Title: Molecular Prevalence of Chlamydia trachomatis Infection among Women Attending
Gynaecological Clinic for Infertility Evaluation
Version: 0 Date: 07 May 2025
Reviewer:  Iheanyi Omezuruike Okonko
Reviewer's report:
An article of medical and public health interest.
STRENGTHS
Clear Rationale and Relevance: The study presents a pertinent public health problem in Nigeria
— infertility due to Chlamydia trachomatis — in a clinical environment where asymptomatic
infections are usually overlooked.
Background context is appropriately established by employing relevant regional data from both
local and international resources.
Use of Molecular Diagnostics (PCR):  The study utilises PCR of ompA gene, a highly specific
and sensitive molecular tool, with strong results compared to serological or antigen tests.
Adequate Sampling Frame: Focus on women who attend an infertility clinic helps ensure that
the population of interest is most likely to have asymptomatic infections that cause reproductive
problems.
Risk Factor Analysis: The study does not stop at prevalence but looks at associated risk factors,
like age, education, STI history, and PID — making it more useful for clinical and public health
interventions.
Multivariate Analysis: Logistic regression application adds strength to the findings by
controlling for confounders and identifying independent predictors of infection.
Ethical and Methodological Rigor: Ethical standards, anonymization of data, and well-specified
exclusion criteria are all observed.
WEAKNESSES
Small Sample Size: 135 participants is quite small for regression-based inference, and
generalizability is limited. The borderline p-values (e.g., education: p=0.05) may not be
replicated in a larger sample.
Sampling Bias: Consecutive sampling of clinic visitors may lead to selection bias — the findings
may not be generalizable to community-level prevalence or women suffering from infertility
who do not use formal care.
Overstated Statistical Interpretation: Some odds ratios are presented with confidence intervals
crossing clinically irrelevant thresholds, and in one case, the interpretation is reversed (e.g.,
OR=0.46 for young age indicates lower odds, but it is read as increased likelihood). A few
associations (e.g., foul odor discharge, p=0.08) are presented as though they are close to
significance, which may mislead readers about their significance.
PCR Temperature Error: There is a misprint in PCR annealing temperature ("[I65°C]") that
reflects sloppy proofreading and raises questions about methodology clarity.
Discrepant Terminology and Data Presentation: The text also uses overlapping/ambiguous terms
at times (e.g., "positive" and "infected" vs. "cases"), and the p-values/effects might have been
better represented by clearer tables or confidence intervals.
Failure to Genotype or Perform Strain Typing: The study stops at the identification of C.
trachomatis DNA and does not explore strain variation or antibiotic resistance determinants,
missing the opportunity for additional molecular epidemiology.
Analysis of Symptomatology Contributes Little
Symptom rating is weakly correlated with infectivity status and possibly not clinically relevant
in the context of the asymptomatic character of most CTIs. The evaluation here does not add
much diagnostic value.
Suggestions for Improvement
Sample Size and Power: Larger multi-center studies would be more generalizable.
Cross-sectional Design: A prospective cohort or case-control design would make causal
inference stronger.
Selection Bias: Random sampling of multiple sites would reduce bias.
Incomplete Symptom-Association Analysis: More subtlety in the discussion of asymptomatic
carriage and possible misclassification of symptoms would add interpretive depth.
Presentation Errors and Ambiguity: Better proofreading and better table formatting would be
more readable and professionally presented.
Discussion Underdeveloped: The authors should detail how the findings will impact STI
screening protocols, infertility treatment regimes, and educational campaigns.
Overemphasis on Statistical Significance: Clinical relevance, confidence intervals, and effect
sizes should be more emphasized at the expense of p-values only.
No Consideration of Male Partners: Male testing should be included in future studies to provide
a comprehensive picture of STI transmission dynamics and infertility.
OVERALL ASSESSMENT
This study does provide a strong contribution to scientific studies on Chlamydia trachomatis
and Nigeria's infertility, especially through the use of molecular techniques and measurement of
relevant risk factors. However, its usefulness is restricted to a narrow sample, shallow molecular
level, and omissions in analysis. Through improved design of the study, large-scale population
coverage, and the addition of a description of strain, the study may have had more extensive
public health impacts.
Although the study offers useful information with strong molecular tools, it could be made
stronger with more diverse and extensive samples, in-depth clinical importance analysis,
enhanced data presentation, and wider inclusion of public health implications. Strengthening
these areas may significantly enhance its value to STI research and infertility treatment in Nigeria
and internationally.