**7. Vaginal microbiome and female infertility**

**2. Position of genital tract infections in infertility work-up**

detected by speculum examination can be a direct cause of female subfertility.

Overt uterine causes of infertility would include clinically symptomatizing cervical and uterine infections, intrauterine adhesions, polypi or uterine cavity malformations. Gynecologists usually pay little care towards manifest lower and upper genital tract infections among infertile

Cervicitis as well as vaginitis has been one of the common diseases influencing the health of female genital system. The happening rate of female vaginal and cervical inflammation is increasing rapidly in modern world which may be organism mutations, immunological changes, and poor hygiene in underdeveloped world or liberal sexual behaviors particularly in western countries. Fortunately enough, with the increased medical knowledge, health education, improved diagnosis and aggressive lines of therapy, prompt eradication of these

In general, cervicitis has a negative impact on pregnancy. When a woman is diagnosed with cervicitis, especially for those who have severe cervicitis, the possibility of infertility is high. When cervicitis occurs, the cervix secretes more discharge with large amount of WBCs and pathogens thus hindering normal vaginal environment. This changes the PH of the vagina and

**3. Manifest (overt) genital tract infections**

women and rely mainly on ultrasonography and hormonal profile.

**4. Increasing rate of lower genital tract infections**

**5. Impact of lower genital tract infection on fertility**

infections is possible.

22 Genital Infections and Infertility

International societies didn't include infections as a definite cause of infertility. Practically, local gynecologic examination should be an essential routine step in infertility evaluation. Both speculum and bimanual examinations can detect or suspect a wide variety of lower or upper genital tract infections. With the extensive routine use of transvaginal ultrasonography (TVS) in all gynecologic clinics, unfortunately many gynecologists miss the five basic steps of gynecologic examination which can detect definite infertility causes (inspection of the external genitalia, palpation of the external genitalia, palpation of the vaginal walls and fornices, bimanual examination and vaginal speculum examination). Moreover, many women don't prefer local gynecologic examination due to fear or inconvenience. Gynecologic examination is a cheap valuable basic step that should not be ignored. Moreover, local examination can detect many vaginal and cervical disorders. For instance, some congenital anomalies like transverse or longitudinal vaginal septae, Gartner's cyst in one of the fornices which occludes the external os or congenital vaginal atresia. Practically and literally, genital tract infection

> Vaginal microbiome is a new era under continuous evaluation and research. It is well estab‐ lished that the vagina is colonized by bacteria that serve important roles in homeostasis. Imbalances in the proportion of bacteria may lead to a predisposition to infection or repro‐ ductive complications. Molecular-based approaches found high variations within and between women than previously reported. Moreover, the vaginal microbiome may increase or decrease according to the health status, menstrual cycle or menopause with ethnic varia‐ tions. Dysbiosis and the transmission of sexually transmitted infections are affected by the

composition of the microbiome. An understanding of the diversity of the vaginal microbial environment during states of health is essential for the identification of risk factors for disease and the development of appropriate treatment [5]

The effect of known pathogens such as Mycoplasma, tuberculosis, Chlamydia trachomatis, and Neisseria gonorrhoeae is clear, causing subclinical changes thought to be risk factors in subfertility. Colonizing the transfer-catheter tip with Lactobacillus crispatus at the time of embryo transfer may increase the rates of implantation and live birth rate while decreasing the rate of infection [6]. On the other hand, the presence of vaginal–cervical microbial con‐ tamination at the time of embryo transfer is associated with significantly decreased pregnancy rates [7]. Nevertheless, the exact implication of microbiome in infertility requires more studies.
