Preserving fertility: an underappreciated aspect of sexual health.

KEY MESSAGES

* STIs are the primary preventable causes of infertility.

* Chlamydial infection and gonorrhea are the two STIs most clearly associated with infertility.

* Screening can identify these two often-silent, fertility-threatening STIs.

Because family planning professionals devote much of their careers to trying to help clients avoid unintended pregnancies, they may neglect the issue of unintended infertility. But efforts to better prevent, diagnose, and treat the main causes of unintended infertility could help preserve the fertility of millions worldwide.

The main preventable causes of infertility are sexually transmitted infections (STIs), primarily chlamydial infection and gonorrhea (see article, page 12). Because these widespread and easily transmitted infections are often "silent" or asymptomatic, active screening of sexually active persons for these particular STIs is crucial. Otherwise, few women will realize that they have a fertility-threatening infection until they try to become pregnant and are unable to do so. Notably, this "prevention-first" approach to preserving fertility involves achieving the still difficult goal of integrating sexual and reproductive health services to address both unintended pregnancy and STIs. (1)

Chlamydial infection and gonorrhea first attack the inner lining of the cervix, then--if untreated--can ascend to the upper genital tract. They do so by moving through the uterus to the fallopian tubes, and in some women, to the ovaries and abdominal cavity. Infection of the uterus, fallopian tubes, or ovaries--called pelvic inflammatory disease (PID)--can cause infertility by either blocking or damaging the fallopian tubes. In long-term follow-up studies in Sweden, 11 percent of 1,309 women with documented acute PID who attempted to conceive were unable to do so because of confirmed post-PID tubal blockage. (2)

Several factors affect the likelihood that PID will result in tubal infertility. The long-term studies conducted in Sweden found that women's risk of infertility increased with each episode of PID: the risk of infertility with one PID episode was 8 percent; with two, 19 percent; and with three or more, 40 percent. The risk of infertility increased directly with the observed severity of tubal inflammation. (3) In addition, delays in seeking health care after pelvic symptoms occur can affect future fertility. In the Swedish studies, women who waited more than three days from the onset of their symptoms to seek medical help--giving inflammation more time to cause damage--had three times the risk of impaired fertility or ectopic pregnancy (outside the uterus) than did women who promptly sought care. (4)

Preventing tubal infertility

Preventing STI-related tubal infertility can occur at two levels. Men and women can achieve primary prevention to block acquisition of infection by delaying initiation of sexual intercourse, choosing an uninfected sexual partner, and--if neither of these conditions is met--using condoms to reduce the risks of chlamydial infection and gonorrhea. Secondary prevention, intended to block progression of lower genital tract infection to the upper genital tract, emphasizes STI screening, partner notification, and treatment. Treating "endstage" tubal infertility is very costly; thus, preventing the condition is imperative.

The secondary prevention approach of screening for STIs can be problematic in many developing-world settings where diagnostic laboratory tests are unavailable or too costly. In the past, authorities have recommended that providers use simple algorithms based on symptoms as a tool to detect symptomatic STIs. While the algorithms for genital ulcers and male urethral discharge (urethritis) have proven useful, this syndromic approach to female vaginal discharge has been less specific for cervical gonorrhea and chlamydial infections. Use of other risk assessment algorithms to predict more accurately who is infected has been helpful in some settings, but these tools are still being developed. (5) The STI tests available in resource-poor settings--such as gram staining or gonorrhea culturing--tend to have problems in sensitivity or specimen storage.

However, secondary prevention for STIs is growing easier and more reliable as nucleic acid amplification tests become available in the developed world for routine use in clinics, public health programs, in the field, and even at home. (6) Although still too costly and complex for routine use in the developing world, the amplification tests have been used successfully for research projects there. Three unique characteristics of these tests make them important tools: 1) their improved sensitivity; 2) the ability to conveniently collect specimens using urine samples, client-collected tampons, or vaginal swabs (rather than endocervical or urethral swabs); and 3) their ability to simultaneously test for multiple organisms. Furthermore, the characteristics of these tests make them accessible to individuals who could not be readily tested with previous techniques. For example, outreach programs can now provide STI testing in settings where women do not undergo pelvic examinations or where men do not have urethral swabs collected. (7) Expanded efforts to screen asymptomatic young women, using self-collected vaginal swabs or first-void urine samples (the first part of the urine stream), have included high school-based testing, testing of both male and female military recruits, and testing in adolescent clinics and emergency departments. (8)

Meanwhile, rapid, easy-to-read, low-cost tests for gonorrhea and chlamydial infection are being developed by the Seattle-based Program for Appropriate Technology in Health (PATH), with support from the U.S. Agency for International Development, the United Nations Population Fund, and the Bill & Melinda Gates Foundation. These immunochromatographic (IC) strip tests can be used without running water or laboratory equipment and will allow screening of specimens from clients in rural or smaller clinics or hospitals in the developing world and other resource-limited settings. Accurate results will be available within 20 minutes, allowing for effective client follow-up, additional counseling, and prescription of drugs, if needed. (9) The IC strip tests may be commercially available within a year or two.

Screening young women for chlamydia will, over time, decrease the prevalence of chlamydial infection and the occurrence of PID in a given population. (10) For example, a randomized intervention trial of screening versus nonscreening among young women in a large health maintenance organization demonstrated substantial reduction in subsequent incidence of PID among those screened. (11) Before nucleic acid amplification tests were available, nearly all recommendations for chlamydia screening focused on women. Now, however, chlamydia screening in young men is possible, and it has several potential advantages (see article, page 13).

Blocking progression of lower genital tract infection to the upper genital tract or progression of upper genital tract infection to tubal obstruction involves treatment of STIs. Treatment recommendations for the curable STIs are updated regularly by the U.S. Centers for Disease Control and Prevention and the World Health Organization (see table, page 11). Many patients find it easier to comply with single-dose treatment regimens for chlamydial infection or gonorrhea, but multi-dose options are equally effective and less expensive. Making sure all sexual partners are treated with the same antibiotics helps prevent reinfections. Providers are increasingly giving STI-infected clients prescriptions for treatment of their partners' STIs.

A woman who has had one STI is at increased risk of reinfection, even after successful treatment. This is either because her sex partner or partners may not have been treated or because she may continue having intercourse within a high-prevalence sexual network. Thus, rescreening all women with documented gonorrhea or chlamydial infection three months after treatment is a high priority. (12) Since repeated infection can double PID risk, this retesting policy also helps prevent infertility.

References

(1) Mayhew S. Integrating MCH/FP and STD/HIV services: current debates and future directions. Health Policy Plan 1996;11(4):339-53; Shelton JD. Prevention first: a three-pronged strategy to integrate family planning program efforts against HIV and sexually transmitted infections. Int Fam Plann Perspect 1999;25(3):147-52.

(2) Westrom L, Joesoef R, Reynolds G, et al. Pelvic inflammatory disease and fertility. A cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex Transm Dis 1992;19(4):185-92.

(3) Westrom.

(4) Hillis SD, Joesoef R, Marchbanks PA, et al. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol 1993;168(5):1503-9.

(5) Cates W Jr, Welsh MJ. STD risk assessment in family planning settings: can we find clinically useful surrogates of infection? IPPF Med Bull 2003;37(3):1-2.

(6) Andersen B, Olesen F, Moller JK, et al. Population-based strategies for outreach screening of urogenital Chlamydia trachomatis infections: a randomized, controlled trial. J Infect Dis 2002;185(2):252-58.

(7) Stamm WE. Expanding efforts to prevent chlamydial infection. N Engl J Med 1998; 339(11):768-70; Stamm WE. Chlamydia trachomatis--the persistent pathogen. Sex Transm Dis 2001;28(12):684-89.

(8) Cohen DA, Nsuami M, Etame RB, et al. A school-based chlamydia control program using DNA amplification technology. Pediatrics 1998;101(1):E1; McKay L, Clery H, Carrick-Anderson K, et al. Genital Chlamydia trachomatis infection in a subgroup of young men in the UK. Lancet 2003;361(9371):1792; Gaydos CA, Howell MR, Quinn TC, et al. Sustained high prevalence of Chlamydia trachomatis infections in female army recruits. Sex Transm Dis 2003;30(7):539-44; Oh MK, Richey CM, Pate MS, et al. High prevalence of Chlamydia trachomatis infections in adolescent females not having pelvic examinations: utility of PCR-based urine screening in urban adolescent clinic setting. J Adolesc Health 1997;21(2):80-86; Moens V, Baruch G, Fearon P. Opportunistic screening for Chlamydia at a community based contraceptive service for young people. BMJ 2003; 326(7401):1252-55; Aldeen T, Haghdoost A, Hay P. Urine based screening for asymptomatic/ undiagnosed genital chlamydial infection in young people visiting the accident and emergency department is feasible, acceptable, and can be epidemiologically helpful. Sex Transm Infect 2003:79(3):229-33.

(9) Program for Appropriate Technology in Health (PATH). IC strip test for chlamydia. HealthTech Update May 2003. Available: http://www.path. org/files/htup-IC_striptest_Chlamydia.pdf; Program for Appropriate Technology in Health (PATH). IC strip test for gonorrhea. HealthTech Update May 2003. Available: http://www.path. org/files/htup-IC_striptest_Gonorrhea.pdf.

(10) Nelson HD, Helfand M. Screening for chlamydial infection. Am J Prev Med 2001; 20(3 Suppl):95-107; Kamwendo F, Forslin L, Bodin L, et al. Decreasing incidences of gonorrhea- and chlamydia-associated acute pelvic inflammatory disease: a 25-year study from an urban area of central Sweden. Sex Transm Dis 1996;23(5):384-91.

(11) Scholes D, Stergachis A, Heidrich DM, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;334(21):1362-66.

(12) U.S. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002; 51(RR-6):33. Available: http://www.cdc.gov/ mmwr/preview/mmwrhtml/rr5106a1.htm; Golden MR, Handsfield HH. Rescreening for chlamydial infection and gonorrhea. Medscape Infect Dis 2003;5(2).

Should Men Be Screened for Chlamydia?

Screening asymptomic young men for chlamydia is emerging as a possible strategy to protect their female sexual partners from this fertility-threatening infection. Screening men is now feasible because chlamydial infection can be detected using new tests on first-void urine specimens (the first part of the urine stream) rather than uncomfortable urethral swabs. Furthermore, these new tests--called nucleic acid amplification tests--are highly accurate and can be performed outside of clinic settings, offering opportunities for widespread use.

Some experts argue that all sexually active men ages 18 to 25 years should be offered such screening. This is necessary, they say, because adolescent and young adult men are more likely than older men to acquire the infection, which is often "silent." Up to three-quarters of infected men in the general population do not report any signs or symptoms. (1) Worldwide, some 92 million new chlamydial infections occur each year, (2) and up to 40 percent of women with untreated chlamydial infection develop pelvic inflammatory disease (PID). (3) PID, in turn, increases the risks of ectopic pregnancy (outside of the uterus) and infertility. Identifying chlamydial infection (through screening), then treating infected men would likely lower the risk that women will be infected and develop PID, just as screening women for chlamydia has been shown in two randomized controlled trials to at least halve their risk of developing PID. (4)

Acceptability studies have shown that about a third of men would participate in community-based screening for chlamydia. (5) If a third of men indeed participated, "there would be a dramatic impact," says Dr. Lars Ostergaard, chief physician in the Department of Infectious Diseases at Aarhus University Hospital in Denmark. Dr. Ostergaard has conducted research to develop new molecular techniques for diagnosing chlamydial infection and ways to use them in clinical practice. Recently, he has focused on the public health impact of using home-sampling strategies to screen for chlamydia.

Widespread screening of asymptomatic sexually active men, however, may entail prohibitive social, psychological, and economic costs. Stigmatization may occur, (6) and Dr. Ostergaard says his research has shown that "men's ethnicity and religion may reduce their acceptance of the screening test." Although screening men can be cost-effective in some settings, it may cease to be so if the prevalence of infection is low in a population. "One would need to begin screening slowly, because cost factors vary markedly from one setting to another," he says.

Given these potential problems, experts tend to agree that more effective screening of women, especially in settings with limited resources, may be a better course to take for the short term. In 2001, the U.S. Preventive Services Task Force issued evidence-based recommendations calling for chlamydia screening for all sexually active women younger than 26 years and for all women at increased risk of infection (for example, those who have a new sexual partner and those with multiple sexual partners). (7) The U.S. Centers for Disease Control and Prevention issued similar recommendations in 2002. (8) "Until we have successfully implemented screening in most high-risk women, we should wait to do widespread screening of men," says Dr. Walter Stamm, professor of medicine and head of infectious diseases at the University of Washington in Seattle. Dr. Stamm has conducted research to develop and evaluate new molecular diagnostic tests for chlamydial infection and to determine the impact of chlamydia screening on PID prevention.

Clearly, many women are not screened. A study conducted between 1996 and 1999 of some 23,000 female army recruits throughout the United States showed that many infected women had "fallen through the cracks," Dr. Stamm says. The prevalence of chlamydial infection in this population ranged from nearly 6 percent in the West to 12 percent in the South. (9) Low rates of screening among sexually active female adolescents--who are generally at greater risk of chlamydial infection than are older women--have been observed, (10) as well as high rates of reinfection among inner-city adolescent girls. (11)

"Since most women are not screened and even those who are tested and treated have a high recurrence rate," says Dr. Stamm, "we should concentrate on wider, community-based screening of women and subsequent rescreening, especially in settings with limited resources. Meanwhile, we should continue studies of the feasibility and effectiveness of screening in men."

Dr. Stamm emphasizes that screening men for chlamydia is designed to benefit women, not men themselves. The adverse consequences of this infection for men are low, with epididymitis (inflammation of the tubes through which sperm move from the testes to the vasa deferentia) developing in only one of every 100 infected men. Considering all the potential barriers to widespread, community-based chlamydia screening in sexually active men--including problems of access, acceptability, unclear screening criteria, and unclear criteria for follow-up screening and partner management--"we should instead pay more attention to expanded screening of women," he says, "and only then consider how efforts to screen men might fit into the approach of improving screening of women."

References

(1) Farley TA, Cohen DA, Elkins W. Asymptomatic sexually transmitted diseases: the case for screening. Prev Med 2003;36(4):502-9.

(2) World Health Organization. Department of HIV/AIDS. Chlamydia. In Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections. Overview and Estimates. Geneva, Switzerland: World Health Organization, 2001. Available: http://www.who.int/docstore/ hiv/GRSTI/003.htm.

(3) U.S. Centers for Disease Control and Prevention. Division of Sexually Transmitted Diseases. Chlamydia Disease Information, 2001. Available: http://www.cdc.gov/nchstp/dstd/ Fact_Sheets/FactsChlamydiaInfo.htm.

(4) Scholes D, Stergachis A, Heidrich FE, et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N Engl J Med 1996;334(21):1362-66; Ostergaard L, Andersen B, Moller JK, et al. Home sampling versus conventional swab sampling for screening of Chlamydia trachomatis in women: a cluster-randomized 1-year follow-up study. Clin Infect Dis 2000;31(4):951-57.

(5) Bloomfield PJ, Kent C, Campbell D, et al. Community-based chlamydia and gonorrhea screening through the United States mail, San Francisco. Sex Transm Dis 2002;29(5):194-97; Stephenson J, Carder C, Copas A, et al. Home screening for chlamydial genital infection: is it acceptable to young men and women? Sex Transm Infect 2000;76(1):25-27.

(6) Andersen B, Kangas I, Olesen F, et al. Psychosocial consequences of Chlamydia trachomatis testing [poster presentation]. The 2003 International Society for Sexually Transmitted Diseases Research Congress, Ottawa, Canada, July 27-30, 2003.

(7) U.S. Preventive Services Task Force. Screening for chlamydial infection: recommendations and rationale. Am J Prev Med 2001;20(3S):9094. Available: http://www.ahrq.gov/clinic/ ajpmsuppl/chlarr.htm#source.

(8) U.S. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002;51(RR-6):32. Available: http://www.cdc.gov/std/treatment/rr5106.pdf.

(9) Gaydos CA, Howell MR, Quinn TC, et al. Sustained high prevalence of Chlamydia trachomatis infections in female army recruits. Sex Transm Dis 2003;30(7):539-44.

(10) Cook RL, Wiesenfeld HC, Ashton MR, et al. Barriers to screening sexually active adolescent women for chlamydia: a survey of primary care physicians. J Adolesc Health 2001;28(3):204-10.

(11) Oh MK, Cloud GA, Fleenor M, et al. Risk for gonococcal and chlamydial cervicitis in adolescent females: incidence and recurrence in a prospective cohort study. J Adolesc Health 1996;18(4):270-75.

The Most Easily Transmitted STIs

Both chlamydial infection and gonorrhea are widespread globally: 92 million cases of genital chlamydial infection and 62 million cases of gonorrhea occur among adults each year. (1) They are also among the most easily transmitted STIs. About one in every five unprotected sexual acts by someone with chlamydial infection will result in transmission to an uninfected partner. For gonorrhea, the risks of transmission are even higher: about one of every two exposed individuals will be infected. (2) Consistent and correct condom use can reduce the risk of transmitting these infections. However, because condoms can slip or break, they do not provide absolute protection. The only way to absolutely prevent transmission of STIs, and thus preserve fertility, is to delay or abstain from sexual intercourse or be sexually active only in a monogamous relationship with an uninfected individual.

References

(1) World Health Organization. Department of HIV/AIDS. Chlamydia. In Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections. Overview and Estimates. Geneva, Switzerland: World Health Organization, 2001. Available: http://www.who.int/ docstore/hiv/GRSTI/003.htm.

(2) Anderson RM. Transmission dynamics of sexually transmitted infections. In Holmes KK, Sparling PF, Mardh P-A, eds. Sexually Transmitted Diseases. (New York: McGraw-Hill, 1999)25-37.

STI Treatment Guidelines

If detected early, fertility-threatening chlamydial infection
and gonorrhea are easily treatable with antimicrobial drugs
available throughout the world. The following treatment regimens
for nonpregnant adults are recommended by the U.S. Centers for
Disease Control and Prevention and/or the World Health Organization

Regimen       Uncomplicated Chlamydial
              Anogenital Infections

Recommended   Doxycycline 100 mg orally twice a day for 7
              days;

              or Azithromycin 1 g orally in a single dose.

Alternative   Erythromycin base 500 mg orally 4 times a day
              for 7 days;

              or Erythromycin ethylsuccinate 800 mg orally 4
              times a day for 7 days;

              or Ofloxacin 300 mg orally twice a day for 7 days;

              or Levofloxacin 500 mg orally once a day for 7
              days;

              or Amoxicillin 500 mg orally 3 times a day for 7
              days;

              or Tetracycline 500 mg orally 4 times a day for 7
              days.

Regimen       Uncomplicated Gonococcal
              Anogenital Infections

Recommended   Ciprofloxacin * 500 mg orally in a single dose;

              or Azithromycin 2 g orally in a single dose;

              or Ofloxacin * 400 mg orally in a single dose;

              or Levofloxacin * 250 mg orally in a single dose;

              or Ceftriaxone 125 mg intramuscular (IM) injection,in a
              single dose.

              Plus, if chlamydial infection is not ruled out, provide
              concurrent treatment for co-infection.

Alternative   Spectinomycin 2 g IM in a single dose. Spectinomycin is
              highly effective and useful for patients who cannot
              tolerate cephalosporins and quinolones.

              or Single-dose cephalosporin regimens (other than
              ceftriaxone 125 mg IM) include ceftizoxime (500 mg IM),
              cefoxitin (2 g IM with probenecid 1 g orally), and
              cefotaxime (500 mg IM). None of the injectable
              cephalosporins offers any advantage to ceftriaxone.

              or Single-dose quinolone * regimens include gatifloxacin
              400 mg orally, norfloxacin 800 mg orally, and
              lomefloxacin 400 mg orally. None of these regimens
              appears to offer any advantage over ciprofloxacin,
              ofloxacin, or levofloxacin.

              or Kanamycin, 2 g in a single IM dose;

              or Trimethoprim (80 mg)/sulfamethoxazole (400 mg), 10
              tablets orally, as a single dose daily for 3 days. Both
              should be used only where in vitro resistance rates are
              low and monitored regularly.

* Quinolones should not be used for gonorrhea acquired in Asia or the
Pacific, including Hawaii, due to the prevalence of quinolone-resistant
gonorrhea in these areas.

Sources: U.S. Centers for Disease Control and Prevention. Sexually
transmitted diseases treatment guidelines 2002. MMWR 2002;51(RR-6):
33,37. Available: http://www.cdc.gov/mmwr/preview/mmwrhtml/
rr5106a1.htm; World Health Organization. Guidelines for the Management
of Sexually Transmitted Infections. 2001.Available:http://www.who.int/
docstore/hiv/STIManagemntguidelines/who_hiv_aids_2001.01/index.htm.

Global Trends Confirm STI-Tubal Infertility Link

In areas of the world where gonorrhea and chlamydial infection are more common, infertility due to blocked fallopian tubes is also more common. (1) The geographic association of gonorrhea is most strongly linked with infertility, (2) but the role of chlamydial infection in causing tubal infertility has been more exhaustively studied.

Investigators from more than 25 different cities around the world have documented that tubal occlusion is strongly associated with evidence of past chlamydial infection. When these studies are combined, approximately 70 percent of women with tubal infertility, versus 26 percent of women without tubal infertility, had antibodies to chlamydia. (3) Chlamydial infection is particularly worrisome because it causes relatively benign symptoms and signs, yet apparently causes as much tubal inflammation--and ultimately tubal damage--as other infections such as gonorrhea or those caused by anaerobic organisms.

Globally, a World Health Organization multicenter study has compared infection-related infertility among couples in four different regions of the world. More than 5,800 infertile women in the study had their fallopian tubes evaluated. The study found the prevalence of tubal occlusion in Africa to be more than three times that of Asia, Latin America, or the developed world (see table above) and that two of every three African women with a history of a sexually transmitted infection (STI) had both tubes blocked. (4) The higher prevalence of past STIs and pregnancy complications among infertile African women than among infertile women from other regions appears to explain this finding. (5)

Percentage of Infertile Women
with Bilateral Tubal Occlusion
(by region)

Africa          49.0
Asia            14.1
Latin America   15.3
Developed       10.6

Source: World Health Organization.
Infections, pregnancies, and infertility:
perspectives on prevention. Fertil Steril
1987:47(6):966.

Note: Table made from bar graph.

References

(1) Sciarra JJ. Sexually transmitted diseases: global importance. Int J Gynecol Obstet 1997;58(1):107-19; Cates W, Farley TM, Rowe PJ. Worldwide patterns of infertility: is Africa different? Lancet 1985;2(8455):596-98.

(2) Griffith HB. Gonorrhea and fertility in Uganda. Eugen Rev 1963;55(2):103; Arya OP, Nsanzumuhire H, Taber SR. Clinical, cultural, and demographic aspects of gonorrhoeae in a rural community in Uganda. Bull WHO 1973;49(6):587-95; Arya OP, Taber SR, Nsanze H. Gonorrhea and female infertility in rural Uganda. Am J Obstet Gynecol 1980;138(7Pt2):929-32.

(3) Cates W Jr, Wasserheit JN. Genital chlamydial infections: epidemiology and reproductive sequelae. Am J Obstet Gynecol 1991;164(6 Pt 2):1771-81.

(4) World Health Organization. Infections, pregnancies, and infertility: perspectives on prevention. Fertil Steril 1987;47(6):964-68; Cates, Farley, Rowe.

(5) Cates, Farley, Rowe.

Triple Protection Addresses Unplanned Pregnancy, Infections, and Infertility

Many family planning providers have begun to counsel clients who are at risk of both unplanned pregnancy and sexually transmitted infections (STIs) about dual protection against both conditions.

But rather than dual protection, what many young women need is "triple protection" against unplanned pregnancy, STIs, and infertility, says Martha Brady, an associate with the New York-based Population Council's Gender, Family and Development Program.

Dual protection can be achieved by abstaining from sexual intercourse, by using contraception and having mutually monogamous intercourse with an uninfected partner, or by using condoms consistently, either alone or with another more effective method of contraception. (If a condom is used alone and fails, emergency contraception can serve as a backup contraceptive method but will not protect against STIs.) Brady points out that each of the dual protective measures also helps women preserve their fertility by preventing STIs that can lead to infertility without prompt, effective treatment.

Adding infertility prevention to the dual protection message would focus attention on the neglected public health problem of infertility, while potentially strengthening family planning and STI prevention efforts, Brady argues in a recent article in the journal Reproductive Health Matters. (1) "Expansion of the message to encompass triple protection could use the visibility of fertility and infertility--and people's immediate connection with the issue--to promote protection against STIs and HIV," she writes. "Linking safer sex to fertility, rather than disease prevention per se, also might destigmatize the issues around STIs and HIV," Brady says.

Promoting ways to simultaneously protect against both unplanned pregnancies and STIs has proved challenging. This dual protection message is more complicated than focusing on only preventing unplanned pregnancies or only preventing STIs. Some reproductive health experts fear that adding a third message about preventing infertility might make the task even more difficult.

Brady acknowledges this challenge. "But adding this message about preventing infertility is important, particularly for young women," she says. "The same methods that offer dual protection also offer the possibility of triple protection, so only the message needs to change. It is a conceptual shift, rather than a new program."

Furthermore, this conceptual shift offers opportunities for more holistic approaches to reproductive health, Brady notes. By preventing and even treating infertility, for example, family planning programs could help both women and men with fertility problems, involve men in protecting reproductive health, and win the trust of their communities, while reducing STI rates and unplanned pregnancies.

[GRAPHIC OMITTED]

Reference

(1) Brady M. Preventing sexually transmitted infections and unintended pregnancy, and safeguarding fertility: triple protection needs of young women. Reprod Health Matters 2003;11(22):134-41.

Programs Begin to Emphasize STI, Infertility Link

Many people are unaware that lack of treatment or improper treatment of sexually transmitted infections (STIs)--particularly among women--is a major cause of infertility in developing countries. (1)

So, some family planning programs are emphasizing the link between STIs and infertility as they begin to offer more comprehensive reproductive health services, including infertility prevention and treatment. For example, the Family Planning Association of India's Comprehensive Reproductive Health for All project provides education and counseling about STIs to its clients, including men attending its infertility clinic or male reproductive health clinic (see article, page 19).Preserving fertility through STI prevention and treatment is an important theme in the program's community outreach efforts through village-level groups for women and men. (2)

Also attempting to increase awareness of the link between STIs and infertility is the Women's Health and Research Action Centre, a nongovernmental organization based in Benin City, Nigeria. The center's staff members hold community forums and appear on television and radio programs to educate people about the need for STI prevention and treatment to preserve fertility.

The center in Nigeria conducted a trial to evaluate an STI-prevention pilot program in schools. The pilot program, which included peer education, reproductive health clubs, and provider training to improve the quality of STI care for students, focused on preventing infertility. Researchers found statistically significant reductions in reported STI symptoms among students in four participating schools in Benin City, compared with students in eight local schools who did not receive this STI prevention information. The study also found significant improvements in knowledge of STIs and in partner notification and STI treatment-seeking behaviors among students in the intervention group. (3) The Women's Health and Research Action Centre subsequently has worked with communities to adapt the pilot program to reach out-of-school youth.

Dr. Friday Okonofua, executive director of the Centre, advocates early intervention to educate people about preserving their fertility through STI prevention and treatment. "Many people fear infertility," he says. "So, if we are able to tie STIs to information on infertility, these people will be much more receptive to our messages."

References

(1) Dyer SJ, Abrahams N, Hoffman M, et al. Infertility in South Africa: women's reproductive health knowledge and treatment-seeking behavior for involuntary childlessness. Hum Reprod 2002; 17(6):1657-62; Passey M, Mgone CS, Lupiwa S, et al. Community based study of sexually transmitted diseases in rural women in the highlands of Papua New Guinea: prevalence and risk factors. Sex Transm Infect 1998;74(2):120-27.

(2) Datta B. "What about us?" Bringing infertility into reproductive care. Quality/Calidad/Qualite 2002;13:3-29.

(3) Okonofua FE, Coplan P, Collins S, et al. Impact of an intervention to improve treatment-seeking behaviour and prevent sexually transmitted diseases among Nigerian youths. Int J Inf Dis 2003; 7(1):61-73.

Dr. Cates is an epidemiologist whose public health career has focused on reproductive health and STIs, including HIV. Before joining FHI in 1994, he headed the Division of STD/HIV Prevention at the U.S. Centers for Disease Control and Prevention for a decade. He recently received the Thomas Parran Award at the 2003 International Society for Sexually Transmitted Diseases Research Congress in Ottawa, Canada. The award recognizes lifetime achievement in the field of STI research.