**10. Similar studies**

(20%) in both groups respectively with a high statistically significant difference (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 IUI and the pathological lesions diagnosed by laparoscopy (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, which demonstrate a highly significant correlation between confirmed hidden IUI and abnormal laparoscopic findings in UI. Laparoscopy revealed upper genital tract pathology in 30 cases (71.4%) of positive cases of hidden infections (42 cases) and it was negative in 3 cases (37.5%) of negative cases of hidden intrauterine infections (P Value= 0.0001). Cases with abnormal laparoscopic findings (33 cases) could be explained by positive culture of hidden intrauterine infection in UI group except 7 cases of endometriosis and 3 cases were culturefree. Abnormal laparoscopic findings were found more in positive cases with Mycoplasma (10

cases), Chlamydia (8 cases), Klebsiella (3 cases) and Proteus (2 cases) respectively.

Hidden IUI may be a possible cause of UI [18]. This can be achieved by alterations in the intraperitoneal environment that may lead to an inflammatory process in the absence of visible abnormalities [19]. In our work, high prevalence of hidden IUI (84%) proved by culture of endouterine discharge in women with UI raise the recommendation that before starting a lengthy and costly list of sophisticated level II investigations of both partners, attention to hidden IUI is a mandatory basic step in UI. 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 [20]. We think that culture would be accepted as a basic screening tool for hidden IUI due to availability and feasibility in many hospitals. Screening test should not be expensive, time consuming or complicated before being extended to all hospitals particularly

Our work 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 a previous study, screening for Chlamydia was recommended for cases with all cases with UI [18]. 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 [12]. In this study, proteus infection was reported in 10% of infected cases. This particular organism is commonly noticed in the urinary system infections. 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 [18]. This big difference may clarify the variability of frequency of hidden intrauterine infections in different populations and high‐

**9.3. Discussion on prevalence of hidden IUI**

28 Genital Infections and Infertility

in low resource countries with limited resources.

lights importance of studies on prevalence in each community.

One hundred seventy infertile women and 45 pregnant women in the third trimester were evaluated in one study for the prevalence of uterine infections [25]. Classical methods and real time PCR were applied to each cervical sample to detect the presence of these sexually transmitted microorganisms; the ELISA method was applied to blood samples to detect C. trachomatis antibodies (IgA, IgM and IgG). The proportion of C. trachomatis IgG was significantly higher in the infertile group (23.8%) than in the pregnant group (4.4%), p < 0.05. For C. trachomatis antigen (Ag) and N. gonorrhoea Ag no differences were observed between the two groups. The prevalence of mycoplasma genital infections was higher in the pregnant group (U. urealyticum - 53.3% and M. hominis - 20%) than in the infertile group (U. urealyticum - 39.7% and M. hominis - 7.3%). Higher rate of co-infection with C. trachomatis and myco‐ plasma were observed among the infertile women (25.7%) than among the pregnant women (7.7%). This combination could be involved in the appearance of pelvic inflammatory disease (PID) and its sequele, including infertility. C. trachomatis IgG determination still remains the gold standard for the diagnosis of PID and should be used as a screening test for the prediction of tubal damage in infertile women. They concluded that in view of the large number of cases involving the co-existence of genital infections with C. trachomatis, M. hominis and U. urealyticum, it is clearly necessary to perform screening for all three microorganisms among all women of reproductive age but especially those who are infertile.

Another study [26] was constructed to investigate the detection rates of Chlamydia tracho‐ matis, Neisseria gonorrhoeae, Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma urealyticum, Gardnerella vaginalis, Escherichia coli, Streptococcus agalactiae and Enterococ‐ cus faecalis, in asymptomatic fertile and infertile women. It encompassed 161 women, including 101 women treated for infertility and 60 fertile women who had already given birth to healthy children. The material for the presence of C. trachomatis, N. gonorrhoeae, M. genitalium, M. hominis and U. urealyticum was collected from the cervical canal and analyzed by PCR. Furthermore, BD Probe Tec ET system was used to detect C. trachomatis infection. Vaginal swabs were collected for classification of bacterial vaginosis and aerobic vaginitis and assessed according to the Nugent score, as well as by traditional culture methods. U. urealy‐ ticum was identified in 9% of the infertile women and in 8% of controls. Presence of M. hominis was demonstrated only in the former (4%) and C. trachomatis only in latter (3%). N. gonor‐ rhoeae and M. genitalium were not found in any of the examined women. The frequency of aerobic vaginitis in both groups was estimated at 12%. There were 7% bacterial vaginosis cases in the study group, and none in the control group (p=0.0096). They concluded that despite having no symptoms of an ongoing acute inflammation of the reproductive tract, many women may experience permanent or periodic shifts of equilibrium of the vaginal and/or cervical microflora. BV develops more frequently in infertile patients when compared to the fertile women.

#### **11. Infection induced by infertility work-up maneuvers**

During the course of infertility work-up, women are subjected to many invasive diagnostic procedures like hysterosalpingography, hysteroscopy, sonohystrography, premenstrual biopsy or laparoscopy. Moreover, some therapeutic procedures are done to treat definite problems like selective salpingography, egg retrieval, operative resectoscopy or hysteroscopy and operative laparoscopy in addition to some minor vaginal maneuvers. All these diagnostic and operative interventions carry the risk of introduction of infection to the genital tract and disruption of the natural protective mechanisms. The gynecologist should pay attention to the possibility of inducing infection and stick to aseptic strict precautions during every step. Lastly, whenever suspicion of introduction of infection is raised, proper broad spectrum antibiotics should be considered.
