**7. Uterovesical pouch abnormalities**

**Uterovesical pouch abnormalities:**  Not uncommonly in post-cesarean section patients, we notice a thick central band between the uterus and the anterior abdominal wall attracting the uterus anteriorly causing severe anteversion. By this way infertility may occur due to relative shortening of the tubes as they will be far from the pouch of Douglas despite being completely healthy. The job of the laparoscopist in such Not uncommonly in post-cesarean section patients, we notice a thick central band between the uterus and the anterior abdominal wall attracting the uterus anteriorly causing severe anteversion. By this way infertility may occur due to relative shortening of the tubes as they will be far from the pouch of Douglas despite being completely healthy. The job of the laparoscopist in such cases is to cut this band to allow the tubes for proper function. One of the practical tricks, to know proper lysis is to test the level of the cervix by vaginal examination. Easy traction of the cervix is a good parameter of success. Moreover, the laparoscopist should look at the fimbrial relation to the pouch of Douglas. Care should be exerted to avoid bladder injury which can be easily induced particularly if a broad band with dense sealing is seen.

#### know proper lysis is to test the level of the cervix by vaginal examination. Easy traction of the **8. Role of Bacterial Vaginosis (BV) and the implementation of laparoscopy in these cases**

cases is to cut this band to allow the tubes for proper function. One of the practical tricks, to

cervix is a good parameter of success. Moreover, the laparoscopist should look at the fimbrial

We believe that occult infections are important explanation of UI particularly in patients who are unable to clearly give a history to explain a source for their tubal adhesions. BV infection

was reported as a significant association with infertility and its proper treatment had lead to pregnancy, emphasizing the value and clinical implication of its screening and treatment [58]. It is hypothesized that immunity to infection might be correlated to sperm rejection in women with positive BV, leading to infertility [59]. On the other hand, low prevalence of BV (4.2%) was reported in a population of women undergoing in-vitro fertilization/embryo transfer (IVF-ET) where 331 infertile women were selected [60]. Variable results of many studies on the prevalence of BV among infertile women particularly UI were one of the main indications to construct a prospective study.Its aim was to estimate the prevalence of bacterial vaginosis (BV) among women with unexplained infertility (UI) and to describe laparoscopic appearances in positive cases. It was a prospective cross sectional comparative observational study done in a tertiarycare referralfacilityandUniversityhospital.It comprisedonehundredandfiftywomen divided into UI study group (120 cases) and a control group (30 cases). Vaginal and cervical swabs formtwosubgroupsoftheUIgroup(60caseseach)andvaginal swabs fromcontrolgroup (30 cases). All swabs were tested using Amsel's criteria then cultured. Thereafter, UI group (60 cases) was subjected to diagnostic laparoscopy. Main outcome measures were the prevalence of BV among women with UI and laparoscopic findings among positive cases. In the study group, the number of positive cases of BV confirmed by culture was 51 cases (42.5 %) while it was diagnosed in only 3 cases (10%) in group B (p value 0.0001). BV was positive in 24 and 27 cases with periods of infertility less than and more than 3 years respectively and in 39 patients (32.5%) with recurrent vaginitis without statistical significance. There was an insignificant difference indiagnosis ofBV whetherthe site of sample is vagina or cervix. Positive laparoscop‐ ic findings were reported in 77 patients (64.2 %). The most common laparoscopic abnormali‐ ties were hyperemic uterus and chronic salpingitis. In this study, we found that the prevalence of BV in women with UI is 42.5%, while the prevalence of BV in the fertile women (the control group)was 10%(PValue=0.0001).These resultswere similartootherswhoreportedBVin45.5% Vs 15.5% of the infertile and the control groups respectively [58]. On the other hand, BV was reported in only 18.9% of women with UI [61]. They reported rates of 12–15% in those with endometriosis and male factor infertility and 33–36% in those with anovulation and tubal infertility.Women with tubalfactor were two to three timesmore likely to haveBV than women with other types of infertility [62]. These findings highlight the importance of searching for BV incaseswithtubalfactorofinfertility.This studyreportednosignificantdifference inthe results of samples takenfromtheposteriorfornixofvaginaandthose takenfromthe endometrial cavity (P Value=0.853). However, detection of clue cells in the endometrial cavity of women with UI demonstrates the possibility of ascending route of BV to the upper genital tract.

Regarding the role of culture for diagnosis of BV, we reported in 45.8% and 42.5% in culture and usingAmsel`s criteria respectively without any significantdifference.In this study, culture was a sensitive but not a specific method for diagnosing of BV compared to Amsel`s criteria which is demonstrated by ROC curve. Likewise, culture was unhelpful for the diagnosis of BV due to an imbalance of the normal organisms, without any pathogens necessarily being present [63].

The sensitivity and specificity of vaginal cultures for anaerobic bacteria (*Bacteroides* and *Peptostroptococcus*) and *Mycoplasma hominis* were reported in one study. They found that the presence of these organisms was a more specific indicator of BV than the presence of *G. vaginalis* but their detection had inadequate sensitivity [64]. Another group of anaerobic bacteria, Mobiluncus species, which is highly associated with BV, was very difficult to recover with culture methods [65].

was reported as a significant association with infertility and its proper treatment had lead to pregnancy, emphasizing the value and clinical implication of its screening and treatment [58]. It is hypothesized that immunity to infection might be correlated to sperm rejection in women with positive BV, leading to infertility [59]. On the other hand, low prevalence of BV (4.2%) was reported in a population of women undergoing in-vitro fertilization/embryo transfer (IVF-ET) where 331 infertile women were selected [60]. Variable results of many studies on the prevalence of BV among infertile women particularly UI were one of the main indications to construct a prospective study.Its aim was to estimate the prevalence of bacterial vaginosis (BV) among women with unexplained infertility (UI) and to describe laparoscopic appearances in positive cases. It was a prospective cross sectional comparative observational study done in a tertiarycare referralfacilityandUniversityhospital.It comprisedonehundredandfiftywomen divided into UI study group (120 cases) and a control group (30 cases). Vaginal and cervical swabs formtwosubgroupsoftheUIgroup(60caseseach)andvaginal swabs fromcontrolgroup (30 cases). All swabs were tested using Amsel's criteria then cultured. Thereafter, UI group (60 cases) was subjected to diagnostic laparoscopy. Main outcome measures were the prevalence of BV among women with UI and laparoscopic findings among positive cases. In the study group, the number of positive cases of BV confirmed by culture was 51 cases (42.5 %) while it was diagnosed in only 3 cases (10%) in group B (p value 0.0001). BV was positive in 24 and 27 cases with periods of infertility less than and more than 3 years respectively and in 39 patients (32.5%) with recurrent vaginitis without statistical significance. There was an insignificant difference indiagnosis ofBV whetherthe site of sample is vagina or cervix. Positive laparoscop‐ ic findings were reported in 77 patients (64.2 %). The most common laparoscopic abnormali‐ ties were hyperemic uterus and chronic salpingitis. In this study, we found that the prevalence of BV in women with UI is 42.5%, while the prevalence of BV in the fertile women (the control group)was 10%(PValue=0.0001).These resultswere similartootherswhoreportedBVin45.5% Vs 15.5% of the infertile and the control groups respectively [58]. On the other hand, BV was reported in only 18.9% of women with UI [61]. They reported rates of 12–15% in those with endometriosis and male factor infertility and 33–36% in those with anovulation and tubal infertility.Women with tubalfactor were two to three timesmore likely to haveBV than women with other types of infertility [62]. These findings highlight the importance of searching for BV incaseswithtubalfactorofinfertility.This studyreportednosignificantdifference inthe results of samples takenfromtheposteriorfornixofvaginaandthose takenfromthe endometrial cavity (P Value=0.853). However, detection of clue cells in the endometrial cavity of women with UI

14 Contemporary Gynecologic Practice

demonstrates the possibility of ascending route of BV to the upper genital tract.

Regarding the role of culture for diagnosis of BV, we reported in 45.8% and 42.5% in culture and usingAmsel`s criteria respectively without any significantdifference.In this study, culture was a sensitive but not a specific method for diagnosing of BV compared to Amsel`s criteria which is demonstrated by ROC curve. Likewise, culture was unhelpful for the diagnosis of BV due to an imbalance of the normal organisms, without any pathogens necessarily being present [63].

The sensitivity and specificity of vaginal cultures for anaerobic bacteria (*Bacteroides* and *Peptostroptococcus*) and *Mycoplasma hominis* were reported in one study. They found that the presence of these organisms was a more specific indicator of BV than the presence of *G. vaginalis* but their detection had inadequate sensitivity [64]. Another group of anaerobic In a previous study, 114 women with UI were examined laparoscopically Laparoscopy revealed pelvic pathology in 95 patients. Endometriosis, pelvic adhesions and tubal disease were observed and treated in 72, 46 and 24 patients, respectively. They could treat 72 patients of them, and 35 of them conceived using their own tubes. However they concluded that diagnostic laparoscopy should be strongly considered in UI work-up, and tubal efficacy should not be underestimated [66]. In this study, positive laparoscopic findings were reported in 77 patients (64.2 %). We found that laparoscopy can reveal upper genital tract pathology in 50% of positive cases with BV and it was negative in 35% of negative cases with BV (P Value=0.0001). There was a significant correlation between the positive cases of BV and the pathological lesions diagnosed by laparoscopy especially hyperemic uterus, chronic salpingitis and massive adhesions (P Value=0.0001) as shown in the following table.
