| Abstract: |
Summary and ConclusionPelvic inflammatory disease PID is a common and poorly managed condition, untreated or inadequately treated ; it leads to tubal infertility, ectopic pregnancy and chronic pelvic pain . The common aetiological agents Chlamydia trachomatis , Neisseria gonorrhoea, genital mycoplasms and aerobic and anaerobic bacteria.Microbiology :Chlamydiae are non motile, gram-negative bacterial pathogens that were once mistakenly thought to be viruses because of their obligate intracellular life cycle, chlamydiae are metabolically deficient in their ability to synthesize ATP and thus require exogenous sources of this high – energy compound.Incidence :Chlamydiae trachomatis is recognized as the most common sexually transmitted disease among reproductive age women .Cates and Wasserheit have reported that the failure to control Chlamydial infection & resultant increased incidence of these infection can be attributed to several factors as non specific signs and symptoms , which may be absent or mild , inadequate laboratory facilities , expense &technology , lack of familiarity has with Chlamydial infection ,at least 7-days of multiple-dose therapy and inadequate resources directed to screening high risk patients, contact tracing &treatment of partners .Chlamydial Species, serotypes and genotypes :The genus regarded to consist of 3 species : C. trachomatis, C. psittaci ,and C. pneumonia. A fourth species ,Chlamydia pecorum , has recently been proposed.Serovares D to K are responsible for urogenital infection, of which serovars E, F and D accounts for up to 60-70 % of these infections .Typing of C. trachomatis serovars has no far been limited to the identification withMonoclonal antibodies (MABS) (serotyping) of specific immuno-epitopes carried by the major outer membrane protein (MOMP) . Analysis of the corresponding MOMP gene has also been used for typing of C. trachomatis serovars.Chlamydial Antigens :A- Lipopolysaccharide LPS : contain common antigen structure. Demonstrated by a monoclonal antibody raised against C. trachomatis serovar L2, which only recognized Chlamydial LPS.B- Outer membrane protein: we know that Chlamydia lacks outer rigid peptidoglycan layer instead it has cysteine-rich outer membrane proteins are synthesized late in the growth cycle during the conversion of RBS to EBS. They are three :1-Major outer membrane protein (MOMP) mol. Weight 40000. 2-outer membrane protein 2 (OMP 2) mol.weight 60000. 3-Third protein has molecular weight of 15000. MOP has been found in all chlamydiae , it contains genus, species, subspecies and serovar-specific antigen determinants.C- C-Heat Shock protein HSPs : also known as stress proteins ;as stress can induce their synthesis, 4 group by mol. Weight.D- Cell binding proteins : They present in EB not RB . Antibodies against them rosed &absorbed with MOMP inhibit the association of Ebs with cells and neuteralize their infectivity.Cinical Manifestations :On behalf of the Infectious Disease Society for Obstetrics and Gynecology: lower abd. tenderness , cervical motion tenderness, Adenxial tenderness, palpable mass are prerequisites for diagnosis or some with others.Diagnosis Of PID : White cell count, erthrocyte sedimentation rate, and C reactive protein-which aid diagnosis .Laboratory Diagnosis Of Chlamydia Trachomatis :Cytology. 2- Immunologic Detection of Chlamydial Antigens.3-Isolation of the Organism in Cell Culture.4- Serologic Testing.5-Gen Probe Assay (GP assay).6-Polymerase Chain Reaction (PCR) .7-Ligase Chain Reaction Assay of urine. (LCR)8-Immunochromatography.Hysterosalpingography: optimally done towards the end of the first week after the menstrual period, using water-soluble medium with second film after 20 minutes, or oily medium used with second film after 24 hours. Findings: uterine cavity normal triangular with a small outline. Tubes; interstitial portion and the isthmus as threads or as loops if antero -posterior view. Ampulla as ribbon shape below the fundus and its mucosal rugae as longitudinal linear shadows if water- soluble dye is used.Fimbriae may be visualized, dye spreads over peritoneum as more or less large tails.Peritoneal spillage takes an amorphous shape around the end of the tube .Normal Tubal Ultra structure And Function :Its ultra structure is under direct influence of ovarian estrogen and progesterone ( P)The mucosal of the fallopian tube is lined by ciliated and mucus- secreting cells.Both cell types demonstrate structural changes related to circulating levels of these hormones . The growth of the cilia and their and beat frequency are enhanced by estrogen and by P. Similarly, the nonciliated mucus-secreting cells of the tubal mucosal secrete thick tenacious mucus under the influence of estrogen. This mucus is responsible, in part, for retaining the fertilized egg in the ampulla after fertilization .Incidence : Infertility affects approximately 10% of couples.14% to 38% of female infertility is associated with a” tubal factor”.Pathophysiologic And Etiologic Aspects :#1- Pelvic inflammatory diseaseNeisseria gonorrhoea, Chlamydia trachomatis, Mycoplasms hominis, and anaerobic bacteria have been isolated.Salpingitis can be subdivided into 1-Primary salpingitis caused by : a-Exogenous agents:1- Sexually transmitted microorganisms. 2- Iatrogenic PID, spread of cervical infection to tubes by procedures or IUD insertions. b-Endogenous agents: ascending spread of the endogenous vaginal or perianal flora.2- Secondary salpingitis direct spread from nearby pelvic organs, as appendix.3- Miscellaneous: as smoking as it alters both humoral& cellular immune system; possibly alter tubal physiologic features, with altered tubal transport possible early or delayed entry of blastocyst into the uterus, and alteration in the immune system that can account for the epidemiologic association between smoking and decreased fecundity from tubal causes.#11- Pelvic Adhesive Disease: PADThe mechanism by which PAD affect infertility is unclear, but may interfere with mobility of the tube or prevent ovum pickup by surrounding ovaries, or may hinder ovum retrieval by LAP. Pathongenesis of Adhesion: injured peritoneum ,or ischemic tissue produced by coagulation,ligation, or devascularization induce adhesion as ischemic peritoneum losses its intrinsic ability to lyse fibrin.#111-Endometriosis:Usually affect the proximal portion of the tube ,Intramural endometriosis can be encountered in 7 to 19% of patients undergoing tubal surgery.#1V Specific Tubal Abnormalities :A- Distal tubal obstruction mostly PID causes it .B- Proximal tubal obstruction usually caused by isthmica nodosa or PID.C- Midtubal obstruction common after surgical sterilization or tubal pregnancy.Tubal Function After Tubal Disease:Peritubal and intratubal adhesions that are common sequel of PID can interfere with tubal motility and ovum transport and thus predispose to ectopic ,more important destruction of the endosalpinx a major source of tubal dysfunction; as ciliated cells are low, beat frequency is low. Ultrastructur study of tube obtained from patient at time of surgery for ectopic pregenancy demonstrate a decrease in cell hight and an early onset of deciliation.Diagnosis:1- Tests where medium introduced transcervically2- Direct cannulation of the fallopian tubes.3- Tests dependant on particular transportHSG usually reveals the first evidence of possible distal tubal occlusion.LAP is the best means of accurately differentiating between true tubal occlusion and a patent tube bounding to the ovary by adhesions and causing intratubal loculation.Subjects and MethodsProspective controlled study was carried out on 80 attendants to gynaecological outpatients clinic at Zagazig University Hospital in the period of 1st March1999,to 25 April 2004, but 20 women did not continue with us, one divorced, some transferred to distant location with their husbands for their jobs, some refused hysterosalpingography, others didn’t agree to undergo laparoscopy. Forty participants constituted the group of cases, the first 20 suffered from secondary infertility others primary infertility. Twenty participants formed the control group . All patients presenting by infertility of at least one- year duration with regular sexual relation without use of contraceptives. Afull detailed history was taken from all women with special emphasis on history of sexual transmitted disease or PID , general, abdominal and local examination were done ,abdominal and pelvic ultrasonography were done.Investigations to detect the cause of infertility astimed premenstrual Endometrial biopsy, repeated semen for husband, timed postcoital test,HSG and insome cases laparoscopy will be carried out with methylene blue dye to determin tubal patency when HSG suggest tubal damage, also to detect other cause of infertility during laparoscopic procedure. Blood samoles will be taking during an outpatient clinic visit; sera will be tested with fluorescent conjugated of anti human IgG by micro-immunoflourescent test . Clark laboratories. Inc, immunodiagnostic was used:Enzyme-Linked Immunosorbent Assys (ELISA) rely on the ability of biological materials, (i.e. antigen) to adsorb plastic surfaces such as polystyrena (solid phase) .When antigens bound to the solid phase are brought into contact with a patient’s serum, antigen specific antibody , if present will bind to the antigen on the solid phase forming antigen-antibody complexes. Excess antibody is removed by washing.This is followed by the addition of goat anti-human IgG globulin conjugated with horseradish peroxidase which then binds to the antibody-antigen complexes.The excess antibody is conjugate is removed by washing , followed by the addition of chromogen/ substrate tetramethylbenzidine ( TMB). If specific antibody to the antigen is present in the patient’s serum, a blue color develops. When the enzymatic reaction is stopped with 1N H2SO4, the contents of the wells turn yellow. The color , which is proportional to the concentration of antibody in the serum, can be read on a suitable spectrophotometer or ELISA microwell plate reader. ISRvalue for each patient sample is calculated by dividing the sample absorbance by the calibrator value which obtained by multiply the mean absorbance of the Calibrators by the factor assigned and is recorded on the kit packing list and on the Calibrator vial lable.We consider ISR –ve if is }0.90, ISR equivocal if is 0-.91-1.09, ISR Positive if is >1.10 indicate presence of detectable antibody by the ELISA test.Results:Serological test for chlamydia infection was done among different groups. It was found that the result was negative in control group, while in secondary and primary infertility it was found that positivity is higher in secondary than primary infertility when compared to negative result by 80% and 50 % respectively with high statistical significance P= 0.001 (table 5) متصلحةResult of hysterosalpingography among control : that normal tubal patency is higher in normal uterus. One Bicornuate uterus and two septate uteri were discovered by HSG. (table 6).Relation between ELISA results &HSG in cases was done.It was found that negative result for chlamydiae by ELISA in 14 patients; 5for peritubal adhesion,5 for tubal block and 4 for fimbrial adhesion and non for tubal opacity.Positive result chlamydiae was found in 26 patients 11 for peritubal adhesion, 8 for tubal block , 2 for fimbrial adhesion, one for patent tube and 4 for tubal opacity &hyderosalpinges ( table 7).Comparing peritubal adhesion as shown by HSG &ELISA .findings, it was found that in negative ELISA 5 cases from 34 cases with peritubal adhesion, while in positive ELISA 11 cases from 26 cases with peritubal adhesion with statistical significance of P= <0.05 (table 9).Laparoscopic finding among control group there were 20 patients , 10 of them their tubes were patent, while in 6 with PCO and 4 cases diagnosed as septate uteri (table 11) .Relation between laparoscopic finding and ELISA result can be demonstrated in table 12, it was found that 14 cases with negative ELISA and 26 cases with positive ELISA . In negative ELISA laparoscopic finding were 3 cases were normal, 2 cases with PCO, 2 cases with hyderosalpinges and 2 cases with fimbrial adhesion.In the other hand in positive ELISA laparoscopic finding were :7 cases were normal2 cases with PCO .7 cases with peritubal adhesion. Statistically significant. 4 cases with tubal block4 cases with hyderosalpinges2 cases with fimbrial adhesion . (table 12) .Discussion :The result of this work confirm those of Punnonen et al 1979, also with the study of my professor Dr Moustafa M. Zaiton AND Ahlam M. Zaiton 1990.Kelver ME ,Nagamani M and et al (1989) their finding suggest that Chlamydia infection, as evidenced by positive antibody titer associated with a significantly high incidence of tubal infertility and that in the majority of these patients, the prior infection was subclinical and asymptomatic. (View table 10,12, 13, 14).In contrary of (Dabskausen YA and et al 1994) ,who concluded that trachomatis antibody testing is simple, inexpensive, more likely than HSG to be abnormal in patients with tubal factor infertility. C. trachomatis antibody testing deserves to become an integral component of the initial fertility work-up. (View table7,8,9) .Zhonghua Fu Chan Za Zhi 1995 said that early laparoscopy for tubal infertility& Chlamydia trachomatis sampling is the key method for early diagnosis and treatment of Chlamydia trachomatis.Ficicioglu C, Api M and et al 1995 their study evaluate the role of Chlamydia serology &HSG in predicting tubal disease. Chlamydia antibody titer positive predictive value PPV 37%, while NPV was80%. (View table 3). For HSG –PPV was71%,while NPV was 92% ( View table 8,9) .While Ault KA, and et al 1998 reported that Chlamydia that antibodies to 60 Kilodalton heat shock protein are strongly associated with tubal factor infertility.But Gijsen AP , and et al 2002 reported that Chlamydia trachomatis antibody testing in screening for tubal factor subinfertility is limited by false negative results i.e negative antibody tests in patients with tubal pathology at laparoscopy. They found 18% showed decline in IgG titre by micro-immunofluoresence MIF over period of 4-7 years but signal/ cut off values by ELISA did not change.Wiesenfeld and et al September 2002 said that “subclinical (PID) , is believed to be an important cause of tubal factor infertility their results subclinical PID was present in 27% of women with Chlamydia trachomatis (odds ratio 3.4,95% confidence interval (CI) 1.8,6.3).Last I have read about Chlamydia trachomatis associated tubal factor infertility (TFI) what Kinnunen A and et al February2003 ,reported that TFI involves enhanced humoral and cell- mediated immune response to the Chlamydia 60 KD heat shock protein (CHSP60),their conclusion : found prominentIL-I0 secretion in response to CHSP60 in the TFI group suggests that the CHSP60 may have a specific role in regulating the immune reactions during Chlamydia infection and may consequently contribute to the immunopathogensis of TIF.
|
|
|