Role of STI in Infertility

1. Role of STI in Infertility Dr William Wong MB ChB DHCL DRCOG MPH MD FRCGP FRCAGP MFTM RCPS honMFPH, Clinical Associate Professor, Department of Family Medicine & Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong

2. Outlines • What’s STI? • Clinical presentation of urethritis (STI) • Relationship of STI and infertility • Epidemiology of certain STIs • Care of STI in HK • How to take a sexual history • STI from patients’ perspective

3. The Ultimate Goal of sexual health “The integration of the somatic, emotional, intellectual, and social aspects of sexual well-being in ways that are positively enriching and that enhance personality, communication, and love” World Health Organization

4. Female reproductive system

6. Bacteria Neisseria gonorrhoeae Chlamydia trachomatis Mycoplasma hominis Ureaplasma urealyticum Mycoplasma genitalium Treponema pallidum Gardnerella vaginalis Mobiluncus curtisii Mobiluncus mulieris Haemophilus ducreyi Calymmatobacterium granulomatis Shigella spp Campylobacter spp Helicobacter cinaedi Helicobacter fenneliae What are STDs/ STIs?

7. Viruses Human immunodeficiency virus, types 1 and 2, and subtype 0 Herpes simplex virus Human papillomavirus Hepatitis A virus Hepatitis B virus Hepatitis C virus Cytomegalovirus Molluscum contagiosum virus Human T-cell lymphotrophic virus,types I and II Human herpes virus type 8 Protozoa Trichomonas vaginalis Entamoeba histolytica Giardia lamblia Fungi Candida albicans Ectoparasites Phthirus pubis Sarcoptes scabiei Continued

9. STI and Infertility • Complications from urethritis include a 1-year incidence of pelvic inflammatory disease (PID) occurring in nearly 10% of untreated patients and an infertility rate of 8% after a single PID episode, raising to 38% after three episodes (hence huge disease burden and cost), as well as chronic pelvic pain, ectopic pregnancy, pre-term delivery, neonatal conjunctivitis and pneumonia • Complication from primary HSV2 can result in neonatal death

10. Gerbase AC, et al. Lancet 1998;351 (SIII):2-4

11. STIs in Hong Kong • There are NO official STI surveillance data in Hong Kong since Hepatitis B is the only notifiable STI. • Many STI prevalence studies from Hong Kong were focused on high risk groups. • Proxy data on pregnant women or blood donors • Not representative • Not differentiate treated cases • STIs are on the rise • 2011-2015, the STI cases diagnosed at Social Hygiene Clinics (SHCs) had increased by 9.8% whilst primary and secondary cases of syphilis had been more than doubled (Sit & Yim, 2016).

12. Annual reported STIs in Social Hygiene Service, HK

13. Major STIs seen in SHS

14. Prevalence and Risk Factors of Chlamydia, Gonorrhoea and Syphilis Infection in Hong Kong: A Population-based Geospatial Household Survey and Testing

15. Aim and objectives Objective 1: Prevalence of STIs Aim: to better control and prevent STIs • To determine the prevalence of three major STIs among individuals 18-49 years old in Hong Kong: • Chlamydia • Gonorrhoea • Syphilis Objective 2: Individual & Contextual Risk Factors of STIs • To identify individual-level risk factors • To identify contextual risk factors using spatial analyses

16. Random sampling method Hong Kong – 18 Districts further divided into 412 District Council Constituency Areas (DCCAs) each based on population of 17,000 people. (All data from 2011 Census boundary map): • 79 DCCAs proportionally selected based on number of DCCAs in each district. • Geospatial Modelling Environment used to drop random points within the selected DCCAs. • Points matched to proximally located residential buildings. • Proportional number of households relative to the buildings was selected (roughly 7-20).

17. Example: Sham Shui Po • 200 points randomly dropped across 4 randomly selected DCCAs. • 48 buildings proximal to randomly dropped points were selected. • 526 household randomly selected from these buildings. 1 of 4 randomly selected DCCAs in Sham Shui Po district

18. Sampling Procedures and size • Then invitation letters were sent to household a week prior to visits from interviewers. • A team of interviewers would visit them thriceto identify if there were eligible persons. • Next Birthday Methods if >1 eligible. • Questionnaire and testing can take place at home or at the four centres scattered in Hong Kong. • Sample size based on prevalence (of Chinese Health and Family Life Survey of 2.3%): Using Z 2 * (p) * (1-p)/c 2 , our targeted sample Size: 863 Participants

19. Table 2: Completion of districts

20. Survey Response and Outcomes Total addresses selected = 9307 Eligible addresses = 3647 Ineligible addresses = 5660 Known ineligibles = 2685 Estimated ineligibles = 2975 Completed interviews = 906 Refusals = 2741 1) Compulsory Urine Test Revoked/refused to provide urine sample = 13 Provided urine sample = 893 Response rate = 24.5% 2) Optional Syphilis Screening Un-usable urine samples = 12 Usable urine samples = 881 Disagreed to screening = 290 Agreed to screening = 603 16 “+ve” CT, 3 “+ve” NG Failed syphilis tests = 10 Successful syphilis screens = 592 “-ve” and 1”+ve”

21. Table 3. Unweighted observations and weighted distribution of the demographic info (N=881) ~ 0 sex partners in the past 12 months included 57 married people who did not have sex in the past 12 months and they were later regrouped into the sexually experienced group (as in Table 2). * Only to be answered by female participants (please note that “No” here includes “partner didn’t leave” and “no partner” and “sexually inactive”. ^ Permanent resident is defined in article 24 of the Hong Kong Basic Law and paragraph 2 of schedule 1 to the Immigration Ordinance, it includes those born in HK and those live in Hong Kong for more than sevenyrs

22. Table 4. Unweighted observations and weighted distribution of sexual behaviour & health (N=881) ~ 0 sex partners in the past 12 months included 57 married people who did not have sex in the past 12 months and they were later regrouped into the sexually experienced group (as in Table 2). * Only to be answered by female participants (please note that “No” here includes “partner didn’t leave” and “no partner” and “sexually inactive”. ^ Permanent resident is defined in article 24 of the Hong Kong Basic Law and paragraph 2 of schedule 1 to the Immigration Ordinance, it includes those born in HK and those live in Hong Kong for more than sevenyrs

23. Results Table 5. Prevalence of composite STIs 1. Sexually active: reported having sex in the last 12 months 2. Sexually experienced: admitted having sex in the last 12 months and those who indicated sex experience beyond the last 12 months.

24. Results Table 6. Prevalence of chlamydia 1. Sexually active: reported having sex in the last 12 months 2. Sexually experienced: admitted having sex in the last 12 months and those who indicated sex experience beyond the last 12 months.

25. Comparison with other studies’ results Table 7. Prevalence of chlamydia found comparison

26. Table 9. Associations of participants’ characteristics, behaviours and chlamydia using univariate analysis

27. Table 11. Multivariable analyses of factors associated with Chlamydia trachomatis infection

28. Table 13. Multivariable analyses of factors associated with Chlamydia trachomatis infection among the female participants

29. Summary of key findings • TeSSHS identified three common curable STIs’ composite as well as chlamydia prevalence among the general population in Hong Kong • The risk factors identified are useful information for further STIs prevention and control • Travel history • Living alone • Younger age • Older age 29