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Abstract
Pelvic 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 with Monoclonal 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 disease Neisseria 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: PAD The 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.