The role of sexually transmitted infections in PMA failures

The need and interest have emerged from clinical practice to deepen the study of some intracellular pathogens, largely unknown, and to highlight them. Namely tests for Mycoplasma and Ureaplasma, namely.

The Epidemiological and Clinical Importance

  • • Chlamydia Trachomatis • Mycoplasma
  • Chlamydia Trachomatis Infection
  • C. Trachomatis is an obligate endocellular parasite (serotypes D to K)
  • Also, C. genital infection is frequent (3-5% of sexually active women) and often occurs in both men and women in an asymptomatic way
  • C. Trachomatis is characterized by 2 morphofunctional entities that alternate during the development cycle:
  • Also, The elementary body is incapable of reproducing but capable of surviving outside the host cell.
  • But the reticular body is capable of reproducing but incapable of infecting.

Epidemiology of C. Trachomatis

However, for INCIDENCE:

  • Approximately 2.8 million new cases/year in the USA and 3 million in Europe
  • One of the most common bacterial STDs
  • Rates 4 times higher in women
  • Its prevalence decreases in countries where control programs are applied
  • High sexual transmission (>50%)

Therefore, the infection can present itself in the following ways:

  • Asymptomatic
  • Paucysymptomatic

Symptoms usually appear within 1-3 weeks of infection

But the most frequent clinical manifestations are:

  • Urethritis in men
  • Cervicitis in women

Mc Ilhaney, 2000

Also, for the C. Trachomatis Infection

  • MAN


Urethral secretions


Subacute epididymitis


Rectal infections

Reactive arthritis


Asymptomatic 80%

Abnormal vaginal discharge

Mild burning upon urination

Intermenstrual or post-coital bleeding

Mucopurulent cervicitis

Pelvic inflammatory disease

Reactive arthritis

Genital Mycoplasma

However, tests show that of the approximately 200 known species of Mycoplasma, only 6 have a certain or presumed pathogenic role in humans, 5 of which reside in the urogenital system: •

  • Mycoplasma hominis
  • MGen genitalium
  • Myco fermentations
  • Ureaplasma urealyticum
  • Urea Parvum

Also, for the Ureaplasma Urealyticum Infection

  • U. urealyticum, like all diseases, is the smallest Ureaplasma bacterium capable of autonomous life. However, in women, it is a commensal of the vaginal flora together with lactobacilli, which in normal conditions hinders its excessive proliferation
  • The women most affected by the infection are those aged between 18 and 40 years

Epidemiology of U. Urealyticum

– No certain epidemiological data are reported

– Published studies on pathogenicity are burdened by important methodological limitations

– Higher prevalence of U.U. infection variable from 4-40% in infertile couples (much higher than the prevalence of C. Trachomatis variable between 1-15%)

U. Urealyticum Infection

  • MAN

But Asymptomatic 30%

And Urethral secretions

Also, Burning urination

And Prostatitis and prostatitis-vesiculitis with azoospermia


Asymptomatic 50%

And Bacterial vaginosis

Also, for Urethral syndrome and dysuric disorders

And the Pelvic inflammatory disease

However, only a portion of cases of sexually transmitted diseases are recognized.

Therefore, for the Diagnosed Cases

  • Asymptomatic
  • Oligosymptomatic
  • Incorrect diagnoses
  • Self-therapy

The Undiagnosed Cases

But the Conventional Laboratory Diagnosis: Techniques

  • Microscopic observation of pathological material
  • Direct immunofluorescence
  • Culture examination
  • Research of genetic material (DNA) using PCR
  • Nucleic acids amplification test
  • Indirect search for the infectious agent through serological investigations

The Diagnostic Criteria for the Diagnosis of Accessory Gland Infections (MAGI)

  • Firstly, for Group A (History/Physical Signs): History of urinary infection, Epididymal infection, STD
  • Group B (Urine after Prostatic Massage): Abnormal Urine after Massage, Positive Culture for Chlamydia
  • Group C (Ejaculation Signs). The elevated number of white blood cells is positive for peroxidase. And the Mycoplasma Culture with significant growth of pathogenic germs. Also, the Culture was positive for chlamydia, Abnormal Appearance and Viscosity and pH. And don’t forget the Abnormal Biochemical Indices of Semen and Elevated Levels of Infection Markers.

The Clinical Cases

  • Can the constant reduction in male fertility without an apparent cause (OAT) be the result of unknown infections of the urogenital tract?

Also for Therapy

  • – In case of seminal parameters “indicative” of unknown infection, some pharmacological approaches with antibiotics are proposed. However, antibiotic therapy improves seminal parameters without an apparent increase in pregnancy rate.
  • – Many drugs are active for intracellular bacteria, such as Tetracyclines, Macrolides, Fluoroquinolones, and Rifampicin.
  • However Persistence of intracellular pathogens after adequate antibiotic treatment is common (23-68%). In these cases, combined and long-term treatment is indicated.
  • However, in my clinical experience, I frequently encounter cases that cannot be included within the current guidelines on seminal tract infections. Therefore, I implemented a new treatment scheme to improve seminal parameters and…

Therefore, for the Results

– Improvement of symptoms
– “After about 7 years, I can finally have sex with Diego without feeling pain. But before his treatment, every intercourse was followed by cystitis. So it seemed that I had to live with these pains and continuous cystitis for life..”
– So, “I have excellent news. Furthermore, now I can have normal intercourse, I no longer have pain… only pleasure. And now I can say that I am normal, that I have no psychological blocks, and that sex is a beautiful thing. So, come what may, it’s already a success. And if the baby arrives, it will be the icing on the cake… if it doesn’t happen, we are happy like this..”
– “I felt such intense pleasure that I no longer remembered; I felt like I was flying..”

But the Pregnancy Rate

  • Global Pregnancy Rate 46.8% (44/94)
  • 24/94 (25.5%) at subsequent PMA treatment
  • 20/94 ( 21.3%) naturally

Therefore the Conclusions

– Suspected urogenital infections from intracellular germs certainly have a negative influence on sperm quality and couple infertility. Furthermore, even today, there is no gold standard in MGen diagnostic tests. Therefore, it is important to evaluate the seminal parameters to get closer to the diagnosis. Additionally, always consider the couple as a single entity in the diagnostic process.
– In the presence of even minimal variations in semen parameters in patients with OAT for several years and negative results in common diagnostic tests for genital infections caused by intracellular germs, considering combined therapy with Doxycycline, Azithromycin, and Moxifloxacin is a valid option. Moreover, such combined therapy may offer a comprehensive approach to addressing potential underlying infections contributing to semen parameter variations.

Dr. Scarano Pasquale Head of Andrology module U.O. UrologyInfermi Hospital

Rimini – Italy