Factores causales de infertilidad / Fatores causadores de infertilidade / Causative factors of infertility

Introducción: la infertilidad adquiere cada día mayor auge en las sociedades. Objetivo: facilitar la labor del médico de la familia en la captación y seguimiento de los casos de infertilidad. Método: se realizó una revisión bibliográfica, mediante consulta digital de las revistas especializadas, actualizadas y de libre acceso disponibles en el sitio web de la Biblioteca Virtual de Salud. Para la localización de las publicaciones fueron empleadas varias palabras clave, que contuvieron fundamentalmente el término infertilidad. Las citas digitales más recientes y que mostraban el trabajo de manera íntegra, fueron sometidas a un análisis que permitió obtener la información. Desarrollo: dentro de las causas de infertilidad identificadas con mayor frecuencia se encuentran en el caso de las femeninas, las infecciones genitales y como exponente de la masculina con el varicocele. Conclusiones: fomentar la incorporación del conocimiento permitirá el diseño de acciones preventivas sobre los principales factores causales de la infertilidad desde la Atención Primaria de Salud(AU)

Introduction: infertility is becoming increasingly popular in societies. Objective: to facilitate the work of the family doctor in the collection and follow-up of cases of infertility. Method: a bibliographic review was carried out, through digital consultation of specialized journals, updated and freely available on the website of the Virtual Health Library. Several keywords were used to locate the publications, which mainly contained the term infertility. The most recent digital citations, which showed the work in their entirety, were subjected to an analysis that allowed obtaining the information. Development: Among the causes of infertility identified most frequently are in the case of females, genital infections and as an exponent of the male with the varicocele. Conclusions: promoting the incorporation of knowledge will allow the design of preventive actions on the main causal factors of infertility from the Primary Health Care(AU)

Introdução: a infertilidade está se tornando cada vez mais popular nas sociedades. Objetivo: facilitar o trabalho do médico de família na coleta e acompanhamento de casos de infertilidade. Método: foi realizada uma revisão bibliográfica, por meio de consulta digital de periódicos especializados, atualizado e disponível gratuitamente no site da Biblioteca Virtual em Saúde. Diversas palavras-chave foram utilizadas para localizar as publicações, que continham, principalmente, o termo infertilidade, sendo que as citações digitais mais recentes, que apresentaram o trabalho na íntegra, foram submetidas a uma análise que permitiu a obtenção das informações. Desenvolvimento: Dentro das causas da infertilidade identificaram mais freqüentemente encontrada no caso das mulheres, infecções genitais e como um expoente do sexo masculino com os varicocele. Consideraciones finais: promover a incorporação do conhecimento permitem o desenho de ações preventivas em principais fatores causais da infertilidade da Atenção Primária à Saúde(AU)

[Pelvic inflammatory disease due to Herlyn-Werner-Wunderlich syndrome]. / Enfermedad inflamatoria pélvica causada por el síndrome de Herlyn-Werner-Wunderlich.

BACKGROUND: Herlyn-Werner-Wunderlich syndrome is a congenital urogenital malformation that is associated with a uterus didelphys and a longitudinal vaginal septum, resulting in a blind hemivagina and ipsilateral renal agenesis. Clinical presentation is highly variable, delaying diagnosis and leading to important complications. CLINICAL CASE: We present the case of a 13-year-old female who was diagnosed with Herlyn-Werner-Wunderlich syndrome following an acute abdomen due to a right tubo-ovarian abscess. She had a vaginal septum giving rise to a right blind hemivagina. It was microperforated, causing intermittent genital bleeding. This hematocolpos was colonized by microorganisms that ascended to the pelvic cavity, causing right tuboovarian abscess. Nuclear magnetic resonance imaging provided theWernermost diagnostic information. We performed a vaginal septum resection, and both hemiuteros communicated with a single vagina, resulting in an asymptomatic patient. CONCLUSION: Herlyn-Werner-Wunderlich syndrome is a little known entity and can be presented atypically, resulting in diagnostic difficulty and treatment delay. It is important to be aware of this syndrome in order to avoid irreversible complications.

ANTECEDENTES: el síndrome de Herlyn-Werner-Wunderlich es una malformación urogenital congénita que asocia un útero didelfo con un tabique vaginal longitudinal que forma una hemivagina ciega y agenesia renal ipsilateral a ésta. La presentación clínica es muy variable, lo que retrasa el diagnóstico y provoca algunas complicaciones que pueden ser graves. Caso clínico: paciente femenina de 13 años de edad, con diagnóstico de síndrome de Herlyn-Werner-Wunderlich a raíz de un cuadro de abdomen agudo por un absceso tuboovárico derecho. El tabique vaginal formaba una hemivagina ciega derecha microperforada que provocaba sangrados genitales intermitentes. Este hematocolpos se colonizó con microorganismos y el ascenso de estos a la cavidad pélvica causó el absceso tuboovárico derecho. La resonancia magnética nuclear aportó mayor información para el diagnóstico. La resección del tabique vaginal comunicó los dos hemiúteros con una sola vagina y los síntomas desaparecieron. CONCLUSIÓN: el síndrome de Herlyn-Werner-Wunderlich es poco conocido y puede manifestarse de forma atípica, lo que dificulta el diagnóstico y retrasa el tratamiento. Para evitar complicaciones irreversibles es importante mantener una alta sospecha clínica.

Abordagem atual da doença inflamatória pélvica / Current approaches to pelvic inflammatory disease

A doença inflamatória pélvica (DIP) é um processo inflamatório de natureza infecciosa que pode atingir estruturas e órgãos do trato genital superior. Devido à sua importância epidemiológica e de suas graves complicações, este artigo atualiza e propõe uma abordagem sistemática da DIP. Os principais agentes etiológicos são a Neisseria gonorrhoeae,Chlamydia trachomatis e outros agentes etiológicos de uretrites, cervicites, vulvovaginites e vaginoses, em geral, polimicrobiana, o que é a base de sua terapêutica. A mulher deve ser investigada para DIP quando apresenta, especialmente, desconforto abdominal, dor lombar, dispareunia e nódoas ou manchas ao exame ginecológico, previamente a procedimentos transcervicais. A classificação clínico-laparoscópica deDIP pode ser dividida em: a) estágio I (endometrite/salpingite sem peritonite); estágio II (salpingite aguda com peritonite); estágio III (salpingite aguda com oclusão tubária ou abscesso tubo-ovariano); estágio IV (abscesso tubo-ovariano roto). A definição do estágio orienta a conduta e o tratamento, pois em formas leves (estágio I) o tratamento e seguimento podem ser feitos ambulatorialmente, enquanto para os casos moderadosou graves a internação hospitalar está indicada para início do tratamento por via endovenosa e monitorização da resposta ao tratamento. O tratamento suportivo, retirada de dispositivo intrauterino (DIU), abstinência sexual e repouso também são indicados, além de orientações sobre as implicações da doença e abordagem do parceiro.

Pelvic inflammatory disease (PID) is an inflammatory process of infectious nature that can affect structures and organs of the upper genital tract. Considering this disease's epidemiological relevance and severe complications, this article provides an update and proposes a systematic approach to PID. The main etiological agents are Neisseria gonorrhoeae, Chlamydia trachomatis and other etiological agents of urethritis, cervicitis, vulvovaginitis and vaginoses. These are generally of polymicrobial origin, which determines the treatment basis for pelvic inflammatory diseases.Women must be checked for PID when experiencing abdominal discomfort, backache, dyspareunia, or presenting with stains during gynecological examination and prior to transcervical procedures. The clinical and laparoscopic classification of PID can be divided into: a) stage I (endometritis/salpingitis without peritonitis), stage II (acute salpingitis with peritonitis), stage III (acute salpingitis with tubal occlusion or tube-ovarian abscess), and stage IV (tube-ovarian abscess rupture). Defining the stage guides procedures and treatment, given that in mild forms (stage I) the treatment and follow-up can be performed in the ambulatory environment while moderate to severe cases require hospitalization so that intravenous treatment and treatment outcome monitoring can be started. Supportive treatment, removal of intrauterine device (IUD), sexual abstinence and rest are also indicated, as well as counseling on the implications of the disease and partner approach.

Doença inflamatória pélvica aguda: ensaio iconográfico com enfoque em achados de tomografia computadorizada e ressonância magnética / Acute pelvic inflammatory disease: pictorial essay focused on computed tomography and magnetic resonance imaging findings

O objetivo deste trabalho é descrever os principais achados em tomografia computadorizada e ressonância magnética em pacientes com dor abdominal aguda decorrente de doença inflamatória pélvica. Dois radiologistas em consenso selecionaram e analisaram exames de tomografia computadorizada e ressonância magnética, realizados entre janeiro de 2010 e dezembro de 2011, de pacientes com quadro comprovado de doença inflamatória pélvica levando a um quadro de abdome agudo. Os principais achados foram coleções líquidas intracavitárias, realce anômalo na escavação pélvica e densificação dos planos adiposos anexiais. A doença inflamatória pélvica é uma das principais causas de dor abdominal em mulheres em idade reprodutiva e tem sido progressivamente diagnosticada mediante uso da tomografia computadorizada e ressonância magnética, que complementam o papel da ultrassonografia. É crucial que os radiologistas se familiarizem com os principais aspectos diagnósticos em imagem seccional desta causa comum de abdome agudo.

The present study was aimed at describing key computed tomography and magnetic resonance imaging findings in patients with acute abdominal pain derived from pelvic inflammatory disease. Two radiologists consensually selected and analyzed computed tomography and magnetic resonance imaging studies performed between January 2010 and December 2011 in patients with proven pelvic inflammatory disease leading to presentation of acute abdomen. Main findings included presence of intracavitary fluid collections, anomalous enhancement of the pelvic excavation and densification of adnexal fat planes. Pelvic inflammatory disease is one of the leading causes of abdominal pain in women of childbearing age and it has been increasingly been diagnosed by means of computed tomography and magnetic resonance imaging supplementing the role of ultrasonography. It is crucial that radiologists become familiar with the main sectional imaging findings in the diagnosis of this common cause of acute abdomen.

Infecção por Chlamydia trachomatis e anticorpos contra proteína de choque térmico 60 (HPS60) associados a fator de infertilidade tubária / Chlamydia trachomatis and antibodies against heat shock protein 60 (HPS60) associated with tubal factor infertility

Chlamydia trachomatis é uma bactéria transmitida sexualmente e uma frequente causa de doença inflamatória pélvica (DIP) que, com sua evolução, pode levar à gravidez ectópica ou a fator de infertilidade túbaria (TFI). Hipóteses sugerem que reações imunes à proteína de choque térmico 60 (HPS60) de Chlamydia trachomatis induz à DIP e à consequente infertilidade. A revisão sistemática foi conduzida utilizando artigos científicos das bases de dados MEDLINE, PubMed e Scopus, com estudos que associavam o aumento do TFI à presença de anticorpos contra HPS60 em mulheres portadoras da bactéria. Foram incluídos 12 estudos. As evidências de 11 estudos caso-controle sugerem a confirmação da associação do TFI com maior produção de anticorpos contra HPS60 de Chlamydia trachomatis. Inversamente ao resultado, foi encontrado um estudo do tipo ensaio clínico controlado randomizado em que os anticorpos contra HPS60 da Chlamydia não foram significamente associados a sequelas por doença inflamatória pélvica. Nossos achados confirmam uma associação entre TFI e anticorpos para HSP60 da Chlamydia trachomatis, mas enfatizamos a necessidade de mais estudos com ensaio clínico controlado e randomizado.

Chlamydia trachomatis is a sexually transmitted bacteria and a common cause of pelvic inflammatory disease (PID); its evolution can lead to ectopic pregnancy or tubal infertility factor (TFI). Hypotheses suggest that immune reactions to heat shock protein 60 (HPS60) of Chlamydia trachomatis induces DIP and, thus, infertility. A systematic review was conducted of scientific articles using MEDLINE, PubMed and Scopus, with studies that linked the increase in the TFI HPS60 presence of antibodies in women with the bacterium. We included 12 studies. Evidence from 11 case-control studies suggest confirmation of the TFI association with increased production of antibodies against HPS60 Chlamydia trachomatis. In contrast to the result, we found a type study randomized controlled trial in which the antibodies of Chlamydia HPS60 were not significantly associated with sequelae of pelvic inflammatory disease. Our findings confirm an association between TFI and antibodies to HSP60 of Chlamydia trachomatis, but emphasize the need for more studies with randomized controlled trial.

Knowledge and attitudes about intrauterine devices among women's health care providers in El Salvador.

In order to gain an understanding of Salvadoran health care providers' clinical knowledge, attitudes, and practice toward the intrauterine device (IUD), Ministry of Health providers completed a self-administered, anonymous survey. Surveys were completed by 135 participants. The majority (94.7% and 97.0%) agreed the IUD is a safe and effective form of contraception. Only 46.6% of participants had ever received training in IUD placement, and 32.0% of them had ever inserted more than 10 IUDs. The majority of providers (54.2%) believed that the IUD was associated with a higher rate of infection than is described in the literature. Lack of formal training and knowledge about persistent infection rates associated with IUDs may contribute to low IUD placement by Salvadoran providers. Health care providers surveyed are open to learning more about the IUD and sharing the information with their patients.

Knowledge and attitudes about intrauterine devices among women's health care providers in El Salvador / Conocimientos y actitudes de los prestadores de atención de salud de la mujer en El Salvador acerca de los dispositivos intrauterinos

In order to gain an understanding of Salvadoran health care providers' clinical knowledge, attitudes, and practice toward the intrauterine device (IUD), Ministry of Health providers completed a self-administered, anonymous survey. Surveys were completed by 135 participants. The majority (94.7 percent and 97.0 percent) agreed the IUD is a safe and effective form of contraception. Only 46.6 percent of participants had ever received training in IUD placement, and 32.0 percent of them had ever inserted more than 10 IUDs. The majority of providers (54.2 percent) believed that the IUD was associated with a higher rate of infection than is described in the literature. Lack of formal training and knowledge about persistent infection rates associated with IUDs may contribute to low IUD placement by Salvadoran providers. Health care providers surveyed are open to learning more about the IUD and sharing the information with their patients.

A fin de evaluar el conocimiento, las actitudes y las prácticas clínicas de los prestadores de atención de salud salvadoreños en torno al dispositivo intrauterino (DIU), se solicitó a un grupo de prestadores del Ministerio de Salud que respondiera un cuestionario anónimo autoadministrado. Se recibieron 135 respuestas. La mayoría manifestó que el DIU es un método anticonceptivo seguro (94,7 por ciento) y eficaz (97,0 por ciento). Solo 46,6 por ciento de los participantes habían recibido algún tipo de capacitación acerca de la colocación del DIU y 32,0 por ciento habían colocado más de 10 dispositivos. La mayoría de los prestadores (54,2 por ciento) consideraron que el DIU está asociado a una incidencia de infecciones más alta que la descrita en la bibliografía. La escasa frecuencia con que los prestadores salvadoreños colocan el DIU probablemente sea atribuible, en cierta medida, a la falta de capacitación formal y de conocimiento acerca de los índices de infección persistente asociados a los DIU. Los prestadores de servicios de salud encuestados refirieron estar dispuestos a instruirse más acerca del DIU y a transmitir la información a sus pacientes.

Doença inflamatória pélvica / Pelvic inflammatory disease

Doença inflamatória pélvica é causada pela infecção polimicrobiana do trato genital superior.Os agentes patogênicos são sexualmente transmissíveis (clamídia, gonococo e micoplasmas) e endógenos (aeróbios, anaeróbios e facultativos).O envolvimento de germes sexualmente transmissíveis preceitua o rastreamento das demais doenças sexualmente transmissíveis em todas as pacientes e seus parceiros.A prevalência da forma subclínica aumenta o risco de falta de diagnóstico e subestimação.Vaginose bacteriana e instrumentação uterina aumentam o risco.Canal cervical com corrimento branco, amarelado ou sangramento induzido indicam infecção por clamídia, gonococo ou micoplasmas.O tratamento deve ser instituído quando estão presentes dores à palpação do baixo ventre ou anexial e à mobilização do colo uterino.O tratamento precoce se justifica porque a infecção experimental mostra que as lesões tubárias não revertem com antibióticos administrados 12 dias depois da inoculação de clamídia.

The T 380A intrauterine device: a retrospective 5-year evaluation.

BACKGROUND: The undue resistance to intrauterine device (IUD) use seen in several settings does not seem to occur in the Family Planning Unit of UNIFESP-EPM (São Paulo Federal University, Brazil). In fact, the Copper T 380A IUD in this clinic has reached an outstanding importance and this motivated us to present our differing experience. The prevalence of this method in this clinic is as high as 40%. This contrasts to the low use in the rest of the country, where tubal ligation is by far the most used contraceptive method (40%) and where IUD is inexpressive (1.1%). STUDY DESIGN: This is a retrospective study of the records of 118 users of Copper T 380A IUD inserted at the clinic and who were followed during 5 years. RESULTS: The cumulative pregnancy rate was 0.8%. The main cause for discontinuation of the study was loss to follow-up (21.3%). Other reasons for the withdrawal of the device were personal option (13.6%), dislocation (11.7%) and pregnancy wish (3.4%). There was no withdrawal by pelvic inflammatory disease. Bleeding (0.8%) was not an important cause for withdrawal, and there were no withdrawals due to pain. The continuation rate at 5 years was 46.7%. The structured service and an adequate educative program perhaps could explain at least partially the good performance of IUD use in this clinic. There was an amazing prevalence of the components of the metabolic syndrome. This could represent contraindications for hormonal contraception, and, in consequence, it could influence the increased option for and continuation of the IUD. CONCLUSION: These data show a good performance of the IUD for long duration, in relation to other studies, and this should be considered as a reliable alternative to the high prevalence of female sterilization in this country.

Intrauterine devices - upper and lower genital tract infections.

The clinical diagnosis of a pelvic inflammatory disease (PID) is notoriously difficult. The incidence rate of PIDs among intrauterine device (IUD) users as reported from different studies depends heavily on the definition used and the means available for diagnosing PIDs. It varies by almost 10-fold from 1 per 100 to 1 per 1000 woman-years in different publications. PID risk has been found to be 6-fold higher in the first month after IUD insertion than it is thereafter. It is not known if the overall PID risk in IUD users beyond the first month of IUD insertion is higher than that in nonusers; however, if it is higher, the additional risk is small. The PID risk in IUD users is modified by the number of sexual partners of the IUD user and that of her partner(s), community prevalence of STDs and age of the IUD user. Bacterial vaginosis appears not to be associated with IUD use. Overall, bacterial vaginosis is not associated with PIDs, but specific subgroups of patients with BV that may be difficult to identify clinically are at an increased risk for PIDs. Because of the long duration of use of current copper IUDs, replacement of the IUD is infrequent and insertion-associated PIDs should consequently also be less frequent. IUD use has become safer with respect to PIDs through more effective screening and counseling procedures described in current guidelines for the initiation of IUD use. Current guidance must be followed to preserve the IUD as a safe contraceptive method.

[Chlamydia trachomatis infection in men and its association with gynecologic alterations in their sexual partners]. / Infección por Chlamydia trachomatis en varones y su asociación con las alteraciones ginecológicas de su compañera sexual.

OBJECTIVE: To determinate the frequency of Chlamydia trachomatis infection in male partners of infertile couples who attend to the infertility clinic at Instituto Nacional de Perinatología, as well as to compare the clinical data and lifestyle between C. trachomatis-infected and uninfected men to establish a possible association with gynecological damage in their sexual female partners. METHODS: An open prospective study was performed in infertile couples, whose follow up was carried out at Instituto Nacional de Perinatología between June 2000 and April 2001. Urethral and cervical swabs were obtained from each couple and the specimens were subjected to a C. trachomatis-specific liquid-phase hybridization test (PACE-2) and routine microbiological analysis. Semen analysis were also included. A relative risk (RR) test was done to analyze variables and square chi test was used to analyze clinical and gynecological data from female partners and data from semen examination. Statistical differences were considered as significant when the p value was below 0.05. RESULTS: C. trachomatis active infection was found in 14 out of 384 urethral swabs (3.6%). No significant alterations were observed in semen samples of C. trachomatis-infected men, as compared to non-infected individuals. Microbiological analyses of semen showed a significant isolation of Mycoplasma sp (RR = 5.87, IC95% 1.4-24.7). Eight out of fourteen female partners of C. trachomatis-infected men were also infected with C. trachomatis (RR = 10.57, IC95% 5.67-19.7), Candida albicans was other pathogen isolated from 8/14 of those women (RR = 1.89, IC95% 1.17-3.05). Gynecological and obstetrical associations found among female partners of C. trachomatis-infected men were as follows: tubal adhesions in 10/14 (RR = 1.54, IC95% 1.08-2.18), salpingitis in 2/14 (RR = 2.2), history of ectopic pregnancies in 11/14 (RR = 2.94, IC95% 1.01-8.53) and abnormal pregnancy loss in 9/14 (RR = 1.5). CONCLUSION: A low prevalence of C. trachomatis infection was observed among male partners of infertile couples as compared with other reports, but this discrepancy could be attributable to the specimen collection and diagnostic assay used. Otherwise, this data suggests that a chronic pathogen's antigenic stimulation may result in an increased formation of tubal adhesions and/or in ectopic pregnancies among female partners of C. trachomatis-infected individuals. Thus, preventive and control measures must be introduced into men's healthcare services, through laboratory and clinical examination, since these subjects are the main reservoirs of C. trachomatis.

Infección por Chlamydia trachomatis en varones y su asociación con las alteraciones ginecológicas de su compañera sexual / Chlamydia trachomatis infection in men and its association to gynecologic alterations of his sexual mate

Objective.To determinate the frequency of Chlamydia trachomatis infection in male partners of infertile couples who attend to the infertility clinic at Instituto Nacional de Perinatologia, as well as to compare the clinical data and lifestyle between C. trachomatis-inifected and uninfected men to establish a possible association with gynecological damage in their sexual female partners. Methods. An open prospective study was performed in infertile couples, whose follow up was carried out at Instituto Nacional de Perinatologia between June 2000 and April 2001. Urethral and cervical swabs were obtained from each couple and the specimens were subjected to a C. trachomatis-specific liquid-phase hibridization test (PACE-2) and routine microbiological analysis. Semen analysis were also included. A relative risk (RR) test was done to analyze variables and square chi test was used to analize clinical and gynecological data from female partners and data from semen examination. Statistical differences were considered as significant when the p value was below 0.05. Results. C. trachomatis active infection was found in 14 out of 384 urethral swabs (3.6%). No significant alterations were observed in semen samples of C. trachomatis-infected men, as compared to non-infected individuals. Microbiological analyses of semen showed a significant isolation o/Mycoplasma sp (RR = 5.87, IC95% 1.4-24.7). Eight out of fourteen female partners of C. trachomatis-infected men were also infected with C. trachomatis (RR= 10.57, IC95% 5.67-19.7), Candida albicans was other pathogen isolated from 8/14 of those women (RR = 1.89, IC95% 1.17-3.05). Gynecological and obstetrical associations found among female partners of C. trachomatis-infected men were as follows: tubal adhesions in 10/14 (RR = 1.54, IC95% 1.08-2.18), salpingitis in 2/14 (RR = 2.2), history of ectopic pregnancies in 11/14 (RR =2.94, IC95% 1.01-8.53) and abnormal pregnancy loss in 9/14 (RR = 1.5). Conclusion. A low prevalence of C. trachomatis infection was observed among male partners of infertile couples as compared with other reports, but this discrepancy could be attributable to the specimen collection and diagnostic assay used. Otherwise, this data suggests that a chronic pathogen's antigenic stimulation may result in an increased formation of tubal adhesions and/or in ectopic pregnancies among female partners of C. trachomatis-infected individuals. Thus, preventive and control measures must be introduced into men's healthcare services, through laboratory and clinical examination, since these subjects are the main reservoirs of C trachomatis.

Objetivo. Determinar la frecuencia de infección por Chlamydia trachomatis y comparar la información clínica y el estilo de vida de varones con y sin infección por este patógeno, así como su asociación con las alteraciones ginecológicas que presenta su compañera sexual en un grupo de parejas que asisten a la Clínica de Infertilidad del Instituto Nacional de Perinatologia de la Ciudad de México. Métodos. Se realizó un estudio abierto, longitudinal y prospectivo en un grupo de parejas con diagnóstico de infertilidad, que fueron tratadas en el Instituto Nacional de Perinatologia durante el periodo de junio del 2000 a abril del 2001. Se recolectaron muestras uretrales y cervicales de cada pareja para el diagnóstico de C. trachomatis mediante la prueba de hibridación en fase líquida (PACE-2). También se recolectaron muestras de semen para el análisis de espermatobioscopia y se hicieron cultivos microbiológicos de rutina a las muestras cervicales y de semen. Los datos microbiológicos, clínicos y ginecológicos de los participantes fueron comparados por %z, el análisis de tendencia para proporciones fue usado para establecer el nivel de riesgo en las variables (RR). Las diferencias fueron consideradas estadísticamente significativas si p < 0.05. Resultados. Se analizaron un total de 384 muestras uretrales de varones, 14 presentaron infección activa por C. trachomatis (3.6%), Los datos de espermatobioscopia de los individuos positivos a C. trachomatis no mostraron alteraciones significativas con respecto al de varones no infectados con esta bacteria. El análisis microbiológico del semen mostró un número de aislamientos significativos de infección por Mycoplasma sp. (RR = 5.87, IC95% 1.40-24.70). En cuanto a las muestras cervicovaginales de mujeres con compañero sexual infectado por C. trachomatis, los patógenos aislados con mayor frecuencia fueron: Candida albicans en ocho de 14 (RR = 1.89, IC95% 1.17-3.05) y C. trachomatis en ocho de 14 (RR = 10.57, IC95% 5.67-19.7). Las asociaciones ginecológicas y obstétricas de la compañera sexual de varones positivos a C. trachomatis fueron adherencias tubáricas en 10 de 14 (RR = 1.54, IC95% 1.08-2.18), salpingitis en dos de 14 (RR = 2.2), antecedentes de embarazos ectópicos en 11 de 14 casos (RR = 2.94, IC95% 1.01-8.53) y abortos previos en nueve de 14 (RR = 1.5). Conclusión. Se observó una baja prevalencia de infección por C. trachomatis en los varones de mujeres infértiles en comparación con lo reportado por otros autores, esta diferencia puede estar dada por el método de diagnóstico y la toma del producto. Estos resultados sugieren que el estímulo constante del patógeno produce un aumento de adherencias tubáricas y embarazos ectópicos en las compañeras sexuales de los varones infectados con C. trachomatis. Por lo que una evaluación diagnóstica y de laboratorio deberá ser llevada a cabo en el varón como una medida de prevención y control para la infección por este patógeno, ya que estos individuos actúan como reservónos importantes de infección.

[Risk factors associated with pelvic inflammatory disease]. / Factores de riesgo asociados a enfermedad pélvica inflamatoria.

OBJECTIVE: To determine the socio-demographic and gynecological risk factors in pelvic inflammatory disease (EPI). MATERIAL AND METHODS: A study of the cases and controls divided by the age and the medical attention unit was performed. Women with an active sex life, who chose to participate in the study, were included. The definition of a case were the women who presented at least four of the clinical manifestations identified as critical as the principal criteria for EPI. For both groups a questionnaire was applied which contained the socio-demographical, gynecological and obstetric variables. RESULTS: 50 cases and 50 controls were evaluated. The risk factors associated with EPI were: scholastic level below high school, RMp 2.22 (IC95% 1.03-5.13); low scholastic level of the couple, RMp 2.33 (0.91-6.6); working women, RMp 3.17 (IC95% 1.3-8.7); women with a low socioeconomic level, RMp 2.86 (IC95% 1.24-7.26); a history of infectious vaginitis in the previous three months, RMp 41 (IC95% 7.94-838). The history of a use of intrauterine devices (DIU) did not present any association (RMp 0.06). CONCLUSIONS: The presence of EPI was found to be associated to socio-demographic and previous infectious vaginitis variables. The use of oral hormones and IUD did not show any relation. A greater amount of sexual education is needed for women with an active sex life in order to avoid the pelvic inflammatory disease.

Factores de riesgo asociados a enfermedad pélvica inflamatoria / Risk factors associated with pelvic inflammatory disease

OBJECTIVE: To determine the socio-demographic and gynecological risk factors in pelvic inflammatory disease (EPI). MATERIAL AND METHODS: A study of the cases and controls divided by the age and the medical attention unit was performed. Women with an active sex life, who chose to participate in the study, were included. The definition of a case were the women who presented at least four of the clinical manifestations identified as critical as the principal criteria for EPI. For both groups a questionnaire was applied which contained the socio-demographical, gynecological and obstetric variables. RESULTS: 50 cases and 50 controls were evaluated. The risk factors associated with EPI were: scholastic level below high school, RMp 2.22 (IC95 1.03-5.13); low scholastic level of the couple, RMp 2.33 (0.91-6.6); working women, RMp 3.17 (IC95 1.3-8.7); women with a low socioeconomic level, RMp 2.86 (IC95 1.24-7.26); a history of infectious vaginitis in the previous three months, RMp 41 (IC95 7.94-838). The history of a use of intrauterine devices (DIU) did not present any association (RMp 0.06). CONCLUSIONS: The presence of EPI was found to be associated to socio-demographic and previous infectious vaginitis variables. The use of oral hormones and IUD did not show any relation. A greater amount of sexual education is needed for women with an active sex life in order to avoid the pelvic inflammatory disease.

Uteroglobina endometrial en pacientes con serología positiva para chlamydia trachomatis / Endometrial uteroglobin in patients with positive serology for chlamydia trachomatis

Introducción: Chlamydia trachomatis es causa frecuente de enfermedad inflamatoria pélvica y esterilidad tubaria. La afección endometrial asociada a este germen es dificil de poner de manifiesto. La úteroglobina (Utgh) es una proteína de secreción del tracto respiratorio y genitourinario. En el endometrio se ha detectado durante el comienzo y mitad de la fase selectora. Nuestro objetivo fue localizar la Utgb endometrial por inmunohistoquímica, en pacientes que consultaron por esterilidad y presentaron serología positiva contra C. trachomatis. Material y Metodos: Se estudiaron 30 parejas a las que se les realizó: análisis de esperma, dosajes hormonales, histerosalpingografía, anticuerpos séricos contra C.trachomatis (IgG Cht) y biopsia endometrial (días 19-21 del ciclo). En las biopsias se determinó fechado y presencia de endometritis. La inmunohistoquímica para Utgb se realizó en cortes de parafina usando antisuero policlonal (1:50 y 1:300). Resultados: De las muestras evaluadas, 20 presentaron fechado endometrial acorde al día del prelevamiento (día 19-21). La inmunomarcación para Utgb, fue positiva en el 100 por ciento (20/20) de los casos, con la dilución de anticuerpo 1:50. Se encontró título de IgG Ch t incrementando en 11 pacientes (11/20, 55 por ciento). El 91 por ciento (10/11) de estas presentaron inmunomarcación para Utgb, mientras que el grupo con serología negativa, se detectó en el 44,5 por ciento (4/9) cuando se empleó la dilución 1:300 (p<0.02). La incidencia de endometritis y los niveles de progesterona sérica no mostraron diferencias significativas entre estos grupos. Conclusión: Hemos observado una mayor incidencia de afección endometrial en pacientes con serología positiva para C trachomatis. La inmunodetección de uteroglobina podría ser un marcador de dicha afección, que complementaría la información obtenida por microscopía óptica

Uteroglobina endometrial en pacientes con serología positiva para chlamydia trachomatis / Endometrial uteroglobin in patients with positive serology for chlamydia trachomatis

Introducción: Chlamydia trachomatis es causa frecuente de enfermedad inflamatoria pélvica y esterilidad tubaria. La afección endometrial asociada a este germen es dificil de poner de manifiesto. La úteroglobina (Utgh) es una proteína de secreción del tracto respiratorio y genitourinario. En el endometrio se ha detectado durante el comienzo y mitad de la fase selectora. Nuestro objetivo fue localizar la Utgb endometrial por inmunohistoquímica, en pacientes que consultaron por esterilidad y presentaron serología positiva contra C. trachomatis. Material y Metodos: Se estudiaron 30 parejas a las que se les realizó: análisis de esperma, dosajes hormonales, histerosalpingografía, anticuerpos séricos contra C.trachomatis (IgG Cht) y biopsia endometrial (días 19-21 del ciclo). En las biopsias se determinó fechado y presencia de endometritis. La inmunohistoquímica para Utgb se realizó en cortes de parafina usando antisuero policlonal (1:50 y 1:300). Resultados: De las muestras evaluadas, 20 presentaron fechado endometrial acorde al día del prelevamiento (día 19-21). La inmunomarcación para Utgb, fue positiva en el 100 por ciento (20/20) de los casos, con la dilución de anticuerpo 1:50. Se encontró título de IgG Ch t incrementando en 11 pacientes (11/20, 55 por ciento). El 91 por ciento (10/11) de estas presentaron inmunomarcación para Utgb, mientras que el grupo con serología negativa, se detectó en el 44,5 por ciento (4/9) cuando se empleó la dilución 1:300 (p<0.02). La incidencia de endometritis y los niveles de progesterona sérica no mostraron diferencias significativas entre estos grupos. Conclusión: Hemos observado una mayor incidencia de afección endometrial en pacientes con serología positiva para C trachomatis. La inmunodetección de uteroglobina podría ser un marcador de dicha afección, que complementaría la información obtenida por microscopía óptica (AU)

Complicaciones relacionadas a la utilización de dispositivos intrauterinos: aportes del diagnóstico por imágenes / Complications related to the intrauterine device: an imaging approach

El uso del Dispositivo Intrauterino trae aparejado, en ocasiones, una serie de complicaciones que deben ser reconocidas oportunamente para reducir de esa forma la morbimortalidad que implican las mismas. El presente trabajo revisa e ilustra complicaciones frecuentes e infrecuentes relacionadas al empleo del dispositivo. Se presentan complicaciones infecciosas como endometritis y abscesos tubo-ováricos; ligadas al embarazo: embarazo ectópico, coexistencia DIU-embarazo; perforaciones uterinas. Los casos fueron valorados según cada caso en particular con ultrasonido convencional y/o transvaginal, radiología y tomografía computada (AU)

Prevençäo da iatrogenia / Preventing iatrogeny

O principal objetivo no tratamento da infertilidade deve ser aumentar as taxas de gravidez e reduzir os índices de abortamento, resultando em maior taxa de nascimento de crianças saudáveis. Além disso, deve-se procurar reduzir os casos de hiperestimulaçäo, assim como de gestaçöes múltiplas, com uma concomitante reduçäo das complicaçöes gestacionais e obstétricas. Algumas vezes, o especialista se desvia destes objetivos, podendo trazer à paciente uma complicaçäo iatrogênica. Seräo citadas aqui possíveis complicaçöes e condutas para sua prevençäo.

[Mycoplasma hominis and Ureaplasma urealyticum in different gynecologic diseases]. / Mycoplasma hominis y Ureaplasma urealyticum en diferentes patologías ginecológicas.

The incidence of Mycoplasma hominis (M. hominis) y Ureaplasma urealyticum (U. urealyticum) was investigated in 113 endocervical samples obtained from women who were seen for different gynecological pathologies. Forty-seven (42%) patients were positive to these microorganisms; 26 cases (23%) were positive for M. hominis and 21 (19%; p = NS) for U. urealyticum. Average age was 32.1 +/- 7.7 years; the average number of sexual partners was 1.7 +/- 1.1. Eleven of 17 patients with 3 o more sexual partners were positive for Genital Mycoplasma (GM), and U. urealyticum was found more often in this group. A higher incidence of GM was found in women between 26 and 30 years (34%); 57.5% of the patients with positive cultures for GM had begun sexual activity before 20 years of age. M. Hominis was found in 61% of women with no parity and U. urealyticum in 71% of parous women. The cultures were positive in 10 of 14 patients with pelvic inflammatory diseases (PID). A cervical biopsy was taken from 52 cases and the diagnosis of cervical intraepithelial neoplasia (CIN) was made in 49 (94%) but only 24 of them were positive for GM (50%). Thirty-five patients suffered sterility, and 12 (34%) were positive for GM, however all positive cases consulted because of primary sterility. The conclusions obtained from this study are: 1) Near half of the patients was positive for GM and none of the species was predominant over the other. 2) The more sexual partners the higher was the incidence of GM, especially U. Urealyticum. 3) The lower the age of the first sexual intercourse the higher the probability of contamination with these microorganisms. 4) M. hominis was more common in nulliparous women and U. urealyticum was found more often in parous patients; the number of deliveries did not have influence in these findings. 5) A statistical significance between GM and PID was found (p = 0.03). 6) GM have no influence on spontaneous abortion. 7) No statistical significance was found between GM and the beginning and evolution of CIN. 8) No relation statistically significative was found between GM and sterility.