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Chlamydia trachomatis is one of the most common pathogens of sexually transmitted diseases, and its incidence in genital tract infections is now 4.7% in south China. Infertility is the end result of C. trachomatis-induced fallopian tubal fibrosis and is receiving intense attention from scientists worldwide. To reduce the incidence of infertility, it is important to understand the pathology-related changes of the genital tract where C. trachomatis infection is significant, especially the mechanism of fibrosis formation. During fibrosis development, the fallopian tube becomes sticky and occluded, which will eventually lead to tubal infertility. At present, the mechanism of fallopian tubal fibrosis induced by C. trachomatis infection is unclear. Our study attempted to summarize the possible mechanisms of fibrosis caused by C. trachomatis infection in the fallopian tube by reviewing published studies and further providing potential therapeutic targets to reduce the occurrence of infertility. This study also provides ideas for future research. Factors leading to fallopian tube fibrosis include inflammatory factors, miRNA, ECT, cHSP, and host factors. We hypothesized that C. trachomatis mediates the transcription and translation of EMT and ECM via upregulating TGF signaling pathway, which leads to the formation of fallopian tube fibrosis and ultimately to tubal infertility., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Chlamydia trachomatis (C. trachomatis) is a major pathogen implicated in the formation of hydrosalpinx in the female reproductive tract. In mice, a related strain of Chlamydia, Chlamydia trachomatis (C. trachomatis) can induce almost 100% bilateral hydrosalpinx. This model was used as a hydrosalpinx induction model to test whether oviduct delivery of platelet-rich plasma (PRP) can attenuate chlamydia induction of hydrosalpinx in a mouse model. Mice were infected intravaginally with Chlamydia muridarum organisms, and 21 days after the infection, PRP was instilled into the lumen of one oviduct, and a sham instillation with phosphate buffer solution was performed on the contralateral oviduct. Mice were then sacrificed at designated time points after infection for oviduct pathologic evaluation including incidence, severity, and histopathologic grade of chronic inflammation. Oviduct instillation of PRP was associated with a 36% reduction in the incidence of hydrosalpinx and a 33% reduction in severity compared with sham. The median grade of chronic inflammation on histopathology was significantly lower with PRP instillation compared with sham and control. No differences were observed in vaginal or rectal shedding of C. muridarum between the test group and the control group. In short, the results suggest that oviduct instillation of PRP can significantly reduce the incidence and severity of C. muridarum-induced hydrosalpinx without affecting chlamydial infection courses in CBA/J mice.

Ruminococcus gnavus is a Gram-positive anaerobe and normal gut commensal in the human host. There have been a small number of reported cases of infections attributed to R. gnavus, and no cases of urogenital infections have previously been published. We describe here a case of bilateral tubo-ovarian abscesses (TOAs) which cultured a pure growth of R. gnavus in a young female with concurrent deep infiltrating endometriosis and evidence of pelvic inflammatory disease. This case provides an insight into the behaviour of R. gnavus as a coloniser of the human host and provides further incentive to investigate its potentially pathogenic role in inflammatory conditions such as pelvic inflammatory disease., Competing Interests: Declaration of competing interest No conflict of interest., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

This is the 47th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC.

Purpose: Factors influencing fallopian tube occlusion in women with a lower genital tract infection remain incompletely elucidated. We evaluated whether a polymorphism in the mannose-binding lectin (MBL) gene at codon 54 influences the occurrence of fallopian tube blockage in relation to exposure to Chlamydia trachomatis., Methods: In a case-control study at The Hospital das Clínicas, University of São Paulo, Brazil, 75 women with hysterosalpingography-documented tubal occlusion and 75 women with patent fallopian tubes were analyzed for detection of single-nucleotide polymorphism in codon 54 of the MBL gene and for IgG anti-C. trachomatis antibodies in their sera. Both groups were matched for age, race, and sexual variables., Results: Prior exposure to C. trachomatis, as evidenced by the presence of IgG antibodies, was comparable in both groups. Detection of the polymorphic MBL allele was more prevalent in women with blocked tubes (p < 0.01), regardless of whether or not there was evidence of prior chlamydial exposure., Conclusion: The level of MBL-related innate immunity influences the consequences of infection by C. trachomatis or other microbes.

Objectives: To explore whether non-tuberculous mycobacteria (NTM) are associated with tubal disease leading to infertility., Design: Prospective observational study., Setting: Teaching hospital., Population: Women with tubal factor infertility., Methods: In all, 173 infertile women with tubal disease were investigated for genital tuberculosis, Chlamydia trachomatis and Neisseria gonorrhoeae using polymerase chain reaction, culture and histopathological examination. On culture, NTM were grown in 23.7% of endometrial samples. The mycolic characteristics of these organisms were analysed., Main Outcome Measure: Whether NTM are associated with tubal disease leading to infertility., Results: The organisms identified in association with tubal disease were Mycobacterium tuberculosis in 30%, gonococci in 1.7%, Chlamydia in 7.5% and NTM in 23.7% of cases. Mycobacterium chelonae was the predominant organism identified by high-performance liquid chromatography. In ten women, for whom there was laparoscopic evidence of tubal disease, the only organism that was grown was NTM, and the tests for other organisms were negative. Tests for possible environment (theatre, instruments) contamination was reported negative., Conclusion: While evaluating infertile women for tubal disease, culture studies revealed a high prevalence of NTM in the endometrium. In the absence of M. tuberculosis, gonococci and Chlamydia infection, the presence of NTM suggests the possibility that these organisms may be responsible for tubal damage leading to infertility., Tweetable Abstract: On evaluating the causes of tubal disease, NTM were associated with tubal disease., (© 2019 Royal College of Obstetricians and Gynaecologists.)

A tubo-ovarian abscess (ATO) should be suspected in a context of pelvic inflammatory disease (PID) in case of severe pain associated with the presence of general signs and palpation of an adnexal mass at pelvic examination. Imaging allows most often a rapid diagnosis, by ultrasound or CT, the latter being irradiant but also allowing to consider the differential diagnoses (digestive or urinary diseases) in case of pelvic pain. MRI, non-irradiating examination, whenever it is feasible, provides relevant information, more efficient, guiding quickly the diagnosis. The diagnosis of tubo-ovarian abscess should lead to the hospitalization of the patient, the collection of bacteriological samples, the initiation of a probabilistic antibiotherapy associated with drainage of the purulent collection. In severe septic forms (generalized peritonitis, septic shock), surgery (laparoscopy or laparotomy) keeps its place. In other situations, ultrasound-guided trans-vaginal puncture in the absence of major hemostasis disorders or severe sepsis is a less morbid alternative to surgery and provides high rates of cure. Today, ultrasound-guided trans-vaginal puncture has been satisfactory evaluated in the literature and is part of a logic of therapeutic de-escalation. Randomized trials evaluating laparoscopic drainage versus radiological drainage should be able to answer, in the coming years, questions that are still outstanding (impact on chronic pelvic pain, fertility). The recommendations for the management of ATO published in 2012 by the CNGOF remain valid, legitimizing the place of radiological drainage associated with antibiotic therapy., (Copyright © 2019 CNGOF, SPILF. Published by Elsevier Masson SAS.. All rights reserved.)

Background: Candida species are harmless commensals of hosts, including humans, but they can cause infection when the immune system is compromised. Infections with non-albicans species can occur, ranging from urinary tract infections to sepsis, especially among patients in intensive care units., Case: The patient, a 37-year-old woman, presented with severe abdominal pain, fever, and vomiting. The patient's symptoms and fever continued in spite of treatment with antibiotics, and she underwent exploratory laparotomy. Cyst content culture results showed that Candida kefyr was present in the cyst., Conclusion: To the best of our knowledge, this is the first case report of a tubo-ovarian abscess caused by C. kefyr. Rare pathogens can be found in patients with a tubo-ovarian abscess, so culture of the abscess material is important for determining subsequent treatment, particularly in women who require an operation for tubo-ovarian abscess., (Copyright © 2018 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.)

A 45-year-old, G0P0 premenopausal woman was admitted for investigation of right lower quadrant pain, fever, leucocytosis and right adnexal abscess on CT. She was started on intravenous antibiotics and underwent CT-guided percutaneous drainage from which Bacteroides fragilis was cultured. A few days later, she had an exploratory laparotomy with incision and drainage. Once stabilised, she was discharged on intravenous antibiotics. She was followed outpatient and subsequent imaging demonstrated significant improvement of the abscess. After being asymptomatic for 3 months, she again presented to the emergency department with right lower quadrant abdominal pain, fever and leucocytosis. Two days later, she underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. She made a full recovery and began treatment with a herbal oestrogen derivative to prevent early menopause., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

This prospective observational study was carried out in the Infertility Unit, Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, from February 2011 to December 2013. Sixty-nine (69) subfertile women who were seropositive for Chlamydia Trachomatis were included in this study. Inclusion criteria was patients with sub-fertility having age between 22 and 40 years, seeking infertility treatment, normal ovarian function, all normozoospermic male partner, duration of infertility ranged from 1.5 to 14 years. Exclusion criteria were patients having sub-fertility with extensive pelvic and/or ovarian surgery, endometriosis, ablation of endometriotic spots, pelvic tuberculosis and history of ectopic pregnancy. Before laparoscopic evaluation, all study women were screened for Chlamydia Trachomatis Specific IgG & IgM antibodies using ELISA in the Microbiology Department of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. All the study women had positive results for IgG antibodies. All study women underwent diagnostic laparoscopy. During laparoscopy, we observed the condition of pelvic cavity, uterus, fallopian tubes, ovaries, peritubal adhesions, tubo-ovarian relationship, status of Pouch of Douglas (POD), fimbriae etc. During dye test procedure, dilute methylene blue dye was injected through the cervical canal and the dye spill out was observed to confirm the tubal patency or blockage or pattern of flow of dye. The results of laparoscopic findings demonstrated that mobility of uterus was restricted in 20(29%) cases, adhesion of uterus with peritoneum was in 8(11.6%) cases, uterine fibroid was present in 11(15.9%) cases, hydrosalpinx in right fallopian tubes were in 27(39.1%) cases, in left fallopian tubes were in 32(46.4%) cases and in both fallopian tubes in 16(23.2%) cases, inflamed right fallopian tubes in 32(46.4%) cases, inflamed left fallopian tubes in 36(52.2%) cases and inflamed both fallopian tubes in 26(37.7%) cases, adhesions in pouch of Douglas was in 4(5.8%) cases, collections in pouch of Douglas was in 7(10.1%) cases and obliterations in pouch of Douglas was in 5(7.2%) cases. Results of Dye test during laparoscopy were that right fallopian tube was blocked in 32(46.4%) cases, left fallopian tube was blocked in 32(46.4%) cases and both fallopian tubes were blocked in 21(30.4%) cases. This study shows that by laparoscopy, significant number of cases of tubal and pelvic pathology was diagnosed in the chlamydia trachomatis seropositive subfertile female. This indicates strong correlation between seropositivity of chlamydia trachomatis and/or pelvic pathology detected by diagnostic laparoscopy.

We report a case of a tubo-ovarian abscess infected with Salmonella enterica serotype typhi A 19-year-old Nepalese woman presented to a hospital in Kathmandu with lower abdominal pain, constipation, fever and a non-healing, suppurative surgical wound from an emergency caesarian section performed 2 months previously at 37 weeks of pregnancy. She also had an exploratory laparotomy for an appendix perforation with peritonitis at 25 weeks of gestation. Her wound infection did not respond to cloxacillin and she had an exploratory laparotomy, and a tubo-ovarian abscess was found from which S. typhi was isolated. She had a bilateral salpingo-oophorectomy and responded to 14 days of chloramphenicol. A tubo-ovarian abscess is a rare complication of enteric fever., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

There is established association between oxidative stress, infections of genital tract and fertility. Genital tract infections may provoke increased production of free radicals and generate oxidative stress that can be involved in pathophysiology of a number of reproductive diseases and complications during pregnancy. The aim of this study was to determine connection between oxidative stress and infertility associated with persistent chlamydial infection. Serum samples of infertile women with tubal factor infertility (TFI), women with multiple spontaneous abortions (MSA) and fertile women was screened for C. trachomatis MOMP specific IgG and IgA antibodies and cHSP60 specific igG antibodies using ELISA. The levels of superoxide anion radical, nitric oxide and reduced glutathione were determined spectrophotometricaly. Serum levels of testosterone, luteinizing hormone and follicle stimulating hormone were determined by enzyme-linked fluorescent immunoassay method. Our results showed that persistent infection was more prevalent in TFI than in MSA group, whereas seropositivity was higher in MSA than in TFI group of patients. We also found that superoxide anion was significantly lower, while LH was markedly higher in TFI and MSA group of patients. However, when our results were analyzed according to the serological status of chlamydial infection, we found that parameters of oxidative stress, superoxide anion and index of oxidative stress, defined as relative ratio between superoxide anion and nitrites sum and glutathione ((O 2 - +NO 2 - )/GSH) were significantly elevated in infertile patients with persistent chlamydial infection compared to seropositive and seronegative patients. Our findings point to the possible impact of Chlamydia trachomatis infection on prooxidative-antioxidative balance that can influence fertility potential in women with persistent chlamydial infection., (Copyright © 2017 Society for Biology of Reproduction & the Institute of Animal Reproduction and Food Research of Polish Academy of Sciences in Olsztyn. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.)

Objective: Two years after the French guidelines, the objective was to assess the feasibility and efficiency of ultrasound-guided trans-vaginal drainage of tubo-ovarian abscesses (TOA) and to study the responsible germs., Material and Methods: All the patients with a larger abscess than 20mm were included prospectively from May 2011 to July 2014 in the university hospital of Lille., Results: Sixty-nine drainages were performed among 50 patients. Success rate was 94%. No complication occurred. One germ was found in 55% of patients, the TOA was polymicrobian in 20% of cases., Conclusion: Ultrasound-guided trans-vaginal drainage of TOA is safe and effective with more than 90% of success rate., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objective: To determine the prevalence of bacterial vaginosis among women with tubal factor infertility., Methods: A cross-sectional prospective study of women with tubal factor infertility was conducted at a Nigerian teaching hospital between March and September 2014. An equal number of fertile women attending the family planning clinic were recruited as controls. Interviews were conducted to collect data on sociodemographic characteristics, history and characteristics of vaginal discharge, knowledge, and practices. Bacterial vaginosis was diagnosed using the Amsel criteria. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to determine predisposing factors., Results: Overall, 178 women with tubal factor infertility were recruited. Bacterial vaginosis was noted in 50 (28.1%) of these women, compared with 14 (7.9%) of 178 fertile women (P < 0.001). Patients with tubal factor infertility had an increased risk of bacterial vaginosis when they were of low socioeconomic class (OR 11.89; 95% CI 5.20-27.69), practiced vaginal douching (OR 19.15; 95% CI 7.26-47.75), used vaginal drying agents (OR 17.04; 95% CI 6.91-43.24), had an early sexual debut (OR 32.08; 95% CI 12.02-88.89), and had a history of sexually transmitted infections (OR 12.42; 95% CI 5.36-29.35)., Conclusion: The prevalence of bacterial vaginosis was high among patients with tubal factor infertility. Socioeconomic and cultural factors contribute to the risk of the condition., (Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Hydrosalpinx induction in mice by Chlamydia muridarum infection, a model that has been used to study C. trachomatis pathogenesis in women, is known to depend on the cryptic plasmid that encodes eight genes designated pgp1 to pgp8. To identify the plasmid-encoded pathogenic determinants, we evaluated C. muridarum transformants deficient in the plasmid-borne gene pgp3, -4, or -7 for induction of hydrosalpinx. C. muridarum transformants with an in-frame deletion of either pgp3 or -4 but not -7 failed to induce hydrosalpinx. The deletion mutant phenotype was reproduced by using transformants with premature termination codon insertions in the corresponding pgp genes (to minimize polar effects inherent in the deletion mutants). Pgp4 is known to regulate pgp3 expression, while lack of Pgp3 does not significantly affect Pgp4 function. Thus, we conclude that Pgp3 is an effector virulence factor and that lack of Pgp3 may be responsible for the attenuation in C. muridarum pathogenicity described above. This attenuated pathogenicity was further correlated with a rapid decrease in chlamydial survival in the lower genital tract and reduced ascension to the upper genital tract in mice infected with C. muridarum deficient in Pgp3 but not Pgp7. The Pgp3-deficient C. muridarum organisms were also less invasive when delivered directly to the oviduct on day 7 after inoculation. These observations demonstrate that plasmid-encoded Pgp3 is required for C. muridarum survival in the mouse genital tract and represents a major virulence factor in C. muridarum pathogenesis in mice., (Copyright © 2014, American Society for Microbiology. All Rights Reserved.)

Introduction: Tubo-ovarian abscess (TOA) is a conglomerated mass of pelvic organs including the tube, the ovary, and the bowel. The most commonly isolated organisms from TOAs are Escherichia coli (E. coli) and Bacteroides species., Case Report: We reported a case of Clostridium septicum (C. septicum) infection from a ruptured TOA with atypical clinical features. Culture of intra-abdominal free fluid obtained during surgery yielded C. septicum. VITEK II (bioMérieux, France) automated system was used for advanced identification of the bacteria. Parenteral clindamycin in combination with an aminoglycoside was used. The patient was discharged 19 days after the surgery and was clinically asymptomatic 6 months after the surgery., Conclusion: The differential diagnosis of TOA caused by C. septicum can be difficult, due to the lack of the symptoms. Tissues infected with C. septicum can become necrotic. A combination of early, adequate antibiotic therapy and surgery is the key point of the treatment.

Lower genital tract infection with Chlamydia trachomatis and C. muridarum can induce long-lasting hydrosalpinx in the upper genital tract of women and female mice, respectively. However, A/J mice were highly resistant to induction of long-lasting hydrosalpinx by C. muridarum. We further compared host inflammatory responses and chlamydial infection courses between the hydrosalpinx-resistant A/J mice and CBA/J mice known to be susceptible to hydrosalpinx induction. Both mouse strains developed robust pyosalpinx during the acute phase followed by hydrosalpinx during the chronic phase. However, the hydrosalpinges disappeared in A/J mice by day 60 after infection, suggesting that some early hydrosalpinges are reversible. Although the overall inflammatory responses were indistinguishable between CBA/J and A/J mice, we found significantly more neutrophils in oviduct lumen of A/J mice on days 7 and 10, which correlated with a rapid but transient oviduct invasion by C. muridarum with a peak infection on day 7. In contrast, CBA/J mice developed a delayed and extensive oviduct infection. These comparisons have revealed an important role of the interactions of oviduct infection with inflammatory responses in chlamydial induction of long-lasting hydrosalpinx, suggesting that a rapid but transient invasion of oviduct by chlamydial organisms can prevent the development of the long-lasting hydrosalpinges., (Copyright © 2014, American Society for Microbiology. All Rights Reserved.)

We previously reported that intracervical inoculation with Chlamydia muridarum induced hydrosalpinx in DBA/1j mice, but intravaginal inoculation failed to do so. In the current study, we found unexpectedly that intrabursal inoculation of live chlamydial organisms via the oviduct failed to induce significant hydrosalpinx. We further tested whether primary infection via intravaginal or intrabursal inoculation could induce protective immunity against hydrosalpinx following intracervical challenge infection. Mice infected intravaginally with C. muridarum were fully protected from developing hydrosalpinx, while intrabursal inoculation offered partial protection. We then compared immune responses induced by the two genital tract inoculations. Both inoculations induced high IFNγ and IL-17 T cell responses although the ratio of IgG2a versus IgG1 in intravaginally infected mice was significantly higher than in mice infected intrabursally. When the antigen-specificities of antibody responses were compared, both groups of mice dominantly recognized 24 C. muridarum antigens, while each group preferentially recognized unique sets of antigens. Thus, we have demonstrated that intrabursal inoculation is neither effective for causing hydrosalpinx nor efficient in inducing protective immunity in DBA/1j mice. Intravaginal immunization, in combination with intracervical challenge infection in DBA/1j mice, can be a useful model for understanding mechanisms of chlamydial pathogenicity and protective immunity., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Purpose: To identify the cause of pelvic inflammatory disease (PID) in Shanxi, North China., Methods: Retrospective analysis of 1,922 women with PID who underwent laparoscopy for infertility., Results: 1,922 cases (42.3%) of PID were detected in 4,540 cases of infertility, wherein the incidence rates of nonspecific PID and female genital tuberculosis (FGTB) were 57.9 and 42.1%, respectively. From 1985 to 1995, FGTB (25.1%) was the first reason for infertility, while from 1996 to 2006, nonspecific PID (33.9%) emerged as the most common cause of infertility. Further, FGTB (74.7%) was the major factor causing occluded fallopian tubes, followed by nonspecific PID (61.1%), and the damage of the former was more serious than the latter., Conclusions: PID is the main cause of tubal infertility, but the etiology of PID has changed from FGTB to nonspecific PID in the last 10 years in Shanxi., (© 2014 S. Karger AG, Basel.)

Intravaginal infection with C. muridarum in mice often results in hydrosalpinx similar to that found in women urogenitally infected with C. trachomatis, making the C. muridarum lower genital tract infection murine model suitable for studying C. trachomatis pathogenesis. To our surprise, DBA1/j mice were highly resistant to hydrosalpinx following an intravaginal infection with C. muridarum although these mice were as susceptible to lower genital tract infection as other mouse strains. A significantly lower level of C. muridarum organisms was recovered from the oviduct of DBA1/j mice, correlating the resistance to hydrosalpinx with reduced ascension of C. muridarum to the oviduct. The DBA1/j resistance to hydrosalpinx was effectively overcome by intracervical inoculation with C. muridarum. The intracervically inoculated DBA1/j mice developed severe hydrosalpinx with the highest levels of live C. muridarum organisms recovered from uterine tissue on day 3 and oviduct tissue on day 7 post inoculation while in intravaginally inoculated DBA1/j mice, the peak of live organism recovery from uterine tissue was delayed to day 7 with no rise in the amount of live organisms recovered from the oviduct. These observations have not only validated the correlation between hydrosalpinx and live organism invasion in the oviduct but also demonstrated that the intracervical inoculation, by promoting rapid chlamydial replication in the uterine epithelial cells and ascension to the oviduct of DBA1/j mice, may be used for further understanding chlamydial pathogenic mechanisms. The above findings also suggest that strategies aimed at reducing tubal infection may be most effective in blocking tubal pathology.

Background: A tubo-ovarian abscess (TOA) is a serious complication of pelvic inflammatory disease (PID), predominantly polymicrobial and present in sexually active women. TOA in virginal adolescent females are extremely rare but have serious and lifelong consequences., Case: A 13 y.o. virginal female presented to the Emergency Room of a tertiary care pediatric hospital with abdominal pain and vomiting. Imaging suggested bowel compromise with potential perforation. An exploratory laparotomy revealed TOA which grew Escherichia Coli. This is the first reported case of Escherichia Coli TOA due to suspected bowel translocation., Conclusion: Review of the literature identified 8 cases of TOA in virginal adolescents. Given the severity of outcomes following TOA, this pathology should be considered in the differential diagnosis of virginal adolescents who present with fever and abdominal pain. If suspected, a prompt gynecology consult should be initiated, followed by a first line antibiotic therapy and when indicated, surgical drainage., (Copyright © 2013 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Aim: The aim of this study was to identify factors that can predict the resistance to parenteral therapy in patients with tubo-ovarian abscesses (TOA)., Material and Methods: We conducted a case-control study involving 55 admitted patients with TOA. The subjects eligible for this study included 28 patients who failed antibiotic therapy and required surgery (surgical cases) and 27 patients who were conservatively cured (control cases). The clinical characteristics of the patients on admission were reviewed. Logistic regression analysis was performed after univariate analysis to identify potentially important variables and to calculate odds ratios with 95% confidence intervals., Results: As per the univariate analysis, compared to the control cases, the surgical cases were older (40.4 vs 31.5 years), had higher white blood cell counts (14000 vs 11828 cells/mm³), higher C-reactive protein levels (16.1 vs 7.6 mg/dL), and a larger abscess diameter (6.6 vs 3.9 cm). There were no significant differences in gravidity, parity, body temperature, rate of endometrial cyst formation, and Chlamydia trachomatis infection rates between the groups. Multiple logistic regression analysis indicated that the only statistically significant risk factor predicting parenteral antibiotic therapy failure was the abscess diameter >5 cm (odds ratio = 69.6; 95% confidence interval = 9.3-527, P < 0.0001)., Conclusion: An abscess diameter >5 cm is an important factor for predicting the failure of antibiotic therapy in patients with TOA. Moreover, it is useful for determining whether patients with TOA should be surgically treated., (© 2013 The Authors. Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology.)

The antibiotic treatment is indispensable for the treatment of the tubo-ovarian abscesses (TOA). It has to have a wide spectre and would be secondarily adapted in case of a sexually transmitted infection. The surgery remains indicated in first intention in case of vital threat (generalized peritonitis, toxic shock). In the not complicated TOA, the evacuation of abscesses (by draining under imaging or laparoscopy) with the antibiotic treatment gives better rates of cure than the antibiotic treatment alone. For the surgery, several entrys are possible. The laparoscopy allows a shorter hospitalization with fewer complications and a faster resolution of the fever than the laparotomy. The conservative surgery, realized by laparoscopy, has hight rates of successes with few complications. The radical surgery, by coelioscopy or by laparotomy, has high rates of complications. Transvaginal ultrasound guided aspiration is an alternative in the drainage by laparscopy with identical succes. It has been well evaluated. It has low morbidity and can be proposed in first intention in not complicated TOA., (Copyright © 2012. Published by Elsevier Masson SAS.)

Severe pelvic inflammatory disease and tuboovarian abscesses (TOAs) are common pelvic infections requiring inpatient admission. There are few large randomized trials guiding appropriate clinical management of TOA, including antibiotic selection and timing of surgical management and drainage. The pathogenesis, diagnosis, and management of severe pelvic inflammatory disease and TOA are summarized and reviewed from the most current literature.

A tubo-ovarian abscess (TOA) is a common complication of pelvic inflammatory disease in premenopausal women; however, in virginal females, TOAs are an exceedingly rare occurrence. Within this rare subset of patients, there is almost always an underlying condition, such as vaginal voiding, or a concomitant disease process. A virginal adolescent female with no prior medical history presented with a large pelvic mass which proved to be a TOA. An exploratory laparotomy was eventually required to establish the diagnosis. Open drainage and antibiotic therapy successfully treated the patient. With only the organism, Streptococcus viridians, isolated in her cultures, an etiology of direct ascension from the lower genitourinary tract is implicated. We believe this to be the youngest case of a TOA occurring in a virginal adolescent female without a predisposing condition. A TOA should be considered in the differential diagnosis of pelvic masses in previously healthy pediatric patients regardless of their sexual activity., (© 2012 The Authors. Pediatrics International © 2012 Japan Pediatric Society.)

Background: Tubal patency tests are routinely performed in the diagnostic work-up of subfertile patients, but it is unknown whether these diagnostic tests add value beyond the information obtained by medical history taking and findings at physical examination. We used individual patient data meta-analysis to assess this question., Methods: We approached authors of primary studies for data sets containing information on patient characteristics and results from tubal patency tests, such as Chlamydia antibody test (CAT), hysterosalpingography (HSG) and laparoscopy. We used logistic regression to create models that predict tubal pathology from medical history and physical examination alone, as well as models in which the results of tubal patency tests are integrated in the patient characteristics model. Laparoscopy was considered to be the reference test., Results: We obtained data from four studies reporting on 4883 women. The duration of subfertility, number of previous pregnancies and a history of previous pelvic inflammatory disease (PID), pelvic surgery or Chlamydia infection qualified for the patient characteristics model. This model showed an area under the receiver operating characteristic curve (AUC) of 0.63 [95% confidence interval (CI) 0.61-0.65]. For any tubal pathology, the addition of HSG significantly improved the predictive performance to an AUC of 0.74 (95% CI 0.73-0.76) (P < 0.001). For bilateral tubal pathology, the addition of both CAT and HSG increased the predictive performance to an AUC of 0.76 (95% CI 0.74-0.79)., Conclusions: In the work-up for subfertile couples, the combination of patient characteristics with CAT and HSG results gives the best diagnostic performance for the diagnosis of bilateral tubal pathology.

Genital tract infections with Chlamydia trachomatis (C. trachomatis) are the most frequent transmitted sexually disease in women worldwide. Inefficient clearance or persistence of the pathogens may lead to ascending infections of the upper genital tract and are supposed to cause chronic inflammatory damage to infected tissues (1,2). As a consequence, severe clinical sequelae like pelvic inflammatory disease (PID), tubal occlusion and infertility may occur (3,4). Most of the research with C. trachomatis has been conducted in epithelial cell lines (e.g. HEp-2 cells and HeLa-229) or in mice. However, as with cell- culture based models, they do neither reflect the physiology of native tissue nor the pathophysiology of C. trachomatis genital tract infections in vivo (5). Further limitations are given by the fact that central signaling cascades (e.g. IFN-γ mediated JAK/STAT signaling pathway) that control intracellular chlamydial growth fundamentally differ between mice and humans (6,7). We and others therefore established a whole organ fallopian tube model to investigate direct interactions between C. trachomatis and human fallopian tube cells ex vivo (8,9). For this purpose, human fallopian tubes from women undergoing hysterectomy were collected and infected with C. trachomatis serovar D. Within 24 h post infection, specimen where analyzed using scanning electron microscopy (SEM) and transmission electron microscopy (TEM) to detect Chlamydia trachomatis mediated epithelial damage as well as C. trachomatis inclusion formation in the fallopian tissue.

Purpose: The incidence of tuberculosis (TB) has increased worldwide in the past decade and it still remains an important global public health problem., Method: A retrospective clinicopathological study of 1,548 cases of female genital tuberculosis between 1940 and 2011 was conducted., Results: The mean age of the cases was 29.49 years. Involvement of the endometrium was noted in 1,073, fallopian tubes in 164, cervix in 157, and 154 had multiple organ involvement. Clinically, 115 cases (7.4%) were diagnosed as having primary infertility and 12 cases (0.8%) as having secondary infertility. There was a coexistent carcinoma in 1.5% of the cases. Peritoneal tuberculosis in 21 cases and tuberculous lymphadenitis in 7 cases were seen as well., Conclusion: The clinicopathological criteria of female genital tuberculosis in the different organs are described, and special attention is paid to infertility associated with tuberculous lesion, and awareness of the fact that the disease is still with us is thus particularly important.

Objectives: To estimate the proportion of tubal factor infertility (TFI) caused by Chlamydia trachomatis (CT), the etiologic fraction, from a retrospective study of CT antibody prevalence in TFI cases and controls, adjusted for sensitivity and specificity., Methods: We use published data on sensitivity and specificity to estimate the performance of assays in (a) women with a previous CT infection without sequelae and (b) women with TFI caused by CT. A model was developed and applied to antibody prevalence in TFI cases and controls from 1 published case-control study to estimate the proportion of TFI caused by CT., Results: The proportion of TFI episodes that were due to CT infection was estimated to be 45% (credible intervals: 28%, 62%). Models which assume that test sensitivity is higher in women with CT-related TFI than women with previous infection and no sequelae fit the data significantly better than models that assume the same sensitivity in all those previously infected., Conclusions: Greater attention needs to be paid to methods for characterizing the performance of CT antibody tests. Serological studies could be given a greater role both in CT etiology and in monitoring the effects of prevention and control programmes.

Background: The role of mycoplasmas on the development and sequelae of pelvic inflammatory disease remains controversial. The objective of the present study is to correlate directly the presence of Mycoplasmateceae through polimerase chain reaction (PCR) determinations in cervix and Fallopian tubes of infertile patients with tubo-peritoneal factor diagnosed through laparoscopy., Methods: Thirty patients with tubo-peritoneal infertility and 30 normal fertile patients were included in the study; cervical samples and tubal flushings were obtained during laparoscopy. PCR determinations for the detection of genetic material of Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma urealiticum, Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis in cervix and tubal flushings were performed., Results: No Mycoplasmataceae species as "only" microorganisms were found in tubal flushings of tubo-peritoneal infertility patients, whereas three (10%) fertile patients with normal tubes were positive for mycoplasma presence. This difference was not significant (p = 0.237). Among the 30 patients suffering from tubal infertility diagnosed through laparoscopy, Mycoplasmatecae species were not detected in the Fallopian tubes by PCR determinations, while in normal tubes from fertile patients these and other microorganisms could be found without distorting tubal anatomy., Conclusion: Mycoplasmateceae species were not detected in Fallopian tubes of women with tubo-peritoneal infertility.

We report a tubo-ovarian abscess due to Pasteurella multocida. This zoonotic infection was likely of ascending origin, as Pasteurella was also isolated from vaginal swabs.

The obligate intracellular pathogen Chlamydia trachomatis (Ctr) is a major cause of sexually transmitted disease and infertility worldwide. Ascending genital infections cause inflammation of fallopian tubes and subsequent scarring and occlusion. The cellular basis for such sequelae remains undetermined. We used confocal immunofluorescence microscopy to show that Ctr disrupts epithelial homeostasis in an ex vivo infection model of human fallopian tubes. Ctr triggered loss of polarity of inclusion harboring cells and of neighboring uninfected cells, as shown by subcellular redistribution of adhesion and polarity (occludin) markers. β-catenin (a component of the adherens junction and a Wnt signaling transducer) was recruited to the bacterial inclusion, suggesting a role for Wnt signaling in Ctr-mediated tissue damage. Comparative microarray analysis of infected epithelium in the presence of the Wnt secretion inhibitor (IWP2) demonstrated that the transcriptional response to Ctr infection was highly dependent on active Wnt secretion, moreover IWP2 reversed Ctr-induced tissue phenotypes. Notably, we observed the up-regulation of differentiation and proliferation biomarkers olfactomedin 4 and epithelial cell adhesion molecule, and also Ctr-induced proteolytic activation of epithelial cell adhesion molecule. Thus, acute Ctr infection activates the paracrine Wnt signaling pathway, leading to profound disruption of epithelial structure and function that facilitates the dissemination of damage beyond that of infected cells., (Copyright © 2012 American Society for Investigative Pathology. Published by Elsevier Inc. All rights reserved.)

The female prevalence of the genital infections due to Chlamydia trachomatis (Ct) is considered at 1.6%, but reached 3.6% among women from 18 to 24 years. Ct is one of the most implied bacteria in PID, even if it is not possible to quantify exactly the prevalence of chlamydial salpingitis because of the frequency of the asymptomatic forms. The physiopathology of these complications is not completely elucidated. The natural clearance of Ct at the cervical level has been demonstrated but it varies with the bacterial serovar. The period between cervical infection and salpingitis is also vague. However, we know that the risk of salpingitis increases with the time of start-up treatment. In addition, the risk of PID and sequelae increases with the number of cervical infections. The diagnosis can be evocated on a rise in the rate of anti-Ct IgG correlated with a rise in CRP. The diagnosis of certitude rests on the coelioscopy, but endo-vaginal echography or the MRI can direct the diagnosis. The prevention of these complications remains the targeted screening of chlamydial infections in at-risk populations, teenagers in particular. The recent techniques of self-administrated vaginal swabs are, in this respect, a real progress., (Copyright © 2011. Published by Elsevier SAS.)

Background: The Chlamydia IgG antibody test (CAT) shows considerable variations in reported estimates of test accuracy, partly because of the use of different assays and cut-off values. The aim of this study was to reassess the accuracy of CAT in diagnosing tubal pathology by individual patient data (IPD) meta-analysis for three different CAT assays., Methods: We approached authors of primary studies that used micro-immunofluorescence tests (MIF), immunofluorescence tests (IF) or enzyme-linked immunosorbent assay tests (ELISA). Using the obtained IPD, we performed pooled receiver operator characteristics analysis and logistic regression analysis with a random effects model to compare the three assays. Tubal pathology was defined as either any tubal obstruction or bilateral tubal obstruction., Results: We acquired data of 14 primary studies containing data of 6191 women, of which data of 3453 women were available for analysis. The areas under the curve for ELISA, IF and MIF were 0.64, 0.65 and 0.75, respectively (P-value < 0.001) for any tubal pathology and 0.66, 0.66 and 0.77, respectively (P-value = 0.01) for bilateral tubal pathology., Conclusions: In Chlamydia antibody testing, MIF is superior in the assessment of tubal pathology. In the initial screen for tubal pathology MIF should therefore be the test of first choice.

Purpose: To analyze the authors' success with image-guided drainage of tuboovarian abscesses (TOAs)., Materials and Methods: Retrospective analysis of patients with image-guided TOA drainage from 1999 to 2008 was performed. Patient recovery without salpingo-oophorectomy was considered clinical success. A total of 57 TOAs were drained in 49 female patients (mean age, 43; range, 12 to > 89)., Results: Thirty-three (58%) TOAs were drained percutaneously using computed tomography guidance and 24 were ultrasound guided (21 transvaginally, three transabdominally). Fifty-three TOAs were drained with catheter placement, and four were drained with aspiration alone. Abscess etiologies include pelvic inflammatory disease (n = 21, 37%), gastrointestinal conditions related (n = 21, 37%), gynecologic surgery (n = 8, 14%), and other (12%). Image-guided drainage resolved TOAs without salpingo-oophorectomy in 74% of cases overall (42 of 57) and 88% (29 of 33) of gynecologic-related cases, including 95% (20 of 21) of pelvic inflammatory disease cases. Salpingo-oophorectomy was performed more often in gastrointestinal-related cases (10 of 21, 48%) than for all other causes (five of 36, 14%; P < .001), with concurrent bowel surgery performed in the majority of the gastrointestinal-related cases. Mean follow-up after image-guided drainage was 48 months (range, 1-113) in patients who did not have related surgery. In patients who underwent salpingo-oophorectomy, it was performed on average 2.2 months (range, 0.5-5) after initial drainage. Two minor complications occurred; both involved catheter transgression of the urinary bladder in patients with transvaginal ultrasound-guided drainages. The patients were successfully treated conservatively with Foley catheter bladder decompression, without prolonged hospitalization., Conclusions: TOAs, especially of gynecologic origin, can often be managed successfully with image-guided drainage. After image-guided drainage, patients with gynecologic-related TOA were less likely to undergo salpingo-oophorectomy than patients with gastrointestinal-related TOAs., (Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the usefulness of magnetic resonance imaging (MRI) in women with tubercular tubo-ovarian masses., Methods: Twenty-four women with a confirmed diagnosis of tubercular tubo-ovarian masses underwent MRI. The findings were compared with laparotomy/laparoscopy results wherever possible., Results: The mean age was 30.7 years and the mean parity was 1.5. The main symptom in 37.5% of patients was infertility. The MRI findings included unilateral definitive tubo-ovarian masses (n=4 [16.7%]); bilateral definitive tubo-ovarian masses (n=4 [16.7%]); unilateral hydrosalpinx (n=8 [33.3%]); bilateral hydrosalpinx (n=4 [16.7%]); unilateral adnexal cyst (n=4 [16.7%]), tuberculous deposits on the liver (n=1 [4.2%]); and cervical growth (n=1 [4.2%]). Other associated findings were endometriosis (n=2 [8.3%]), inclusion cyst (n=1 [4.2%]), subserous fibroid (n=1 [4.2%]), sacroiliac joint arthritis (n=1 [4.2%]), and enteritis (n=1 [4.2%])., Conclusion: MRI seems to be a useful modality for the diagnosis of tubercular tubo-ovarian masses., (Copyright © 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Chlamydia trachomatis-induced fallopian tube damage leading to tubal factor infertility (TFI) is linked with TNF, IL-10, and probably IFNG gene polymorphisms. The aim of this study was to clarify the contribution of these cytokine gene polymorphisms to interindividual variation in C trachomatis-specific immune responses and the cross-regulation of secreted cytokines and single nucleotide polymorphisms (SNPs). Cytokine polymorphisms (IL-10 -1082A/G, -819T/C, and -592A/C, IFNG +874T/A, and TNF -308G/A) were genotyped by polymerase chain reaction in 139 women. C trachomatis-specific immune responses were measured using lymphocyte proliferation (LP) induced by C trachomatis E and F strains and chlamydial heat shock protein 60 antigens. Cytokine secretion was measured in culture supernatants of infected and uninfected mononuclear leukocytes. IL-10 -1082/-819/-592 and IFNG +874 SNPs were associated with the intensity of LP responses to C trachomatis antigens. These cytokines also interact with each other and a cumulative effect of IL-10 -1082 and IFNG +874 genotypes was seen in LP responses to C trachomatis antigens. Our data suggest that interleukin-10 and interferon-γ regulate C trachomatis-specific immune responses in humans and that genetic variation in the expression of their coding genes explains interindividual variation in host immune responses to C trachomatis infection., (Copyright © 2011. Published by Elsevier Inc.)

Genital infections with Chlamydia trachomatis (C. trachomatis) continue to be a worldwide epidemic. Immune response to chlamydia is important to both clearance of the disease and disease pathogenesis. Interindividual responses and current chlamydial control programs will have enormous effects on this disease and its control strategies. Humoral immune response to C. trachomatis occurs in humans and persistent antibody levels appear to be most directly correlated with more severe and longstanding disease and with reinfection. There is a close correlation between the presence of antichlamydial antibodies in females and tubal factor infertility; the closest associations have been found for antibodies against chlamydial heat shock proteins. The latter antibodies have also been shown to be useful among infertile patients with prior ectopic pregnancy, and their presence has been correlated with poor IVF outcomes, including early pregnancy loss. We review the existing literature on chlamydial antibody testing in infertile patients and present an algorithm for such testing in the infertile couple., (Copyright © 2011 Amanda J. Stephens et al.)

Objective: To describe a case of pelvic tuberculosis presenting as primary infertility and discuss the various diagnostic modalities., Design: Case report., Setting: Academic reproductive medicine center., Patient(s): A 28-year-old nulliparous Indian immigrant presenting with primary infertility and known tubal pathology., Intervention(s): Laparoscopic bilateral salpingectomy and adhesiolysis and diagnostic endometrial sampling., Main Outcome Measure(s): Acid-fast bacilli were obtained on polymerase chain reaction and culture of endometrial sample., Result(s): The patient was diagnosed with pelvic tuberculosis and treated with a directly observed multidrug regimen., Conclusion(s): Tuberculosis is an important cause of gynecologic morbidity and should be considered in the appropriate patients., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Human ectopic pregnancy (EP) remains a common cause of pregnancy-related first trimester death. Nitric oxide (NO) is synthesized from L-arginine by three NO synthases (NOS) in different tissues, including the Fallopian tube. Studies of knockout mouse models have improved our understanding of the function of NOS isoforms in reproduction, but their roles and specific mechanisms in infection-induced tubal dysfunction have not been fully elucidated. Here, we provide an overview of the expression, regulation and possible function of NOS isoforms in the Fallopian tube, highlighting the effects of infection-induced changes in the tubal cellular microenvironment (imbalance of NO production) on tubal dysfunction and the potential involvement of NOS isoforms in tubal EP after Chlamydia trachomatis genital infection. The non-equivalent regulation of tubal NOS isoforms during the menstrual cycle suggests that endogenous ovarian steroid hormones regulate NOS in an isoform-specific manner. The current literature suggests that infection with C. trachomatis induces an inflammatory response that eventually leads to tubal epithelial destruction and functional impairment, caused by a high NO output mediated by inducible NOS (iNOS). Therefore, tissue-specific therapeutic approaches to suppress iNOS expression may help to prevent ectopic implantation in patients with prior C. trachomatis infection of the Fallopian tube.

Objective: The objective of the study was to assess antibodies against Chlamydia trachomatis heat shock proteins (HSP) in patients with tubal factor infertility (TFI), infertility controls (IFC), and fertile controls (FC). HSPs assist organisms in surviving caustic environments such as heat., Study Design: Twenty-one TFI, 15 IFC, and 29 FC patients were enrolled after laparoscopic tubal assessment. The titers of antibodies against C trachomatis organisms and 14 chlamydial HSPs were compared among the 3 groups., Results: TFI patients developed significantly higher levels of antibodies against C trachomatis and specifically recognizing chlamydial HSP60 and caseinolytic protease (Clp) P, a subunit of the ATP-dependent Clp protease complex involved in the degradation of abnormal proteins., Conclusion: In addition to confirming high titers of antibodies against C trachomatis organisms and HSP60 in TFI patients, we identified a novel link of TFI with anti-ClpP antibodies. These findings may provide useful information for developing a noninvasive screening test for TFI and constructing subunit anti-C trachomatis vaccines., (Copyright © 2010 Mosby, Inc. All rights reserved.)

Chlamydia trachomatis is the most commonly reported infectious disease in the United States. In women, this infection can lead to pelvic inflammatory disease and cause ectopic pregnancy and tubal factor infertility. Oviduct interstitial cells of Cajal (ICC-OVI) have been identified as pacemakers, responsible for generating slow waves that underlie myosalpinx contractions that are critical for egg transport. ICC-OVI are damaged in mice by the host inflammatory response to Chlamydia, leading to loss of pacemaker activity and associated contractions. However the inflammatory mediator(s) that causes this damage has not been identified. Mice resolve C. muridarum 3-4 wk postinfection but it remains unexplored whether ICC-OVI and pacemaker activity recovers. We have investigated the time dependence of C. muridarum infection with respect to ICC-OVI loss and examined the inflammatory mediator(s) that may be responsible for this damage. Intracellular recordings from the myosalpinx were made at 1, 2, 4 and 7 wk postinfection with Chlamydia. Immunohistochemistry was performed at similar time points to examine changes in ICC-OVI networks and expression of nitric oxide synthase 2 (NOS2) and prostaglandin synthase 2 (PTGS2). Chlamydia-induced expression of NOS2 occurred in stellate-shaped, macrophage-like cells, and damage to ICC-OVI and pacemaker activity occurred as NOS2 expression increased. Immunohistochemistry revealed that macrophages were in close proximity to ICC-OVI. Changes to ICC-OVI were not correlated with PTGS2 expression. These data suggest that ICC-OVI networks and pacemaker activity may be damaged by nitric oxide produced in NOS2-expressing macrophages in response to C. muridarum infection. As the infection resolves, NOS2 expression decreases, ICC-OVI networks recover, and pacemaker activity resumes.