|
   |
|
ORIGINAL ARTICLE |
|
|
|
| Year : 2022 | Volume
: 43
| Issue : 2 | Page : 135-140 |
| |
Prevalence of nonviral reproductive tract infections/sexually transmitted infections in female patients with cervicovaginal discharge: Excerpts from a regional reference center in North India
Sunil Sethi1, Nandita Sharma1, Megha Sharma2, Rajneesh Dadwal1, Charu Singh3, Hemant Chaudhary1, Sakshi Malhotra1, Rakesh Yadav1, Vanita Gupta4
1 Department of Medical Microbiology, PGIMER, Chandigarh, India
2 Department of Medical Microbiology, PGIMER, Chandigarh; Department of Microbiology, AIIMS, Bilaspur, Himachal Pradesh, India
3 Department of Medical Microbiology, PGIMER, Chandigarh; Department of Microbiology, BHU, Varanasi, Uttar Pradesh, India
4 Department of Health, Chandigarh State AIDS Control Society, Chandigarh, India
| Date of Submission | 18-May-2021 |
| Date of Decision | 02-Feb-2022 |
| Date of Acceptance | 12-Mar-2022 |
| Date of Web Publication | 01-Aug-2022 |
Correspondence Address:
Dr. Sunil Sethi
Department of Medical Microbiology, PGIMER, Chandigarh - 160 012
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijstd.ijstd_48_21
 Abstract | | |
Background: To study the prevalence of common nonviral reproductive tract infections/sexually transmitted infections (RTI/STI) prevailing among females who presented to our regional STI reference center and to ascertain the association of various symptoms with different RTI/STIs. Materials and Methods: A retrospective analysis of female patients presenting to our STI Regional center located in the Department of Medical Microbiology in PGIMER, Chandigarh, was done between April 2018 and December 2019 for patients presenting with cervico-vaginal discharge. Two to three swabs were collected from each patient. The first swab was subjected to wet mount, gram stain, Potassium hydroxide (KOH) test, and culture on blood agar, the colonies obtained were identified by matrix-assisted laser desorption time of flight mass spectrometer (MALDI TOF-MS). Second swab was used for DNA extraction and detection of Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV), and Chlamydia trachomatis (CT) by polymerase chain reaction. The third swab, when available, was inoculated onto pleuropneumonia-like organisms (PPLO) broth. Results: One thousand and thirteenth of 1472 (69%) female patients were symptomatic and the most common presenting symptoms were vaginal discharge (707/1013 [69.8%]), infertility (266/1013 [26.2%]), genital itching (60/1013 [5.9%]), lower abdomen pain (47/1013 [4.6%]) and burning micturition (16/1013 [1.6%]). The most prevalent RTI/STI was bacterial vaginosis (BV) 18.2% (269/1472), followed by vulvovaginal candidiasis (VVC) 6.8% (100/1472) and trichomoniasis (TV) 1.9% (28/1472). Five cases each of Mycoplasma genitalium and Ureaplasma urealyticum, three of NG and one of CT were also identified. Coinfections were seen in 40 (2.7%) cases. The most common causative agent responsible for VVC in our study was Candida albicans (65%). Conclusion: RTI/STIs were common among women and 69% were symptomatic. BV was the most common STI present in 18.2%, followed by VVC (6.8%) and trichomoniasis (1.9%).
Keywords: Bacterial vaginosis, chlamydia trachomatis, polymerase chain reaction, trichomoniasis
How to cite this article:
Sethi S, Sharma N, Sharma M, Dadwal R, Singh C, Chaudhary H, Malhotra S, Yadav R, Gupta V. Prevalence of nonviral reproductive tract infections/sexually transmitted infections in female patients with cervicovaginal discharge: Excerpts from a regional reference center in North India. Indian J Sex Transm Dis 2022;43:135-40 |
How to cite this URL:
Sethi S, Sharma N, Sharma M, Dadwal R, Singh C, Chaudhary H, Malhotra S, Yadav R, Gupta V. Prevalence of nonviral reproductive tract infections/sexually transmitted infections in female patients with cervicovaginal discharge: Excerpts from a regional reference center in North India. Indian J Sex Transm Dis [serial online] 2022 [cited 2023 Jun 6];43:135-40. Available from: https://ijstd.org/text.asp?2022/43/2/135/352920 |
| Introduction | |  |
Sexually transmitted infections (STIs) are one of the most prevalent infections, being caused by more than 30 pathogens (including bacteria, parasites, and viruses). Yet, they remain one of the most neglected human infections. The World Health Organization 2018 report on global STI surveillance documented that more than 1 million STIs are newly acquired every day.[1] Further, it was estimated that 376 million new infections with one of the four STIs: Chlamydia, gonorrhea, syphilis, and trichomoniasis occur annually worldwide.[1]
The commensal Lactobacilli play an important role in maintaining the vaginal pH in the range of 3.5–4.5, thus keeping a check on the invading microbes. However, alteration in the number of Lactobacilli, due to douching, hormonal changes, sexual exposure, menstrual periods, etc., make the cervico-vaginal epithelium vulnerable by providing a favorable milieu for colonization by potentially pathogenic microbes leading to STI.[2],[3],[4] Among the different STIs, bacterial vaginosis (BV) is the most common form of vaginal infection in women of reproductive ages. It can be a chronic recurrent infection, which is typically characterized by a reduction of Lactobacillus with subsequent overgrowth of Gardnerella vaginalis and other anaerobic bacteria, such as Atopobium vaginae, Bacteroides spp., Mobiluncus spp. and Prevotella spp.[2],[5],[6] Vulvo-vaginal candidiasis (VVC), another common STI, affects up to 75% of women of reproductive age group at least once in their lifetime. Though the majority of the infections are caused by Candida albicans, the incidence of non-albicans Candida infection is increasingly reported.[7] Trichomoniasis, caused by the parasite Trichomonas vaginalis (TV), is the most common curable STI worldwide. Trichomoniasis is associated with a two-fold increased risk of transmission of other STIs, including human immunodeficiency virus (HIV).[8],[9]
Reproductive tract infections (RTI)/STIs present as a syndrome with an overlap of not only several symptoms but, in many cases, several pathogens also. A proper understanding of the pattern of STDs prevailing in different geographic regions of a country is necessary for proper planning and implementation of STD control strategies. There is a paucity of literature regarding prevalence and pattern of various RTI/STIs in North India. Hence, as a part of the Regional STI Reference center, we studied the prevalence of common nonviral RTI/STIs from cervico-vaginal specimens of females representing different sections of society in our setup and their association with the different symptoms.
| Materials and Methods | | |
Study design
A retrospective analysis of data from female patients presenting to the Regional STI Reference, Research and Training Laboratory in the Department of Medical Microbiology at PGIMER, Chandigarh over a period of 21 months (April 2018–December 2019) was analyzed.
The following inclusion criteria were used in the study:
- Specimen type - only swab specimens (cervical swab/vaginal swab/cervicovaginal swab and ulcer swab) and urine specimens were included; serum specimen received for serological investigations were excluded
- Patient type - female patients presenting with symptoms of RTI/STI at our tertiary care hospital [as elaborated in [Table 1]], high-risk groups like female sex workers and transgenders who were approached with the help of nongovernmental organizations (NGOs) and slum population visiting the dispensary attached to our institute. Only those patients were included wherein the age of the patient was between 18 and 45 years and they were not currently undergoing any treatment for RTI/STI
- Exclusion criteria - Pregnant females, HIV/HBsAg/hepatitis C virus positive females and females from whom only blood specimen was received were excluded from the study.
{Table 1}
Specimen collection and processing
According to laboratory policy, a sterile speculum was gently inserted after explaining the procedure to the patient. The genital area was visually inspected for the presence of vaginitis or cervicitis or both. A cotton swab (Hi-Media Laboratories, Mumbai, India), predipped in sterile normal saline, was used to collect the cervical swab specimen and the vaginal specimen was collected from the lateral vaginal wall. Two to three swabs were collected from each patient.
The first (vaginal or cervicovaginal) swab was used to prepare a wet mount, gram stain and inoculated onto blood agar. Briefly, the swab was smeared onto a clean glass slide and inoculated onto blood agar followed by placing the swab in a screw-capped tube (Hi-Media Laboratories, Mumbai, India) containing 0.5 mL of 0.9% saline to carry out wet mount microscopy for detection of TV. The swab was vigorously rotated in the saline and pressed against the side of the tube to express as much fluid as possible. One drop of the expressed fluid was placed on a glass slide with a coverslip and examined at a magnification of ×40 within 4 h of collection of the specimen. The smear on the glass slide was heat-fixed and stained with Gram's stain; reporting was done for the presence of BV (a Nugent score of 0–3 was interpreted as negative for BV and a score of 4–6 as intermediate while a score of 7–10 was interpreted as consistent with BV) and yeast. The second swab (cervical or cervicovaginal) was used to inoculate onto chocolate agar and it was then squeezed thoroughly into a falcon tube containing molecular grade water for DNA extraction. The DNA was extracted using Chelex® (Sigma Aldrich, MO, USA) and amplified for detecting the presence of TV, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) using polymerase chain reactions (PCRs), as described earlier[10],[11] [Supplementary File]. The chocolate agar and blood agar plates were incubated in a CO2 incubator (Binder, GmbH Germany) at 37°C for at least 72 h, the plates were examined for the presence of any visible growth. The colonies so obtained were spotted onto the MALDI-TOF MS target plates and identified using MALDI Biotyper (Bruker Daltoniks, GmbH, Germany).[INLINE:1]
The third swab, whenever available, was used to inoculate PPLO broth for the isolation of Mycoplasma spp. and Ureaplasma urealyticum. The urine specimens obtained were subjected only to PCR, as described earlier[10],[11] [Supplementary File].
Data collection and analysis
Clinical history was collected from all patients with regard to symptoms of STI. The confidentiality of all patients was maintained. High-risk behavior (as informed by the NGOs) was kept anonymous and not included in analysis. The age, specific symptoms, and results of the three swabs were maintained and analyzed in Excel (Microsoft Incorp., USA).
Statistical analysis
The analysis was performed using GraphPad (GraphPad Software Inc., USA). Discrete variables were presented as percentages and Chi-square with Fisher's exact test was applied for the analysis of categorical variables. A P < 0.05 was considered to be statistically significant.
| Results | | |
Out of 3217 specimens received in our regional STI laboratory during the study, 2179 (67.7%) were from female patients and the remaining 1028 (31.9%) were from male patients. Out of 2179 female specimens, 707 were serum specimens sent for rapid plasma reagin/Venereal disease research laboratory and were hence excluded from the study. Of the remaining 1472 specimens, 1433 were swab specimens (97.4%) (1372 [93%] were cervicovaginal swabs, 56 vaginal swabs [3.8%], 3 cervical swabs [0.2%] and 2 ulcer swabs [0.1%]) and remaining 39 (2.6%) were urine specimens. The mean age of study patients was 31.71 years and all were married.
Results of clinical profile of patients
On examination, the inflammation of the cervicovaginal canal was seen in 383 patients, of whom 236 (51.6%) had vaginitis, 126 (51.6%) had cervicitis, and 21 (47%) had vaginitis and cervicitis both [Figure 1]. The maximum occurrence of inflammation was observed in the age group of 25–35 years (51.6%) followed by 18–25 years (23.7%) for vaginitis and 35–45 years (23.8%) for cervicitis. Females aged >45 years had inflammation in <10% of cases.{Figure 1}
Out of 1472 female patients, 459 (31%) were asymptomatic and 1013 (69%) had one or more symptoms of RTI/STIs [Table 1] and [Table 2]. The most common presenting symptom was vaginal discharge in 707 (69.8%), followed by infertility in 266 (26.2%), genital itching in 60 (5.9%) patients, lower abdomen pain in 47 (4.6%), and burning micturition in 16 (1.6%) of female patients. Among 266 patients having infertility, primary infertility was seen in 201 (75.6%) and secondary infertility was seen in 65 (24.4%) and two patients (0.1%) had a genital ulcer.{Table 2}
Results of microbiological investigations
Wet mount examination, gram stain, and culture were performed for all 1433 swab specimens. TV was observed on wet mount examination in 26 cases (1.8%). Gram stain showed BV (score 7–10) in 269 (18.7%) patients; BV intermediate (score 4–6) in 323 (31.8%) patients; Gram-positive budding yeast cells in 100 (9.8%) patients and Gram-negative diplococci suggestive of NG in 2 (0.2%) patients. The culture showed growth of small transparent colonies in 2 specimens and creamy white colonies in 100 specimens. MALDI-TOF MS identified the transparent colonies as NG and creamy white colonies as Candida species. Six different species of candida were identified, the most common being C. albicans (65%) followed by Candida glabrata (24%). Mycoplasma spp. and UU were observed in PPLO broth in five cases each. Swabs from two patients of genital ulcer did not reveal any organisms targeted in the present study.
PCR for CT, NG, and TV was performed in 1314 of the 1472 specimens. PCR was found to be positive in 15 cases (1.1%); 11 were TV, 3 were NG and 1 was CT.
Prevalence of different sexually transmitted infections among females
The most common STIs prevalent in our study were BV 18.2% (269/1472) followed by VVC in 6.8% (100/1472) and TV in 1.9% (28/1472). Mycoplasma hominis and Ureaplasma urealyticum were detected in 5 (0.33%) cases each; NG in 4 (0.27%) and CT in 1 (0.06%). There were 40 (2.7%) cases of coinfection [Table 3], with two patients having a triple infection and one patient having a quadruple infection. The most common causative agent responsible for VVC in our study was C. albicans (65%), followed by C. glabrata (24%).{Table 3}
Results of the association of different symptoms with different STIs are shown in [Table 2].
Among the various symptoms, vaginal discharge was found to have significant association with BV (P = 0.0033, odds ratio [OR] = 1.74, 95% confidence interval [CI] 1.2, 2.51) and TV (P = 0.001, OR = 11.92, 95% CI 1.61–88.26). Among the characteristics of discharge, watery discharge was associated with TV (P = 0.0001, OR = 0.01, 95% CI 0.0.02). Greenish discharge was associated with TV (P = 0.0001, OR = 1518.75, 95% CI 180.32, 12791.62) and white discharge was associated with VVC (P = 0.0001, OR = 37.04, 95% CI 7.29, 188.11).
Infertility, as a whole, was found to be associated with VVC (P = 0.045, OR = 0.54, 95% CI 0.29, 0.99) and TV (P = 0.025, OR = 0.22, 95% CI 0.05–0.93), however no association was found when primary and secondary infertility were evaluated separately. No association was seen among symptoms of urinary tract infection like burning micturition and lower abdominal pain with either BV or VVC or TV [Table 2].
| Discussion | | |
In the present study, the mean age of female patients with RTI/STI was 31.9 years. This is lower than the mean age of 36 years as reported by Sarkar et al. but falls within the range of 25–35 years, as reported by Rajalakshmi and Kalaivani.[12],[13] In our study also more than half of the patients (51%) with vaginitis, cervicitis, and combination of both were aged between 25 and 35 years [Figure 1]. This is higher than that reported in the study by Garba, wherein 33% of symptomatic Nigerian women belonged to this age group.[14]
Out of the 1013 symptomatic females, the most common symptom observed in our study was vaginal discharge seen in 707 (69.8%) patients followed by infertility in 266 (26.2%), genital itching in 60 (5.9%) patients, lower abdomen pain in 47 (4.6%) and burning micturition in 16 (1.6%). These findings are in tune with the study by Narayankhedkar et al. wherein the most common presenting symptoms were vaginal discharge followed by vulval itching/irritation, malodor, pain abdomen, and dysuria.[15] The incidence of vaginal discharge among all female patients of our study (32.4% [707/2179]) was higher than that reported by Sarkar et al. where it was found to be 25% for nontribal females and 14% for tribal females.[12]
BV was found to be the most common STI in our study, with a prevalence of 18.2%. Our findings are in concordance with a community study by Narayankhedkar et al. wherein BV was identified in 17.3% of women of the reproductive age group in Mumbai.[15] Other studies have reported a large variation in the prevalence of BV, ranging from 5 to 50%, mostly arising due to the selection of the specific patient population, economic status and educational background of the patients, and microbiological tools used for the detection of BV.[16] Rajalakshmi and Kalaivani., among their asymptomatic patients, noted a higher prevalence of 59%, while Bitew et al. reported a prevalence of 48.6%among women with vaginitis attending a hospital in Kochi.[13],[17] In the east of Yemen, BV was reported among 39.2% of pregnant women.[18] We found a significant association between BV and discharge (P = 0.005; i.e., women with BV were 1.69 times more likely to have vaginal discharge than those without BV. No significant association of BV was seen with infertility and urinary tract infection (UTI). This is in accordance with Garba, who also found that the symptoms of vaginal discharge were significantly associated with BV.[14]
The second most prevalent STI in our study was VVC contributing to an overall prevalence of 6.8%. This is slightly lower than 7.8% reported by Rajalakshmi and Kalaivani. and 7.5% reported by Pawanarkar et al.[13],[19] These differences could be attributed to variations in patient populations and detection methods selected in these studies. A statistically significant association between VVC infection and the presence of white discharge (P = 0.0001, OR = 72.4, 95% CI 15.61, 335.81) was seen, which corroborates with findings of Narayankhedkar et al.[15]
A weak association of candidiasis with infertility was seen with a P = 0.045 (OR = 0.54, 95% CI 0.29, 0.99); the association was lost when primary and secondary infertility were analyzed separately. Although studies have shown that C. albicans have sperm immobilizing activity, how much of this actually contributes to infertility is not yet determined.[20],[21] A previous study done by Vander et al. in mice showed that when sperm immobilizing strains of C. albicans were intravaginally injected in female mice, it showed a decrease in fertility in all groups as compared to control mice.[20] However, they did not cause clinical and histopathological changes in the genital tract of mice, thus showing that their colonization in the genital tract might impair sperm motility. Mathur et al. showed that in patients with chronic vaginal candidiasis of 5 years duration, a high titer of auto-antibodies to ovary was present, which might be due to the presence of one or more cross-reactive antigens on ovarian follicle and Candida spp.[22] Thus chronic vaginal candidiasis might be associated with decreased ovarian function, thereby affecting the fertility outcome.
Trichomoniasis, the third most prevalent STI, was detected in 1.9% of patients in our study. Narayankhedkar et al. also reported a similar prevalence of 1.8% for TV.[15] Other studies have reported differences in prevalence ranging from <1% in the USA to 4.8% in Senegal.[23],[24] A greenish discoloration was found to be significantly associated with TV discharge (P = 0.0001). This is in concordance with the typical characteristics of TV-associated vaginal discharge reviewed by Petrin et al.[25]
The other less common STIs, prevalent among the female patients, were NG detected in 4 (0.27%) patients and CT in one patient (0.06%). MH and UU were detected in 5 patients each. Maraki et al. have reported a prevalence of 0.6% for MH and 1.7% for UU.[26]
Mixed microbial etiologies were observed in 40 (2.7%) patients in our study with maximum cases of coinfection seen in association with BV (BV + TV IN 0.95% and BV + VVC in 0.95%) [Table 3]. Narayankhedkar et al. reported a mixed infection in 6.4%[15] and Khan et al. reported BV + VVC as the most common coinfection in 3.8% of cases.[27] It might be because women with BV tend to alter the vaginal pH thus predisposing to the acquisition of other coinfections such as TV and Candida.[28]
| Conclusion | | |
STIs were not uncommon among females in North India. The most common STI was BV diagnosed in 18.2% cases followed by VVC and trichomoniasis, coinfections were also encountered. BV was associated with vaginal discharge, VVC with white creamy discharge, and trichomoniasis with watery and greenish discharge. Cervicovaginal swab specimens served as a useful tool for the detection of common agents of STIs.
Financial support and sponsorship
Financial support from NACO and SACS is highly acknowledged.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | WHO Department of Reproductive Health and Research. Report on Global Sexually Transmitted Infection Surveillance, 2018. Geneva, Switzerland. World Health Organization; 2018.  |
| 2. | Jung HS, Ehlers MM, Lombaard H, Redelinghuys MJ, Kock MM. Etiology of bacterial vaginosis and polymicrobial biofilm formation. Crit Rev Microbiol 2017;43:651-67. |
| 3. | Balle C, Lennard K, Dabee S, Barnabas SL, Jaumdally SZ, Gasper MA, et al. Endocervical and vaginal microbiota in South African adolescents with asymptomatic Chlamydia trachomatis infection. Sci Rep 2018;8:11109. |
| 4. | Vodstrcil LA, Twin J, Garland SM, Fairley CK, Hocking JS, Law MG, et al. The influence of sexual activity on the vaginal microbiota and Gardnerella vaginalis clade diversity in young women. PLoS One 2017;12:e0171856. |
| 5. | Hardy L, Jespers V, Van den Bulck M, Buyze J, Mwambarangwe L, Musengamana V, et al. The presence of the putative Gardnerella vaginalis sialidase A gene in vaginal specimens is associated with bacterial vaginosis biofilm. PLoS One 2017;12:e0172522. |
| 6. | Hardy L, Jespers V, Dahchour N, Mwambarangwe L, Musengamana V, Vaneechoutte M, et al. Unravelling the bacterial vaginosis-associated biofilm: A multiplex Gardnerella vaginalis and atopobium vaginae fluorescence in situ hybridization assay using peptide nucleic acid probes. PLoS One 2015;10:e0136658. |
| 7. | Sobel JD. Vulvovaginal candidosis. Lancet 2007;369:1961-71. |
| 8. | Olowe OA, Makanjuola OB, Olowe R, Adekanle DA. Prevalence of vulvovaginal candidiasis, trichomoniasis and bacterial vaginosis among pregnant women receiving antenatal care in Southwestern Nigeria. Eur J Microbiol Immunol (Bp) 2014;4:193-7. |
| 9. | Coleman JS, Gaydos CA, Witter F. Trichomonas vaginalis vaginitis in obstetrics and gynecology practice: New concepts and controversies. Obstet Gynecol Surv 2013;68:43-50. |
| 10. | Khurana S, Dadwal R, Sharma N, Mewara A, Singh S, Bagga R, et al. Loop mediated isothermal amplification assay for detection of Trichomonas vaginalis in vaginal swabs among symptomatic women from North India. Lett Appl Microbiol 2020;70:196-202. |
| 11. | Sethi S, Roy A, Garg S, Venkatesan LS, Bagga R. Detection of Chlamydia trachomatis infections by polymerase chain reaction in asymptomatic pregnant women with special reference to the utility of the pooling of urine specimens. Indian J Med Res 2017;146:S59-63. |
| 12. | Sarkar S, Patra AC, Srinivas P, Ghosh A, Kushbaha G, Saha S. Pattern of sexually transmitted infections: A profile from a rural- and tribal-based sexually transmitted infections clinic of a tertiary care hospital of Eastern India. J Family Med Prim Care 2018;7:1042-6. [ PUBMED] [Full text] |
| 13. | Rajalakshmi R, Kalaivani S. Prevalence of asymptomatic infections in sexually transmitted diseases attendees diagnosed with bacterial vaginosis, vaginal candidiasis, and trichomoniasis. Indian J Sex Transm Dis AIDS 2016;37:139-42. |
| 14. | Garba DJ. Microbiological diagnosis of bacterial vaginosis in pregnant women in a resource limited setting in North Central Nigeria. Am J Life Sci 2014;2:356. |
| 15. | Narayankhedkar A, Hodiwala A, Mane A. Clinicoetiological characterization of infectious vaginitis amongst women of reproductive age group from Navi Mumbai, India. J Sex Transm Dis 2015;2015:817092. |
| 16. | Bhalla P, Chawla R, Garg S, Singh MM, Raina U, Bhalla R, et al. Prevalence of bacterial vaginosis among women in Delhi, India. Indian J Med Res 2007;125:167-72. [ PUBMED] [Full text] |
| 17. | Bitew A, Abebaw Y, Bekele D, Mihret A. Prevalence of bacterial vaginosis and associated risk factors among women complaining of genital tract infection. Int J Microbiol 2017;2017:4919404. |
| 18. | Al-Haik WM, Al-Haddad AM. Bacterial vaginosis among pregnant women in Hadhramout-Yemen. Alandalus J Appl Sci 2017;7:23-33. |
| 19. | Pawanarkar J, Chopra K. Prevalence of lower reproductive tract infection. Health Popul Perspect Issues 2004;27:67-75. |
| 20. | Vander H, Prabha V. Evaluation of fertility outcome as a consequence of intravaginal inoculation with sperm-impairing micro-organisms in a mouse model. J Med Microbiol 2015;64:344-7. |
| 21. | Tian YH, Xiong JW, Hu L, Huang DH, Xiong CL. Candida albicans and filtrates interfere with human spermatozoal motility and alter the ultrastructure of spermatozoa: An in vitro study. Jpn J Oral Biol 2001;43:530. |
| 22. | Mathur S, Melchers JT 3 rd, Ades EW, Williamson HO, Fudenberg HH. Anti-ovarian and anti-lymphocyte antibodies in patients with chronic vaginal candidiasis. J Reprod Immunol 1980;2:247-62. |
| 23. | Keating MA, Nyirjesy P. Trichomonas vaginalis infection in a tertiary care vaginitis center. Sex Transm Dis 2015;42:482-5. |
| 24. | Tine RC, Dia L, Sylla K, Sow D, Lelo S, Ndour CT. Trichomonas vaginalis and Mycoplasma infections among women with vaginal discharge at Fann teaching hospital in Senegal. Trop Parasitol 2019;9:45-53. [ PUBMED] [Full text] |
| 25. | Petrin D, Delgaty K, Bhatt R, Garber G. Clinical and microbiological aspects of Trichomonas vaginalis. Clin Microbiol Rev 1998;11:300-317. |
| 26. | Maraki S, Mavromanolaki VE, Nioti E, Stafylaki D, Minadakis G. Prevalence and antimicrobial susceptibility of ureaplasma species and mycoplasma hominis in Greek female outpatients, 2012-2016. J Chemother 2018;30:140-4. |
| 27. | Khan Z, Bhargava A, Mittal P, Bharti R, Puri P, Khunger N, et al. Evaluation of reliability of self-collected vaginal swabs over physician-collected samples for diagnosis of bacterial vaginosis, candidiasis and trichomoniasis, in a resource-limited setting: A cross-sectional study in India. BMJ Open 2019;9:e025013. |
| 28. | Kenyon C, Colebunders R, Crucitti T. The global epidemiology of bacterial vaginosis: A systematic review. Am J Obstet Gynecol 2013;209:505-23. |
|
|
|
|
|
|
|
|
