**10. Role of hidden intrauterine infections and the value of laparoscopy in these cases**

Existing definitions of infertility lack uniformity, rendering comparisons in prevalence between countries or over time problematic. The absence of an agreed definition also com‐ promises clinical management and undermines the impact of research findings [66]. Unex‐ plained infertility is infertility that is idiopathic in the sense that its cause remains unknown even after basic infertility work-up, usually including semen analysis in the man and assess‐ ment of ovulation and fallopian tubes in the woman. The available diagnostic tools for intrauterine causes of infertility include transvaginal ultrasonograogy, hysterosalpingography (HSG) or sonohysterography [67]. Manifest uterine causes may include clinically symptoma‐ tizing uterine infections, intrauterine adhesions, polypi or uterine cavity malformations. Hidden uterine factors may include thin endometrium, poor endometrial receptivity, and immunological incompatibility which have received the most attention in recent years [68]. In literature, little attention was directed towards asymptomatic hidden intrauterine infections like Mycoplasma, Ureaplasma, Klebsiella and Chlamydia trachomatis particularly among infertile women [69].

Mycoplasma clonieswith fried egg appearance

Chlamydia trachomatis

BV (gram stain) ureaplasmaurealyticum

Subclinical infection can be a possible cause of unexplained infertility [70]. Changes in the intraperitoneal environment leading to an inflammatory process in the absence of visible abnormalities have been suggested as being causal in some cases of UI [71]. 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.

**10. Role of hidden intrauterine infections and the value of laparoscopy in**

Existing definitions of infertility lack uniformity, rendering comparisons in prevalence between countries or over time problematic. The absence of an agreed definition also com‐ promises clinical management and undermines the impact of research findings [66]. Unex‐ plained infertility is infertility that is idiopathic in the sense that its cause remains unknown even after basic infertility work-up, usually including semen analysis in the man and assess‐ ment of ovulation and fallopian tubes in the woman. The available diagnostic tools for intrauterine causes of infertility include transvaginal ultrasonograogy, hysterosalpingography (HSG) or sonohysterography [67]. Manifest uterine causes may include clinically symptoma‐ tizing uterine infections, intrauterine adhesions, polypi or uterine cavity malformations. Hidden uterine factors may include thin endometrium, poor endometrial receptivity, and immunological incompatibility which have received the most attention in recent years [68]. In literature, little attention was directed towards asymptomatic hidden intrauterine infections like Mycoplasma, Ureaplasma, Klebsiella and Chlamydia trachomatis particularly among

BV (gram stain) ureaplasmaurealyticum

Chlamydia trachomatis

**these cases**

16 Contemporary Gynecologic Practice

infertile women [69].

Mycoplasma clonieswith fried egg appearance

We constructed a prospective study aimed to estimate the prevalence of hidden (asympto‐ matic) intrauterine infections among women with unexplained infertility in comparison to fertile women and to describe laparoscopic appearances in positive cases. It was a prospective cross sectional comparative observational study done at a tertiary care referral facility and University hospital. It comprised 50 women with unexplained infertility (study group A) and 50 fertile women (control group B) who came for contraceptive advice. Endouterine swab for bacteriologic study from all cases. Diagnostic laparoscopy for group A. Main outcome measures included prevalence of infections among both groups and to correlate laparoscopic findings to bacteriologic study in group A. There was statistically insignificant difference between both groups regarding the age and residence (p value >0.05) and it was highly significant regarding parity (p value <0.001). Hidden intrauterine infections were diagnosed by culture in 42 cases (84%) and 10 cases (20%) out of both groups respectively (P=0.001). The most common organisms detected in the study group were Mycoplasma (24%), klebsiella (20%), Chlamydia (18%) and Proteus (10%). In group A, positive laparoscopic findings were reported in 33 patients (66 %). There was a significant correlation between the positive cases of hidden intrauterine infections and abnormal laparoscopic findings (P Value=0.0001). The most common laparoscopic abnormalities were hyperemic uterus, peritubal adhesions and chronic salpingitis which were reported in 10 (20%), 6 (12%) and 4 (8%) cases respectively.

