Association of vaginal bacterial communities and reproductive outcomes with prophylactic antibiotic exposure in a subfertile population undergoing in vitro fertilization: a prospective exploratory study

Ashley M Eskew, Molly J Stout, Bronwyn S Bedrick, Joan K Riley, Brandi N Herter, Haley Gula, Emily S Jungheim, Kristine M Wylie, Ashley M Eskew, Molly J Stout, Bronwyn S Bedrick, Joan K Riley, Brandi N Herter, Haley Gula, Emily S Jungheim, Kristine M Wylie

Abstract

Objective: To determine whether prophylactic azithromycin is associated with the vaginal bacterial microbiome and clinical outcomes in subfertile women undergoing in vitro fertilization (IVF).

Design: Prospective exploratory cohort study.

Setting: Single academic fertility center.

Patients: Subfertile women aged 18-43 years undergoing their first IVF cycle and fresh embryo transfer.

Intervention: Primary exposure to prophylactic azithromycin (1 g orally) once at baseline.

Main outcome measures: The primary outcome was the effect of azithromycin on the vaginal microbiome compared with a no-azithromycin group at 3 time points throughout the IVF cycle (baseline, retrieval, and embryo transfer). The secondary outcomes were associations of vaginal bacterial communities with clinical outcomes.

Results: A planned a priori exploratory cohort of 27 subjects (12 in the azithromycin treatment group and 15 in the no-azithromycin group) contributed 79 vaginal swabs for the analysis as part of an ongoing randomized, controlled noninferiority trial. No specific taxa were associated with azithromycin or pregnancy at any time point. Azithromycin did not affect alpha diversity or community stability. Although there were trends of a lower bacterial load and higher percentage of Lactobacillus species in the azithromycin group at the time of transfer, these were not statistically significant. In women who did not become pregnant, the percentage of Lactobacillus species was lower (P = .048; Hodges-Lehmann estimate of difference, 0.41; 95% confidence interval, 0.08-0.65) and the change in community composition over time was higher. The percentage of Lactobacillus species at baseline was not predictive of the percentage of Lactobacillus species at the time of embryo transfer.

Conclusions: Prophylactic azithromycin at baseline is not associated with changes in vaginal bacterial communities. Bacterial community features at the time of embryo transfer are associated with pregnancy. Bacterial community structures at baseline are not predictive of those at the time of embryo transfer.

Clinical trial registration number: NCT03386227.

Keywords: IVF outcomes; Vaginal microbiome; prophylactic antibiotics; reproductive microbiome.

Figures

FIGURE 1
FIGURE 1
Vaginal bacterial community structures in patients undergoing IVF over 3 sampling intervals. The relative abundance of each taxon is represented by a different color. The sequential samples obtained from each subject are represented in a group, with sample A collected at baseline, B just before egg retrieval, and C just before embryo transfer. Subjects who did not undergo prophylactic azithromycin treatment are marked with a black bar labeled “NA,” and those receiving azithromycin are marked with a gray bar labeled “AZ.” Within each of these groups, subjects who did or did not become pregnant are annotated. According to Linear discriminant analysis Effect Size analysis, no specific taxa were associated with azithromycin treatment or pregnancy. IVF = in vitro fertilization.
FIGURE 2
FIGURE 2
Alpha diversity and community stability were not associated with azithromycin treatment. Shannon diversity (A–C) and Bray-Curtis dissimilarity (D–F) are plotted using box and whisker plots to compare the azithromycin and no-azithromycin groups. The median is indicated by a horizontal line, quartiles by boxes, and minimum and maximum by whiskers. Shannon diversities are shown for samples collected at the time of enrollment (panel A), egg retrieval (panel B), and embryo transfer (panel C). Bray-Curtis dissimilarities (representing the degree of change in community structure) are shown for the time period between enrollment and egg retrieval (D), egg retrieval and embryo transfer (E), and enrollment and embryo transfer (F).
FIGURE 3
FIGURE 3
Bacterial community characteristics associated with pregnancy. Shannon diversity (A), 16S rRNA gene copy number (B), the percentage of Lactobacillus species in the samples (C), and the Bray-Curtis dissimilarity measure (D) are represented by box and whisker plots to compare groups based on azithromycin treatment and pregnancy outcome. The median is indicated by a horizontal line, quartiles by boxes, and minimum and maximum by whiskers. In the azithromycin group, the percentage of Lactobacillus species was statistically significantly different between the pregnant and nonpregnant groups (P = .048; HL, 0.41; 95% CI, 0.08–0.65). CI = confidence interval; HL = Hodges-Lehmann estimate of difference.

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