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Genital Mycoplasmal Infections: Their Relation to Prematurity and Other Abnormalities of Reproduction

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Genital Mycoplasmal Infections: Their Relation to Prematurity and Other Abnormalities of Reproduction J Clin Pathol: first published as 10.1136/jcp.29.Suppl_10.95 on 1 January 1976. Downloaded from J. clin. Path., 29, Suppl. (Roy. Coll. Path.), 10, 95-98 Infections Genital mycoplasmal infections: their relation to prematurity and other abnormalities of reproduction WILLIAM M. McCORMACK' From the Channing Laboratory, Departments of Medical Microbiology and Medicine, Boston City Hospital, and the Department of Medicine, Harvard Medical School, Boston, Massachusetts Mycoplasmas are a distinct group of microorganisms Respiratory Genital differing in important biological characteristics from Mycoplasma pneumoniae Mycoplasma hominis bacteria, viruses, fungi, protozoa and chlamydia Mycoplasma salivarium Mycoplasmafermentans (McCormack et al, 1973a).There are eight recognized Mycoplasma orale Ureaplasma urealyticum species of mycoplasmas which have been isolated Mycoplasma buccale from man (table I). Mycoplasma pneumoniae, the Mycoplasmafaucium Eaton agent, causes cold agglutinin-positive primary Table I Human mycoplasmal species atypical pneumonia. M. salivarium, M. orale, M. buccale, and M. faucium are oropharyngeal com- mensals and have not as yet been convincingly implicated in any disease process (Freundt et al, genitalia and upper respiratory tract of about 30 % of copyright. 1974). M. fermentans is an unusual genital isolate newborn infants. These organisms are primarily which also appears to be a commensal. M. hominis acquired during passage through the birth canal; and Ureaplasma urealyticum, also known as the infants who are delivered by caesarian section are T-mycoplasmas or T-strains, are common genital colonized less often than those who are delivered organisms (Shepard et al, 1974). Although M. vaginally (Klein et al, 1969). Colonization does not hominis and U. urealyticum have been implicated in persist throughout childhood. Only about 10% of nongonococcal urethritis, pelvic inflammatory dis- girls between 1 and 10 years ofage have mycoplasmas ease, and a number of other disorders, most interest recovered from the genitourinary tract (Lee et al, in these organisms has centred around their possible 1974). http://jcp.bmj.com/ involvement in disorders of reproduction. The pur- b Following puberty, sexual experience appears to pose of this communication will be to review the be the primary determinant of colonization with evidence linking M. hominis and U. urealyticum to both M. hominis and U. urealyticum (McCormack et infertility, abortion, stillbirth, low birth weight, and al, 1972). Table U summarizes a study in which self- puerperal fever. obtained vaginal cultures and anonymous question- naires were obtained from a group of student and Epidemiological Considerations graduate nurses. Those who had not experienced on September 25, 2021 by guest. Protected genital contact had low rates of colonization, similar Basic to the understanding of the role of a micro- to those seen among young children. Among those organism in human disease is an understanding of who were sexually experienced, colonization with the epidemiology of the organism, its mode of trans- both U. urealyticum and M. hominis rose in relation mission and its prevalence among the normal to the number of sexual partners, reaching 75 % and population. 16x7 % among those who had had intercourse with Genital mycoplasmas can be isolated from the three or more partners. It is against this background that we must view IS upported by research grant HD 03693 from the National Institute of the evidence linking the genital Child Health and Human Development, and research grants Al 11363 mycoplasmas to disorders of reproduction. and Al 12381 and training grant Al 00068 from the National Institute of Allergy and Infectious Diseases. Infertility Please address reprint requests to Dr William M. McCormack, Channing Laboratory, Boston City Hospital, Boston, Massachusetts 02118. A series of reports from Sweden has suggested that 95 J Clin Pathol: first published as 10.1136/jcp.29.Suppl_10.95 on 1 January 1976. Downloaded from 96 William M. McCormack Number of Women Studied Percentage with Percentage with U. urealyticum M. hominis No genital contact 71 5 6 14 Genital contact without vaginal penetration 30 26-7 0 Sexual intercourse One partner 32 37-5 9-4 Two partners 11 54 5 9.1 Three of more partners 12 75 0 16-7 Table II Relationship ofsexual experience to vaginal colonization with genital mycoplasmas among student and graduate nurses U. urealyticum might be an important cause of amniotic fluid whereas isolation from the viscera unexplained involuntary infertility. These workers may be indicative of haematogenous spread, perhaps found that infertile couples were colonized with U. from a placentitis with invasion of the fetus via the urealyticum significantly more often than couples of umbilical vessels (McCormack et al, 1973a). normal fertility. Furthermore, in an uncontrolled The possible association of mycoplasmal infection study, treatment of colonized infertile couples with with fetal loss is of considerable interest and import- mycoplasmicidal antibiotics was associated with con- ance since these organisms are sensitive i'n vitro to ception in about 30 % of cases (Gnarpe and Friberg, tetracycline and other broad-spectrum antibiotics. 1973). In similar studies, Love et al (1973) have Thus, fetal loss, if due to these organisms, could associated M. hominis with infertility. conceivably be prevented by appropriate anti- More recently, de Louvois et al (1974) have re- microbial therapy. It is unfortunate in this regard ported that they isolated both U. urealyticum and that there have been no controlled studies in which M. hominis as often from fertile as from infertile pregnant women with a history of fetal loss have couples, a finding which is in agreement with been randomly assigned to receive antibiotic or unpublished observations from our laboratory. placebo. copyright. The same group of investigators has conducted a In an uncontrolled study, six women with a history controlled therapeutic trial in which couples with of a total of 29 previous unsuccessful pregnancies, infertility of unascertained cause were randomly most of which had ended in spontaneous abortion assigned to receive doxycycline, a placebo or no during the first trimester, were treated with demethyl- treatment. Although doxycycline eradicated both M. chlortetracycline. Treatment began before or shortly hominis and U. urealyticum, the rate of conception after conception and continued through the 28th was no higher in those treated with the drug than in week of pregnancy. Four of the six patients gave the control group. They concluded that mycoplasmas birth to viable infants (Driscoll et al, 1969). These are not associated with primary infertility (Harrison and other instances in which women with a poor http://jcp.bmj.com/ et al, 1975). It should be noted that this negative reproductive history were found to be colonized study is the only properly controlled study in which with U. urealyticum and had successful pregnancies the relationship of mycoplasmas to infertility has after treatment with tetracyclines have led this group been assessed. of investigators to postulate that subclinical infection with mycoplasmas is an important cause of repro- Spontaneous Abortion and Stillbirth ductive failure (Horne et al, 1974). Their hypothesis has been strengthened by the demonstration of in- on September 25, 2021 by guest. Protected Genital mycoplasmas have been isolated from pro- flammation in endometrial biopsies from women ducts of conception of early abortions (Caspi et al, with a poor reproductive history who were infected 1972) and mid-trimester fetal losses (Sompolinsky et with U. urealyticum (Horne et al, 1973). This area, al, 1975) more often than from the products of con- however, remains controversial and well controlled ception of induced abortions. It is not clear from therapeutic trials are urgently needed to settle the these reports whether the mycoplasmas were wholly issue. or partially responsible for fetal death. It is equally likely that these organisms were able to invade the Low Birth Weight fetus and placenta once fetal death had occurred for other reasons. The chain of events linking the genital mycoplasmas Mycoplasmas have been isolated from the viscera to birth weight began about 15 years ago. In studies and lungs of spontaneously aborted fetuses and still- conducted before the association of prenatal born infants. The isolation of mycoplasmas from tetracycline administration to staining of the pri- fetal lungs probably represents aspiration of infected mary dentition was recognized, this antibiotic was J Clin Pathol: first published as 10.1136/jcp.29.Suppl_10.95 on 1 January 1976. Downloaded from Genital mycoplasmal infections: their relation to prematurity and other abnormalities of reproduction 97 administered to pregnant women. In each of two regard, the recent study of Shurin et al (1975) sug- controlled, double-blind studies, treatment with gesting that a substantial proportion of cases of tetracycline for six weeks was associated with a sig- chorioamnionitis may be caused by U. urealyticum nificant reduction in the prevalence of low birth is ofconsiderable interest. These data are summarized weight infants (Elder et al, 1968; Elder et al, 1971). in table V. Although no microbiological examinations were It is not possible to conclude from these data that performed, it was postulated that a tetracycline- U. urealyticum and M. hominis are a cause of low responsive microorganism
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