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Most of these alterations result from infection. Symptomatic, asymptomatic, or latent infections or their sequelae may also contribute to chronic inflammation of the cervix and endometrium, alterations in reproductive tract secretions, induction of immune mediators that interfere with gamete or embryo physiology, and structural disorders such as intrauterine synechiae. Infection is also a major factor in male infertility, second only to oligospermia. Unfortunately, the impact of infectious sequelae on human reproduction continues to increase as a consequence of sexual promiscuity and the popularity of nonbarrier methods of contraception.
Bacterial vaginosis, Trichomonas vaginalis , and Candida albicans are the most prevalent bacterial, protozoan, and fungal causes of lower genital tract infections. Although gonorrheal infections have been on the decline in the last decade, chlamydial infections of the male and female genital tract continue to be an increasing problem, and C. Women are twice as likely as men to acquire gonorrhea or Chlamydia during a single act of unprotected intercourse with an infected partner.
Many newly infected women have no symptoms and so do not seek medical intervention and continue to spread the infection to other sexual partners. The best hope for reducing the incidence of infertility related to infection lies in prevention and early detection and treatment of newly acquired asymptomatic or mildly symptomatic infections. The importance for the preservation of future fertility of avoiding high-risk sexual behavior and the mandatory use of condoms must be stressed.
Concomitantly, there must be an increased awareness by health care providers and consumers of the need for intensive screening using the latest and most effective molecular techniques followed by early effective treatment if positive. Despite the current focus on sexually transmitted diseases STDs , infertility may also follow bloodborne infections such as tuberculosis, mixed aerobic and anaerobic infections of other pelvic sites, inflammatory complications of surgical trauma, postabortal and puerperal sepsis, and appendiceal rupture.
Because inflammatory factors may affect the reproductive tract at virtually every level, it is useful to follow an anatomic approach in considering the relationship of infection to infertility. Infections in the male are discussed in the context of managing the infertile couple as a reproductive unit. Cultures obtained at hysterectomy indicate that the endometrial cavity is normally sterile. Endometrial infections may follow procedures that alter the usual protective role of the cervix, such as cervical conization or procedures associated with the introduction of contaminated cervical mucus into the uterus.
Endometrial biopsy, hysterosalpingography, and the insertion of an IUD may predispose to endometritis and ascending genital tract infection. Secondary infections of the endometrium may follow primary invasion with C. Uterine infections are more likely to occur in postpartum women when decreased host resistance and surgical trauma act synergistically to make the uterine cavity more susceptible to infection.
Factors that tip the balance in favor of bacterial invaders are prolonged labor, premature rupture of the membranes, and operative delivery. Prophylactic antibiotics appear to decrease the incidence but not the severity of infections in cesarean section patients. In managing patients with secondary infertility, it is especially important to elicit the details of past cesarean section or postpartum endometritis.
Acute endometritis, especially as observed postpartum or after abortion, is a misnomer, because the infection is unlikely to involve the endometrium alone. Usually, there is an associated inflammatory reaction of the myometrium, parametrium, and in some cases, adnexal structures. Patients with endometritis usually have a decrease in lochial flow for 12 to 24 hours before becoming febrile.
It is important to establish prompt uterine drainage and to remove any retained infected tissue. Broad-spectrum coverage for the most frequently recovered aerobic and anaerobic organisms includes the use of single extended-spectrum drugs, such as cephalosporins cefoxitin or cefotetan or penicillins mezlocillin or piperacillin or the combination of an amino glycoside and clindamycin or metronidazole. Triple antibiotic therapy with the addition of ampicillin is usually reserved for the critically ill patients, whereas a single drug or the combination of two drugs that provide activity against anaerobes is often used in less serious situations.
The principles of management and antibiotic therapy of major gynecologic sepsis are discussed in detail elsewhere in these volumes. It is generally acknowledged that the prognosis for future fertility is improved if the initial response to antibiotics is prompt.
The patients requiring operative intervention for postpartum sepsis are at greater risk for developing pelvic adhesions and subsequent infertility. For most patients, endometritis after cesarean section infrequently interferes with tubal morphology and function unless a pelvic abscess develops. Identification and treatment of C. Obstruction of the uterotubal junction may accompany septic abortion or streptococcal infection. As a practical matter, it is difficult to relate any particular organism causing endoparametritis to unique structural reproductive damage.
Endometritis in nonpregnant women can be classified into acute, chronic, and fibrotic stages Table 3. Because many women have neither organism although testing by the more sensitive PCR technique is not often used , it seems likely that other bacteria also cause endometritis in nonpregnant women. After the acute inflammatory process has subsided, an endometrial biopsy should be obtained to exclude persistent inflammation.
Foreign bodies, retained products of conception, infected polyps, chronic salpingitis, and uterine cancer can also lead to chronic endometritis. Although the causative agents in the chronic condition may vary as indicated in Table 3 , the histopathologic features are similar. The characteristic picture consists of a diffuse infiltration of plasma cells in the endometrial stroma. The presence of plasma cells is also highly correlated with salpingitis.
Moreover, women diagnosed clinically with salpingitis but found to have normal fallopian tubes at laparoscopy frequently demonstrate endometritis by biopsy. Histologic dating of the endometrium may be inaccurate because chronic endometritis is frequently associated with a mixed proliferative and secretory endometrium or inactive cyclically dilated glands.
The usual clinical presentation includes discharge, pelvic pain, and dysfunctional uterine bleeding. In contrast to other types of endometritis, the response of the endometrium to tuberculosis is much more specific. The typical lesion is the noncaseating granuloma composed of epithelial cells, giant cells, and peripheral lymphocytes. Genital tuberculosis is rare, but it should be considered when the endometrium shows s of inflammation. It is nearly always secondary to a focus elsewhere in the body.
Many of the agents implicated in chronic endometritis have also been implicated in spontaneous abortion, including C. Women with serologic evidence of C. There is increasing evidence that an endometritis can interfere with implantation of the embryo or that spermatozoa are removed more quickly from the uterine cavity in the presence of a chronic inflammatory reaction. In laboratory animals, a single intrauterine injection of glycogen induces a marked leukocytic response and effectively terminates pregnancy before and during the implantation period.
Transfer of viable leukocytes to the uterine lumen during early pregnancy causes a marked reduction in fertility. Inflammatory cells and their products have been shown to be toxic to preimplantation embryos in vitro. Although still controversial, a large of studies indicate an adverse effect of prior chlamydial infection as determined by positive chlamydial serology or heat shock protein [HSP60] antibodies on in vitro fertilization IVF outcome.
Endometrial infection may induce macrophage activation and proinflammatory cytokine production. The latter mechanism is supported by other studies that demonstrate that inflammatory hydrosalpinges have an adverse effect on endometrial receptivity, which in some cases may be overcome by surgical treatment of the hydrosalpinges. Traumatic damage to the endometrium may cause hypomenorrhea, amenorrhea, and intrauterine adhesions i.
The extent of intrauterine adhesions correlates with the degree of menstrual insufficiency. The adhesions are sequelae of uterine trauma, almost always related to pregnancy. It is likely that infection plays a contributory role in their pathogenesis. Intrauterine adhesions may develop with a tuberculous endometritis, lending further support to the idea that Asherman's syndrome has an infectious basis.
Fertility is severely impaired in this entity and may be caused by interference with implantation or to changes in endometrial metabolism. In the event of conception, potential complications include abortion, premature delivery, and problems with separation of the placenta. The diagnosis of intrauterine adhesions depends on hysterosalpingography or hysteroscopy. The prognosis for this syndrome with reference to fertility varies with the severity of the adhesions. Whenever possible, the cause of chronic endometritis should be determined.
The bacterial origin for non-STD organisms is difficult to prove, because endometrial cultures taken by the transcervical route are contaminated with cervical organisms. The tissue diagnosis of chronic nonspecific endometritis is best made during the follicular phase to avoid the normal inflammatory changes that occur premenstrually.
Conversely, if tuberculosis is being considered, the granulomas are best recognized on days 24 to 26 of the cycle or within 12 hours after the onset of menstruation. The diagnosis of tuberculous endometritis may be aided by creating a pseudopregnancy without menses for 2 to 3 months, followed by a thorough curettage.
The curettings are divided into two portions, one for histologic examination and one for culture. If these are positive for Mycobacterium tuberculosis , prolonged treatment with antituberculous agents is necessary, and the prognosis for fertility is poor. Nonspecific chronic endometritis can be selflimited and is not uniformly influenced by therapy, but it may respond to curettage and cyclic estrogen and progestin therapy.
Conjugated estrogens 2. A posttreatment biopsy is useful to determine whether therapy has been helpful. Treatment of Asherman's syndrome is primarily surgical. In some cases, cervical and isthmic adhesions respond to transcervical dilatation and lysis.
Adhesions can be resected with a hysteroscope under direct vision. In more severe instances, the dangers of perforating the bladder or uterus are best avoided by approaching the adhesions with a transfundal hysterotomy. If the vaginal approach is chosen, it is useful to be prepared for diagnostic laparoscopy in the event of a uterine perforation. An IUD is left in situ for 6 weeks postoperatively to prevent apposition of raw surfaces. The patient receives broad-spectrum antibiotics during this time and is maintained on large doses of conjugated estrogens and progestin cyclically for 2 months.
PID is a common but vaguely defined complex of s and symptoms resulting from the spread of pathogenic microorganisms from the vagina and endocervix to the uterus, body of the endometrium, and fallopian tubes. Of the estimated 1 million women who annually develop PID, an average of , enter hospitals each year. The long-term consequences of PID include chronic pelvic pain, infertility, and ectopic pregnancies that are increased several-fold.
The best data on involuntary infertility after salpingitis are found in large Swedish studies, 1 , 34 in which the initial diagnosis was confirmed by laparoscopy. TABLE 4. Clinical Findings. Am J Obstet Gynecol , Acute salpingitis with or without oophoritis often coexists with various degrees of pelvic peritonitis. Infertility from tubal occlusion, peritubal adhesions, or adhesions encasing the ovary in any combination. Tubal infertility is directly related to a of factors present during the initial episode of salpingitis, which include besides the of episodes the initial severity of tubal inflammation, the organisms responsible, and the occurrence of a subsequent ectopic pregnancy.
The best predictor of subsequent infertility is the degree of tubal inflammation observed through the laparoscope during the acute phase Table 4. The estimation of severity was based on direct observation of the tube and not on the severity of clinical symptoms and s such as pain, fever, tenderness, or leukocytosis. Approximately one half of the women with an ectopic pregnancy have grossly visible tubal damage or a partial occlusion of the tubes.
Ectopic pregnancy provides a poor prognosis for fertility. To establish the diagnosis of salpingitis, other diseases, such as acute appendicitis, endometriosis, ovarian cysts, ectopic pregnancy, urinary tract infection, and gastrointestinal disease, must be excluded. The clinical diagnosis of acute salpingitis is confirmed by laparoscopy in fewer than two thirds of the patients. In the remaining patients, one fifth have normal pelvic findings, and other diagnoses are established in the others. Prompt recognition and vigorous treatment reduce subsequent severe complications of salpingo-oophoritis, such as generalized pelvic peritonitis, abscess formation, and adnexal destruction.
It deserves reemphasis that salpingitis often produces minimal clinical s. This finding correlates with the observation that most women with tubal infertility have never been treated for a recognized episode of salpingitis. Epidemiologic studies support the concept of silent PID wherein a strong link exists between serum antibodies to C. Physicians should be willing to treat women with mild symptoms for salpingitis. If the patients with mild symptoms had only cervicitis or cervicitisendometritis and not salpingitis, prompt treatment before the onset of salpingitis would have a major impact on preventing tubal occlusion.
Inadequate treatment may predispose the patient to recurrent pelvic infection with the sequelae of hydrosalpinx, infertility, ectopic pregnancy, and chronic pelvic pain. So-called chronic salpingitis is often caused by indolent infection in patients who have received suboptimal antimicrobial therapy or to recurrent infection. Failure to use doxycycline or azithromycin to inhibit C. A population-based study of fertility in women with human immunodeficiency virus type 1 HIV-1 infection in Uganda demonstrated that fertility is greatly reduced in HIVinfected women because of a lower rate of conception and increased rates of miscarriage and stillbirth.
The low prevalence and incidence of pregnancy among HIV-infected women could reflect preexisting tubal factor infertility and higher clinical and subclinical fetal losses resulting from HIV-1 infection. Salpingitis caused by M. Nontuberculous salpingitis can be divided into gonococcal, chlamydial, and nongonococcal-nonchlamydial disease based on the of endocervical or peritoneal fluid cultures.
When endocervical cultures are routinely employed, N. The frequency of gonococcal disease varies with the socioeconomic status of the population studied. The recovery of N. The variable correlation between positive endocervical gonococcal cultures and specimens from peritoneal fluid has several possible explanations.
Gonococci that invade the upper genital tract have different auxotrophic types and are less susceptible to antibiotics than are gonococci from uncomplicated anogenital gonorrhea. Not only is the organism difficult to isolate from pus, but the recovery of N. The gonococcus is most frequently isolated within 2 days of the onset of symptoms and is rarely isolated if symptoms are present for 7 or more days. These observations are consistent with the view that the gonococcus initiates the infection and, if the infection is not promptly treated, sets the stage for a mixed aerobic-anaerobic infection, involving pathogens that originate in the cervix and vagina.
It takes a longer time for C.Women seeking sex Conception Missouri
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The meaning of postpartum sexual health for women living in Spain: a phenomenological inquiry