Laparoscopic findings in female genital tuberculosis

OBJECTIVES: To evaluate the laparoscopic findings in genital tuberculosis (TB). METHODS: A total of 85 women of genital TB, who underwent diagnostic laparoscopy for infertility or chronic pelvic pain were enrolled in this retrospective study conducted in our unit at All India Institute of Medical Sciences, New Delhi, India from September 2004 to 2007. RESULTS: The mean age was 28.2 years and the mean parity was 0.24. Most women were from poor socioeconomic status (68.1%). Past history of TB was seen in 29 (34.1%) women with pulmonary TB in 19 (22.35%) women and extrpulmonary in 10 (11.7%) women. Most women presented with infertility (90.6% primary 72.9%; secondary 17.6%) while the rest had chronic pelvic pain (9.4%). The mean duration of infertility was 6.2 years. A total of 49 (57.6%) women had normal menses, while hypomenorrhea, oligomenorrhea, secondary amenorrhea and menorrhagia were seen in 25 (30.1%), 3 (3.5%), 5 (5.9%), and 2 (2.4%) women respectively. Diagnosis of genital TB was made by histopathological evidence of TB granuloma in 16 (18.8%) (Endometrial biopsy in 12.9%, laparoscopy biopsy in 5.9%) women, demonstration of acid fast bacilli (AFB) on microscopy in 2(2.3%), positive AFB culture in 2 (2.3%), positive polymerase chain reaction (PCR) in 55 (64.7%) and laparoscopic findings of genital TB in 40 (47.1%). The various findings on laparoscopy were tubercles on peritoneum (12.9%) or ovary (1.2%), tubovarian masses (7.1%), caseous nodules (5.8%), encysted ascitis in 7.1% women. Various grades of pelvic adhesions were seen in 56(65.8%) women. The various findings on fallopian tubes were normal looking tubes in (7.1%), inability to visualize in 12(14.1%), presence of tubercles on tubes in 3 (3.52%), caseous granuloma in 3 (3.52%), hydrosalpinx in 15 (17.6%) (Right tube 11.7%, left tube 5.9%), pyosalphinx in 3 (3.5%) on right tube and 2 (2.35%) in left tube, beaded tube in 3 (3.5%) on right tube, 4 (4.7%) in left tube with tobacco pouch appearance in 2 (2.35%) women. The right tube was patent in 9 (10.6%) while left tube was patent in 10(11.7%) cases only, while they were either not seen (absent in one case due to previous salphingectomy, inability to see due to adhesion in 14.12%) or blocked at various sites with cornual end being most common in 3 (3.5%) showing multiple block in right tube and 4.7% in left tube. CONCLUSION: There is a significant pelvic morbidity and tubal damage in genital tuberculosis.     

Current Diagnosis and Management of Female Genital Tuberculosis

Female genital tuberculosis (FGTB) is an important cause of significant morbidity, short- and long-term sequelae especially infertility whose incidence varies from 3 to 16 % cases in India. Mycobacterium tuberculosis is the etiological agent for tuberculosis. The fallopian tubes are involved in 90–100 % cases, endometrium is involved in 50–80 % cases, ovaries are involved in 20–30 % cases, and cervix is involved in 5–15 % cases of genital TB. Tuberculosis of vagina and vulva is rare (1–2 %). The diagnosis is made by detection of acid-fast bacilli on microscopy or culture on endometrial biopsy or on histopathological detection of epithelioid granuloma on biopsy. Polymerase chain reaction may be false positive and alone is not sufficient to make the diagnosis. Laparoscopy and hysteroscopy can diagnose genital tuberculosis by various findings. Treatment is by giving daily therapy of rifampicin (R), isoniazid (H), pyrazinamide (Z) and ethambutol (E) for 2 months followed by daily 4 month therapy of rifampicin (R) and isoniazid (H). Alternatively 2 months intensive phase of RHZE can be daily followed by alternate day combination phase (RH) of 4 months. Three weekly dosing throughout therapy (RHZE thrice weekly for 2 months followed by RH thrice weekly for 4 months) can be given as directly observed treatment short-course. Surgery is rarely required only as drainage of abscesses. There is a role of in vitro fertilization and embryo transfer in women whose fallopian tubes are damaged but endometrium is healthy. Surrogacy or adoption is needed for women whose endometrium is also damaged.     

Hysteroscopic metroplasty in patients with a uterine septum and otherwise unexplained infertility

Objective

To evaluate the reproductive outcomes of patients with a uterine septum and otherwise unexplained infertility who underwent hysteroscopic metroplasty, and to compare them with those of patients with the same diagnosis who did not have hysteroscopic metroplasty.

Methods

The present retrospective study included 127 patients with diagnosis of a uterine septum and otherwise unexplained infertility. The reproductive outcomes of 102 patients who underwent hysteroscopic metroplasty (group 1) and 25 patients who rejected the operation (group 2) were compared.

Results

Of the 102 patients who underwent hysteroscopic metroplasty, 44 (43.1%) were able to achieve pregnancy, as compared with 5 (20%) of the 25 patients who did not undergo the operation (P = 0.03). The abortion rate was 11.4% (5/44) in group 1, compared with 60% (3/5) in group 2 (P = 0.02). The live birth rate was 35.3% (36/102) in group 1, as compared with 8% (2/25) in group 2 (P = 0.008).

Conclusions

The results indicate that hysteroscopic metroplasty improves reproductive outcome for patients with a uterine septum and otherwise unexplained infertility.     

Hysterosalpingographic findings in infertile women with genital tuberculosis

OBJECTIVES: To evaluate the hysterosalpingographic findings from infertile women who were subsequently diagnosed with genital tuberculosis. METHODS: A retrospective study of 70 infertile women who underwent hysterosalpingography to investigate infertility and were subsequently diagnosed with genital tuberculosis. RESULTS: The mean age of the women was 27.3 years and the mean duration of infertility was 6.1 years. A total of 57 (81.4%) women had primary infertility while 13 had secondary infertility. Diagnosis of genital tuberculosis was made by polymerase chain reaction (54.3%), tuberculous granuloma on biopsy (22.8%), acid-fast bacilli culture (2.8%), and at laparoscopy or hysteroscopy (20%). Hysterosalpingographic findings were a normal uterine cavity observed in 57.1% of women, an irregular cavity in 18.5%, a shrunken cavity in 2.8%, and an irregular filling defect in 18.5%. Synechiae were observed in 17.1% of women. CONCLUSION: Genital tuberculosis is a common cause of infertility in India, causing significant uterine and tubal pathologies.     

继发不孕患者阴道常见致病菌及耐药性分析

目的:分析继发不孕患者下生殖道的致病菌感染及耐药情况,明确导致女性下生殖道感染的主要致病菌及其对常用抗菌素的敏感状况,以有效指导临床抗感染用药。方法:收集确诊为继发不孕且阴道分泌物培养菌阳性的606例患者的临床资料,回顾分析其致病菌分布及抗菌素耐药情况,研究从该人群中病原体的高分离率与女性生殖道的并发症是否存在联系。结果:继发不孕患者中,引起生殖道炎症的病原菌排名前三者为大肠埃希菌、粪肠球菌和白色念珠菌,支原体培养阳性率为48.8%。大肠埃希菌、肺炎克雷伯菌等肠杆菌科细菌对氨苄西林、头孢噻肟、头孢他啶、复方新诺明等耐药率较高,而对亚胺培南、美洛培南、阿米卡星等耐药率低。革兰阳性球菌等对万古霉素、呋喃妥因、利奈唑烷等有较高的敏感性,粪肠球菌对氨苄西林的敏感性较高,解脲支原体对多西环素/强力霉素和美满霉素等敏感性高。结论:万古霉素、呋喃妥因、利奈唑烷等可作为革兰阳性菌球菌治疗的首选;氨苄西林可作为粪肠球菌治疗的首选;多西环素/强力霉素和美满霉素可作为治疗支原体感染的一线药物。     

Second-look hysteroscopy after antitubercular treatment in infertile women with genital tuberculosis undergoing in vitro fertilization

Objectives

To assess the efficacy of antitubercular treatment on the uterine cavity in infertile women diagnosed with genital tuberculosis using second-look hysteroscopy.

Methods

A total of 70 women with genital tuberculosis who underwent second-look hysteroscopy were enrolled in the study. They were started on antitubercular drugs and followed up after 6 months of therapy with second-look hysteroscopy. McNemar's χ² test was used to compare the hysteroscopy findings before and after antitubercular treatment.

Results

Antitubercular treatment improved hysteroscopy findings in women with thin or flimsy adhesions (grade I), singular dense adhesions (grade II), and occluding adhesions at the internal os (grade IIa) (P < 0.01). Patients with extensive adhesions, extensive endometrial scarring, fibrosis, and a tubular cavity showed no improvement after antitubercular treatment. Mean endometrial thickness of the 70 patients on day 21 prior to starting drug therapy was 6.8 mm, which increased to 8.1 mm after 6 months of treatment.

Conclusion

Considering the exorbitant cost of assisted reproductive technology in low-resource countries, it is necessary to consider reassessment of the uterine cavity prior to beginning such treatment.     

Follicle stimulating hormone receptor gene variants in women with primary and secondary amenorrhea

Purpose  

This retrospective study was designed to analyze the FSHR gene variants in subjects with primary and secondary amenorrhea with hypergonadotropic hypogonadism.     

Estimates of first-generation women and girls with female genital mutilation in the European Union,Norway and Switzerland

Background: Female genital mutilation (FGM) is the practice of partial or total removal of female genitalia for non-medical reasons. The procedure has no known health benefits but can cause serious immediate and long-term obstetric, gynaecological and sexual health problems. Health workers in Europe are often unaware of the consequences of FGM and lack the knowledge to treat women adequately.

Objective: Our goal was to estimate the number of first-generation girls and women in the European Union, Norway and Switzerland who have undergone FGM. Before migration from FGM-practicing countries began, FGM was an unknown phenomenon in Europe.

Methods: Secondary analysis of data from the 2011 EU census and extrapolation from age-specific FGM prevalence rates in the immigrants’ home countries to these data were used to provide our estimates. Estimates based on census and other demographic data were compared to our results for Belgium.

Results: In 2011 over half a million first-generation women and girls in the EU, Norway and Switzerland had undergone FGM before immigration. One in two was living in the UK or France, one in two was born in East-Africa.

Conclusions: For the first time, scientific evidence gives a reliable estimate of the number of first-generation women and girls in Europe coming from countries where FGM is practiced. The use of census data proves reliable for policy makers to guide their actions, e.g., regarding training needs for health workers who might be confronted with women who have undergone FGM, or the need for reconstructive surgery.     

Genital tuberculosis in infertile women: Assessment of endometrial TB PCR results with laparoscopic and hysteroscopic features

Objective

Mycobacterial infections of the genital tract have been implicated in the etiology of female infertility. The correlation of endometrial TB PCR with laparoscopic and hysteroscopic features in patients with infertility was evaluated.

Methods

Women suffering from infertility and undergoing diagnostic laparoscopic and hysteroscopic examination were included. Endometrial specimens were assayed by Nested PCR for mycobacterium complex and the results were then retrospectively correlated with laparoscopic and hysteroscopic features.

Results

Positive TB PCR was observed in 32.18% (n=56) women. Out of these 56 patients, 48 had endoscopic abnormalities suggestive of tuberculosis (TB) and rest 8did not reveal any endoscopic abnormalities. However, of 174 patients 139 had endoscopic abnormalities with positive TB PCR in only 48. Sensitivity and specificity of endoscopic evaluation was 85.71 and 22.8%, respectively. The presence of periovarian adhesions, cornual block, tubal beading, tubercles, intrauterine adhesions, and ostial fibrosis had very strong association with positive TB PCR. Total predictive value of endoscopic evaluation in diagnosis of genital TB was 42.52%.

Conclusion

This study highlights that endoscopic evaluation is an important diagnostic tool, but can neither confirm nor exclude genital TB. Endometrial TB PCR may have to be routinely resorted to make a definite diagnosis of mycobacterial infection in endemic areas.     

Endometrial polyps with increased plasma cells are associated with chronic endometritis in infertility patients: Hysteroscopic findings and post-polypectomy pregnancy rates

Purpose

The relationship between endometrial polyps (EPs), chronic endometritis (CE), hysteroscopic findings, and antimicrobial in infertility patients was determined.

Methods

We retrospectively enrolled 115 infertility patients with suspected EPs who underwent office hysteroscopy. Patients were divided into 3 groups: 38 with increased plasma cells in EPs (group 1); 31 without increased plasma cells in EPs (group 2); and 46 without EPs (group 3). The 3 groups underwent hysteroscopy with or without polypectomies, and immediately thereafter, an endometrial aspiration biopsy (EAB) was performed. CE was diagnosed based on plasma cell infiltration in the non-polypoid endometrium obtained by EAB.

Results

The percentage of CE was 68.4%, 32.2%, and 28.3% in groups 1, 2, and 3, respectively. CE was more frequent in group 1 than group 2 or 3 (P = .01 and P = .002, respectively). The number of polyps was higher in group 1 than group 2. After adjustment for age and assisted reproductive technology, antibiotic therapy was not associated with pregnancy (adjusted odds ratio, 0.44; 95% confidence interval, 0.05-3.57) in patients with EPs and CE.

Conclusions

Group 1 was associated with CE, and hysteroscopic findings were different from group 2. Antibiotic therapy after polypectomy for EPs with CE may not always be necessary.

     

The relationship between antisperm antibodies prevalence and genital Chlamydia trachomatis infection in women with unexplained infertility

BackgroundChlamydia trachomatis infection is one of the most common sexually transmitted diseases. Sperm-associated antibody could impair fertility through various mechanisms; both factors could be correlated to affect the fertility status of women.DesignA retrospective case-control study was performed enrolling ninety (n = 90) patients with primary or secondary infertility as the case group, in addition to another eighty (n = 80) healthy women attending the family planning clinic to investigate the correlation between C. trachomatis past and current infections and antisperm antibodies (ASA) in women with unexplained infertility.ResultsThe PCR prevalence of C. trachomatis did not differ significantly among both groups (2.4% versus 1.6%, p value = 0.66). In contrast, significantly higher prevalence of anti-C. trachomatis specific IgG (39% versus 19%, p value = 0.87) antibodies was found among infertile women. ASA prevalence was significantly higher in infertile group (20% versus 5%, p = 0.04). The final study results have failed to find a positive correlation between current or past C. trachomatis infection and the level of antisperm antibodies level in women suffering of un-explained infertility.ConclusionAntisperm antibodies were significantly higher in infertile women, but without a significant difference between the incidences of ASA in infertile women with past or current C. trachomatis current infection.     

Experiences from pregnancy and childbirth related to female genital mutilation among Eritrean immigrant women in Sweden

OBJECTIVE: to explore Eritrean immigrant women's experiences of female genital mutilation (FGM) during pregnancy, childbirth and the postpartum period. DESIGN: qualitative study using an ethnographic approach. Data were collected via tape-recorded interviews. SETTING: interviews in the Eritrean women's homes located in and around Uppsala, Sweden. PARTICIPANTS: 15 voluntary Eritrean immigrant women. DATA COLLECTION AND ANALYSIS: Semi-structured interview and open-ended questions were used. The interviews were tape-recorded, transcribed verbatim and then analysed. FINDINGS: six themes of experiences of FGM among Eritrean women during pregnancy and childbirth were identified. They are (1) fear and anxiety; (2) extreme pain and long-term complications; (3) health-care professionals' knowledge of circumcision and health-care system; (4) support from family, relatives and friends; (5) de-infibulation; and (6) decision against female circumcision of daughters. KEY CONCLUSION AND IMPLICATIONS FOR PRACTICE: the Eritrean women had experiences of FGM and had suffered from its complications during pregnancy, childbirth and the postpartum period. Midwives and obstetricians should have competence in managing women with FGM, and they need increased understanding of cultural epistemology in order to be able to provide quality care to these women. At antenatal centres, circumcised women should be advised to de-infibulate before pregnancy. Special courses about anatomical differences should be offered to these women and their husbands. It is also important to inform them about Swedish law, which prohibits all forms of FGM.     

Strategies for the use of insulin-sensitizing drugs to treat infertility in women with polycystic ovary syndrome

OBJECTIVE: Insulin resistance and its compensatory hyperinsulinemia play a key pathogenic role in the infertility of the polycystic ovary syndrome. Numerous studies indicate that insulin-sensitizing drugs can be used to enhance spontaneous ovulation and the induction of ovulation in the syndrome. The aim of this review is to summarize the studies in which insulin-sensitizing drugs were used to increase ovulation rate or improve fertility in women with the PCOS and to translate the information into practical guidelines for the use of these drugs by reproductive endocrinologists. DESIGN: Review and critique of studies in which an insulin-sensitizing drug was used to increase ovulation rate or improve infertility in women with the polycystic ovary syndrome. MAIN OUTCOME MEASURE(S): Ovulation rate and pregnancy rate. RESULT(S): Studies have demonstrated that insulin-sensitizing drugs can increase spontaneous ovulation, enhance the induction of ovulation with clomiphene citrate, and increase clinical pregnancy rates. CONCLUSION(S): An algorithmic approach is provided for the use of insulin-sensitizing drugs to treat the anovulation and infertility of women with the polycystic ovary syndrome.     

Placental site trophoblastic tumor in a patient with secondary infertility and radiological findings consistent with a leiomyoma: a case report

Placental site trophoblastic tumor (PSTT) is the rarest form of gestational trophoblastic diseases. We report a 40-year-old woman who presented initially after a year of secondary infertility with prolonged menstrual flow. Her last pregnancy ended in a suction dilation and curettage at 8 weeks' gestation for a missed abortion. A hysterosalpingogram revealed a solid 5 x 4.5 cm filling defect impinging on the endometrial cavity suggestive of a submucosal leiomyoma. A vaginal sonogram confirmed the findings. The patient underwent a laparotomy for excision of the 5-cm friable, necrotic mass that was performed by curetting. Pathologic examination of the specimen revealed sheets of intermediate trophoblastic cells characterized by large polyhedral cells and positive human placental lactogen staining consistent with PSTT. The patient eventually underwent total abdominal hysterectomy 4 weeks later with no evidence of residual tumor on histologic examination.     

Repeated laparoscopic ovarian diathermy is effective in women with anovulatory infertility due to polycystic ovary syndrome

OBJECTIVE: To assess the effectiveness of a second laparoscopic ovarian diathermy (LOD) in women with polycystic ovary syndrome (PCOS). DESIGN: Retrospective study. SETTING: Tertiary infertility clinic. PATIENT(S): Twenty anovulatory infertile women with PCOS who underwent LOD 1-6 years previously. Twelve subjects had previously responded positively to the first LOD, but the anovulatory status recurred (Group I), whereas eight subjects had not responded at all (Group II). INTERVENTION(S): Laparoscopic ovarian diathermy. MAIN OUTCOME MEASURE(S): Rates of ovulation, pregnancy and resumption of menstrual regularity, and biochemical changes. RESULT(S): An overall ovulation rate of 12 out of 20 women (60%) and a pregnancy rate of 10 out of 19 (53%) were achieved after the second LOD. In women (n = 12) who previously responded positively to the first LOD (LOD-sensitive), the ovulation and pregnancy rates were 10 out of 12 (83%) and 8 out of 12 women (67%), respectively, which were significantly (P<.05) higher than 2 out of 8 (25%) and 2 out of 7 (29%) of the previous nonresponders (LOD-resistant). Statistically significant hormonal changes including reduction of luteinizing hormone (LH), testosterone (T), and free androgen index (FAI) after the repeat LOD were only observed in the LOD-sensitive group. CONCLUSION(S): Repeat LOD is highly effective in women who previously responded to the first procedure.     

The influence of body weight on response to ovulation induction with gonadotrophins in 335 women with World Health Organization group II anovulatory infertility

OBJECTIVE: To assess the influence of body weight on the outcome of ovulation induction in women with World Health Organization (WHO) group II anovulatory infertility. DESIGN: The combined results of two studies in which either a highly purified urinary follicle-stimulating hormone or highly purified urinary menotrophin were compared with recombinant follicle-stimulating hormone. SETTING: Thirty-six fertility clinics. POPULATION: A total of 335 women with WHO group II anovulatory infertility failing to ovulate or conceive on clomifene citrate. METHODS: Ovarian stimulation using a low-dose step-up protocol. MAIN OUTCOME MEASURES: The effects of body weight on ovarian response, ovulation rate and pregnancy rate after one treatment cycle. RESULTS: With increasing body mass index (BMI), a higher threshold dose of gonadotrophins was required and there were more days of stimulation; yet, despite a greater concentration of antral follicles, there were fewer intermediate and large follicles. There was no difference in the rates of ovulation and clinical pregnancy in relation to body weight. CONCLUSIONS: Body weight affects gonadotrophin requirements but not overall outcome of ovulation induction in women with anovulatory polycystic ovary syndrome and a BMI of less than 35 kg/m2.     

无刺激周期未成熟卵母细胞体外培养用于多囊卵巢综合征不孕患者治疗的临床观察

目的探讨无刺激周期未成熟卵母细胞体外培养在治疗多囊卵巢综合征(PCOS)不孕患者的应用价值。方法对70例PCOS患者,在人工周期或自然周期第10～12天行阴道B超监测,如双侧卵巢中无直径>8mm的卵泡,即肌内注射人绒毛膜促性腺激素10000IU,36h后经阴道穿刺取卵,将取出的未成熟卵母细胞进行体外成熟及体外受精胚胎移植。结果共进行体外成熟周期94个,移植周期75个。共获得卵母细胞1283个,获得成熟838个(65.3%,838/1283),其中受精553个(66.0%,553/838),获得胚胎402个(48.0%,402/838),获得优质胚胎199个(23.7%,199/838)。生发泡期卵母细胞的成熟率、受精率、获得胚胎率及优质胚胎率,分别为67.7%、66.4%、47.6%及24.1%;第1次减数分裂中期的卵母细胞,分别为69.7%、71.7%、52.2%及26.1%,生发泡期与第1次减数分裂中期比较,差异均无统计学意义(P>0.05)。无法评价的卵母细胞的成熟率、受精率、获得胚胎率及优质胚胎率,分别为44.8%、53.8%、46.2%及16.9%,与生发泡期及第1次减数分裂中期比较,差异均有统计学意义(P<0.05)。75个移植周期中,18例获得临床妊娠,妊娠率为24%(18/75)。结论无刺激周期未成熟卵母细胞体外成熟及体外受精胚胎移植可用于PCOS不孕患者的治疗,并能取得一定的妊娠成功率。