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Pregnancy and fertility-related adverse outcomes associated with Chlamydia trachomatis infection: a global systematic review and meta-analysis
  1. Weiming Tang1,2,
  2. Jessica Mao3,
  3. Katherine T Li4,
  4. Jennifer S Walker5,
  5. Roger Chou6,
  6. Rong Fu7,
  7. Weiying Chen8,9,
  8. Toni Darville10,
  9. Jeffrey Klausner11,
  10. Joseph D Tucker12,13
  1. 1 Project-China, University of North Carolina, Guangzhou, China
  2. 2 STI Control, Guangdong Provincial Center for Skin Diseases and STIs control, Guangzhou, Guangdong, China
  3. 3 Depatment of Obstetrics and Gynecology, Johns Hopkins University, Baltimore, Maryland, USA
  4. 4 Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
  5. 5 Health Sciences Library, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
  6. 6 School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
  7. 7 Department of AIDS/STD Control and Prevention, Guangzhou Center for Disease Control and Prevention, Guangzhou, China
  8. 8 Social Entrepreneurship to Spur Health, Guangzhou, Guangdong, China
  9. 9 Center for Chronic Disease Control, Shenzhen, Guangdong, China
  10. 10 Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
  11. 11 Medicine, University of California, Los Angeles, San Francisco, California, USA
  12. 12 UNC Project-China, Guangzhou, Guangdong, China
  13. 13 Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
  1. Correspondence to Dr Joseph D Tucker, UNC Project-China, Guangzhou 510075, China; jdtucker{at}


Background Genital chlamydia infection in women is often asymptomatic, but may result in adverse outcomes before and during pregnancy. The purpose of this study was to examine the strength of the relationships between chlamydia infection and different reproductive health outcomes and to assess the certainty of the evidence.

Methods This review was registered and followed the Cochrane guidelines. We searched three databases to quantitatively examine adverse outcomes associated with chlamydia infection. We included pregnancy and fertility-related outcomes. We performed meta-analyses on different study designs for various adverse outcomes using unadjusted and adjusted analyses.

Results We identified 4730 unique citations and included 107 studies reporting 12 pregnancy and fertility-related outcomes. Sixty-eight studies were conducted in high-income countries, 37 studies were conducted in low-income or middle-income countries, and 2 studies were conducted in both high-income and low-income countries. Chlamydia infection was positively associated with almost all of the 12 included pregnancy and fertility-related adverse outcomes in unadjusted analyses, including stillbirth (OR=5.05, 95% CI 2.95 to 8.65 for case–control studies and risk ratio=1.28, 95% CI 1.09 to 1.51 for cohort studies) and spontaneous abortion (OR=1.30, 95% CI 1.14 to 1.49 for case–control studies and risk ratio=1.47, 95% CI 1.16 to 1.85 for cohort studies). However, there were biases in the design and conduct of individual studies, affecting the certainty of the overall body of evidence. The risk of adverse outcomes associated with chlamydia is higher in low-income and middle-income countries compared with high-income countries.

Conclusion Chlamydia is associated with an increased risk of several pregnancy and fertility-related adverse outcomes in unadjusted analyses, especially in low-income and middle-income countries. Further research on how to prevent the sequelae of chlamydia in pregnant women is needed.

Trial registration number CRD42017056818.

  • chlamydia trachomatis
  • pregnancy
  • infertility
  • meta-analysis
  • women

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  • Handling editor Nicola Low

  • WT, JM and KTL contributed equally.

  • Contributors JM, WT and JDT drafted the protocol. JSW performed the literature search. JM, WT, WC and RF extracted the data. JDT solved the inconsistency in the data extraction process. RC and WT evaluated the quality of the evidence. JK, TD, RC and JM contributed ideas for analysis. WT and KTL did the statistical analysis and interpreted the results. KTL and WT wrote the manuscript with input from JDT, JK, TD, RC and JM.

  • Funding This work was supported by the National Institutes of Health [NIAID 1R01AI114310, K24AI143471, and R34MH119963].

  • Competing interests JK has received research support and donated testing supplies from Cepheid and Hologic.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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