The increased availability of reliable and safe contraception in the United States has provided many couples with an important choice: when and/or if to have a child. Ironically, this reproductive choice is threatened by a largely preventable epidemic that severely impairs fertility or leaves many women-particularly young, sexually active women-involuntarily sterile.

This epidemic is caused by two bacteria predominately responsible for the majority of STD-related reproductive tract damage in women: Chlamydia trachomatis and Neisseria gonorrhea.' Of the two, chlamydia is the more common with an estimated 4 million new infections occurring every year.2 In fact, in 1995, the first year that it was nationally reportable, chlamydia led the list of infections reported to the National Notifiable Disease Surveillance System (NNDSS).3

Fortunately, uncomplicated chlamydial and gonococcal infections are easily cured by early treatment with a short course or single dose of specific antibiotics.

MILD SYMPTOMS, SIGNIFICANT DAMAGE

Virtually all studies on chlamydia point to its asymptomatic nature. In fact, approximately 75 percent of infected women and up to half of infected men have no symptoms or such mild ones that they will not likely seek treatment.4 This results in continued disease transmission, and, for women, increased risk for upper reproductive tract complications.

Of the estimated 2.6 million American women with chlamydia, 20 to 40 percent of those with untreated infections will develop pelvic inflammatory disease (PID), a spectrum of female upper genital tract disorders caused mostly by chlamydia and gonorrhea ascending from the cervix and vagina. This often results in scarring in and around the fallopian tube.5

Approximately one in five of those women with PID will become infertile and almost one in ten will experience a potentially life-threatening ectopic pregnancy. More than a third of those hospitalized with PID and over 90 percent of those hospitalized with chronic infection will eventually undergo surgery for pelvic pain.6

Diagnosis of PID is often difficult because no specific laboratory test or physical examination result is definitive. Although a "classic" case of gonococcal PID may cause appendicitis-like symptoms such as fever and acute lower pelvic pain, most cases of silent chlamydial PID often go unrecognized because the symptoms are so subtle, and the discomfort so mild or transitory (similar to the lower abdominal discomfort caused by menstrual pain or gastrointestinal upset) that a woman may not seek treatment. This "silent" form of PID may present a greater threat to a woman's fertility than the more "classic" form because those with acute PID are more likely to seek prompt care.

IN TREATMENT DELAY IS DANGEROUS

Unfortunately, delay in treatment increases the risk of transmission to unsuspecting sexual partners, anc., in women, increases the likelihood for more serious medical problems. A recent study found that women with chlamydia or gonorrhea-related PID were two and a half times more likely to have impaired fertility when they delayed seeking treatment for three or more days after noticing symptoms than women who sought care immediately.7

Chlamydia, in particular, can impair ol destroy the fragile cilia (hairs) in the fallopian tube and cause enough thickening to block it. These cilia, through their waving motion, transport the fertilized ova through the tube. Once destroyed, they do not regenerate. Furthermore, a tube blocked with scar tissue will lead to infertility because neither ova nor sperm can move through it. All of this damage can happen with very few symptoms. In one study, 50 percent of women seeking infertility treatment and with confirmed tubal occlusion reported no history of PID yet showed serological evidence of prior genital chlamydia infection. 8

Infants born to mothers who are infected -with chlymadia can also develop serious complications. Up to 50 percent of infants born to mothers with active chlamydial infection contract congenital eye infections, while almost one in five develop neonatal pneumonia.9

While only 1 percent of men develop painful epididymitis as a result of chlamydial infection, several recent studies suggest that a substantial level of symptomatic infection may exist in males. Such infection contributes to the transmission of infections to women. It also increases the risk of HIV transmission at least two-to fivefold.10

TESTING, TREATMENT WORK

There is clear and compelling scientific evidence that routine testing and treatment for chlamydial infection results in a significant reduction of its prevalence and, more important, of PID incidence.

In a landmark study reported in the New England Journal of Medicine in May 1996, a randomized trial of chlamydia screening and treatment in a large Pacific Northwest Health Maintenance Organization (HMO) showed a 56 percent reduction in PID in the 12 months following intervention."

Participants in the study were women under 34 years of age identified as at high risk for chlamydia. Half were offered chlamydia tests; 7 percent were found infected and were treated with antibiotics. The other half received no screening or treatment. After 12 months, the study found that less than 1 percent (0.9 percent) of those screened and treated developed PID, while 2.1 percent of the untested and untreated were diagnosed with PID.'2

Over the past six years, a demonstration project in four Northwestern states has shown dramatic reductions of almost 60 percent in chlamydia infections in women following implementation of screening and treatment programs through family planning and other health care services.

Using similar models, a study in Wisconsin found that the prevalence of chlamydia infection in women was reduced 35 percent over a five-year period, and a study in Ohio, found a decline of 59 percent."3

Since 1994, with limited Congressional appropriations specifically aimed at chlamydia screening and treatment, the U.S. Centers for Disease Control and Prevention (CDC) has funded infertility prevention activities in publicly funded family planning and STD clinics. They have resulted in similar rapid declines in the prevalence of chlymadia.

WHO IS AT RISK?

The highest rates of chlamydia infection are consistently found among sexually active adolescent females under 20 years old, with reported prevalences of at least 10 percent and higher. Chlamydia infection rates in women 20 to 24 years of age are also unacceptably high: they are frequently reported in the range of 3 to 8 percent of all tested.4

Unlike gonorrhea, chlamydial infection occurs in all geographic regions of the country, is widely dispersed across racial and ethnic groups, and affects all socioeconomic classes.

Less information exists about rates of chlamydia infection in males because, for a variety of reasons, diagnostic testing is limited. A new, highly sensitive urine test, which will obviate the need for painful swabbing of the male urethra, will now, however, make it easier to determine male infection rates. Such a urine test is also now available to women.

Several studies of asymptomatic males have documented prevalences ranging from 4 to 10 percent while rates of infection in symptomatic males are much higher.'5 Though men rarely develop serious reproductive complications as a result of the disease, they serve as transmitters of the infection to women.

SCREENING GUIDELINES

Current screening guidelines published by the CDC recommend that all sexually active female adolescents test for chlamydia when they have a pelvic examination. Cervical biology places them at higher risk than older women because more columnar epithelium are exposed and vulnerable. Behavior places them at higher risk because they are more likely to have multiple sexual partners, to engage in unprotected sexual intercourse, and to have partners at higher risk for infection compared to mosi adults." Several studies have shown that they are also at very high risk for persistent and recurrent infection-factors that contribute to upper reproductive tract sequelae17

A recently published study demonstrates the need to screen all sexually active adolescents regardless of prior chlamydial infection. In this longitudinal study, teens with chlamydia at their first visit were predictably at highest risk for a subsequent infection. A disturbing finding showed that 6 percent of those uninfected at their first visit (and with no behavioral risk factors in the past three months) were found infected with chlamydia at their second visit.18

The CDC also recommends that sexually active females more than 20 years old should test for chlamydia if (1) they have clinical signs of mucopurulent cerviciti; (MPC) or a yellow or green discharge from the cervix; (2) report either a new or more than one sexual partner during the last three months; or (3) report inconsistent use of barrier contraceptives.