**8. Role of cervical-vaginal swab in overt lower genital tract infections**

#### **8.1. The vaginitis wet mount test**

It is the simplest and cheapest test to detect vaginal infection by taking a high vaginal swab to be examined by wet mount microscopy. It may detect vaginal yeast infection, trichomoniasis and bacterial vaginosis. Vaginal bleeding may alter the results. The patient should be instruct‐ ed to avoid condoms or tampon use or vaginal sex 24 hours before the test. Moreover, vaginal pessaries, creams or douches should not be used during the 2 to 3 days before the test.

The test is very easy where a speculum is inserted inside the vagina while the patient is in the lithotomy position to get a sample fluid from the upper vagina. The sample is then smeared on a glass slide mixed with few drops of saline and examined by wet mount microscopy. Normally, no yeast, trichomonas or clue cells are found on the slide.

#### **8.2. Additional vaginal discharge tests**

In a previous study [8], we performed more evaluation of vaginal discharge as a screening for bacterial vaginosis. Sterile cotton tipped swab was inserted in the posterior vaginal fornix, then two swabs were taken. The first swab was rolled on a clean slide, and then a drop of isotonic saline was added and the slide was examined microscopically (¥400) for the presence of clue cells;7 0.1 mL methylene blue was also added to the wet preparation, so that the blue stained bacteria on clue cells could be easily seen. A second swab of secretions was applied to a clean glass slide and allowed to dry in air. This sample was later fixed by flame and Gram staining was performed to visualize clue cells. The slide was examined under oil immersion microscopy (¥1000). After examination of vaginal discharge, the diagnosis of BV was made if three of the four criteria of Amsel and Thomson's criteria were fulfilled: these include thin homogenous vaginal discharge, vaginal pH 4.5, characteristic amine or fishy odor when alkali (10% KOH) is added to the specimen of vaginal secretions, and the presence of clue cells on wet mount examination of vaginal fluid. Clue cells are described as a vaginal epithelial cell with an illdefined outline that appeared to be granular because of the large number of bacillary *G.* *vaginalis* (and other bacteria) attached to their surface. To be significantly indicative of BV, more than 20% of the epithelial cells on the slide should be clue cells.

#### **8.3. Screening for Chlamydial Infection [9]**

composition of the microbiome. An understanding of the diversity of the vaginal microbial environment during states of health is essential for the identification of risk factors for disease

The effect of known pathogens such as Mycoplasma, tuberculosis, Chlamydia trachomatis, and Neisseria gonorrhoeae is clear, causing subclinical changes thought to be risk factors in subfertility. Colonizing the transfer-catheter tip with Lactobacillus crispatus at the time of embryo transfer may increase the rates of implantation and live birth rate while decreasing the rate of infection [6]. On the other hand, the presence of vaginal–cervical microbial con‐ tamination at the time of embryo transfer is associated with significantly decreased pregnancy rates [7]. Nevertheless, the exact implication of microbiome in infertility requires more studies.

**8. Role of cervical-vaginal swab in overt lower genital tract infections**

It is the simplest and cheapest test to detect vaginal infection by taking a high vaginal swab to be examined by wet mount microscopy. It may detect vaginal yeast infection, trichomoniasis and bacterial vaginosis. Vaginal bleeding may alter the results. The patient should be instruct‐ ed to avoid condoms or tampon use or vaginal sex 24 hours before the test. Moreover, vaginal pessaries, creams or douches should not be used during the 2 to 3 days before the test.

The test is very easy where a speculum is inserted inside the vagina while the patient is in the lithotomy position to get a sample fluid from the upper vagina. The sample is then smeared on a glass slide mixed with few drops of saline and examined by wet mount microscopy.

In a previous study [8], we performed more evaluation of vaginal discharge as a screening for bacterial vaginosis. Sterile cotton tipped swab was inserted in the posterior vaginal fornix, then two swabs were taken. The first swab was rolled on a clean slide, and then a drop of isotonic saline was added and the slide was examined microscopically (¥400) for the presence of clue cells;7 0.1 mL methylene blue was also added to the wet preparation, so that the blue stained bacteria on clue cells could be easily seen. A second swab of secretions was applied to a clean glass slide and allowed to dry in air. This sample was later fixed by flame and Gram staining was performed to visualize clue cells. The slide was examined under oil immersion microscopy (¥1000). After examination of vaginal discharge, the diagnosis of BV was made if three of the four criteria of Amsel and Thomson's criteria were fulfilled: these include thin homogenous vaginal discharge, vaginal pH 4.5, characteristic amine or fishy odor when alkali (10% KOH) is added to the specimen of vaginal secretions, and the presence of clue cells on wet mount examination of vaginal fluid. Clue cells are described as a vaginal epithelial cell with an illdefined outline that appeared to be granular because of the large number of bacillary *G.*

Normally, no yeast, trichomonas or clue cells are found on the slide.

and the development of appropriate treatment [5]

24 Genital Infections and Infertility

**8.1. The vaginitis wet mount test**

**8.2. Additional vaginal discharge tests**

The primary focus of chlamydia screening efforts should be to detect chlamydia infection, prevent complications and test and treat their partners. Several sequelae can result from *C. trachomatis* infection in women including PID, ectopic pregnancy, and infertility. *C. trachoma‐ tis* urogenital infection can be diagnosed in women by testing first-catch urine or collecting swab specimens from the endocervix or vagina. Nucleic acid amplification tests (NAATs) are the most sensitive tests for these specimens and therefore are recommended for detecting *C. trachomatis* infection [10]. NAATs that are FDA-cleared for use with vaginal swab specimens can be collected by a provider or self-collected in a clinical setting. Self-collected vaginal swab specimens are equivalent in sensitivity and specificity to those collected by a clinician using NAATs, and women find this screening strategy highly acceptable [11]. Previous evidence [12] suggests that the liquid-based cytology specimens collected for Pap smears might be accept‐ able specimens for NAAT testing, although test sensitivity using these specimens might be lower than that associated with use of cervical or vaginal swab specimens; regardless, certain NAATs have been FDA-cleared for use on liquid-based cytology specimens.

#### **8.4. Cervical screening opportunity**

Perfect diagnosis utilizing a simple bivalve vaginal speculum is the key of success for proper diagnosis and subsequent treatment of local genital tract infections. Don't ignore to screen for premalignant cervical lesions even if your patient is young. Premalignant cervical lesions usually precede invasive cervical cancer by about 17-25 years. So, your patient's health should have the priority before treating infertility. Screening starts by meticulous naked eye exami‐ nation of the cervix. It is a very important costless step. In a previous study [13], we tested the reliability of unaided Naked-Eye Examination (UNEE) of the cervix as a sole screening test for cervical premalignant and malignant lesions as compared to the standard cervical cytology. A total of 3,500 non pregnant women aged between 25 and 55 years were included. An unlubricated bivalve speculum was inserted into the vagina under good light to visualize the cervix. A thorough UNEE of the cervix was done to detect any apparent lesions. Cervical smears were obtained using the long tip of Ayre's spatula. An additional endocevical sample was obtained by cytobrush. Woman with abnormal Pap smear or visible cervical lesions by UNEE were scheduled for colposcopic examination. A biopsy was taken in every abnormal colposcopic examination. Preinvasive cervical lesions (CIN 1-3) diagnosed by various diag‐ nostic tools used in the study and confirmed by histopathological examination were 9 / 3500 cases (2.57 %). Invasive cervical lesions were diagnosed in 6 /3500 cases (1.71 %). The sensitivity of UNEE was much more better than Pap smear (80 % vs 60 %) but less than colposcopy (86.7 %). However, specificity of UNEE was lower than Pap smear (91.16 %) vs. 100 %) and better than colposcopy (83.12 %). UNEE had poor positive predictive value (3.75 %) when compared to Pap smear (100 %) and to colposcopy (20 %). The negative predictive values of the three tests were nearly comparable. Whenever access to Pap smear is limited, UNEE performed by general gynecologists and a well-trained nurse is an acceptable alternative for detection of cervical premalignant or malignant lesions especially in low resource settings. Optimally, a Pap smear should be taken routinely from every patient. Any suspicion of premalignant or malignant lesions deserves a colposcopically-guided biopsy.
