MEET DELIA—PRETTY, DYNAMIC, AND AMBITIOUS. SHE WAS diagnosed with attention deficit disorder as a child, and comes in a few times a year for Ritalin refills. At twenty-seven, she is about to get her Ph.D. in geology. Delia has a great job lined up in Dallas, and can’t wait to shine there. We speak about life after graduation and her long-term goals. She wants to establish her career, pay back loans, and get married. What about kids? I ask. Oh, yes, for sure, she says with a smile, I’ve always known I wanted kids. My dream is to have three or four. And, Delia adds, fertility won’t be a problem, because in college she unfortunately had to get an abortion. So there are no worries in that area.
Delia’s enthusiasm is infectious, with her easy smile and positive attitude. Her future looks bright indeed. I share her excitement about all the good things yet to come, congratulate her on her accomplishments, and urge her to keep in touch.
She leaves, and I review her records. The treatment for ADD has been straightforward, and does not concern me. But her women’s health history has red flags.
Sexually active at sixteen, one STD, one abortion, on the pill for seven years, eleven lifetime male partners.
Nothing that unusual—her history is like that of many of her peers. Still, Delia’s sexual lifestyle puts her at risk for some problems when she decides to start her family. The reason: an infection treated long ago, so long it’s nearly forgotten—chlamydia.
At the time, Delia took antibiotics for a week, as did her boyfriend. Testing negative a few months later, they were pronounced cured. No infection, clean as a whistle, like it never happened. Another miracle cure, thanks to antibiotics? The current experts say…maybe.
My medical school text, published the year Delia was born, describes Chlamydia trachomatis as a cause of blindness in third-world countries, spread by dirty fingers and flies. 1 Only secondarily does it mention the bacteria as a venereal disease, as sexually transmitted diseases were called then. By the time Delia was a teen, chlamydia was gaining ground as an STD. Now it’s the most common sexually transmitted bacteria, responsible for three million new cases a year in the United States, most of them in young women.
Yes, that’s three million new cases a year. The yearly cost of managing chlamydia and its consequences: $2.4 billion.
It’s a clever little bug. 2 It sneaks into a healthy cell, hides out, pilfers food, and multiplies. It evades detection in the most ingenious ways, for instance, by wrapping itself in molecules stolen from the host’s own skin, fooling the cell into thinking it belongs there. The chlamydia outsmarts its host, who is blind to the enemy within until the end.
When the body gets wind of the attack, it reacts with inflammation. White cells and chemical messengers arrive to contain the invasion by walling it off. There is swelling and heat, but usually too little to cause pain or fever. Normal tissue is damaged, and in healing forms a scar. That’s not usually a big deal, unless the scar is in a structure with a tiny canal, like the fallopian tubes.
You see, in a woman, chlamydia starts in the lower genital tract, with infection of the opening of the uterus. That’s not so dangerous; there are other organisms there, and the vagina has a pretty effective self-cleaning system. But sometimes the bugs travel quietly through the cervix, perhaps by hitching a ride on a sperm going that way. They reach the uterus and then settle down in the fallopian tubes, areas that are normally sterile. The diameter of the tubes is about one millimeter. As they are so narrow, it doesn’t take much of a scar to block or even seal them closed. Scarred tubes cause ectopic pregnancy—which can kill—and fertility problems.
About four inches long, the fallopian tubes retrieve the egg from the ovary and carry it toward the uterus. It’s worthwhile spending a moment describing the remarkable way this happens. 3
It’s like a complex dance, or a symphony. There are players, choreography, movement, rhythm, a beginning and an end. Instead of ballerinas and a wind section, there are specialized cells and messengers in the blood. They have dry, lifeless names—columnar epithelium, endosalpinx, prostaglandin F2a—that belie their mystery and wonder.
Every month, a message from the brain to the fallopian tubes says: Get ready—an egg is on the way. Drop down to the ovary, sweep its surface, and find the ovum about to be released. Contract your muscles and lift up the egg. Rev up the cilia, the tiny hairs; pull in the prize with their current. Make juice, and make it rich—then nourish the egg, and watch it grow. Now relax your muscles, float the egg downstream, and prepare for the big moment: fertilization.
For all this to go off without a hitch requires precise timing and coordination, exact levels of hormones, and exquisitely sensitive cells. And so it is: a weak message from the brain—no ovum matures. Cilia beating out of sync—the egg is lost. Fluid gone awry—it starves. A canal too wide will rush it, but in a narrowed one, the egg may get stuck. Estrogen low when you need it, or high when you don’t, and the whole operation is out of whack. A million things could go wrong in that four-inch area.
Did Delia’s infection reach her tubes? There’s no way to know now, without doing invasive tests. It’s possible she was treated early, before the bacteria had a chance to travel. That’s the best scenario: the bacteria are gone, and her tubes are wide open.
But what’s “early”? Time is of the essence in treating chlamydia; we’re in a race to get it before it advances. Once it reaches the tubes, it may be impossible to eradicate. 4 Sexually active women who show up for their yearly checkups should be routinely screened for chlamydia, and treated if positive. But what if they were infected months earlier? How long does it take for the bacteria to reach the tubes? We don’t know. In the female pig-tailed macaque monkey, it takes about eight weeks. 5
There’s more we don’t know. We don’t know, for one thing, how well the screening test identifies cases where the infection is dormant. A negative result does not guarantee the absence of infection. 6 We’re not sure which antibiotic is best, or how long treatment should last. We don’t know if treatment always wipes out the whole infection. It’s possible that in some cases, medication temporarily stops the bacteria from reproducing, only to be reactivated later. 7 And we don’t understand why women with chlamydia are more likely to get cervical cancer.
We do know that most women who have been infected discover it in a startling way—when they can’t conceive. Since in up to 80 percent of infected women, chlamydia produces no pain, fever, or discharge, a woman thinks she’s fine. Like her infected cells, she’s an unsuspecting hostess to a dangerous guest. Years later, when she’s settled down, married, and put the partying and hookups behind her, she’s told that her blood has antichlamydial antibodies—evidence of old infection. The doctor puts a scope through her navel to look at her fallopian tubes, and discovers they are enlarged and scarred by adhesions. And this is the reason she cannot have a baby.
The experts say that Delia may hear this someday, because she has some of the risk factors that may lead to chlamydia infection: intercourse at an early age, many partners, and possibly use of oral contraceptives. Having intercourse at an early age was dangerous because—as explained earlier—her immature cervix had a larger transformation zone, containing cells that are more susceptible to infection. These vulnerable cells form a bright red circle in the center of the cervix. Delia’s teenage cervix provided a larger target area for infection than if she had waited until she was older. 8 With each new man in her life, Delia increased the likelihood of infection because men are not screened unless they have symptoms. As a result, there is a huge pool of infected men unknowingly passing the infection along, especially on college campuses. 9 If Delia is like the majority of college students, she’s used condoms inconsistently. 10 Finally, there’s the pill. It’s suspected, but not yet proven, that oral contraceptives may facilitate infection by enlarging the transformation zone, 11 or by decreasing the amount of menstrual blood, which can act to flush the bacteria down and out.
But let’s think positive. Let’s assume Delia’s treatment was effective, the antibiotics eliminated the chlamydia, and her subsequent liaisons did not re-expose her. Her tubes are healthy, the plumbing is in order. She’s out of the woods, right?
Not necessarily.
There’s one more thing to consider—Delia’s memory of the infection. Not her cognitive memory, the recall of details like the boy’s name and what it was like to find out. It was ten years ago, her freshman year. She was a bit wild for a time, did her share of drinking and partying: it was a phase. She hardly remembers the details—what for?
We’re not talking names, places, when, and how. Delia carries in her a different sort of memory—an immunological one. And although she may have forgotten the chlamydia affair, her white cells surely have not.
It works like this. While the chlamydia were hiding out in Delia’s cells, they made a type of protein called hsp. This molecule has many different jobs and comes in lots of varieties. The hsp was released when the cell died. Her white cells, on the patrol for alien matter, correctly identified the hsp as foreign, and made antibodies. In the process, the white cells memorized the architecture of the hsp.
Fast-forward a dozen years. An egg has been fertilized, and the embryo is newly implanted in Delia’s uterus. A positive pregnancy test! She’s overjoyed. But one of the first proteins the embryo makes is a type of hsp, and it’s very similar to the chlamydial hsp. That’s not good. White cells see the new hsp and can’t tell the difference—they think it’s the chlamydia infection acting up. They signal for help. Specialized fighter cells and toxins arrive, ready to destroy. They believe their target is a hostile invader, but it’s not. It’s the embryo.
This autoimmune mechanism causes early pregnancy loss and decreased in vitro fertilization success, even years after an apparently successful antibiotic treatment. 12 This was first published in the medical literature in 1994. Delia was in tenth grade, fifteen years old. By the time she entered college, were young women warned? Could she have known?
No, on both counts. And what’s puzzling is that today’s college students—unless they happen to subscribe to Infectious Diseases in Obstetrics and Gynecology—also can’t possibly know.
This is alarming. Medical journals tell of finding chlamydial DNA in fallopian tubes, even after treatment, and describe how chlamydial hsp causes miscarriage years after silent infections. 13 They report that antibiotics might be more successful if extended to one week, instead of the current recommendation of one day. 14 But Delia doesn’t read these journals. She gets her STD information from other sources, and those sources depict chlamydia as easy to detect and treat. For example, consider the Columbia University health information Web site goaskalice.com. Here Delia would learn that if she screens positive for the bacteria, she’ll take a “simple and effective” course of antibiotics. In a few months, she’ll return for retesting, but in the meantime, she can rest assured—only untreated infections cause sterility.
Let’s take a closer look. First, consider the detection process. The question of who to screen, and how often, is open to question. The recommendation to screen women annually is arbitrary, based in part on cost-effectiveness. 15 The test is expensive, and the argument is made that the extra cases detected with more frequent screening do not justify the expenditure. Some experts propose more frequent screening for high-risk groups like women under twenty-five, maybe every six months. 16 Others have shown that treatment of asymptomatic men will reduce disease in women, but no one screens asymptomatic men. 17 Then there’s the test itself. The gold standard these days is a urine test, but there is some risk of false negatives. 18 An infected woman who tests negative will believe she’s fine, an assumption that could be perilous for herself and others. Next, the antibiotic “cure.” Antibiotics cure chlamydia—sometimes. When they don’t, the infection can persist for years, evading detection and damaging the tubes. Finally, years after an infection and regardless of treatment, an autoimmune reaction can occur, sometimes fatal to an embryo.
“Simple and effective” treatment for chlamydia? Not always. Not for everyone.
Student health and counseling centers are in a unique position to make these facts known to their students, and they know it. The editor of the Journal of American College Health put it this way: “Perhaps what most distinguishes college health from healthcare in any other form or setting is the opportunity it offers…. College health has the chanceto marry a pivotal developmental moment with very focused resources to produce a greater probability that students will enjoy healthy lives.”19
The opportunity is taken seriously, and health centers make it their responsibility to educate students about all sorts of health issues. To take an obvious example, they offer flyers on nutrition, explaining carbs, proteins, and saturated and unsaturated fat. Students learn that high cholesterol causes plaque, clogged arteries, and heart attacks. They know that sunscreen is necessary to protect against melanoma. And is anyone on campus unfamiliar with the finer points of exercise: aerobic, anaerobic, cardio, how often and for how long? The message is loud and clear: learn about good health, take care of yourself. There are consequences to your lifestyle, so work at changing it. Have the fruit instead of the pizza, take the stairs, not the elevator. Sure, it’s not so fun, it takes discipline and self-control, but hey, that’s what we’ve got to do to stay healthy. Later on, you’ll be glad you did!
As another example, here’s how the Journal of American College Health sees the issue of osteoporosis prevention:
College students of all ages deserve to be educated about the risk factors that lead to osteoporosis. Young women, in particular, need to be informed about how proper nutrition and regular exercise can help them achieve optimal peak bone mass. They need to be aware that a diet low in calcium and vitamin D as well as smoking, alcohol abuse, steroid use, high-protein diets, and both physical inactivity and excessive exercise may have a negative impact on the lifetime health of their bone structure and may predispose them to a higher risk of osteoporosis in later years.20
Question: If there is a need to educate a twenty-something-year-old woman about the prevention of a postmenopausal condition, is there not an equal or greater need to make sure she’s well informed about fertility?
Given that many college women postpone childbearing longer than ever, and others expose themselves to genital bacteria and viruses, one might wonder why we don’t find a warning of this sort in the campus health literature:
College students of all ages deserve to be educated about the risk factors that lead to infertility. Young women, in particular, need to be informed about when is the optimal period in their reproductive lives to conceive and deliver a healthy child. There are always exceptions, but they need to be aware that often waiting until after age thirty-five, as well as smoking, obesity, and having more than one lifetime sexual partner, may have a negative impact on their ability to conceive and may predispose them to a higher risk of infertility, spontaneous abortion, miscarriage, and childlessness in later years.
Questions for student health professionals: Where’s the pamphlet on how to keep your reproductive system buffed? Where are women reminded that they have within them a sensitive ecosystem, where each month a complex, fine-tuned production takes place? How about introducing the terms cervical transformation zone and chlamydial hsp to the vocabulary of college women, so they can understand their physiology, and see clearly why promiscuity is so dangerous? Maybe there is a place in health promotion for some respect—even awe—for how a woman’s body prepares for conception. And maybe there’s a place for this warning: Don’t take it for granted and mess with it, counting on a prescription to make it like new.
There’s something else campus health centers can do. They can require all incoming students who are sexually active—both women and men—to be tested for chlamydia, the way international students are tested for tuberculosis. Just as healthy students deserve protection from a coughing, TB-infected classmate, young college women deserve protection from that popular frat boy, you know the one, who always has a few girls hoping to spend time with him over the weekend. He may be sharing more with them than his smile.
In the 1970s, a woman with tubal damage who could not conceive was sometimes told that maybe a virus had damaged her system in childhood. A doctor wanted to be able to tell his patient—distraught, hopeless, and desperate to understand what caused her condition—something, and having a reason helped her peace of mind. 21
Now we are wiser. We know that for many women, the cause of their misery is this horrible little bug, and we know what it looks like, how it invades, and where it hides. But there’s a gap between what we have discovered about chlamydia in the laboratory and what we communicate. What we know—and have known for over a decade—is sobering, but what we tell young people is sugarcoated. It’s so oversimplified and incomplete as to border on misinformation.
How this happened and continues to happen, I don’t know. But it is profoundly disconcerting that this is the case, when three million young women will be infected just this year. When I think of this information not reaching those who need it most, I see red. How dare anyone decide to withhold, not to fully inform? Who composes all the patient information, anyway, and who gives them the right to teach half-truths, to whitewash, sugarcoat, oversimplify, and reassure when there’s still room for worry?
In how many of those women will chlamydia bring the nightmare of infertility or habitual miscarriage? With so much at risk, how can we fail to reach every young woman and spell it out: Even if you’re “good,” even if you get tested and take antibiotics, this bacteria can hurt you. Sometimes there is no cure. If you want to be a mother someday, this bug can destroy your dream.
For women like Delia, having a family is one dream of many. When it comes to their dreams of grad school, travel abroad, a job, or financial stability, there’s loads of guidance, all of it accurate and up-to-date: how to study for the SATs, get accepted to the right college, find a summer internship, ace the GREs, get into grad school, complete a thesis, write a résumé, prepare for a job interview. But when it comes to their fertility, their knowledge is likely not so accurate. When it comes to that particular dream, they may not be so well informed. Is this another example of the PC agenda: sex without consequences, career over motherhood, women are just like men? It makes me livid to realize that, due to misinformation, whitewashing, and lack of warning, young women may be blind to the risks they are taking. How many of them will never know pregnancy and motherhood, experiences central to a woman’s essence?
But it’s too late to intervene; the harm’s been done. Delia’s on her way to Dallas, building her future, fully expecting to have it all: career, husband, kids. She’s worked hard, and deserves to succeed. I hope fate will smile on her and grant her healthy, beautiful babies, as many as she wants. If not, she, like many others, will pay a heavy price.