O papel dos polimorfismos genéticos na etiologia da endometriose / The role of genetic polymorphism in the etiology of endometriosis

O objetivo deste estudo é apresentar uma revisão atualizada sobre o papel dos polimorfismos genéticos na etiologia da endometriose. Trata-se de uma pesquisa bibliográfica feita no PubMed utilizando os descritores "polymorphism and endometriosis". Foram identificados 36 artigos e após aplicação dos critérios de inclusão foram selecionados 17 artigos para a amostra final. Os principais resultados foram: 1) cerca de 60% dos artigos foram publicados em 2019; 2) em 35,3% dos estudos o número de casos e controles investigados foi menor que 100; 3) a maioria dos trabalhos investigou de um a dois polimorfismos por gene; 4) a produção científica sobre endometriose é maior em países orientais; 5) houve heterogeneidade quanto aos periódicos onde os trabalhos foram publicados; 6) as principais técnicas para detecção de polimorfismos foi a PCR-RFLP e o PCR em tempo real, com frequências semelhantes. Em suma, os polimorfismos genéticos podem estar implicados na etiologia da endometriose.

The aim of this study is to present an updated review on the role of genetic polymorphisms in the etiology of endometriosis. This is a literature review made on PubMed using the descriptors "polymorphism and endometriosis". A total 36 articles were identified and, after applying the inclusion criteria, 17 articles were selected for the final sample. The main results were: 1) approximately 60% of the articles were published in 2019; 2) 35.3% of the studies investigated less than 100 cases and controls; 3) most studies investigated one to two polymorphisms per gene; 4) scientific production on endometriosis is higher in Eastern countries; 5) heterogeneity was observed regarding the journals where works were published; 6) the main techniques for detecting polymorphisms were PCR-RFLP and real-time PCR, with similar frequencies. In summary, it can be concluded that genetic polymorphisms may be implicated in the etiology of endometriosis.

Increasing the chances of natural conception: opinion statement from the the brazilian federation of gynecology and obstetrics associations - FEBRASGO committee of gynecological endocrinology / Aumentando as chances de concepção natural: parecer da comissão nacional de ginecologia endócrina da Federação Brasileira das Associações de Ginecologia e Obstetrícia

Abstract Considering that myths and misconceptions regarding natural procreation spread rapidly in the era of easy access to information and to social networks, adequate counseling about natural fertility and spontaneous conception should be encouraged in any kind of health assistance. Despite the fact that there is no strong-powered evidence about any of the aspects related to natural fertility, literature on how to increase the chances of a spontaneous pregnancy is available. In the present article, the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO, in the Portuguese acronym) Committee on Endocrine Gynecology provides suggestions to optimize counseling for non-infertile people attempting spontaneous conception.

Resumo Uma vez que mitos e equívocos sobre a procriação natural se espalham rapidamente na era do fácil acesso à informação e às redes sociais, o aconselhamento adequado sobre a fertilidade natural e a concepção espontânea deve ser encorajado em qualquer tipo de assistência à saúde. Apesar do fato de não haver evidências fortes sobre qualquer dos aspectos relacionados à fertilidade natural, existe literatura sobre como aumentar as chances de uma gravidez espontânea. No presente artigo, a Comissão Nacional de Ginecologia Endócrina da Federação Brasileira das Associações de Ginecologia e Obstetrícia (FEBRASGO) oferece sugestões para otimizar o aconselhamento a pessoas que tentam a concepção espontânea, na ausência do diagnóstico de infertilidade.

Avaliação da reserva ovariana na predição do mau prognóstico reprodutivo: quando e como investigar / Ovarian reserve evaluation in the prediction of poor reproductive prognosis: when and how to investigate?

Muitas vezes, torna-se um grande desafio para o ginecologista a identificação daquelas com maior ou menor chance de concepção. Vários marcadores laboratoriais e ultrassonográficos, conhecidos conjuntamente como testes de avaliação da reserva ovariana, são estudados há décadas com a intenção de se buscar uma ferramenta para a predição do potencial reprodutivo. E, embora ainda se busquem os marcadores ideais para aplicação clínica, mais difícil do que os definir é definir quando eles estão indicados. Este artigo de atualização, assinado pela Comissão Nacional Especializada em Ginecologia Endócrina da Febrasgo, pretende oferecer ao leitor as ferramentas necessárias para o uso racional dos testes de avaliação da reserva ovariana no cotidiano.(AU)

Often, it becomes a great challenge for the gynecologist to identify women with a greater or lesser chance of conception. Several laboratory and ultrasound markers, known jointly as ovarian reserve evaluation tests, have been studied for decades with the intention of seeking a tool for the prediction of reproductive potential. And, while the ideal markers for clinical application are still sought, defining them is as harder as defining when they are indicated. This update article, signed by the National Specialized Committee on Gynecologic Endocrinology, Febrasgo, intends to offer the reader the necessary tools for the rational use of ovarian reserve evaluation tests in daily practice.(AU)

Síndrome de ovario poliquístico / Polycystic ovary syndrome

El síndrome de ovario poliquísticos (SOP) representa una de las endocrinopatías más frecuentes en la mujer y es la principal causa de hiperandrogenismo (HA). Se trata de un trastorno complejo, multifactorial, poligénico con influencias ambientales. Aunque se han propuestos diferentes criterios para su diagnóstico, se prefiere el uso del más abarcativo (Criterio de Rotterdam) con la presencia de 2 de 3 de los siguientes: 1) HA clínico o bioquímico, 2) oligoanovulación crónica (OA), 3) poliquistosis ovárica por ecografía, excluyendo otras etiologías. Es frecuente su asociación con comorbilidades metabólicas (obesidad, diabetes 2, dislipidemia, apnea del sueño, etc.) y trastornos reproductivos (hiperplasia endometrial e infertilidad), sobre todo en los fenotipos clásicos, con HA y OA. El tratamiento estará orientado a las características clínicas de cada paciente y al deseo reproductivo. La pérdida de peso en aquellas con sobrepeso u obesidad o ambos factores puede restaurar los ciclos menstruales y disminuir el riesgo metabólico y representa la primera línea de tratamiento. Los anticonceptivos orales (ACO) son el tratamiento farmacológico de elección ya que atenúan las manifestaciones de HA y ofrecen protección endometrial. En las pacientes con oligoanovulación que buscan embarazo, el citrato de clomifeno es el tratamiento aconsejado en primera instancia. La metformina podría usarse en aquellas con intolerancia a la glucosa o diabetes 2 y también como segunda línea de tratamiento para restaurar los ciclos e inducir la ovulación. (AU)

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women, the main cause of hyperandrogenism (HA). It is a complex, multifactorial polygenic disorder with environmental influences. Although there have been proposed different criteria for diagnosis, using the most comprehensive (Criteria Rotterdam) with the presence of 2 of 3 of the following is preferred: 1) HA clinical or biochemical, 2) oligo-anovulation chronic (OA), 3) polycystic ovaries by ultrasound, excluding other etiologies. It is frequently associated with metabolic comorbidities (obesity, type 2 diabetes, dyslipidemia, sleep apnea, etc.) and reproductive disorders (endometrial hyperplasia and infertility), especially in the classical phenotypes, with HA and OA. The treatment will be oriented to the clinical characteristics of each patient and reproductive desire. Weight loss in those who are overweight and / or obesity can restore menstrual cycles and decrease metabolic risk and represents the first line of treatment. Oral contraceptives (OC) are the pharmacological treatment of choice as it attenuates the manifestations of HA and offer endometrial protection. In patients seeking pregnancy with oligo-anovulation, clomiphene citrate would be used at first instance. Metformin may be used in those with impaired glucose tolerance or type 2 diabetes and also as a second-line treatment to restore cycles and induce ovulation. (AU)

Prevalência de fatores associados à infertilidade em mulheres inférteis submetidas à laparoscopia diagnóstica / Prevalence of factors associated with infertility in infertile women undergoing diagnostic laparoscopy

Objetivo: Analisar o papel da laparoscopia na investigação da infertilidade nos últimos cinco anos na Universidade Estadual de Campinas. Métodos: Estudo retrospectivo descritivo com todas as videolaparoscopias para o diagnóstico da infertilidade feitas de 2008 a 2012 na Universidade Estadual de Campinas. Foram analisados 353 prontuários de mulheres com infertilidade submetidas à laparoscopia diagnóstica. Foram avaliadas as características clínicas dessas mulheres e os achados intraoperatórios. Foi feita uma análise univariada de frequência, médias e desvio padrão para cada uma das variáveis e para avaliar as associações entre as variáveis foi usado o teste de Kruskal-Wallis. Resultados: A média de idade das mulheres com infertilidade foi de 32 ± 4,4 anos. A laparoscopia encontrou 52,98% de alterac¸ões tubárias, 17,84% de endometriose e 11,33% de aderências. Quase 18% dos exames não apresentaram qualquer tipo de alteração. A histerossalpingografia apresentou sensibilidade de 84,61% e especificidade de 32,58% em relação à laparoscopia. As mulheres com infertilidade apresentaram maior risco de ter alterações tubárias. Conclusão: As alterações tubárias são ainda a principal causa de infertilidade. A laparoscopia se mostra como uma técnica melhor do que a histerossalpingografia para detecção de alterações tubárias, além de permitir detectar alterações em outros órgãos que possam causar infertilidade.(AU)

Objective: To evaluate the role of laparoscopy in the investigation of infertility at the University of Campinas in the last five years. Methods: Retrospective descriptive study with all diagnostic laparoscopy in the last five years made in endoscopic gynecology clinic of the tertiary hospital. 353 medical records of women with infertility undergoing diagnostic laparoscopy between the years 2008 to 2012 were analyzed the clinical characteristics of these women and the indications of laparoscopy and intraoperative findings were evaluated. Descriptive analysis (frequency, mean and standard deviation) was performed for categorical variables. To evaluate the association between the variables, we used the Kruskal Wallis test. Results: The women were on average 32 ± 4.4 years. Laparoscopy found 52.98% of tubal alterations, 17.84% of endometriosis and 11.33% of adhesions. Almost 18% of tests did not show any change. The hysterosalpingography had a sensitivity of 84.61% and specificity of 32.58% compared to laparoscopy. Infertile women have a higher risk for tubal changes. Conclusion: Tubal alterations are still the leading cause of infertility. Laparoscopy appears as a better technique hysterosalpingography for detecting tubal alterations, in addition to be able to detect changes in other organs that can cause infertility.(AU)

Cromotubación histeroscópica: técnica alternativa para la evaluación de la permeabilidad tubárica y la cavidad uterina en un solo paso / Hysteroscopic chromotubation: an alternative technique for the evaluation of tubal patency and uterine cavity in a single step

La evaluación de la permeabilidad tubárica es un paso esencial en el estudio de la infertilidad femenina. Existen varios métodos que permiten realizar esta evaluación. La histerosalpingografía (HSG) se ha considerado el método estándar, sin embargo es conocida su limitación en la evaluación de la obstrucción proximal con alta tasa de falsos positivos. Presentamos una técnica alternativa para la evaluación por medio de cromotubación histeroscópica, que tiene entre otras, la ventaja de permitir la evaluacion del factor uterino y tubárico en un solo paso y además, supera la dificultad de los falsos positivos de la HSG, en cuanto a la obstrucción proximal.

The evaluation of tubal patency is an essential step in the study of female infertility. There are several methods to perform this evaluation. Hysterosalpingography (HSG) has been considered the standard method, however it is known to limitations in the assessment of proximal obstruction with high false positive rate. We present an alternative technique for evaluation by hysteroscopic chromo tubation, which has among others, the advantage of allowing the evaluation of uterine and tubal factor in one step and also overcomes the difficulty of false-positive HSG, as to the proximal obstruction.

Perfil epidemiológico das pacientes inférteis com endometriose / Epidemiological profile of infertile patients with endometriosis

Objetivo: Descrever o perfil epidemiológico e clínico de pacientes inférteis com endometriose. Métodos: Estudo transversal que avaliou 450 prontuários de mulheres que procuraram tratamentos de reprodução assistida entre outubro de 2006 e maio de 2012. Analisaram-se sintomas como dismenorreia, intensidade da dor, alterações intestinais e doenças associadas. O software estatístico usado foi o Stata 11.0.Resultados: A mediana de idade foi 34 anos. A dismenorreia acometeu 84,2% das pacientes, de intensidade grave em 40,4%. Alterações intestinais presentes em 54,4%. Dentre as doenças ginecológicas associadas, destaca-se mioma em 23,3%. Em relação às doenças em tratamento, destaca-se a metabólica (8,4%). Discussão: Sabe-se que a dismenorreia é o sintoma mais prevalente nas mulheres com endometriose, assim como alterações intestinais, presente em 6% a 30% das mulheres com a endometriose profunda. Justifica-se a relação com outras doenc¸as também estrogênio-dependentes, como miomas e pólipos, devido ao endométrio dessas mulheres ter aromatases p450 e cyp19, que gerariam ambiente hiperestrogênico. No grupo estudado de mulheres brasileiras, o perfil de idade compreende a quarta década de vida, com infertilidade predominantemente primária, significativa prevalência de dismenorreia grave e associação com pólipos e mioma.

Aims: To describe epidemiological and clinical aspects of infertile patients with endometriosis. Methods: Cross section study of 450 medical records of infertile patients with endometriosis from October, 2006 to May, 2012. Symptoms such as dysmenorrhea, pain intensity, intestinal disorders where analyzed, as well as, associated diseases and treatments. The statistical software used was Stata 11.0. Results: The median age was 34 years. 84.2% of patients presented dysmenorrhea and 40.4% had severe pain intensity. Intestinal disorders was found in 54.4%. From the associated gynecologic diseases, 23.3% had myoma. Metabolic disease was found in 8.4% among the diseases in treatment. Discussion: It is known that dysmenorrhea is the most prevalent symptom in women with endometriosis, as well as intestinal disorders, that can be found between 6% and 30% women with severe endometriosis. Other studies have demonstrated the relationship of estrogen-dependent disease and women with endometrial endometriosis with aromatase enzyme P450 CYP19 mutations; which generate a hyperestrogenic environment, contributing to the development of polyps and myomas. The profile of these patients was traced as being inthe fourth decade of life, with predominantly primary infertility with prevalent symptoms of severe dysmenorrhea and association with polyps and myomas.

Tensión arterial y masa corporal en mujeres infértiles con síndrome de ovario poliquístico y su relación con el perfil hormonal / Blood pressure and body mass in infertile women polycystic ovary syndrome and its relation to the profile hormone

Objetivo: Evaluar perfil hormonal, índice de masa corporal y tensión arterial en 40 mujeres infértiles con ovario poliquístico. Métodos: En la consulta del Centro de Atención Integral de la Universidad de Los Andes se valoró talla, peso y tensión arterial. Durante la fase folicular del ciclo menstrual en ellas se midió en sangre las hormonas sexuales e insulina (basal y 2 horas poscarga glucosada) por electroquimioluminiscencia. Resultados: El índice de masa corporal se correlacionó directamente con el valor de tensión arterial sistólica, la relación LH/FSH y la testosterona sérica; e inversamente con las hormonas FSH y PRL. Los datos clínicos y de laboratorio se observaron dentro de los límites de referencia; sin embargo, la testosterona guardó relación directa con LH/FSH, índice de masa corporal y tensión arterial sistólica. Al compararse dos grupos de paciente con base al valor de la mediana poblacional, los grupos masa corporal > 24 kg/m2 y tensión arterial sistólica >120 mmHg mostraron niveles de DHEA-S e insulina (basal y 2 h) más elevados que en mujeres con índice de masa corporal y tensión arterial sistólica más bajos. Conclusiones: Existe correlación entre niveles séricos de andrógenos con sobrepeso e hipertensión arterial por mecanismos etiológicos interrelacionados. Síndrome de ovario poliquístico es de origen multicausal eventualmente con hiperandrogenemia. La falla metabólica debe controlarse en estas pacientes, lo que permitiría bajar el efecto de los andrógenos y favorecer el estado de fertilidad, pero sobre evita a largo plazo complicaciones como obesidad, diabetes mellitus tipo 2 e hipertensión arterial.

Objective: To evaluate hormonal profile, body mass index and blood pressure in 40 infertile women with polycystic ovary. Methods: In the out patien clinic of the Centro de Atencion Integral de la Universidad de Los Andes, height, weight and blood pressure were assessed. During follicular phase of the menstrual cycle in blood of them sex hormones and insulin (basal, 2 hours post glucose load) were measured by electrochemiluminescence. Results: The body mass index was directly correlated with the value of systolic blood pressure, ratio LH/ FSH and testosterone in serum, and it was inversely correlated with the hormones FSH and PRL. Clinical and laboratory data were observed within the reference limits, but kept directly related to testosterone LH / FSH, BMI and systolic blood pressure. When comparing two patient groups based on the value of the population median, body mass groups > 24 kg/m2 and systolic blood pressure > 120 mmHg, they showed levels of DHEA- S and insulin (basal and 2 h) higher than those women with lower values of BMI and systolic blood pressure. Conclusions: There is a correlation between serum androgen levels with overweight and hypertension by aetiological mechanisms interrelated. Polycystic ovary syndrome is multicausal origin eventually with hyperandrogenemia. Metabolic failure should be monitored in these patients, which would lower the effect of androgens and promote fertility status, but prevents long-term complications such as obesity, type 2 diabetes mellitus and high blood pressure.

Profil clinique et étiologique de l'infertilité féminine à Goma

Objectif : Une etude visant a degager le profil epidemiologique; clinique et etiologique de l'infertilite chez la femme a ete menee a Goma/RDC et ses environs; de janvier 2006 a decembre 2008.Methodologie : il s'agit d'une etude cas-temoins comparant les femmes consultant pour infertilite et les femmes fertiles (gestantes); au regard des parametres sociodemographiques; medicaux; sexuels; gynecoobstetricaux; chirurgicaux; et cliniques. Les patientes infertiles ont beneficie; en plus de l'examen gynecologique approfondi; d'une exploration systematique par l'HSG; les dosages hormonaux; l'echographie endovaginale et pelvienne. Le chi carre de Pearson ou le test de rapport de vraisemblance; et le test t de Student ont ete mis a profit pour l'analyse statistique des donnees.); de loin le plus preponderant; etait suivi par des troubles ovulatoires (41;0); les facteurs uterin et cervicovaginal etaient relativement moins frequents. L'etiologie etait multifactorielle dans 38;1 des cas. La preponderance du facteur tuboovarien suggere une grande implication des infections genitales dans la survenue de l'infertilite feminine a Goma. Resultats : 105 femmes infertiles et 108 gestantes ont ete examinees en series continues. Les patientes fertiles sont significativement plus jeunes que les patients infertiles (p=0;001). Bien que l'age au debut de l'activite sexuelle ne soit pas different entre les patientes et les gestantes (p=0;67); les patientes infertiles etaient caracterisees par une plus grande mobilite conjugale (p=0;015) et sexuelle (p=0;001); une plus grande frequence des antecedents d'infections genitales (p=0;00) et des interventions chirurgicales pelviennes; et par des symptomes suggestifs des sequelles d'infections genitales. Les facteurs etiologiques suivants ont ete identifies : le facteur tubopelvien (67;6

Classical and molecular methods for evaluation of Chlamydia trachomatis infection in women with tubal factor infertility

Chlamydia trachomatis is the most reported bacterial sexually transmitted disease, especially among young women worldwide. The aim of this study was comparison to evaluate the prevalence of Chlamydia trachomatis infection in woman with tubal infertility by means of PCR and cell culture techniques. Fifty-one women with confirmed TFI were enrolled in this study in [avicenna infertility Clinic] between January 2010 and January 2011. Cervical swab and cytobrush specimens were collected from each patient by gynecologists and sent to laboratory in transport media. Detection of Chlamydia trachomatis in samples was performed using PCR and bacteria culture in MacCoy cell line. The data were analyzed by Fisher's exact test and independent t-test. Statistical significance was established at a p-value <0.05. A significant relation was observed between increased the age of first intercourse and chlamydial infection. Six [11.7%] samples had positive PCR result, whereas cell culture results were positive in only 2 [3.9%] samples. A significant relation was also identified between the duration of infertility and infection [p<0.05] by PCR versus cell culture method. The results showed that PCR is a rapid method, compared to cell culture for detecting Chlamydial organism. It also became clear that the age at first intercourse is important to predict the likelihood of Chlamydia trachomatis

Factores asociados a infertilidad en el Servicio de Reproducción Humana del Hospital San Bartolomé: 2006-2011 / Factors associated with infertility in the Service of Human Reproduction at the Hospital San Bartolome: 2006-2011

Objetivos: Identificar los factores asociados a infertilidad en pacientes atendidas en el servicio de reproducción del Hospital Nacional Docente Madre Niño San Bartolomé en el periodo 2006 a 2011. Material y métodos: Se realizó un estudio observacional, analítico, de casos y controles. Se revisaron 154 historias clínicas de pacientes con infertilidad y que no culminaron en embarazo y de 315 historias de pacientes con infertilidad y que culminaron en embarazo en el servicio de reproducción humana en el periodo 2006 al que cumplieron con los criterios de inclusión. Resultados: La media de la edad de los controles fue de 33.6+/-5.1 años y la media de la edad de los casos fue de 39.5+/-4.7 años. La media de la edad de inicio de las relaciones sexuales en el grupo de los controles fue de 20.9+/-9 años y en el grupo de los casos fue de 20.3+/-3.2 años. En el grupo de los casos el 50 por ciento eran casadas, el 54.5 por ciento tenían el antecedente de aborto, el 5.8 por ciento tenían el antecedente de hábitos nocivos. En el grupo de casos, la causa más frecuente de infertilidad fue el factor tubo ovárico peritoneal en el 63.6 por ciento, y en el grupo de los controles la causa más frecuente de infertilidad fue el factor ovulatorio en el 91.4 por ciento Conclusiones: Los factores asociados a infertilidad en pacientes atendidas en el servicio de reproducción del Hospital Nacional Docente Madre Niño San Bartolomé en el periodo 2006 a 2011, fueron el antecedente de aborto, la edad y el antecedente de no gestación (P<0.05). Las causa de mayor frecuencia de infertilidad en las pacientes atendidas en el servicio de reproducción fue el daño tubo ovárico peritoneal.

Abordagem inicial de paciente com queixa de infertilidade / Initial approach of patient with infertility complaint

Infertilidade é uma doença do aparelho reprodutivo caracterizada por ausência de gestação após um ano de relações sexuais frequentes, sem uso de método contraceptivo. As causas podem ser femininas e masculinas isoladas ou em associação. A investigação deve ser iniciada em situações diferentes de acordo com a idade e características de cada paciente e inclui anamnese e exame físico detalhados, além da solicitação de exames como espermograma, histerossalpingografia e comprovação de ovulação.

Infertility is a disease of the reproductive tract characterized by the absence of pregnancy after a year of frequent intercourse without using contraception. The causes can be male and female singly or in combination. The investigation should be initiated in different positions according to the age and characteristics of each patient and includes history and physical examination, also exams like spermogram, histerosalpingography and evidence of ovulation.

Rol de la laparoscopia en la infertilidad inexplicada: experiencia del Hospital Clínico de la Pontificia Universidad Católica de Chile / Role of laparoscopy in unexplained infertility

Antecedentes: Existe una tendencia global creciente de no realizar laparoscopia diagnóstica en el estudio de pacientes con infertilidad inexplicada e histerosalpingografía normal. Este tipo de manejo podría tener ciertos inconvenientes dado que existen lesiones, especialmente tuboperitoneales, que no son diagnosticadas y pudiesen influir en los resultados. Nuestro grupo maneja estas pacientes con laparoscopia diagnóstica/terapéutica y posteriormente tres ciclos de inseminación intrauterina. Objetivos: Validar nuestro manejo de la infertilidad inexplicada, estimar la frecuencia de patología pélvica en pacientes con infertilidad inexplicada con histerosalpingografía normal, evaluar la tasa de embarazo posterior a la resolución laparoscópica de su patología y revisar la literatura existente. Resultados: Se revisaron todas las cirugías laparoscópicas realizadas en pacientes con infertilidad inexplicada del Hospital Clínico de la Universidad Católica, entre los años 2007-2011. De estas, 57 pacientes cumplían los criterios de inclusión y 39 recibieron al menos 1 ciclo de inseminación intrauterina posterior al procedimiento. El 82,4 por ciento de las pacientes presentaron hallazgos a la laparoscopia, siendo los más prevalentes la endometriosis grado I y II (57,8 por ciento), y las adherencias pelvianas (43,8 por ciento). De las 57 pacientes que fueron sometidas a laparoscopia diagnóstica/terapéutica, sólo 25 completaron 3 ciclos de inseminación intrauterina posterior, 8 lograron concepción (32 por ciento). Conclusión: Nuestros resultados son similares a los expuestos en otros trabajos en términos de hallazgos patológicos y tasa de fertilidad post laparoscopia. Dado el escaso acceso a técnicas de fertilización in vitro en nuestro medio, nuestro manejo plantea una excelente alternativa para este grupo de pacientes.

Background: There is an increased global tendency for avoiding a diagnostic laparoscopic surgery, among patients with unexplained infertility and a normal histerosalpingography. This decision may have certain consequences, as there may be undiagnosed lesions, such as tuboperitoneal ones, which could have an impact in the management of these patients. Our group treats them with diagnostic therapeutic laparoscopy, followed by three cycles of intrauterine insemination. Objectives: Validate our management of unexplained infertility, estimate the frequency of pelvic pathology in patients with unexplained infertility with a normal histerosalpingography, evaluate the pregnancy rate after the laparoscopic resolution of their pathology, and review the existent literature. Results: We reviewed all laparoscopic surgeries performed in patients with unexplained infertility in Hospital Clínico de la Pontificia Universidad Católica, between 2007-2011. From these, 57 patients met the inclusion criteria, and 39 of them received at least one intrauterine insemination cycle after the procedure. Laparoscopic alterations were present in 82.4 percent of the patients, being the most prevalent ones endometriosis grade I and II (57.8 percent) and pelvic adhesions (43.8 percent). Of the 57 patients who underwent laparoscopy, only 25 completed three cycles of intrauterine insemination, 8 of which conceived (32 percent). Conclusion: Our results are similar to those exposed in other series, regarding pathologic findings and fertility rate after laparoscopy. As there is limited access to advanced reproductive techniques in our country, our management represents an excellent choice for this group of patients.

Doença celíaca e infertilidade / Celiac disease and infertility

Doença celíaca ou enteropatia por sensibilidade ao glúten é uma doença crônica condicionada pelo desenvolvimento de uma hipersensibilidade ao glúten. É associada a uma ampla gama de manifestações clínicas existindo, simultaneamente, má digestão e um déficit na absorção de muitos nutrientes e vitaminas. Diversos estudos têm mostrado, também, uma maior prevalência desta com quadros de infertilidade, aparentemente sem uma causa definida. Este é o motivo da presente revisão.

Celiac disease or gluten-sensitive enteropathy is a chronic illness characterized by the development of hypersensitivity to gluten. It is associated with a vast array of clinical manifestations, such as the occurrence of digestive problems and poor absorption of nutrients and vitamins. Several studies have also linked it to cases of infertility, apparently, without a known cause. This link is the motivation of the following review.

PCR-based evaluation of tuberculous endometritis in infertile women in north India

Tuberculous endometritis is often a diagnostic dilemma for gynecologists in the evaluation of infertility. This study evaluated and compared different diagnostic methods in tuberculous endometritis. 100 infertile women were investigated for tuberculous endometritis. The endometrial samples obtained by curettage were evaluated by Ziehl-Neelsen [ZN] staining of the smears for acid-fast bacilli [AFB], the samples were also cultured on Lowenstein-Jensen medium, and histopathological examination and nested PCR targeting 'hupB' gene [Rv 2986c in M. tuberculosis and Mb 3010c in M. bovis] which can differentiate between M. tuberculosis and M. bovis were performed. Antibodies against 38-kDa and 16-kDa mycobacterial antigens were detected in serum using ELISA. Statistical analysis was done by online GraphPad Prism software, version 5.0. McNemar's test was applied and Kappa agreement coefficient was calculated for agreement between various methods. A p-value < 0.05 was considered significant. among the 100 evaluated endometrial samples, one was AFB smear positive, none was positive by culture, four were positive by histopathology and 13 were positive by PCR. Of the PRC-positive cases, 38.4% were positive for M. tuberculosis, 23.07% for M. bovis, and 38.4% showed co-infection with both species. 40% of the patients had raised IgG against M. tuberculosis 38-kDa antigen. McNemar's test was applied to PCR and the conventional methods of TB diagnosis [AFB, Culture and histopathology] and the p-value was <0.001 [highly significant] for PCR. Detection by PCR showed a fair agreement with detection by Mantoux test and ELISA. In paucibacillary endometrial tuberculosis, the positive detection rate was found to be significantly higher for PCR compared to other methods. The 'in-house' nested PCR assay targeting the hupB gene and used in this study, can serve as a rapid diagnostic aid for tubercular endometritis. It can also differentiate between members of the mycobacterium tuberculosis complex, namely M. tuberculosis and M. bovis

Avaliação histeroscópica em pacientes com infertilidade / Hysteroscopic evaluation in patients with infertility

OBJETIVO: descrever os achados da histeroscopia em pacientes com infertilidade. MÉTODOS: série retrospectiva de 953 pacientes com diagnóstico de infertilidade avaliadas por histeroscopia. As 957 pacientes em pesquisa de infertilidade foram submetidas à histeroscopia, preferencialmente na primeira fase do ciclo menstrual. Quando necessário, foram realizadas as biópsias, dirigida (sob visão direta durante o exame) ou orientada, utilizando uma cureta de Novak após definir o local a ser biopsiado durante o exame histeroscópico. Foram utilizadas porcentagens para determinação da frequência dos desfechos e teste de χ2 para correlações. O programa estatístico EpiInfo 2000 (CDC) foi utilizado para análise dos dados. RESULTADOS: cavidade uterina normal foi encontrada em 436 casos (45,8 por cento). Esse foi o diagnóstico mais frequente em mulheres com infertilidade primária e naquelas com nenhum ou um aborto (p<0,05). Achados anormais foram diagnosticados em 517 de 953 casos (54,2 por cento) e incluíram sinéquias intrauterinas em 185 pacientes (19,4 por cento), pólipo endometrial em 115 (12,1 por cento), pólipos endocervicais em 66 (6,0 por cento), miomas submucosos em 47 (4,9 por cento), hiperplasia endometrial em 39 (4,1 por cento), adenomiose em cinco (0,5 por cento), endometrite (com confirmação histopatológica) em quatro (0,4 por cento), metaplasia óssea endometrial em dois (0,4 por cento) e câncer do endométrio em um caso (0,1 por cento). Alterações morfológicas e funcionais do útero foram detectadas em 5,6 por cento dos casos, incluindo malformações uterinas em 32 (3,4 por cento) e incompetência istmo-cervical em 21 (2,2 por cento). CONCLUSÕES: sinéquias intrauterinas foram os achados anormais mais frequentes em pacientes avaliadas para infertilidade. Pacientes com histórico de aborto e infertilidade devem ser submetidas à histeroscopia para descartar sinéquias intrauterinas como uma possível causa de infertilidade.

PURPOSE: to describe hysteroscopy findings in infertile patients. METHODS: this was a retrospective series of 953 patients with diagnosis of infertility evaluated by hysteroscopy. A total of 957 patients investigated for infertility were subjected to hysteroscopy, preferentially during the first phase of the menstrual cycle. When necessary, directed biopsies (under direct visualization during the exam) or guided biopsies were obtained using a Novak curette after defining the site to be biopsied during the hysteroscopic examination. Outcome frequencies were determined as percentages, and the χ2 test was used for the correlations. The statistical software EpiInfo 2000 (CDC) was used for data analysis. RESULTS: a normal uterine cavity was detected in 436 cases (45.8 percent). This was the most frequent diagnosis for women with primary infertility and for women with one or no abortion (p<0.05). Abnormal findings were obtained in 517 of 953 cases (54.2 percent), including intrauterine synechiae in 185 patients (19.4 percent), endometrial polyps in 115 (12.1 percent), endocervical polyps in 66 (6.0 percent), submucosal myomas in 47 (4.9 percent), endometrial hyperplasia in 39 (4.1 percent), adenomyosis in five (0.5 percent), endometritis (with histopathological confirmation) in four (0.4 percent), endometrial bone metaplasia in two (0.4 percent), and cancer of the endometrium in one case (0.1 percent). Morphological and functional changes of the uterus were detected in 5.6 percent of the cases, including uterine malformations in 32 (3.4 percent) and isthmus-cervical incompetence in 21 (2.2 percent). CONCLUSIONS: intrauterine synechiae were the most frequent abnormal findings in patients evaluated for infertility. Patients with a history of abortion and infertility should be submitted to hysteroscopy in order to rule out intrauterine synechiae as a possible cause of infertility.

Infección por Chlamydia trachomatis / Chlamydia trachomatis infection

Determinar la prevalencia de la infección por Chlamydia trachomatis en una población de parejas infértiles. Validar la eficacia del diagnóstico de anticuerpos anti Chlamydia para tratar, prevenir y controlar la infección por C. trachomatis. Justificar la necesidad de implementar el monitoreo de rutina para administrar el tratamiento oportuno de la infección por C. trachomatis. Se determinó la prevalencia de la infección por Chlamydia trachomatis en 4 619 pacientes, 2607 mujeres y 2012 hombres en edades reproductivas, entre 1999 y 2008 por problemas de infertilidad. Se detectaron anticuerpos anti-Chlamydia trachomatis (IgG, IgA e IgM) por SeroELISA (Savyon Diagnostics Ltd.) de 1999 a 2005; desde 2006 hasta 2008 se utilizó el kit InmunoComb II (Orgenics). Centro de fertilidad UNIFERTES, Caracas, Venezuela. Se encontró una prevalencia en mujeres de 25,40 ± 6,26 por ciento; y en los hombres de 31,12 ± 2,88 por ciento. La prevalencia de la infección por C. trachomatis en parejas infértiles es alta y no ha disminuido en los últimos 10 años. Se recomienda implementar en Venezuela un monitoreo de rutina para el diagnóstico de C. trachomatis, incluyendo su determinación en el control ginecológico anual y en las evaluaciones urológicas a hombres jóvenes, a fin de prevenir que la infección pase a ser crónica

To determine the prevalence of Chlamydia trachomatis infection in infertile couples. To evaluate the efficiency of the Chlamydia trachomatis screening programs. To establish the need of implementing the routine early diagnosis and opportune treatment of the infection. Prevalence of Chlamydia trachomatis infection was determined in 4619 patients, 2607 women and 2012 men in reproductive agesbetween 1999 and 2008. Anti-chlamydia and C.trachomatis antobodies (IgG, IgA and IgM) were detected by SeroELISA (Savyon Diagnostics Ltd.) from 1999 to 2005; and by the ImmunoComb II kit (Orgenics) from 2006 to 2008. Fertility clinic UNIFERTES in Caracas, Venezuela. A prevalence of 25,40 ± 6,26 percent was found in women and a prevalence of 31,12 ± 2,88 percent was found in men. Prevalence of the C. trachomatis infection in infertile couples is high and has not decreased over the last 10 years. Implementation of routine screening programs for C. trachomatis detection is recommended, including its assessment in annual gynecological controls, as well as in urologic evaluations in young men, in order to prevent the infection from being chronic

Comparison of hysterosalpingography and diagnostic laparoscopy in the assessment of tubal patency for the investigation of subfertility

Infertility is common in our community. Infertility has become nowadays not only a medical, but a social problem as well. Fallopian tube problem is among one of the common causes of infertility. Hysterosalpingography and laparoscopy are used as a screening test for diagnosis of tubal patency. Hysterosalpingography is an out patient X-ray procedure, has for many years been an invaluable procedure for the assessment of tubal pathology and intra-uterine pathology .Laparoscopy is an invasive procedure used since 1944 by Raoul Palmer,of Paris for gynecological examination. We aimed in this paper to explore the role of hystrosalpingography in the evaluation of tubal patency in the diagnosis of the cause of female infertility in our society and to reduce the need for laparoscopy. One hundred fifty seven infertile women with fallopian tubes problem out of one thousand three hundred fifty patients who underwent HSG had given consent to undergo Laparoscopy in Sulaimaniea Maternity Teaching Hospital and in Hatwan Private Hospital during 2nd may. 2007 to 3rd may. 2008. For infertility not less than 2 years duration 1350 infertile patients with age range [20 - 39 ys] underwent HSG, 157 patients show pathology of the fallopian tubes. Diagnostic laparoscopy was performed for them after the HSG procedure to confirm the abnormalities diagnosed by HSG. The results showed non insignificant difference P value, the HSG gave 92.4% sensitivity and 100% specificity, while laparoscopy showed 100% sensitivity and 100% specificity. We conclude the feasibility of using HSG as a diagnostic method for investigating tubal patency in subfertile women when compared to the use of diagnostic laparoscopy

Reprodução e biopolítica: infertilidades e práticas de saúde em um serviço público no Rio de Janeiro / Reproduction and biopolitic: infertilities and health practices in a public in Rio de Janeiro

Apesar de a reprodução assistida possibilitar transformações importantes na parentalidade e nas relações familiares, suas tecnologias têm sido mais frequentemente usadas para reiterar o modelo tradicional de reprodução biológica e social. Este estudo qualitativo, de cunho exploratório, analisou quais normas estariam presentes nas práticas de saúde relativas à dificuldade de engravidar e o que poderia ser revelado a partir destas práticas. Foram observadas interações entre profissionais e pacientes atendidos em um serviço público de reprodução humana no Rio de Janeiro. A discussão dos diagnósticos de infertilidade e de risco, duas importantes estratégias biopolíticas usadas como critério de elegibilidade para o acesso às novas tecnologias reprodutivas, revelou como algumas práticas de saúde reiteram normas de gênero e de reprodução social. Atrelados à condição socioeconômica de seus usuários, estes diagnósticos tendem a agravar exclusões e desigualdades no exercício dos direitos reprodutivos no país. A análise da atenção médica possibilitou conhecer em parte o difícil cotidiano não apenas de homens e mulheres, que por anos persistem em seus desejos por filhos, mas também de profissionais que enfrentam antigas barreiras políticas, econômicas e burocráticas do serviço público de saúde. Este estudo corrobora a visão de que o serviço representa um avanço em termos de direitos sexuais e reprodutivos, apesar de ainda ser longo o caminho para o acesso igualitário e equânime às tecnologias reprodutivas pelo sistema único de saúde brasileiro (SUS).