[Comparison of 2 therapeutic strategies in severe endometriosis, in young women consulting for sterility or pain. II. In the case of infertility, value of ovarian stimulation with intrauterine insemination after surgery]. / Comparaison de deux stratégies thérapeutiques dans les endométrioses sévères, chez des femmes jeunes consultant pour stérilité ou douleurs. II. En cas d'infertilité, intérêt des stimulations ovariennes avec inséminations intra-utérines après la chirurgie.

AIM OF THE STUDY: Define the best medico surgical strategy in infertile women with stage III-IV endometriosis. MATERIAL AND METHODS: Two groups, A (N26) and B (N 37), treated for infertility associated or not with pelvic pain, due to stage AFS III or IV endometriosis, were compared. They had similar surgical procedure: operative laparoscopy including resection of endometriotic lesions, more particularly endometriomas and rectovaginal septum nodules. Associated medical strategy was different: group A, operative laparoscopy without preoperative treatment and in 40% a second laparoscopy taking place after 2-3 months of LHRH analogues; no post operative treatment; group B, operative laparoscopy taking place after ovarian blockage with 3-6 weeks of Diane (Androcur + ethinyl estradiol), then 2-3 months of analogue postoperative treatment immediately followed by ovarian stimulation (OS) + intrauterine insemination (IUI) in women more than 30 years old with operative tubes (N 22), no treatment for six months in similar cases less than 30 (N 5), and IVF in women with damaged tubes (N 5) or after OS + IUI failure (N 4). One patient refused two patients with high FSH level had oocyte donation. RESULTS: Two years evolutive pregnancy rate was significantly higher (p < 0.01) in group B (59%) versus group A (23%) and was higher after OS + IUI (68%) than after IVF (55%) or without any treatment in women < 30 (43%). The difference is equally significant by age (p < 0.05), for endometriomas (p < 0.01) and for recurrences (p < 0.01). CONCLUSION: Similar results obtained for pelvic pain (see chapter I) suggest that both strategies are similarly successful in treating endometriosis. These results confirm the interest of an ART after surgery for stage III-IV endometriosis and show that OS + IUI, a less costly than IVF technique, can be used successfully in selected cases with operative tubes.

[Comparison of 2 therapeutic strategies for severe endometriosis, in young women counsulting for sterility or pain. Results in cases of chronic pelvic pain]. / Comparaison de deux stratégies thérapeutiques dans les endométrioses sévères, chez des femmes jeunes consultant pour stérilité ou douleurs. Résultats en cas de douleurs pelviennes chroniques.

AIM OF THE STUDY: Compare two medical strategies associated to surgery in women requiring for chronic pelvic pain due to stage III-IV endometriosis. MATERIAL AND METHODS: Two different patient groups, A (N 27) and B (N 41), requiring for chronic pelvic pain, associated with AFS stage III-IV endometriosis, operated on from 1992 to 1997, were compared. The medium age was 35 and 34 years, respectively. Pelvic pain, classified in three stages, was similar in both groups but they were more AFS stage IV in group A, 67% than in group B, 46% (p < 0.01). Both groups had similar operative procedure: laparoscopic resection of deep endometriotic nodules or endometriomas, plus destruction of small superficial lesions using CO2 laser (A) or bipolar coagulation (B). Associated medical strategy was different: group A: operative laparoscopy without preoperative treatment and in 25% a second laparoscopy taking place after two-three months of LHRH analogues; no postoperative treatment; group B, operative laparoscopy taking place after ovarian blockage with three-six weeks of Diane (Androcur + ethinyl estradiol), then two-three months of analogue postoperative treatment immediately followed by long term progestoid treatment in order to prevent recurrences in women without pregnancy desire. RESULTS: After one year, 6/27 (22%) of A and 3/41 (7%) of B had no follow-up. Of the followed patients, a complete improvement was observed in 18/21 (86%) A, 33/38 (87%) B, moderate pelvic pain continued in 2/21 (10%) A, 4/38 (11%) B, and the treatment was in failure in 1/21 (5%) A, 1/38 (3%) B, without significant difference. After two years, 67% of A and 76% of B had a follow-up and the corresponding rates of complete improvement are 72% (A), 87% (B), incomplete improvement: 22% (A), 10% (B) and failure: 6% (A), 3% (B). The difference is lightly significant (p < 0.05) and remains so if patients without follow-up are considered as failures. There was no persistence nor recurrence of endometriosis nor endometrioma two years after the surgery was completed. CONCLUSION: Since there were more stage IV endometriosis in group A than in B, the different medical strategies and particularly the long term postoperative treatment used in B seem have little influence on results. However, these data was obtained in women of medium age > 30, with a relatively short follow-up. It should be of interest to compare in a prospective multicentric study the long term follow-up of two cohorts of young women operated on for stage III-IV endometriosis, receiving or not a long term medical treatment after surgery in order to prevent recurrences.

Correlation between an early sexual debut, and reproductive health and behavioral factors: a multinational European study.

OBJECTIVE: To investigate whether women who made an early sexual debut differ from those with a later debut regarding genital signs and symptoms. METHODS: The study included women who considered themselves gynecologically healthy and who attended 17 family planning centers in 13 European countries for contraceptive advice. There were 629 women who made their sexual debut at the age of 16 years or earlier (study population) and 927 women who had their first sexual intercourse at the age of 19 years or later (comparison group). Genital symptoms and signs, contraceptive use, smoking, and genital hygiene habits and previous genital infections were recorded on a structured patient record form. Detection of Chlamydia trachomatis was made by means of a polymerase chain reaction on first-void urine. The study was made, on average, 7-10 years after the women's sexual debut. RESULTS: The mean age of first intercourse was 15.3 years for the study group versus 20.7 years for the control group (p < 0.001). The study population had significantly more symptoms, such as vaginal discharge and pruritus, and signs, such as abnormal discharge, erythema of the vaginal mucosa and lower genital tract infections, than the comparison group. Twice as many women in the study group were smokers and there was a ten-fold increase among these subjects of using low-pH solutions for genital hygiene. The prevalence of C. trachomatis infection did not differ between the two groups (p = 0.22). CONCLUSION: Age at first intercourse is not only a predictor of sexual risk behavior, but also a predictor, regarding both signs and symptoms, of future gynecological problems.

PID: clinical and laparoscopic aspects.

Clinical signs of pelvic inflammatory disease (PID) are not constant and are often limited to slight pelvic pain. Laparoscopy can lead to a rapid and correct diagnosis of PID. Intrapelvic bacteriologic samples can be obtained so as to administer the proper antibiotic. The exact nature of the lesions can be evaluated, and in severe cases, recent abscesses can be treated with good results for fecundity. Because the results in cases of long-standing abscess are not so good, laparoscopy should be performed at the onset of infection and not be reserved until after some weeks of inefficient medical treatment, especially in young women who have not completed their family. In primary chronic salpingitis, the lack of any clinical signs usually leads to a delay in diagnosis until women consult for fertility problems. The ideal point would be to detect some biologic or clinical change that may lead to diagnosis such as a positive anti-Chlamydia trachomatis (CT) serology or, in the future, positive anti-CT Hsp 60 antibody could be the key to detecting and treating silent salpingitis in young women, CT being the main microorganism involved in chronic salpingitis. Screening for C. trachomatis low genital tract infection is mandatory in young people in order to control the epidemic.

Circulating antibodies to a conserved epitope of the Chlamydia trachomatis 60 kDa heat shock protein (hsp60) in infertile couples and its relationship to antibodies to C.trachomatis surface antigens and the Escherichia coli and human HSP60.

To evaluate the relationship between immunity to specific regions of the Chlamydia trachomatis 60 kDa heat shock protein (hsp60), autoimmunity to human HSP60 and infertility, sera from 50 women and 45 men seen for an infertility evaluation were tested. Humoral immunity to human HSP60 was detected in 18% of women and 8.9% of men while antibodies to the Escherichia coli hsp60 were detected in 12% of women and 4.4% of men. These differences were not statistically significant. In contrast, antibodies to a synthetic peptide epitope of the chlamydial hsp60, encompassing amino acids 260-271 (chsp 260-271), were present in sera from 16 (32%) of the women but in only six (13.3%) of the men (P=0.03). Antibodies to chsp 260-271 were present in 11 out of 17 (64.7%) individuals with high titre (>1:160) immunoglobulin (Ig)G antibody to C.trachomatis surface antigens as opposed to only two out of 15 (13.3%) with low titre antibody and two out of of 17 (11.8%) with undetectable chlamydial antibody (P < 0.004). Antibodies to chsp 260-271 were also associated with humoral immunity to human HSP60. 50% of sera with, as opposed to only 18.6% of sera without, anti-human HSP60 IgG were positive for antibodies to chsp 260-271 (P=0.03). In contrast, there was no relationship found between immunity to the E.coli hsp60 and antibodies to human HSP60. Antibodies to chsp 260-271 were more prevalent in women with at least two spontaneous abortions (eight out of 13, 61.5%) than in women with other infertility diagnoses (six out of 35, 17.1%) (P=0.004). Thus, immunity to chsp 260-271 is more prevalent in women than in men, associated with autoimmunity to human HSP60 and may be an immunological marker for spontaneous abortion.

[Chlamydia trachomatis: should it be systematically be screened or treated? Literature review and cost/benefit estimation in France]. / Chlamydia trachomatis: faut-il dépister ou traiter systématiquement? Revue de la littérature et estimation coût/bénéfice en France.

Chlamydia trachomatis is a primary cause of acute or silent salpingitis leading to infertility and ectopic pregnancy. The C. trachomatis epidemic, undiscovered in most cases, spreads, mostly in adolescents, during the years following the onset of sexual activity. As opposed to gonococcal infection which has greatly decreased, C. trachomatis cervical and urethral infection is commun in young occidentals. More then 30 different studies covering 200-12000 subjects screened in family planning centers, college women and men, students and military recruits in different parts of the USA, in Scandinavian countries and France, indicate a prevalence of 5-20% (mean 10%) in apparently healthy young females < 25 years and 5-10% in males. Female prevalence is strongly related to age, being highest (5-20%) in women < 20 years old. Several cost-benefit analysis show that the total cost of the general screening in young populations, which can easily be carried out for women in family planning centers, could save twice the cost of treatment for pelvic inflammatory disease caused by C. trachomatis and six times the total cost of C. trachomatis epidemics if late sequelae are taken into account (tubal infertility treatment, ectopic pregnancy). In France, screening should save 12 to 48 millions French francs each year, depending of the cost of detection. The final benefit of detection should be the eradication of the epidemic as obtained to date in Scandinavian countries.

Hormonal contraception and pelvic inflammatory disease.

Estrogen-progestogen contraception (OC) is significantly associated with a high prevalence of Chlamydia trachomatis in the lower genital tracts of young women. In contrast, pelvic inflammatory disease is less frequent and is associated with milder pelvic lesions in OC users than in non-users. A recent study suggests that OC use can be associated with silent endometritis and salpingitis. The usual clinical, biological and laparoscopic signs of acute and chronic pelvic inflammatory disease are described. As shown tby several cost-benefit analyses, C. trachomatis detection in family planning centers is cost-effective and the eradication of bacteria is obtained in 90% of cases by a new treatment: azithromycin (1 g for 1 day). Although the data clearly show that C. trachomatis screening is cost-effective, selection of the diagnostic laboratory tests used in such screening programs should be carefully evaluated relative to cost, feasibility, specificity and sensitivity, and should be adapted to the presumed prevalence in screened populations. A systematic screening is indicated in populations susceptible to a prevalence of 5% or more.

Chlamydia trachomatis screening in family planning centers: a review of cost/benefit evaluations in different countries.

Chlamydia trachomatis is a primary cause of acute or silent salpingitis leading to infertility and ectopic pregnancy. The C. trachomatis epidemic, undiscovered in most cases, spreads, mostly in adolescents, during the years following the onset of sexual activity. As opposed to gonococcal infection which has greatly decreased, C. trachomatis cervical and urethral infection is common in young occidentals. More then 30 different studies covering 200-12,000 subjects screened in family planning centers, college women and men, students and military recruits in different parts of the USA, in Scandinavian countries and France, indicate a prevalence of 5-20% (mean 10%) in apparently healthy young females < 25 years and 5-10% in males. Female prevalence is strongly related to age, being highest (15-20%) in women < 20 years old. Several cost-benefit analyses show that the total cost of the general screening in young populations, which can easily be carried out for women in family planning centers, could save twice the cost of treatment for pelvic inflammatory disease caused by C. trachomatis and six times the total cost of C. trachomatis epidemics if late sequelae are taken into account (tubal infertility treatment, ectopic pregnancy). There is a debate among authors concerning the relative merits of total screening versus selective screening in family planning centers, the most common opinion being to do a total screening of women < 20 years old and selective screening of women 20-30 years of age with at least one risk factor, the most common risk factors being more than one partner in a year, purulent, cervical discharge, failure to use condoms and use of a contraceptive pill. Although the data clearly show that C. trachomatis screening is cost-effective, conducting of the diagnostic laboratory tests used in such screening programs should be carefully evaluated relative to cost, feasibility, specificity and sensitivity and should be adapted to the presumed prevalence in screened populations.

[Uterine rupture during labor following surgical hysteroscopy]. / Ruptures utérines lors d'accouchements après hystéroscopie opératoire.

Two cases of obstetrical uterine rupture after operative hysteroscopy without perforation are described. One was treated for uterus septus, the other one for synechia. However, the uterus could have been fragilized in both cases: one had been perforated by a uterine device, the other case had a past history of repeated curetage. A review of the literature shows 7 other similar cases, published over last ten years, 6 of them having a past history of perforation during the operative hysteroscopy (5 cases) or by an intra-uterine device. These obstetrical complications, although rare, can lead to consider a uterus treated by hysteroscopy as being at risk for obstetrical rupture.

Clinical consequences of immune response to CT upper genital tract infection in women.

C. TRACHOMATIS (CT) infections of the upper genital tract in women are either acute, sub acute or chronic. CT infection has a tendency to be chronic, latent and persistent as a consequence of the host immune reaction to CT major outer membrane protein, 57 Kd heat shock protein and lipopolysaccharide. Chlamydial persistence can be induced as a result of inflammatory and/or immune regulated cytokines, Interferon gamma depletion of tryptophan causes a stress response involving development of abnormal forms with increased levels of stress response proteins which maintain host immune responses with continuous fibrin exudate.The main clinical consequences are acute and chronic pelvic inflammatory disease, with infertility, ectopic pregnancy and, less frequently, chronic pelvic pain as late sequelae.PID, WHEN ACUTE, IS MARKED BY BILATERAL PELVIC PAIN, PLUS OTHER INFECTIOUS SIGNS IN TYPICAL CASES: fever, leucorrhea, red and purulent cervix. In 50% cases, infectious signs are slight or absent or there is an atypical clinical situation. Laparoscopy is the key for diagnosis. It allows the surgeon to have a direct look at the pelvic organs and perform microbiologic and histologic sampling. In severe cases, laparoscopy allows the surgeon to aspirate the purulent discharge and successfully treat pelvic abscesses.Chronic PID usually is clinically silent. It is in most cases discovered some years after the onset of CT infection, in women operated on for tubal infertility or ectopic pregnancy. Further studies, to evaluate treatments efficiency in chronic cases and factors leading to ectopic pregnancy or to recurrence, are indicated.

[Adolescents and chlamydia: cervix microbiology among adolescents; the first statistics of the family planning centers according to the Calmat law]. / Adolescents et chlamydiose: le portage cervical chez les adolescentes; premières statistiques des centres de planification familiale en application de la loi Calmat.

Infertility due to Chlamydia trachomatis infection can be prevented by systematic screening of low genital tract infection. This screening is to be done systematically in women < 25 years old in Family Planning Centers. In France, according to Calmat's low, screening and treatment are anonymous and free of charges for adolescents and people without National Health care. In a foreseeable future, screening will be done for both sexes, by PCR or LCR, on first void urines.

Role of laparoscopy in the management of pelvic adhesions and pelvic sepsis.

Operative laparoscopy in pelvic sepsis is useful in acute cases: (a) for diagnosis, as there are 20-30% false positive and false negative diagnoses based on clinical and laboratory data alone; and (b) for treatment in severe cases and mainly in tubo-ovarian abscesses, laparoscopy allows aspiration of purulent discharge and, in recent cases, removal of fresh adhesions. In most cases, rapid and complete recovery is associated with treatment with an effective polyvalent antibiotic. Fertility is also preserved in most cases as assessed by a small series of bilateral abscesses with long-term follow-up. In CS associated with infertility, laparoscopic treatment is limited to velamentous adhesions or to dense adhesions of small extent. If performed after the completion of the inflammatory episode, laparoscopic surgery can give results comparable to those of microsurgery. A full bacteriological investigation and appropriate antibiotic treatment are necessary in order to stop or reduce the inflammatory condition which is usually associated with the development of adhesions and is a possible cause of their recurrence.

Post-therapeutic evolution of serum chlamydial antibody titers in women with acute salpingitis and tubal infertility.

OBJECTIVE: To determine if serologic data and, more particularly, antichlamydial immunoglobulin (Ig) M can be used for diagnosis of current chlamydial intrapelvic gynecologic infection. DESIGN: Forty-two women with acute salpingitis (group A), 131 women with tubal factor infertility (group B), and 98 pregnant women (control group C) were studied. SETTING: Hôpital Jean Rostand, Sèvres (patients), Laboratories Magenta and Eylau, Paris (serology), Institut Pasteur, Paris (cultures). INTERVENTIONS: Study groups: endocervical/urethral swabs, pelvic samples; serologic study before and after treatment. CONTROL GROUP: Serologic study. MAIN OUTCOME MEASURES: Serum samples were collected from each patient initially and 6 to 9 weeks later; additionally, two to five sequential sera were obtained from 22 (group A) and 25 (group B) patients with positive cultures, evolutive serology, or positive antichlamydial IgM. Sera were tested for antichlamydial IgG by a microimmunofluorescence assay using Chlamydia trachomatis elementary bodies and for IgA and IgM by whole inclusion-fluorescent assay. RESULTS: Before treatment, there was a correlation between the presence of antichlamydial IgM and positive cervical and/or intrapelvic chlamydia cultures. After treatment, antichlamydial IgM, when initially positive, rapidly disappeared in most subjects; its persistence after 4 months was significantly associated with tubal sequelae in group A patients and persistence of positive intrapelvic chlamydial cultures in group B women. CONCLUSION: Serologic analysis of women with acute salpingitis or tubal infertility, including antichlamydial IgM, may aid both in the before treatment diagnosis of chlamydial infection and in the follow-up evaluation.

Detection of Chlamydia trachomatis in fallopian tube tissue in women with postinfectious tubal infertility.

OBJECTIVE: Biopsy tissues from women with postinfectious tubal infertility were studied for the presence of Chlamydia trachomatis. STUDY DESIGN: Tubal biopsy specimens from 25 women with postinfectious tubal infertility undergoing laparoscopy for repair of fallopian tubes were evaluated by culture, in situ hybridization. Immunocytochemistry, and transmission electron microscopy for the presence of Chlamydia trachomatis. Serum was also tested for Chlamydia trachomatis antibodies. RESULTS: Chlamydia trachomatis was detected in postinfectious tubal biopsy specimens in three of 25 patients by culture, 12 of 24 by in situ hybridization, 15 of 22 by immunoperoxidase stain, and two of 10 by transmission electron microscopy. Serum antibody against Chlamydia trachomatis was detected in 15 of 21 patients. CONCLUSION: Chlamydia trachomatis deoxyribonucleic acid or antigens were detected at a high percentage (19/24 women) in the biopsy tissues of the fimbrial and peritubal adhesions by in situ hybridization or immunoperoxidase stain, suggesting a persistent infection in these women even after antibiotic treatment.

[A new therapeutic strategy using a ofloxacin-amoxicillin-clavulanic acid combination in the treatment of upper gynecologic infections. Apropos of 123 cases]. / Nouvelle stratégie thérapeutique par l'association ofloxacine-amoxicilline-acide clavulanique dans le traitement des infections gynécologiques hautes. A propos de 123 cas.

OBJECTIVE: To evaluate a new antibiotic strategy with a combination of ofloxacin + co-amoxiclav in the treatment of pelvic infectious diseases. DESIGN: An open-non-comparative multicentre (10) study. SUBJECTS: 123 patients (118 salpingitis and 5 endometritis) were included clinical, laparoscopic and bacteriological assessments were performed before treatment and a laparoscopic control was done in 35% of cases. Among positive bacteriological samples before treatment 48.7% C. trachomatis were isolated; 56.1% of salpingitis were considered as severe (COGIT score > 6). TREATMENT: Patients received at entry oral ofloxacin 200 mg bid in combination with parenteral co-amoxiclav 2 to 4 g following by oral route. Total duration of treatment was 21 days. RESULTS: With respectively 97.2% and 91.6% satisfactory clinical and bacteriological results, this combination should take a major place in the treatment of pelvic infectious diseases.