruitment. The patients were informed about the procedure, and the outcome of the investigations. The referring doctors were also informed of those women who required treatment. The first step was to give premedication with intramuscular buscopan 10 mg and 10 mg of Diazepam as mild sedative for the very anxious patients. A sterile speculum examination was performed and then an endo-cervical swab was taken aseptically into a transport medium for immediate evaluation in the laboratory (microscopy, culture, and sensitivity). Thereafter, the endo-cervix was prepared aseptically and the HSG study carried out using standard procedures.
The HSG films were reported by the Consultant Radiologist (one of the authors). Patency of the fallopian tubes, presence of fibroids, pelvic adhesions, and hydrosalpinx were documented from the HSG. In addition, the pattern of wet preparation findings, Gram-staining, and amount of growth, culture yield, and sensitivity to antimicrobial agents were determined from the pre-HSG swabs. Statistical analysis was done using the computer software SSPS version 15.
| Results|| |
A total of 53 clients were studied; 60.4% had secondary infertility while 39.6% were primarily infertile. Their age range was 25-52 years with a mean of 34 + 5.76 years. The duration of infertility is displayed in [Figure 1]. Many clients had infertility of at least 2 years (52.8%).
Both fallopian tubes were patent in 12 patients while in 13 cases both tubes were blocked [Table 1]. Fourteen (26.4%) cases had unilateral hydrosalpinx, right tube contributing 4 (7.5%), and left tube 10 (18.9%). Bilateral hydrosalpinges were noted in 10 (18.9%). Either pelvic or cervico-uterine cavity adhesions were observed in 35 (66.0%) of the cases, while 18 (34.0%) patients had no radiographic evidence of adhesions. Cervico-uterine adhesions were seen as marginal irregularities or linear filling defects and pelvic adhesions were represented as forced spillage and pockets of contrast medium within the pelvic cavity. There were 11 patients (20.8%) with demonstrable features of uterine fibroids seen as filling defects or enlargement of the uterine cavity. These patients were sent for further evaluation by pelvic ultrasound scanning. The most common radiological abnormality was pelvic adhesions (as described above) (66%) and followed by hydrosalpinges (45.3%).
The results of the initial wet preparation showed that 69.8% of the clients had only epithelial and pus cells, 15.1% had epithelial, pus, and yeast cells, 11.3% had only epithelial cells, while only two women had no demonstrable cells on wet preparation. The pattern of gram staining on microscopy is illustrated in [Table 2]. Gram stain was positive in 54.7% of cases, while there was a mixture of both Gram-positive and-negative organisms in 9.4%. Mild to heavy growth occurred in 67.9% of the cases; while there was no growth in 30.2% of the samples.
|Table 2: The pattern of gram stain of isolates from endocervical swabs taken before HSG|
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The most commont organism was Staphylococcus spp (28.3%), followed by coliform bacteria in 15.1%. No pathogen was isolated in 16 (30.2%) clients. Candida albicans was isolated in 5 (9.2%) patients. Other microbial isolates are shown in [Table 3]. Forty-five percent of yields were sensitive to more than two drugs and only three were sensitive to Azithromycin alone. Similarly, Azithromycin was the sensitive agent either alone or with another agent in 13.3% of the culture yields. Multi-drug resistance (≥4) was observed in 26.4% of the cultures. Only one culture was resistant to all drugs [Table 4].
|Table 3: Organisms on culture yield or growth of endo-cervical swabs taken before HSG|
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|Table 4: The pattern of drug sensitivity and resistance of culture yield from endo-cervical swabs before HSG|
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Coliform bacteria, Staphylococcus spp, and Candida ablicans were more frequent in cases with blocked tubes than those with patent tubes [Table 5].
Statistically, alternative hypothesis states that there is statistical significant relationship between the presence of pathogens in the endo-cervix and the frequency of tubal disease, P < 0.05.
| Discussion|| |
The mean age of the infertile women in this study was 34.3 years. This is comparable with the mean age of 34.6 and 30 years in a review of HSG in infertile women at Nnewi  and Abakaliki  south-eastern Nigeria, respectively. In Kampala, Uganda, the mean age of the women studied was 29 years.  The value in this study is much higher than 23.2 years reported by Okpala  et al. 15 years ago at Nnewiin South-East Nigeria.
This probably suggests a change in the trend in the age of women presenting for tubal assessment due to infertility in our environment.
Secondary infertility was reported in 52.8% of the clients. This is comparable to findings of other authors ,,, in our environment. This is not surprising because 50-80% infertility in sub Saharan Africa usually follows ascending genital infections from complicated abortions and unsupervised deliveries, resulting in tubal pathologies. ,,,
The most common radiological abnormality in this study was pelvic/uterine adhesions, whereas hydrosalpinx was the most common abnormality reported in an earlier prospective review in Ilorin over a decade ago.  However, the reported percentage of 45.3% of hydrosalpinx in this study is still higher than the 23.3% reported a decade ago in Ilorin.  This may not directly mean that the incidence of hydrosalpinx is rising in our environment but just a reflection of the differences in the methodology and the sample sizes of the two studies. Most studies showed that tubal blockage was the most common HSG abnormality among infertile women in Africa. ,, Hydrosalpinx with associated thinning of adherent fimbriae and destruction of the mucosa  is also a consequence of the prevalent PID, postabortal, and puerperal infections in this part of the world. ,,,
Staphylococcus aureus was the most common organism isolated in this study and this is similar to findings of investigators at Ile-Ife among both fertile and infertile women.  Isolation of Candida spp was low in this study when compared with the isolates from women at Ile-Ife.  Candida is not an organism that is regularly cultured in the endo-cervix but a genital tract commensal. The Ife study cultured both high vaginal and endo-cervical swabs; this partly explains the higher yield of Candida, which is a vaginal flora. Moreover, it becomes pathogenic when there is an overgrowth and inflammation. The possibility of contamination by Candida cannot be completely ruled out in this study.
The isolation of microbial pathogens in 69.8% of the clients is surprisingly high because the clients were asymptomatic for genital infections. Thus, there is a possibility of iatrogenic ascending genital infection in this environment following HSG and the place of prior endo-cervical culture for microscopy and sensitivity is supported by this finding. This becomes even more important when the contribution of genital infections to infertility is given uttermost contribution irrespective of clinical symptomatology.
A total of 64.2% of the cultures/growths were sensitive to at least one antimicrobial agent while 45.3% were sensitive to more than two agents. This suggests a high level of resistance to antimicrobial agents in our environment as supported by the 28.3% rate of resistance to > three drugs in this study. Azithromycin had the highest coverage. It may then be advisable to use at least two agents that include Azithromycin in the treatment of cervical infections especially when there is no demonstrable vaginal discharge before uterine instrumentation. There is a paucity of information on this from this environment.
| Conclusion|| |
This study suggests the possibility of post-HSG infection due to the presence of pathogenic microbial isolates from endo-cervical swabs in asymptomatic infertile women. HSG is one of the most important investigations in the evaluation of tubal patency in infertility. Therefore it is important to ensure its safety and minimize postprocedural complications like pelvic infections. It is advocated that prophylactic antibiotic treatment should be given before HSG.
| References|| |
|1.||Westrom LV. Sexually transmitted diseases and infertility. Sex Transm Dis 1994;21:S32-7. |
|2.||Witkin SS, Toth A. Relationship between genital tract infections, sperm antibodies in seminal fluid and infertility. Fertil Steril 1983;40:805-8. |
|3.||Achenbach DA. Infertility caused by infection. Contemp Obstet Gynecol 1987;32:29-46. |
|4.||Araoye MO. Epidemiology of Infertility: Social problems of the infertile couples. West Afr J Med 2003;22:101-6. |
|5.||Okonofua FE, Makinde ON, Ayangade SO. Yearly trends in caesarean section and caesarean mortality at Ile-Ife, Nigeria. Trop J Obstet Gynaecol 1988;1:31-5. |
|6.||Okonofua FE, Onwudiegwu U, Odunsi OA. Illegal induced abortion: A study of 74 cases in Ile-Ife, Nigeria. Trop Doct 1992;22:75-8. |
|7.||Ibeziako PA. Effect of post-caesarean section sepsis on subsequent fertility. West Afr J Med 1986;5:35-9. |
|8.||Lema VM, Majingi CR. Acute pelvic infection following hysterosalpingography at the Kenyatta National Hospital, Nairobi. East Afr Med J 1990;70:551-5. |
|9.||Tuveng JM, Vold I, Jerve F, Eng J, Skaug K, Eyolfsson O. Hysterosalpingography: Value in estimating tubal function, and risk of infectious complications. Acta Eur Fertil 1985;16:125-8. |
|10.||Forsey JP, Caul EO, Paul ID, Hull MG. Chlamydia trachomatis, tubal disease and the incidence of symptomatic and asymptomatic infections following hysterosalpingograph. Hum Reprod 1990;5:444-7. |
|11.||Thinkhamrop J, Laopaiboon M, Lumbiganon P. Prophylactic antibiotics for transcervica intrauterine procedures. Cochrane Database Syst Rev 2010;5. |
|12.||Land JA, Gysen AP, Evers JL, Bruggeman CA. Chlamydia trachomatis in subfertile women undergoing uterine instrumentation: Screen or treat? Hum Reprod 2002;17:525-7. |
|13.||Stumpf PG, March CM. Febrile morbidity following HSG: Identification of risk factors and recommendations for prophylaxis. Fertil Steril 1980;33:487-92. |
|14.||American College of Obstetrics and Gynecology: ACOG practice bulletins no 104: Antibiotic prophylaxis for gynaecologic procedures. Obstet Gynecol 2009:113:1180-9. |
|15.||Acton CM, Devitt JM, Ryan EA. Hysterosalpingography in infertility- an experience of 3631 examinations. Aust N Z J Obstet Gynaecol 1988;28:127-33. |
|16.||Eleje GU, Okaforcha EI, Umeononihu OS, Udegbunam OI, Etoniru IS, Okwuosa AO. Hysterosalpingographic Findings among Infertile Women: Review at a Tertiary health CareInstitution in Nnewi, South-east Nigeria. Afrimedic J (NAUTH) 2012;3:21-23. |
|17.||Imo AO, Sunday-Adeoye I. Radiological assessment of the uterus and fallopian tubes in infertile women at Abakaliki, Nigeria. Niger J Clin Pract 2008;11:211-5. |
|18.||Kiguli-Malwadde E, Byanyima RK. Structural findings at hysterosalpingography in patients within fertility at two private clinics in Kampala, Uganda. Afr Health Sci 2004;4:178-81. |
|19.||Okpala OC, Okwoli NR. Genital tract microbial floral hysterosalpingography.Trop J Med Res 2005;9:28-30. |
|20.||Bello TO. Pattern of Tubal Pathology in Infertile Women on Hysterosalpingography in Ilorin. Ann Afr Med 2004;3:77-9. |
|21.||Akinola RA, Akinola OI, Fabamwo AO. Infertility in women: Hysterosalpingographic assessment of the fallopian tubes in Lagos, Nigeria. Educ Res Rev 2009;4:86-9. |
|22.||Okonofua FE, Ako-Nai KA, Dighitoghi MD. Lower genital tract infections in infertile Nigerian women compared with controls. Genitourin Med 1995;71:163-8. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]