PREVALENCE RATE OF CHLAMYDIA TRACHOMATIS INFECTION IN EGYPTIAN INFERTILE WOMEN

Chlamydia trachomatis is one of the most common curable bacterial sexually transmitted infections (STIs) worldwide, and its complications in infected women in terms of pelvic inflammatory disease (PID), infertility and ectopic pregnancy among others with this infection highlights the need of its diagnosis in women with a history of infertility and recurrent spontaneous abortion for their better management.the present study evaluates the relationship between either past or current C. trachomatis infection in asymptomatic Egyptian females with unexplained infertility. This may be needed to be highlighted to attract the attention of clinical investigators. In addition the study compares the effectiveness of the point of care (POC) chlamydia test with polymerase chain reaction (PCR) as a potential tool for rapid Chlamydia diagnosis and screening .In the present study we enrolled women attending the gynecology outpatient department (OPD) of Ain shams educational hospital in the period from January 2013 to September 2013.The case group comprised of seventy five married infertile women. control group of twenty patients who were attending the clinic for other gynecologic purposes The clinician team did a routine gynecological per speculum examination to record signs of infection and collected two cervical swabs and blood samples, The first swab was shaken on a vortex mixerThe contents of the tube were used for direct Geimsa staining and point of care testing. The second swab was shaken on a vortex mixer then it was removed after pressing against the tube wall. And the content was preserved at -70oC until used for DNA extraction and PCR Chlamydia rapid test (CRT) wasperformed,The detection of IgG antibodies against C. trachomatis was performed by using a commercial ELISA kit . Seventy five infertile women and twenty control females were tested for current C,trachomatis infection by PCR, C.trachomatis POC test and geimsa staining. AS well as serum samples were collected to detect C.trachomatis specific IgG by ELISA. The Participants of the infertility cases were between 20-45 years old with a mean of (34.18± 5.3) The overall prevalence of anti C trachomatis antibodies (ACTA) IgG in infertile women was 27/75 (36%) in infertile women and 2/20 (10%) in control group ,the difference was statistically significant (P<0.05 )The overall prevalence of genital C.trachomatis by PCR was (22/75)29.3% in infertile women and 1/20 (5%) in control subjects versus (18/75) 24% by C.trachomatis POCT. Sensitivity, specificity, Positive predictive value and Negative predictive value of C.trachomatis POCT was compared to PCR for the diagnosis of C.trachomatis infection and it revealed 81.8%, 98.1%, 94.7% and 92.9% respectively conclusion, we find a strong relationship between past and current C.trachomatis infection and infertility in a sample of Egyptian infertile women. No difference was found in the prevalence of current or past C.trachomatis infection and fertile controls. The Chlamydia rapid test achieves relatively high diagnostic sensitivity and provides results within 30 minutes. It is suitable as primary diagnostic tool for Chlamydia infection and in settings where PCR tests was limited or absent thus it could be used as a screening tool. Az. J. Pharm Sci. Vol. 48, September, 2013. 2

relationship between either past or current C. trachomatis infection in asymptomatic Egyptian females with unexplained infertility.This may be needed to be highlighted to attract the attention of clinical investigators.In addition the study compares the effectiveness of the point of care (POC) chlamydia test with polymerase chain reaction (PCR) as a potential tool for rapid Chlamydia diagnosis and screening .In the present study we enrolled women attending the gynecology outpatient department (OPD) of Ain shams educational hospital in the period from January 2013 to September 2013.The case group comprised of seventy five married infertile women.control group of twenty patients who were attending the clinic for other gynecologic purposes The clinician team did a routine gynecological per speculum examination to record signs of infection and collected two cervical swabs and blood samples, The first swab was shaken on a vortex mixerThe contents of the tube were used for direct Geimsa staining and point of care testing.The second swab was shaken on a vortex mixer then it was removed after pressing against the tube wall.And the content was preserved at -70ºC until used for DNA extraction and PCR Chlamydia rapid test (CRT) wasperformed,The detection of IgG antibodies against C. trachomatis was performed by using a commercial ELISA kit .Seventy five infertile women and twenty control females were tested for current C,trachomatis infection by PCR, C.trachomatis POC test and geimsa staining.AS well as serum samples were collected to detect C.trachomatis specific IgG by ELISA.The Participants of the infertility cases were between 20-45 years old with a mean of (34.18± 5.3) The overall prevalence of anti C trachomatis antibodies (ACTA) IgG in infertile women was 27/75 (36%) in infertile women and 2/20 (10%) in control group ,the difference was statistically significant (P<0.05)The overall prevalence of genital C.trachomatis by PCR was (22/75)29.3% in infertile women and 1/20 (5%) in control subjects versus (18/75) 24% by C.trachomatis POCT.Sensitivity, specificity, Positive predictive value and Negative predictive value of C.trachomatis POCT was compared to PCR for the diagnosis of C.trachomatis infection and it revealed 81.8%, 98.1%, 94.7% and 92.9% respectively conclusion, we find a strong relationship between past and current C.trachomatis infection and infertility in a sample of Egyptian infertile women.No difference was found in the prevalence of current or past C.trachomatis infection and fertile controls.The Chlamydia rapid test achieves relatively high diagnostic sensitivity and provides results within 30 minutes.It is suitable as primary diagnostic tool for Chlamydia infection and in settings where PCR tests was limited or absent thus it could be used as a screening tool.

INTRODUCTION:
Data on the prevalence of Chlamydia trachomatis ( C. trachomatis)  The study mentioned that empirical treatment is recommended as the diagnosis is costly and usually not available.Among Egyptian infertile women, the prevalence of c. trachomatis infection ranged from 15%-45% depending on the method of diagnosis.Authors of previous studies concluded that C. trachomatis play a role in infertility, and should be considered in the investigations of these patients.(Chavez-Badiola et al., 2008 andDutta et al., 2008).Siam and Hefzy (2011) reported that the prevalence of anti C.trachomatis IgG in asymptomatic infertile and control Egyptian women was (31.1% and 17.5% respectively).Prevalence of current infection was (4.4% and 7.5%) in infertile and fertile groups respectively (P value =0.87)and they concluded that no difference was found in the prevalence of current or past C.trachomatis infections between unexplained infertility cases and fertile controls.Although Bas et al., (2008) and Haggerty et al., (2010) mentioned that correlation of the c.trachomatis past and current infection with the infertility was clearly shown.
With the advent of nucleic acid amplification tests (NAATS), which can use non invasive specimens and have high sensitivity and specificity, improved detection and treatment of Chlamydia infection has been possible(Lau and Qureshi.2002) However , these laboratory tests involve a delay between specimen submission and receipt of test results.This delay may lead to overtreatment (if patients are treated presumptively at their initial visit), postponed treatment) if the follow -up visit occurs days/ weeks later), or even lack of treatment (if patients are lost to follow up).(Schwebke et al., 1997) Recently, several companies have developed point-of-care (POC) tests that provide rapid results for the detection of chlamydia at the index visit.This can dramatically reduce the time between testing and treatment, as well as increase treatment rates.(Swain et al., 2004) However, sensitivities of the three US Food and Drug Administration-approved POC chlamydia tests (25%-65%) preclude more widespread use in clinical setting.(Huppert et al., 2010) In Egypt the impact of current Chlamydia trachomatis (C.trachomatis) in reproductive health remains a neglected area of investigation.Thus the present study evaluates the relationship between either past or current C. trachomatis infection in asymptomatic Egyptian females with unexplained infertility.This may be needed to be highlighted to attract the attention of clinical investigators.In addition the study compares the effectiveness of the point of care (POC) chlamydia test with polymerase chain reaction (PCR) as a potential tool for rapid Chlamydia diagnosis and screening.

MATERIALS AND METHODS:
In the present study we enrolled women attending the Gynecology outpatient Department (OPD) of Ain shams educational hospital in the period from January 2013 to September 2013.
The case group comprised of seventy five (75) married infertile women.Primary infertility was forty six (46) and secondary infertility was twenty nine (29) patients.Primary infertility was defined as the inability to conceive after 1 or more years of regular coital activity without contraception, and secondary infertility was defined as the inability to conceive after 6 or more months of regular coital activity without contraception with a history of previous pregnancy The study included a control group of twenty patients (20) who were attending the clinic for other gynecologic purposes (abnormal uterine bleeding, ovarian cyst, intrauterine device insertion family planning.All the control group women had no complaint of infertility. All cases were in the childbearing ages (20-45 years old).They were asymptomatic in terms of genital tract infection.None of the women received antibiotics or corticosteroids at least for 15 days before samples were taken.Basic infertility investigation included full detailed medical history and clinical examinations were done.During the standard infertility investigations, all female patients were checked for tubal patency and normal uterine cavity by hysterosalpingography (HSG) and/or laparoscopy and for the hormonal factor, including tests for ovarian, pituitary, thyroid and adrenal gland function.Sperm analysis was performed for their male partners.

Specimen collection
The clinician team did a routine gynecological per speculum examination to record signs of infection and collected two cervical swabs from 75 infertile and 20 control women, after cleaning the cervix with a dry cotton swab.Dacron swabs (Human For biochemical and diagnostic mbH,.Max-Plank-Ring 21-D-65205 wiesbaden -Germany) were used.They were preserved in 1.5 mL of a sterile medium containing 6.7 mg/mL KH2PO4, 3.36 mg/mL KH2PO4, 227 mg/mL sucrose, 50 mg/L gentamicin, 100 mg/L vancomycin and 50 mg/L amphotericin B.
One swab was shaken on a vortex mixer then it was discarded after pressing against the tube wall.The contents of the tube were used for direct Geimsa staining and point of care testing.The second swab was shaken on a vortex mixer then it was removed after pressing against the tube wall.The content was preserved at -70ºC until used for DNA extraction and PCR.
Blood was collected by venipuncture, allowed to clot and serum was separated by centrifugation at room temperature.Specimens were stored -20ºC for detection of C.trachomatis specific IgG by ELISA circulating anti C.trachomatis IgG antibodies in the serum of both study and control groups.

1) Extraction of DNA
DNA was isolated from cervical specimen using a rapid non-enzymatic method.The cells were pelleted and resuspended in Tris-MgCl 2 -KCl buffer (pH=7.4) and treated with 10% sodium dodecyl sulphate at 55 °C for 10 min to lyse the cells.DNA was precipitated by 100% ethanol and eluted in Tris EDTA buffer (Lahiri and Nurnberger 1991).The method avoids the use of any organic solvents.This was achieved by salting out the cellular proteins by dehydration and precipitation with a saturated sodium chloride solution.

PCR for diagnosis of C. trachomatis
PCR was performed on extracted DNA using primers designed from the conserved region of MOMP gene of C. trachomatis with sense primer: 5' GCC GCT TTG AGT TCT GCT TCC 3' and anti-sense primer: 5' GTC GAA AAC AAA GTC ACC ATA GTA 3' to amplify a 180 bp DNA fragment common to all serotypes (Mania -Pramanik et al., 2006) The reaction was carried out in a volume of 50 µl.It contained primers (0.5 µm each), 0.2 mM dNTP's, PCR buffer (10 mM Tris buffer; pH=9), 1.25 units of Taq polymerase, 10 µl of DNA specimen and the volume was adjusted with sterile distilled water.Positive and negative controls were also run in each experiment.Reaction was performed in a thermal cycler (Perkin Elmer 2400) as per the following protocol: initial denaturation was done for 5 min at 94 °C.This was followed by 35 cycles of 30 s each of denaturation at 94 °C, annealing at 55 °C and extension at 72 °C for 1 min.The final extension step was carried out at 72 °C for 5 min.The amplified products were run on 2% agarose gel, observed under a UV transilluminator while the results were being documented.Presence of 180 bp repeat sequences in positive control specimen and its absence in the negative control indicated reaction had been completed satisfactorily.

2) Point of care chlamydia rapid test
Chlamydia Rapid Test CRT was performed.Version 6.1 of the Chlamydia Rapid Test (P/N 1200-20) instructions for use (C03-0008) was used.Shortly, each swab was subjected to extraction by sequential addition of 400 µl of reagent 1, 300 µl of reagent 2, and 100 µl of reagent 3 to the swab in a tapered sample preparation tube, with gentle mixing between additions.The sample preparation reagents were administered with unit dose pipettes.The extraction tube was then capped and used as a dropper to deliver 5 drops (approximately 100 µl) of the extracted sample to a tube containing the lyophilized amplification and detection reagents.The resulting mixture was agitated gently until a clear pink solution was obtained, after which the test strip, coated with a monoclonal antibody to chlamydial lipopolysaccharide (LPS) and including a procedural control, was added to the solution and allowed to stand for 25 minutes before the result was read.Each swab was subjected to one extraction.The test strip was used in the interpretation of the result; a clearly visible test line indicated a positive result, provided that the control line was also visible on the test strip.(CTK Biotech, USA,2006).

3) Giemsa staining
The typical chlamydia inclusions were described for the first time in Giemsa stained epithelial cells in the infected conjunctivae of primates (Munday 1980).Characteristic cytoplasmic inclusion bodies infected cells).

4) Serology
The detection of IgG antibodies against C. trachomatis was performed by using a commercial ELISA kit (C.trachomatis IgG ELISA, Novum Diagnostics, Germany) Nova TecImmunodiagnostica, GMBH In brief, microtitre wells precoated with C. trachomatis antigens were incubated with serum specimen at a 1:100 dilution so that any corresponding antibodies present in the serum would bind to the antigen to form complexes.After washing the wells to remove all unbound sample material, horseradish peroxidase (HRP) labeled antihuman IgG conjugate was added which would bind to captured Chlamydia specific antibodies.The immune complex formed by the bound conjugate was visualized by adding tetramethylbenzidine (TMB) substrate, which gives a blue colored reaction product.After terminating the reaction using a stop solution (Sulphuric acid, 0.2 mol/l), the absorbance of the end product, which is yellow in color, was read at 450 nm using an ELISA plate reader (μ Quant, Bio-Tek Instruments Inc.).The intensity of this product is directly proportional to the amount of Chlamydia-specific IgG antibodies in the specimen.The specimens with O.D. higher than the cut-off value (0.250-0.900) were considered positive for Chlamydia-specific antibodies and used as an indicator of past Chlamydia infection

RESULTS
Seventy five infertile women and twenty control females were tested for current C,trachomatis infection by PCR, C.trachomatis POC test and geimsa staining.AS well as serum samples were collected to detect C.trachomatis specific IgG by ELISA.The Participants of the infertility cases were between 20-45 years old with a mean of (34.18± 5.3).and the control group were between 22-43 years old with a mean of (34.05± 4.9).Difference between the two groups was not statistically significant.(P>0.05) The overall prevalence of anti C trachomatis antibodies (ACTA) IgG in infertile women was 27/75 (36%) and 2/20 (10%) the difference was statistically significant (P<0.05)(Table 1)and figure 1 Higher prevalence of anti C trachomatis IgG was found in the serum of primary infertility women 18/46 (39.1%) than 2ry infertility women 9/29(31.03%).However, the difference between both groups was not significant (P=0.87) as shown in (Table 2) and figure 4. The overall prevalence of genital C.trachomatis by PCR was (22/75)29.3% in infertile women and 1/20 (5%) in control subjects versus (18/75) 24% by C.trachomatis POCT (Table 3) with a significant difference between both groups (P<0.05).3 The control group showed only one case to be C.trachomatis PCR positive, on revising the clinical profile of this patient; it revealed that she was complaining of pelvic pain.(Table 7) (Table 8) described that tubal factor as a cause of infertility in the studied population was the highest 29/75 (38.7%) and is highly correlated with C.trachomatis PCR positive results 13/29 (44.8%) were positive C.trachomatis PCR.
(Table 9 )compare the causes of infertility between the 1ry and 2ry groups and their correlation with the C.trachomatis PCR positive results and it was found that tubal factor was the highly correlated with both groups with no significant difference    But this recent study was not in line with Siam and Hefzy (2011) who found that the PCR prevalence of current genitourinary C.trachomatis was 4.4% in infertile Egyptian women and 7.5% in control subjects with no significant difference between both groups.An explanation for the difference between this present result and the results reported by Siam and Hefzy (2011) may be attributed to the difference in the study population, male partner infection, the sensitivity of the laboratory method used as well as the type of sample collected.The variation observed of C trachomatis prevalence between Middle Eastern studies as well as rest of the world could be due to study population (educational level, sample size), rate of infection in the study area, hygiene level and socioeconomic status of the study area, culture of the society and the technique used for the detection.
Tubal factor as a cause of infertility in the studied case group was the highest cause of infertility 29/75 (38.6%) and C. trachomatis PCR positive results was high among this group 13/29 (44.8%).This is in accordance with Bebear and Barbeyrac ( 2009 This study showed the prevalence of current genital C.trachomatis by PCR in 1ry infertility was 12/46(26%) and in 2ry infertility was10/29(34.4%)and this difference was not statistically significant this is in line with results reported with Siam and Hefzy (2011).This study investigated the relationship between past C.trachomatis (examined by anti C.trachomatis antibodies IgG assay detected by ELISA) and infertility in asymptomatic Egyptian women with primary and secondary infertility.It revealed that prevalence of anti C.trachomatis IgG in asymptomatic infertile and control women was 27/75 (36%) and 2/20(10%) respectively.This result is in line with previous studies performed by Siam and Hefzy (2011) who found IgG antibodies to C.trachomatis were 31.1% of the infertile Egyptian women.
In another study, higher prevalence rates for ACTA IgG than the present study was present Anti chlamydial IgG antibodies were present in 68% of women with infertility.Where Chlamydia IgG antibodies have been found in 30-60% of subfertile women and are considered as markers for past pelvic infections.(Mittal et al., 2010;Olsen et al., 2010).No explanation for this striking high prevalence was found except that might be misinterpretation of results or the difference in the study population.In this study higher prevalence of anti C trachomatis IgG was found in the serum of 1ery infertility women 18/46 (39.1%) than 2ry infertility women 9/29 (31.03%).However, the difference between both groups was not significant (P=0.87)this was in line with Siam and Hefzy 2011 who found no statistical significant difference between anti C trachomatis IgG antibodies between primary and secondary infertility although they were found high prevalence of anti C trachomatis IgG antibodies in serum of secondarily infertile women than primary infertility patients.The difference between these results and this study may be attributed to difference between the sample sizes As C.trachomatis is an obligate intracellular pathogen, cell culture remains the reference method and it has 100% specificity but it is not recommended for routine use because of its technical; complexity, the long turn-around time and it is unsuitable in developing countries.Therefore many commercial non -culture-based assays are now available for diagnosis.(Carder et al., 2006) Bebear and Barbeyrac (2009) concluded that the diagnosis of C.trachomatis is best made by using nucleic acid amplification tests , because they perform well and do not require invasive procedures for specimen collection.
The Chlamydia Rapid Test is an immunoassay based test that detects Chlamydia lipopolysaccharide (Michel et al., 2006).This new test provides a same day result, which would allow immediate treatment of the infected patient.Unlike other rapid tests, the novel signal amplification system of the Chlamydia Rapid Test maximises the visual test signal, and the improved sample preparation chemistry overcomes signal inhibition caused by the high viscosity and variability of vaginal fluid.Specimen types for Chlamydia trachomatis testing have evolved in recent years, as studies have shown that vaginal specimens perform as well as, if not better than, endocervical swabs or first void urine across a range of nucleic acid amplification tests.

(Shafer et al., 2003)
With the Chlamydia Rapid Test, results are available within 30 minutes, allowing all patients testing positive to be offered treatment while still at the clinic.Given that about 3% of women diagnosed with Chlamydia infection have been found to develop pelvic inflammatory disease in the interval between testing and their return for treatment.The prompt treatment of infected women made possible by the Chlamydia Rapid Test would be expected to avert this outcome.

(CDC 2002)
This study compared the prevalence of Current genital C trachomatis by PCR and rapid POCT in the infertile and control subjects and it reported that PCR was able to detect 29.3%(22/75 patients) whereas rapid point of care was able to detect 24% (18/75 patients) On comparing the sensitivity, specificity, PPV and NPV of the rapid point of care test in comparison to PCR it revealed that 81.8%, 98.1%, 94.7% and 92.9% respectively.The chlamydia trachomatis POCT gave one false positive result and failed to detect four cases (false negative results.This results are nearly in line with Mahilum-Tapay (2007) who Compared chlamydia trachomatis POCT with polymerase chain reaction assay, and found sensitivity, specificity, positive predictive value, and negative predictive value of the Chlamydia Rapid Test were 83.5% (91/109), 98.9% (1224/1238), 86.7% (91/105), and 98.6% (1224/1242) the slight difference between the two studies may be due to the difference in the size of the studied population , the type of the sample collected.Huang et al. (2013) reported that the sensitivity and specificity of the experimental vaginal POC test were 92.9% 98.5%, respectively.The positive and negative predictive values were 86.7% and 99.2% respectively.The difference in the results may be attributed to the way and type of sample collected.
The present study reported that Giemsa stain was able to detect 7/75 cases (9.3%) in comparison to 29.3% to PCR and 24% to the rapid POCT this is in line with Mohammad zadeh et al. (2011) who failed to detect Chlamydia with Giemsa stain when compared it with PCR and immunofluorescence assay and concluded that Giemsa staining is not a suitable and reliable technique for chlamydia trachomatis detection.
As a final conclusion, we find a strong relationship between past and current C.trachomatis infection and infertility in a sample of Egyptian infertile women.No difference was found in the prevalence of current or past C.trachomatis infection and fertile controls.The Chlamydia rapid test achieves relatively high diagnostic sensitivity and provides results within 30 minutes.It is suitable as primary diagnostic tool for Chlamydia infection and in settings where PCR tests is limited or absent thus it could be used as a screening tool.
There is a need to address this invisible and poorly quantified cause of infection among the infertile women on a wide scale.

Figure 1 :Figure 2 :Figure 3 :
Figure 1 : The detection of IgG antibodies against C. trachomatis was performed by using a commercial ELISA

Figure 4 :
Figure 4 : Prevalence of current genital C trachomatis by PCR ( POCT) and Geimsa stain ) who reported that one third of ectopic pregnancies are associated with C.trachomatis infection.As well as El-Shorbagy et al. (2010) reported that that incidence of Chlamydial infection was 51.8% among tubal infertility subjects and Mania-Pramanik et al. (2012) reported that one fourth of ectopic pregnancies are associated with current C trachomatis infection.C.trachomatis is a common cause of cervicitis and uretheritis, and sequeleae include pelvic inflammatory disease, ectopic pregnancy ad tubal factor infertility (Carey and Beagley 2010)

C
.trachomatis is the most common bacterial cause of sexually transmitted infections.Genetic predisposition and host immune response play important roles in the pathogenesis of long term complications after C.trachomatis infections.(Bas et al., 2008; Brocklehurst and Rooney 2002)

Hernandez
Trejo et al. (2009) identified that a titer greater or equal to 1:152 of anti Chlamydia IgG antibodies could be used to differentiate tubal damage infertility from other causes of subfertility in a group of Mexican women.Sonmez et al. (2008) found a positive correlation between high Chlamydia trachomatis antibodies and tubal damage.As well as Jeremiah et al. (2011) concluded that there is a strong association between Chlamydia antibody positivity and tubal occlusion.

Mc Farland et al., 2010)
infection in the Middle East and North Africa (MENA) region remain scarce due to its limited research capacity and sociocultural sensitivity around sexually transmitted infections (STIs).( This challenge is further compounded by methodological limitations in available studies and by the logistical difficulty in conducting STI studies among women.(

Abu-Raddad et al., 2010).
Considering that C. trachomatis is one of the most common curable bacterial STIs worldwide, and its complications in infected women in terms of pelvic inflammatory disease (PID), infertility and ectopic pregnancy among others.(WHO.2013) Chlamydial PID is the most important preventable cause of infertility and adverse pregnancy outcome.Based on the available studies, approximately 20% of women with chlamydial genital infection will develop PID, 3% develop infertility, 2% develop adverse pregnancy outcome.(

Bohm et al., 2009; Carey et al., 2010) Pramanik et al. (2012) suggested
association between current C. trachomatis infection and infertility.Absence of signs and symptoms associated with this infection highlights the need of its diagnosis in women with a history of infertility and recurrent spontaneous abortion for their better management.

El-Shorbagy et al. (2010) investigated
genital Chlamydial infection incidence among high risk clinical conditions in Egyptian women and found that incidence of Chlamydial infection was 79.3% among cervicitis group, 33.3% among subjects with inflammatory smear, 75.2% among those with cervical condyloma, 82.6% among those with cervical intraepithelial neoplasia, 51.8% among tubal infertility subjects, 77.2% among ectopic patients and 56.3% among subjects with preterm labor.

.
Nevertheless, POC tests can be beneficial in settings where patients do not reliably return for treatment.

(Swain et al., 2004) Based
on focus group discussions with clinicians, opinion leaders and public health professionals, and a recent clinician survey, an ideal POC test should have ≥90% sensitivity, require ≤30 min to process, and cost ≤US$20 (

Table 4 ) and figure 2
Sensitivity, specificity, Positive predictive value and Negative predictive value of C.trachomatis POCT was compared to PCR for the diagnosis of C.trachomatis infection and it revealed 81.8%, 98.1%, 94.7% and 92.9% respectively.(

Table 1 :
Prevalence of anti Chlamydia antibodies (IgG) in serum of cases and control:

Table 2 :
Prevalence of anti Chlamydia antibodies (IgG) in serum of primary and secondary infertility

Table 3 :
Prevalence of Current genital C trachomatis by PCR (POCT) and Geimsa stain

Table 4 :
Comparison of Current genital C. trachomatis by PCR between primary and

Table 5 :
C.trachomatis point of care test (POCT) compared to the PCR for the diagnosis of C.trachomatis infection: PCR C.trachomatis POCT C.trachomatis POCT Total

Table 6 :
Sensitivity, specificity, positive predictive value and negative predictive value of POCT in comparison to PCR for the diagnosis of C.trachomatis infection: TP: true positive, FP: false Positive, TN: true Negative, FN: False negative Positive predictive value (PPV) Negative predictive value (NPV)

Table 7 :
The control group clinical condition profile in correlation to C. trachomatis PCR

Table 8 :
Cause of infertility in the case group, with correlation to C.

Table 9 :
Cause of infertility in the primary and secondary infertility groups, with the results of polymerase chain reaction testing for Chlamydia trachomatis

Agha, A.S.; El-Mashad, N.; Rakha A. S.; and El Metwally G. A. (2011):
Value of direct antigen detection methods in diagnosing women with suspected genital Chlamydia trachomatis infection African Journal of Microbiology Research; 5(10): 1215-1219.Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae Among Asymptomatic Women Attending the Capital Health Region Clinics in Kuwait.Sexually Transmitted Diseases 38(9): 793-797 Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: time for strategic action, Middle East and North Africa HIV/AIDS Epidemiology Synthesis Project.World Bank/UNAIDS/WHO Publication.Washington, DC: The World Bank Press.