**13. Correlation between positive cases of hidden intrauterine infection and laparoscopic findings in UI group**

We concluded that despite being an underestimated cause of female infertility, hidden intrauterine infections are frequent and strongly implicated in UI. Laparoscopy is very beneficial in explaining the effect of hidden intrauterine infections on the upper genital tract. We recommend postoperative screening for hidden intrauterine infections in UI cases with abnormal laparoscopic findings. Further studies are required to test pregnancy rate after proper treating of these infections in case of UI.



**Control group (B) study group (A)**

**Percent No (50) Percent No (50)**

**laparoscopic findings in UI group**

**laparoscopic findings in UI group**

proper treating of these infections in case of UI.

**Endometriosis**

**chronic salpingitis**

**Culture for intrauterine infection**

18 Contemporary Gynecologic Practice

+ve


Total

+ve (42)


% of Total

100% 50 100% 50 Total

**12. Correlation between positive cases of hidden intrauterine infection and**

**Abnormal laparoscopic findings**

+ve -ve

No. 30 12 42

% of Total 50% 16% 82%

No. 3 5 8 % of Total 16% 18% 16%

No. 33 17 50 % of Total 66% 34% 100.0%

**13. Correlation between positive cases of hidden intrauterine infection and**

We concluded that despite being an underestimated cause of female infertility, hidden intrauterine infections are frequent and strongly implicated in UI. Laparoscopy is very beneficial in explaining the effect of hidden intrauterine infections on the upper genital tract. We recommend postoperative screening for hidden intrauterine infections in UI cases with abnormal laparoscopic findings. Further studies are required to test pregnancy rate after

> **hyperemic uterus**

8% 14% 12% 20% 2% 4% 24% 84%

No. 4 7 6 10 1 2 12 42

No. 0 2 0 1 0 0 5 8

**Tubal block (uni/bi)**

**Fimbrial agglutination** **Normal (17)**

**Total (50)**

**fine peritubal adhesions** **Organism**

**Total P Value**

0.0001

In this study, we found that the prevalence of hidden intrauterine infections proved by culture of endouterine discharge in women with UI was 84% while the prevalence in the fertile women (the control group) was 20% (P Value=0.0001). Based on our results, we recommend that before starting a lengthy and costly list of sophisticated level II investigations of both partners, focusing attention to hidden uterine infections is very important basic step in UI. These results were similar to others who reported high prevalence of different types of infections [72]. It has been found that women with tubal factor were two to three times more likely to have genital tract infections than women with other types of infertility [73]. Likewise, our findings highlight the importance of searching for genital tract infections in cases with tubal factor of infertility. In this study we used culture of the intrauterine discharge as a diagnostic test for different infections. Biochemical confirmation was also performed. Others used more sophisticated tests like ELIZA and PCR [72,73]. We think that culture should be accepted as a basic screening tool due to availability and feasibility in many hospitals. Screening test should not be expensive or complicated to be extended to all hospitals particularly in low resource countries like ours.

This study demonstrated a high prevalence of Mycoplasma (24%), klebsiella (20%), Chlamydia (18%) and Proteus (10%) among women with UI. These results of high prevalence compared to fertile women would call for more attention to screening protocols in all infertility units dealing with UI ideally prior to laparoscopic intervention. Due to high prevalence of Chla‐ mydia in infertile women in one previous study, screening for Chlamydia was recommended for cases with UI [72]. We reported Mycoplasma in about one quarter of positive cases. Likewise, mycoplasma was reported in 32% of infertile cases with a statistically significant difference from fertile group [77]. In this study, we cultured proteus infection in 10% of infected cases. This particular organism is commonly noticed in the urinary system. Reporting it in the genital tract would requires more studies to define its role in infertility. Unlike others, we reported low prevalence of Ureaplasma in only 4% of cases despite its previous reports of up to 32% infertile cases [72]. This wide difference may demonstrate the variability of frequency of hidden intrauterine infections in different populations and highlights detection of preva‐ lence in each community.

The role of laparoscopy in the evaluation of infertility is crucial [78]. In this study we reported 33 case (66%) of abnormal laparoscopic findings in the infertile group. In a previous study [79], abnormal laparoscopic findings were reported in about 53 % of infertile women. Pelvic adhesions were the most frequent finding in their study. Others [80] reported a higher prevalence of abnormal laparoscopic findings in UI up to 87.2% who described endometriosis lesions, peritubal adhesions and tubal obstruction. In a previous study, 114 women with UI were examined laparoscopically. Laparoscopy revealed pelvic pathology in 95 patients. Endometriosis, ptielvic 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 [65]. In this study, positive laparoscopic findings were reported in 33 patients (66 %). We found that laparoscopy can reveal upper genital tract pathology in 30 cases (71.4%) of positive cases with hidden infections (42 cases) and it was negative in 3 cases (37.5%) of negative cases with hidden intrauterine infections (P Value=0.0001). We reported a significant correlation between the positive cases of intrauterine infections and the pathological lesions diagnosed by laparoscopy especially hyperemic uterus, chronic salpingitis and peritubal adhesions (P Value=0.0001). Subsequently, we recommend meticulous screening of women with these abnormal laparo‐ scopic findings for possibility of hidden intrauterine infections. Small sample size of individual types of hidden intrauterine infections and lake of precise description of a particular abnormal laparoscopic finding for each organism are clear limitations of this study. Diagnostic accuracy for Chlamydia detection would be better if we used Nucleic Acid Amplification (NAAT) instead of the only available direct immunofluorescence assay (IFA). From this study, we conclude that despite being an underestimated cause of female infertility, hidden intrauterine infections are frequent and strongly implicated in UI. Laparoscopy is very beneficial in explaining the effect of hidden intrauterine infections on the upper genital tract. We recom‐ mend postoperative screening for hidden intrauterine infections in UI cases with abnormal laparoscopic findings. Further studies are required to test the impact of proper treating these infections in cases of UI.

#### **14. Hidden ovarian factors of infertility**

The ovaries are easily and clearly seen by transvaginal ultrasonogtraphy. Intraovarian and capsular abnormalities can be detected in most of the cases. Despite properly confirmed ovulation in an otherwise normal couple, pregnancy could not be achieved. On doing diagnostic laparoscopy in those cases some tiny ovarian abnormalities could be diagnosed. Subtle surface ovarian endometriosis could be only diagnosed by laparoscopy. In such cases surface coagulation of red, white or vesicular lesions is easy. Moreover, typical black or blue lesions can be only seen and treated by laparoscopy. In some cases, we notice fine periovarian adhesions hindering rupture of the growing folloicles and preventing pick-up of the oocytes. In such cases, fine microsurgical adhesiolysis without capsular injuring using a delicate fine scissors is feasible by laparoscopy. We may see some dense ovarian adhesions to the lateral or anterior abdominal wall that clearly affect fertility In such cases, microsurgical adhesiolysis will regain the normal anatomy. Lastly, we may notice fine or dense adhesions between the ovary and the back of the uterus or the fallopian tubes. All these mechanical factors will not be seen by HSG and highlight the importance of implication of dual laparoscopy and hys‐ teroscopy in all cases of infertility particularly women with previous pelvic or uterine surgery.
