Frequency and patterns of abnormal Pap smears in Sudanese women with infertility: What are the perspectives?

BACKGROUND: Pelvic inflammatory disease is one of the major causes of infertility in females. Also, women with infertility are at high-risk of developing cervical intraepithelial lesions or even carcinoma. AIM: To assess the prevalence and patterns of epithelial cell abnormalities in cervical smears in Sudanese infertile and fertile women.
MATERIALS AND METHODS: The present study included 200 cases (women with infertility) of age group 20-60 years who had routine pap smear. A total of 700 fertile women constituted the control group.
RESULTS: Among the 200 infertile women, 93.5% reported as negative for intraepithelial lesion or malignancy (NILM), and 6.5% were epithelial cell abnormalities (atypical squamous cells of undetermined significance and above). In the control group 96.6% of the smears reported as NILM and 3.4% as epithelial cell abnormalities. The percentage of abnormal pap smears in the infertile women was significantly higher when compared with the control group.
CONCLUSIONS: Epithelial cell abnormalities are significantly higher in women with infertility as compared with fertile women. Importantly, inflammatory smears were reported two times more than in the controls. We recommend pap smear as a routine practice for all women assessed for infertility problems. Further studies are necessary to evaluate the incidence of human papilloma virus infections in infertile women with abnormal cervical cytology.

Introduction

Infertility is a global health issue affecting approximately 8-10% of couples.[1] Usually infertility is secondary to pelvic inflammatory disease, which is commonly caused by sexually transmitted diseases (STDs), especially Chlamydia trachomatis (CT).[2] The facts that women with infertility are exposed to STDs and human papilloma virus (HPV), and usually treated with exogenous hormones, supported the theory that women with infertility are at high-risk of developing cervical intraepithelial lesions or even carcinoma.[23] In Sudan, infertility is a common health problem with high proportion of secondary infertility and a greater contribution of the female factors to infertility. Failure of ovulation is the most common cause of female infertility in Sudan.[4]

The pap test is considered by many to be the most cost-effective cancer reduction program ever devised.[5] The pap smear or Papanicolaou test is a microscopic examination of cells taken from the cervix. It is primarily designed to detect pre-malignant and malignant processes in the cervix. Furthermore, it can also be used to detect non-cancerous conditions such as infections and inflammation. Cervical cancer is a common health problem in Sudan, and account for about 17% of all cancers in Sudanese women and is the second cause of death after breast cancer. Alarmingly, about 78% of women present with stage III or IV and this is attributed to the lack of a national screening program for cervical cancer in Sudan.[6] The aim of this study is to evaluate the cytological findings of 200 cervical smears collected from women with infertility who attended the gynecological clinics and on opportunistic screening base. The findings were compared with cervical smears from control group of 700 fertile women.

Materials and Methods

In this prospective case-control study we included 200 women with infertility who consulted the Department of Obstetrics and Gynecology in the period from February 2010 to June 2011. The control group comprises 700 fertile women who had had a cervical smear. Cervical smears in the case group were collected from all women with infertility irrespective of the age and causes of infertility. The smears were stained with conventional papanicolaou stain and screened by senior cytologist and abnormal cases reviewed by consultant cytopathologist. Demographic and clinical data (irregular bleeding, discharge, pelvic inflammatory disease (PID), abortion) were considered. The results of control cases were retrieved from Cytopathology Department of Reproductive Health Center and smears reported as unsatisfactory were excluded. Epithelial cell abnormalities included, atypical squamous cells of undetermined significance (ASC-US) and above. The 2001 Bethesda System was adopted to classify the epithelial abnormalities.[7] Test results with a probability value (P) of <0.05 were considered to be statistically significant. Statistical Package for Social Sciences (SPSS) version 14.0 software was used to perform the statistical analysis.

Results

The present study included 200 cases (women with infertility) of age group 20-60 years who had a pap smear. Majority of cases 82 (41%) belonged to age group (20-29) years and the mean age was 34 years. A total of 700 fertile women constituted the control group, of age group 20-60 years, and the majority of cases 364 (52%) at the age group 30-39, with mean age 38 years.

Among the 200 infertile women, 93.5% reported as negative for intraepithelial lesion or malignancy (NILM), and 6.5% were epithelial cell abnormalities (ASC-US and above). In the control group 96.6% of the smears reported as NILM and 3.4% as epithelial cell abnormalities. The percentage of abnormal pap smears as observed in the cases was significantly higher when compared with the control group (P = 0.014; i.e., P < 0.05) as shown in Table 1.

Table 1

Distribution of cervical cytology amongst cases and controls

The distribution of abnormal cervical cytology in the two groups is summarized in Table 2. The cases group showed more smears reported as atypical glandular cells (AGC) (15.4% in cases, and 4.2% in control group). No smear was observed with adenocarcinoma in the infertile women, while 8.3% smears were diagnosed as adenocarcinoma in the control group. The cases and controls showed similar results regarding the low-grade squamous intraepithelial lesion (LSIL) (6 (46.2%), and 11 (45.8%)) respectively. However, 3 smears out of the 6 in the cases showed HPV changes (Koilocytosis) [Figure 1]. Graph 1 summarized the percentage of the distribution of inflammatory pap smears findings in the cases. Bacterial vaginosis (BV) was the most frequent finding (27 [51.9%]). Chlamydia trachomatis infection was suggested by the presence of intracytoplasmic eosinophilic inclusion surrounded by small hallo in metaplastic cells [Figure 2], and identified in 9 (17.3%) cases.

Table 2

Distribution of epithelial cell abnormalities in the cases and the controls

Figure 1

Low-grade squamous intraepithelial lesion, with human papilloma virus changes (Koilocytosis). (Pap, ×400)

Graph 1

Distribution of inflammatory pap smears findings in case population (n = 52). BV = Bacterial vaginosis, TV = Trichomonas vaginalis, NSI = Non-specific inflammation; HSV = Herpes simplex virus; FC = Follicular cervicitis; NB: Chlamydia indicates intracytoplasmic inclusion consistent with Chlamydia trachomatis

Figure 2

Metaplastic squamous cells with eosinophilic intracytoplasmic inclusion surrounded by clear halo (arrow) suggestive of Chlamydia infection. Background of numerous inflammatory cells. (Pap, ×400)

Discussion

Cervical cancer is the second most common cause of death in Sudanese women after breast cancer, and accounts for about 17% of all cancers.[6] In Sudan there is no national screening program for cervical cancer and cervical smear (pap test) is usually performed in an opportunistic bases for women consulting gynecologic clinics. Infertility is a common health problem with high proportion of secondary infertility and a greater contribution of the female factors to infertility.[4]

In this study, epithelial cell abnormalities were observed significantly more often in women with infertility (6.5%) as compared with fertile women (3.4%). These results are consistent with study conducted by van Hamont et al.[2] They observed abnormal pap smears in 6.1% of cases compared to 3.9% in the controls. Another study conducted in Saudi Arabia in 2010, reported abnormal cervical cytology in 29.5% in sub-fertile women in the study by Al-Jaroudi et al.,[8] however, this study lacked the control group of fertile women.[8] Different findings were reported by Lundqvist et al.[9] They reported abnormal cytology in 2.3% of the infertile women and 4.1% of the controls, however, the study has some limitations such as small size of the controls (197 women), and the age was not matched between the two groups.

Three smears out of the 6 reported as LSIL showed HPV changes (Koilocytosis) [Figure 1]. The category of AGC was observed in two smears (15.4%), and one smear (4.1%) in cases and controls respectively, however, distribution of abnormal pap smears in the two groups was relatively similar, and this may be attributed to the matched age, similar demographic, and geographic backgrounds in both cases and controls. Limitations of our study is the difficulty with cyto/histology correlation and patients follow-up resulting from absence of addresses as majority of subjects of the study (women) were either nomads or coming from remote areas.

Available evidence suggests that majority of infertility cases in Sudanese women are associated with previous genital tract infections. In this study inflammatory smears were observed in 52 (26%) of infertile women, however, cervical cytology is believed to be inaccurate test in the evaluation of gynecologic infections, and in most cases further microbiology and immunology investigations are highly recommended. The most frequent findings in our study were BV in 27 (51.9%) cases, followed by intracytoplasmic inclusion suggestive of CT infection in 9 (17.8%) cases [Figure 2]. Chlamydial infection is an important source of gynecological morbidity, being commonly associated with acute and chronic PID and therefore, infertility.[10] Prevalence of C. trachomatis infections varies from 5% in asymptomatic women in the general population to 24% in women assessed for fertility problems.[1112] Recent studies have shown that HPV persistence is associated with concurrent Chlamydia infection and that C. trachomatis antibodies were associated with a significant increase of squamous cell cervical cancer.[1314] These findings indicates that C. trachomatis might increase the host susceptibility to HPV or enhance the effects of HPV. However, pap smear is not an ideal modality for the detection of Chlamydia infections, and currently different immunologic and molecular tests are available.

Conclusions

In conclusion, cervical epithelial cell abnormalities are common findings in both fertile and infertile women. However, this study observed abnormal pap smears significantly more often in women with infertility as compared with fertile women. Inflammatory smears were reported two times more in cases in comparison with controls. These findings support the association between genital tract infections and infertility. This may in part support our hypothesis that women with infertility had higher frequency of epithelial cell abnormalities than fertile women. We recommend pap smear as a routine practice for all women visiting gynecologic or STDs clinics with infertility problems. Further studies are necessary to evaluate the incidence of HPV in infertile women with abnormal cervical cytology.