sign in sign up
<<
Home , Cervicitis, Tubal factor infertility

Al-Azhar Med. J. Vol. 49(1), January, 2020, 229-240 DOI : 10.12816/amj.2020.67131 https://amj.journals.ekb.eg/article_67131.html

ANTI-CHALMYDIAL ANTIBODY AS A PREDICTIVE TEST FOR TUBAL FACTOR

By

Emad A. El-Tamamy, Ashraf H. Mohamed, Wael R. Hablas* and Shaban H. Abd El-Rahman ** Departments of & Gynecology and Clinical Pathology*, Faculty of Medicine, Al-Azhar University **Corresponding E-mail: [email protected]

ABSTRACT

Background: Infertility is a common gynaecological problem that has a multi factorial aetiology. Conception and depend on complex physiological, anatomic and immunological factors. Objective: to evaluate the prevalence of chlamydial infection, especially subclinical cases, in a population of Egyptian tubal infertile women and to relate it to history, symptoms, clinical, and laparoscopy findings. Finally, to find any advantage of detecting antichlamydial antibodies in serum of these patients and evaluate its importance in prediction of tubal factor of infertility. Patients and Methods: This study includes 50 primary or secondary infertile females (patients group) their age between 20-30 years, and 50 random fertile females (control group) and Blood sample for IgG, trachomatis antibodies were drawn from all cases of the study for ELISA test. Results: The prevalence rate of IgG antibodies was significantly higher in infertile group than that of control group. There was significant higher rate and ratio of positive results in infertile group than that of control group concerning anti-chlamydial IgG. There was a strong correlation between serum levels of anti-chlamydial IgG in the infertility patients. There was a significant correlation between serum anti-chlamydial IgG levels and the duration of infertility. There was no relation between the serum level of anti-chlamydial IgG and the age of the patients of the type of infertility. The results of this study are matched with most of the previous published studies yet there are some differences in the positive and negative ratios. Conclusion: Chlamydia trachomatis plays a major role in the occurrence of tubal factor of infertility. Subclinical chlamydial salpinigits was an important cause of tubal infertility. Serological test for Chlamydia trachomatis namely anti-chlamydial antibodies IgG are sensitive, simple, and inexpensive tests even if compared by using direct methods for detection and should be done as a routine part of infertility investigations. The serological test could be an accurate non-invasive predictor of tubal status especially if combined with other methods as HSG, good history taking and examination. Key words: Anti-chlamydial antibody, tubal factor, infertility.

INTRODUCTION believed to play an important role in the increase of the infertility, particularly is one of the when it is caused by tubal factors. Female main causes of involuntary infertility is attributed to the tubal factors in women (Tabong and Adongo, 2013). in about 14-38% of the cases (Tsevat et Sexually Transmitted Diseases (STDs) are

229

230 EMAD A. EL-TAMAMY et al.,

al., 2017). The tubal damage is presumed These deceptively mild symptoms to be secondary to , with a two- allow the infection to go unnoticed, with third of the subjects being asymptomatic minimal patient awareness, until the while the remaining third present with secondary or the tertiary symptoms symptoms (Surana et al., 2012). develop. Serious sequelae like acute The obligate intracellular salpingitis and pelvic inflammatory Chlamydia trachomatis belongs to the disease often occur in association with most common sexually transmitted repeated or persistent infections (Peivandi bacterial organisms, worldwide (Bastidas et al., 2009). et al., 2013). According to the Centers for C.trachomatis may cause intraluminal Disease Control and Prevention (CDC), adhesions, fibrosis, and about one million reported C. trachomatis pelvic adhesions. Due to the serious infections occur annually among sexually consequences of these conditions, the C. active young people in the United States. trachomatis infection can lead not only to Based on the antigenic reactivity of the significant morbidity, but it can also affect major outer membrane protein, C. a woman’s fertility (Surana et al., 2012). trachomatis is divided into 15 serovars In addition, C. trachomatis-specific whereby the serovars D through K antibodies have been associated with tubal typically cause nongonococcal damage and infertility (Budrys et al., in men and in-women 2012). (O’Connell and Ferone, 2016). Several studies have demonstrated that The C. trachomotis infection is the tubal factor infertility was significantly most common sexually transmitted associated with the serum antibodies to C. infection worldwide, especially among trachomatis, which resulted in infertility young adults (Cárcamo et al., 2012). (Hjelholt et al., 2011). The chlamydial infection produces less A better understanding of the role of severe symptoms than other sexually persistent C. trachomatis infections in transmitted infections (O’Connell and tubal factor subfertility may be useful in Ferone, 2016). optimizing the fertility work-up by The bulk of infections remains incorporating screening tests for persistent undetected and untreated because most C. trachomatis infections, aiming to infected people are oligo- or accurately estimate the risk of persistence asymptomatic and do not seek medical and identify those women who are at attendance. If untreated, chlamydiae may highest risk of tubal pathology (Seth- reach the upper genital tract of affected Smith et al., 2013). women and cause pelvic inflammatory Serological testing of uncomplicated C. disease (PID) with the risk of severe trachomatis infections of the lower genital reproductive complications, such as tubal tract has not been recommended, but factor infertility and ectopic pregnancy antibody titers are especially high in (Bastidas et al., 2013). women with PID (Joolayi et al., 2017).

231 ANTI-CHALMYDIAL ANTIBODY AS A PREDICTIVE TEST FOR TUBAL…

The present study aimed to evaluate type of infertility, investigations and the chlamydial infection in women who treatment received before. Menstrual suffered from tubal infertility by the history and obstetric history were taken in detection of the anti-chlamydial IgG details with special attention to antibodies using E.L.I.S.A. spontaneous or induced and the postoperative period. History also PATIENTS AND METHODS included detailed information about the This case control study was done contraceptive methods used, its duration, between September 2018 to May 2019. and complications, chronic The study population consisted of 50 (including dysparunia) and chronic women of the reproductive ages (17yrs- . We asked also about 40yrs), who has lyr or 2yr infertility history of treated pelvic infections with specially tubal factor infertility diagnosed special attention to those who entered a by HSG or Laparoscopy, and attended the fever hospital and those with history of infertility clinic of Al-Hussein University admission to chest hospital. Complete Hospital, Al-Azhar University, for the examination of these patients was evaluation of their fertility problem. Fifty performed with special attention to the healthy women of a similar age group presence of pelvic mass, chronic cervicitis who attended the clinic and purulent or mucopurulent end cervical during the study period were the control discharge. group for receiving suitable contraceptive Serological Studies: method. All the 50 patients who proved to have The study excluded patients with male a tubal factor as the only or the major cause of fertility as each patient had a cause for their infertility, as diagnosed by recently done semen analysis for husband HSG and DL, were further investigated or was advised to have a recent one if a for the presence of anti-chlamydial IgG previous semen analysis revealed antibodies in their serum. The same tests abnormal or subnormal results in one or were done for serum obtained from the more of the semen parameters, or if more control women. than one year has elapsed since the last test Patients with clinical symptoms of Statistical analysis: acute PID and infertility due to other Recorded data were analyzed using causes rather than tubal factor. the statistical package for social sciences, Informed consents were taken from all version 20.0 (SPSS Inc., Chicago, Illinois, patients after explaining the purpose and USA). Quantitative data were expressed nature of the study. as mean ± standard deviation (SD). Qualitative data were expressed as A detailed history was obtained from frequency and percentage. Probability (P- these patients including details of age, value): P-value <0.05 was considered marital status, occupation, duration and significant.

232 EMAD A. EL-TAMAMY et al.,

RESULTS

The distribution of infertility group those of equal or more than 3 years according to age, revealed that 12% were duration of infertility was 52% of cases. <20 years old, 60% were between 21-30 Maximum duration of infertility in years and 28% were between 31-40 years. infertility patients studied was 8 years and It also shows that the distribution of minimum duration was one year with a infertility group according to duration of mean of 3.04 years and a standard infertility taking the 3 years duration as a deviation of 1.42 years duration. 66% of cut-off value, gave rise to two groups: a cases had primary infertility while 34% of group of duration of infertility of less than cases had secondary of infertility (table 1). 3 years was 48% of infertility group while

Table (1): Distribution of age, duration of infertility, type of infertility in infertility group Age (years) No. % <20 years 6 12.0% 21-30 years 30 60.0% 31-40 years 14 28.0% Total 50 100.0% Duration of infertility No. % <3 years 24 48.0% ≥3 years 26 52.0% Total 50 100.0% Type of infertility No. % Primary infertility 17 34.0% Secondary infertility 33 66.0% Total 50 100.0%

The anti-chlamydial IgG values between both groups (infertility group and between the infertility group and the control group) as regard IgG level (table control was highly significant p-value 2). <0.001. i.e. high significant difference

Table (2): Comparison between the two groups according to anti-chlamydial IgG Groups Control Infertility Anti- Group Group t-test p-value Chlamydial (n=50) (n=50) IgG Range 0.114-1.465 0.113-2.310 3.501 <0.001** Mean±SD 0.235±0.267 0.587±0.659 3.501 <0.001**

30% of patients with tubal infertility in their serum, which is significant. It also patients has anti-chlamydial IgG for shows that 6% of the control group had chlamydia trachomatis in their serum, anti-chlamydial IgG in their serum compared to 70% who did not show anti- compared to 94% who did not show anti- chlamydial IgG for chlamydia trachomatis chlamydial IgG in their serum (table 3).

233 ANTI-CHALMYDIAL ANTIBODY AS A PREDICTIVE TEST FOR TUBAL…

Table (3): Frequency of Anti-chlamydial IgG among infertility group Anti-chlamydial IgG (Control group) No. % Positive IgG 3 6.0% Negative IgG 47 94.0% Total 50 100.0% Anti-chlamydial IgG (Infertility group) No. % Positive IgG 15 30.0% Negative IgG 35 70.0% Total 50 100.0%

Number of positive IgG patients from IgG values between the cases and the case group were 15 cases, (30% of the control was highly significant p 0.004*, cases) and number of positive IgG from i.e. high significant difference between control group were 3 (6% of control both groups (infertility group & control patients), comparing the anti-chlamydial group) ads regard IgG level (table 4).

Table (4): Percent of infertility group and control group with Positive Anti- chlamydial IgG and their percent Groups Infertility Control group Anti- group Chi-square test (n=50) chlamydial (n=50) IgG No. % No. % x2 p-value Positive 3 6.0% 15 30.0% 8.198 0.004* Negative 47 94.0% 35 70.0% 8.198 0.004*

DISCUSSION In addition, C. trachomatis-specific In this study 15 out of 50 (30%) of antibodies have been associated with tubal patients of the infertility group showed damage and infertility (Budrys et al., Chlamydia trachomatis infection as 2012). proved by the presence of anti-chlamydia The study has demonstrated that tubal IgG in their serum in relation to 3 out of factor infertility was significantly 50 (6%) of the control group. associated with the serum antibodies to C. Chlamydia may reach the upper genital trachomatis, which resulted in infertility. tract of affected women and cause pelvic A previous study agreed with our inflammatory disease (PID) with the risk study, done in Baghdad 2011 by May and of severe reproductive complications, Amer, (2012) the antichlamydial IgG such as tubal factor infertility and ectopic raised in 25% of infertile women, while pregnancy (Bastidas et al., 2013). controls showed only 4% positive IgG Serious sequelae like acute salpingitis index. and pelvic inflammatory disease often In a study carried out by Jorn et al. occur in association with repeated or (2008) found that the sero pervelance rate persistent infections (Peivandi et al., among women suffering from infertility 2009). was 39.3%.

234 EMAD A. EL-TAMAMY et al.,

Keltz et al. (2006) found that 84 out of Immunoglobulin G antibody to Chlamydia 210 (40%) of infertile women in the study trachomatis using rapid test kits. The HSG were seropositive for Chlamydia IgG findings were correlated with the result of antibodies. Chlamydia serology. Data was analyzed Another study for Jeremiah et al. using the computer software, Statistical (2011) disagree with current study showed Package for Social Science (SPSS) that the prevalence of IgG Antibody was version 20. The level of significance (p significantly higher in women with tubal value) was set at 0.05. pathology (54.2%), while the rate was A total of 120 infertile women (7.9%) in the women without tubal completed the study, 5 had incomplete pathology. In 313 sub fertile women, investigations and were excluded from the serological test results and laparoscopy analysis. The prevalence of TFI was reports were available for analysis. Of 47.5%, while that of positive chlamydia those 313 women, 59 (18.8%) met the serology was 36.5%. The prevalence of definition of distal tubal pathology chlamydial seropositivity was 59.6% for (extensive peri-adnexal adhesions and/or patients with TFI but 15.9% for non-TFI. distal occlusion of at least one tube), There was a significant association whereas 254 women (81.2%) did not have between positive chlamydia serology and distal tubal pathology and served as TFI p< 0.05. The study revealed moderate controls. Of those 254 women without sensitivity 59.6%, and negative predictive distal tubal pathology, 94.9% had patent value 69.7% but high specificity 84.1% tubes and 5.1% had proximal occlusion of and positive predictive value of 77.2%. In at least one tube. Since proximal tubal this study the odds for diagnosing tubal occlusion is considered not to be related to infertility was 7.8 Chlamydia serology is chlamydia disease, all 254 women without useful in predicting TFI and should be distal tubal pathology served as controls. incorporated in the routine work up for In women with and without distal tubal infertility. pathology, mean age (30.6 and 31.2 years There are other studies that disagree respectively) and duration of subfertility with the study as Israel et al. (2011) (2.4 and 2.3 years respectively) were reported that antibodies were present comparable. against Chlamydia trachomatis in 74% of This was in disagreement with Amadi patients, compared to 51 % of the control et al. (2019) in a study done on 125 group. This difference may be due to large women with infertility who met the cases size, age, socioeconomic level, and inclusion criteria were enrolled into the sexual practice which considerable study. Relevant information on their influence on the prevalence of socio-demographic characteristics, c.trachomatis. gynecological symptoms and risks factors This study clearly demonstrate that for infertility were obtained. Participants sexually active women who didn't use had Hysterosalpingography (HSG) as part where more likely to acquire of their fertility work-up while 5ml of chlamydia infection. venous blood was withdrawn to check for

235 ANTI-CHALMYDIAL ANTIBODY AS A PREDICTIVE TEST FOR TUBAL…

These differences are due to large presence or absence of chlamydial sample size, many clinical conditions. antibodies in serum. Another study in 2012 has done by Out of 200 patients, 10 patients tested Surana et al. (2012) found a high positive for chlamydial antibody. seropotivity in 60% for the anti- Chlamydial antibody was found positive chlamydial antibody and 52% of the in 20% and 22.7% of patients with tubal females in the study show bilateral tubal pathology and peri-hepatic adhesions of block mostly in the ampullary part. patients, respectively. The sensitivity of chlamydial antibody for diagnosing tubal Higher titre was reported in a study done by Claude et al. (2011) show that the pathology was found to be 20%, while prevelance of Chlamydia antibody were specificity was 100%. The positive 90.9% of cases and 19.9% of control chlamydial antibody test was not group. statistically associated with involvement of one or both tubes and site of tubal Gorwitz et al. (2017) aiming to find the block. prevalence of chlamydia trachomatis seropositivity among women with Chlamydia antibody test did not appear infertility of tubal origin. Forty women to be good screening test for tubal with tubal infertility (verified at pathology especially in Indian subcontinent. In view of its high hysterosalpingography and laproscopy), 20 women with infertility due to variety of specificity, this test can be used to identify other reasons and 20 healthy fertile patients with higher chances of tubal women of reproductive age were enrolled pathology requiring operative in the study. It was found that the intervention. presence of Chlamydia specific IgG These results were different, possibly antibody was significantly higher (70%) because our demographic profile is in women with infertility of tubal origin as different too. Our study population compared to 35% seropositivity in healthy comprised of only those women who fertile women and 55% seropositivity in underwent laparoscopy. Though the infertile women with cause of infertility percentage of possible tubal factor other than tubal factor. infertility was higher, but other factors Singh et al (2016) disagreed with the like unexplained, ovarian or uterine factor results of the current stuidy, in a infertility were also parts of this cohort. prospective study was conducted on 200 The methodologies used to detect consecutive patients undergoing antibodies vary in their utility and laparoscopy as a part of infertility work- populations studied may vary in their up. Preoperatively, serological genetic predisposition to immune response determination of Immunoglobulin G (IgG) and antibody production and persistence. specific antibodies against Chlamydia Therefore, laboratory and regional Trachomatis was done by Enzyme linked differences could exist in chlamydial. immunosorbant assay (ELISA). Findings This variability was found to be of laparoscopy were evaluated against subjected to how the tubal pathology was

236 EMAD A. EL-TAMAMY et al.,

verified and type of chlamydia antibody factor infertility, normal fertility, and acute titre assay. Infection. Obstetrics and Gynecology; 119(5): 1009. A previous study has also considered 4. Cárcamo CP, Campos PE, García PJ, seropositivity for chlamydial antibody in Hughes JP, Garnett GP, Holmes KK, and relation to type and sites of tubal block. Peru PREVEN Study Team (2012): They found that seropositivity for Prevalences of sexually transmitted infections chlamydia IgM antibody was the highest in young adults and female sex workers in Peru: a national population-based survey. The among the subjects with a fimbrial Lancet Infectious Diseases. 12(10): 765-73. blockage (80%), followed by those with an ampullary blockage (66.6%). Results of 5. Claude M, Nathalie D, Rita V, Marleen T, Geert C and Elizaveta P. (2011): Surana et al. (2012) are different from Chlamydia trachomatis infection in fertile current study. These prospective studies and subfertile women in Rwanda: prevalence were carried out at a tertiary care hospital and diagnostic significance of IgG and IgA in north India. antibodies testing; Human Reproduction; 26(12): 3319–3326. CONCLUSION 6. Gorwitz RJ, Wiesenfeld HC, Chen PL, Chlamydia trachomatis plays a major Hammond KR, Sereday KA, Haggerty CL, role in the occurrence of tubal factor of Johnson RE, Papp JR, Kissin DM, Henning TC and Hook III EW. (2017): infertility. Subclinical chlamydial Population-attributable fraction of tubal salpinigits was an important cause of tubal factor infertility associated with chlamydia. infertility. Serological test for Chlamydia American Journal of Obstetrics and trachomatis namely anti-chlamydial Gynecology; 217(3):336-e1. antibodies IgG, are sensitive, simple, and 7. Hjelholt A, Christiansan G, Johansson TG, inexpensive tests even if compared by Ingerslev HJ and Birkelund S. (2011): using direct methods for detection and Tubal factor infertility is associated with antibodies against Chlamydia trachomatis should be done as a routine part of heat shock protein 60 (HSP60) but not human infertility investigations. HSP60. Human Reprod: 26: 2069- 2076. REFERENCES 8. Israel J, Ola O and Chris A. (2011): The Prevalence of Serum Immunoglobulin G 1. Amadi L, Onwudiegwu U, Adeyemi A, Antibody to Chlamydia Trachomatis in Nwachukwu C and Abiodun A. (2019): Subfertile Women Presenting at the Usefulness of Chlamydia serology in University of Port Harcourt Teaching prediction of tubal factor infertility among Hospital, Nigeria, Int J Biomed Sci.; 7 (2): infertile patients at Federal Medical Centre, 120-124. Bida, North Central Nigeria. Int J Reprod Contracept Obstet Gynecol.; 8(2): 412-419. 9. Jeremiah I, Okike O and Akani C. (2011): The prevalence of serum immunoglobulin G 2. Bastidas RJ, Elwell CA, Engel JN and antibody to Chlamydia trachomatis in Valdivia RH. (2013): Chlamydial subfertile women presenting at the University intracellular survival strategies. Cold Spring of Port Harcourt teaching hospital, Nigeria. Harbor perspectives in medicine; 3(5): International journal of biomedical science: a010256. IJBS; 7(2):120. 3. Budrys NM, Gong S, Rodgers AK, Wang 10. Joolayi F, Navidifar T, Jaafari RM and J, Louden C, Shain R, Schenken RS and Amin M. (2017): Comparison of Chlamydia Zhong G. (2012): Chlamydia trachomatis trachomatis infection among infertile and antigens recognized by women with tubal fertile women in Ahvaz, Iran: A case-control

237 ANTI-CHALMYDIAL ANTIBODY AS A PREDICTIVE TEST FOR TUBAL…

study. International Journal of Reproductive sequences of Chlamydia trachomatis directly Biomedicine; 15(11):713. from clinical samples without culture. Genome Research; 23(5),855-66. 11. Jorn S, Oliver T, Yaw L, Peter A, Danso K, Rolf K and Andreas E. (2008): 17. Singh S, Bhandari S, Agarwal P, Chlamydia trachomatis Infection as a Risk Chittawar P and Thakur R. (2016): Factor for Infertility among Women in Chlamydia antibody testing helps in Ghana, West Africa, Am J Trop Med Hyg., identifying females with possible tubal factor 78(2): 323- 327. infertility. International Journal of Reproductive BioMedicine; 14(3),187. 12. Keltz MD, Gera PS and Moustakis M. (2006): Chlamydia serology screening in 18. Surana A, Rastogi V and Nirwan PS. infertility patients. Fertility and Sterility, (2012): Association of the serum anti- 85(3):752-4. Chlamydial antibodies with tubal infertility. Journal of Clinical and Diagnostic Research: 13. May K and Amer S. (2012): Evaluation of JCDR, 6(10): 1692. Chlamydia Trachomatis Antibodies In Women with Infertility; Al- Mustansiriya J. 19. Tabong PT and Adongo PB. (2013): Sci., 23(3): 273-281. Infertility and childlessness: a qualitative study of the experiences of infertile couples 14. O’Connell CM and Ferone ME. (2016): in Northern Ghana. BMC pregnancy and Chlamydia trachomatis genital infections. , 13(1):72. Microbial cell, 3(9):390. 20. Tsevat DG, Wiesenfeld HC, Parks C and 15. Peivandi S, Moslemizadeh N, Gharajeh S Peipert JF. (2017): Sexually transmitted and Ajami A. (2009): The role of the diseases and infertility. American journal of Chlamydia trachomatis IgG antibody testing Obstetrics and Gynecology. 216(1),1-9. in predicting the tubal factor infertility in northern Iran. International Journal of Fertility and Sterility, 3 (3): 143-148. 16. Seth-Smith HM, Harris SR, Skilton RJ, Radebe FM, Golparian D, Shipitsyna E, Duy PT, Scott P, Cutcliffe LT and O’Neill C, Parmar S. (2013): Whole-genome

238 EMAD A. EL-TAMAMY et al.,

األجسام المضادة للكالميديا كعامل تنبؤ فى حاالت العقم الناتج عن إصابة فى قنوات فالوب عماد عبد الرحمن التمامى، أشرف حمدى محمد، وائل رفعت حبلص*، شعبان حسين عبد الرحمن محمد

قسم التوليد وأمراض النساء، *وقسم الباثولوجيا اإلكلينيكية، كلية الطب، جامعة األزهر

خلفي ة البح يُعتبرررررق أعدرررررك ت رررررع أي رررررأمر أ ررررر وعن مررررر ررررر ت رررررق أ ررررر يررررر ك عرررررررل سعرررررررر أي ررررررربب ر أيقيرررررررحن تعرررررررع أع ررررررر يعتيرررررررع أ يررررررر ع ررررررر ع ررررررر م ح أ جحن ت قي حن عحن عدع

اله دف م ن البح تدحرررررررحك ررررررع كت رررررر خ عرررررررع أأم حررررررعي ررررررن أ ررررررر ر إلك ح حأحررررررررن مرررررررر ي عررررررررن ررررررررل أ ررررررررحع ر أياررررررررقي ر أيارررررررر س ر سرررررررر أعدك كبرررررررر س عمقترررررت س أترررررر خيا عرررررق أ ترررررر وا إلك ح حأحررررررن أت حرررررق أب رررررر كيررررر ي ررررررع أرررررر أعثررررر خ ع ررررر تا حرررررج مررررر كت ررررر ج ررررر أي ررررر أي ررررر ر أأم حرررررعي مررررر اررررر هؤ أيقي تدححك تهيحت م أت بؤ س أعدك أ تا عل سن س أب قحل

المرض ى وح ر البح شررررررري ل هررررررر أعخ رررررررن 50 رررررررحع رررررررل أياررررررر س ر سررررررر أعدك ستررررررررع و ت أثرررررررر ك ا ت ي عررررررررن أيقيرررررررر تتررررررررق تعيرررررررر خهل سررررررررحل 17-40 ع رررررررر 50 ررررررررل أ ررررررررحع ر رررررررر تكي ي عررررررررن أ رررررررر س ن عح ررررررررن أ رررررررر ج رررررررر أي رررررررر أ أم حررررررررعي ت أيتررررررررعاق أ ثقيررررررررن تررررررررك ت م رررررررر ررررررررل جيحرررررررر أ رررررررر ر أي خكن م أعخ ن عل طقيق تد حن إلأحج

نت ائث البح كرررررر عررررررع كت رررررر خ ج رررررر أي رررررر أيتررررررعاق أ ثقيررررررن IgG تع رررررر سأثحررررررق مرررررر ي عررررررن أعدررررررك ررررررل ت ررررررل أي ي عررررررن أ رررررر س ن ه رررررر ك رررررربن ر أررررررن ارررررر وحن قت عررررررن مرررررر ي عررررررن إل رررررر سن سرررررر أعدك ررررررل ت ررررررل أي ي عررررررن أ رررررر س ن محيرررررر يتع ررررررررق سي رررررررر ر أت رررررررر م ه رررررررر عمقررررررررن ع يررررررررن سررررررررحل ررررررررت ي ر IgG أي رررررررر أ أم حرررررررعي مررررررر أرررررررع رررررررع أعدرررررررك ت جرررررررع عمقرررررررن سرررررررحل رررررررت ج ررررررر أي ررررررر أ أم حررررررعي سيارررررر أررررررع سررررررحل عيررررررق قيرررررر أعدررررررك تت مررررررق كترررررر وا هرررررر أعخ ررررررن رررررر ع رررررررك أعخ ررررررر ر أي ررررررر خ أ ررررررر سدن أأرررررررل ه ررررررر سعرررررررر تممررررررر ر مررررررر أ ررررررر إلي سحن أ بحن

239 ANTI-CHALMYDIAL ANTIBODY AS A PREDICTIVE TEST FOR TUBAL…

االس تنتا ت عررررر أيترررررعاق أ ثقيرررررن خ خوح رررررح مررررر رررررع أعدرررررك أبررررر ق أ عدرررررك تعرررررع أأم حرررررعي ررررربب ه ررررر أن ررررر سن سررررر أعدك أ ررررر تا عرررررل ررررر سن سررررر أب قحل تبررررر خ أياررررر أرررررررع أيترررررررعاق أ ثقيرررررررن تا ج ررررررر أي ررررررر أ أم حرررررررعي تبررررررر خ ررررررر س رررررررح غحرررررق أ رررررم تررررر أررررر تيرررررل د خكترررررت س رررررت ع طرررررق ب شرررررق أ أ رررررم ي ب ررررر جرررررق ك رررررج خ تح ررررر رررررل م ررررر ر أعدرررررك ييأرررررل ت يأررررر تبررررر خ أياررررر ؤشرررررق قحدررررر غحرررررق ترررررع أ أ رررررم عرررررل أبررررر رررررن ترررررك ررررر ررررر طرررررق ت رررررق ثررررر شرررررعن س أاب ن ع أب قحل ت ت خيا جحع عي أ ر أمز ن