Recovery of Chlamydia trachomatis from the endometria of women with unexplained infertility.

Fifty-two women with unexplained infertility and 55 controls with recently proved fertility were screened for Chlamydia trachomatis (CT) infection in the blood and genital tract. Serum antibody titration was performed with indirect fluorescence. Cell cultures were performed to screen for CT in urethral and endocervical swabs, in endometrial samples taken without endocervical contamination and in salpingeal and/or peritoneal fluid samples. Anti-CT serum antibodies were detected in 36.5% of the patients; CT was isolated in urethral cultures in 26.9%, endocervical cultures in 23.1%, endometrial cultures in 25% and endosalpingeal and/or peritoneal fluid cultures in 1.9%. Comparison of the results in the patients and controls showed a significant difference in the incidence of CT infection in endometrial, urethral and endocervical cultures. Chlamydial endometritis could have been the direct cause of infertility in the patients studied or merely might have indicated endosalpingitis that was not detectable at laparoscopy.

Ectopic pregnancy and recurrent spontaneous abortion: two associated reproductive failures.

The association between spontaneous abortion and ectopic pregnancy was evaluated in a case-control study conducted on 161 women (cases) with recurrent spontaneous abortions (two or more consecutive spontaneous abortions) and 170 control subjects who delivered normal infants. The risk of ectopic pregnancy in women with a history of recurrent spontaneous abortion was about fourfold that of controls (relative risk adjusted for age and number of pregnancies = 4.3; 95% confidence interval 1.4-14.7). This association was confirmed by comparing the observed number of extrauterine pregnancies in women with recurrent spontaneous abortions with the expected number computed from regional data on the frequency of ectopic pregnancies; the estimated relative risk was 3.7, with a 95% confidence interval of 2.2-7.0. The present report found an association between spontaneous abortions and ectopic pregnancies, suggesting some common risk/etiologic factors for these two reproductive failures.

Increased frequency of complete hydatidiform mole in women with repeated abortion.

The association between spontaneous abortion and gestational trophoblastic disease (GTD) has been investigated in a study based on 93 women with 2 consecutive (repeated) spontaneous abortions and 82 control subjects who delivered normal babies. Nine molar pregnancies were observed among 7 of the 93 cases of repeated abortion while no control reported previous GTD. This difference was statistically significant and was not explained by allowance for age and number of pregnancies between cases and controls (chi 2(1) = 4.20; P = 0.04). When the observed number (9) of hydatidiform mole in the 385 pregnancies of the women with repeated abortion was compared with the expected one (0.28) based on the regional frequency data, the estimated relative risk was 32.1 with a 95% confidence interval from 13.9 to 63.3. The present findings confirm the association between GTD and spontaneous abortion and indicate that the risk is larger in women with repeated abortions.

Short-term reproductive prognosis when no cause can be found for recurrent miscarriage.

The short-term reproductive prognosis of recurrent miscarriage for which no cause was found has been evaluated in 95 couples investigated between 1980 and 1986 at the First Obstetric and Gynaecological Clinic of the University of Milan. The actuarial overall 3-year livebirth delivery rate was 64%, increasing constantly with time. The reproductive success rate decreased with the number of previous miscarriages from 80% in women with two, to 60% with three and 46% with four or more miscarriages. No effect of age and socio-economic status emerged. There was a positive association between the number of previous miscarriages and the risk of miscarriage in the next pregnancy. Compared with women with two miscarriages the relative risk of another miscarriage was 2.3 for those with three previous miscarriages and 5.0 for those with four or more (chi 2 1 for trend adjusted for age = 5.2, P = 0.02).

Communicating uteri: description and classification of a new type.

A case of bicornuate-bicervical communicating uterus with atresia of the right hemicervix is reported. This cannot be included in any of the nine groups of Toaff's classification of uterine malformations proposed in 1984, and should be classified as a new, tenth type.

Second-look hysteroscopy after conservative surgery of the uterus.

A hysteroscopic second look has been performed following sixteen intracavitary myomectomies, twenty-nine metroplasties and thirty-four intra-uterine adhesiolyses. This control has been performed three months after laparotomic operation and after forty-five days of sequential estro-progestogen treatment in cases of transcervical operation. The hysteroscopic second-look proved to be an excellent follow-up method after uterine conservative surgery and it avoids the use of X-rays, allows a detailed morphological evaluation of the uterine cavity and offers the possibility of complementary surgery, when necessary.

Intrauterine adhesions: current diagnostic and therapeutic trends.

In the period January 1981-December 1984, 31 cases of intrauterine adhesions (8 severe, 10 moderate and 13 minimal) were diagnosed at the First Department of Obstetrics and Gynecology, University of Milan. This pathology had altered the menstrual function in 21 subjects and reproductive capacity in 27. Synecholysis was performed at hysteroscopy, followed by application of an IUD in 7 patients and sequential treatment with estrogens and progestins in 22. After treatment 67.7% of the women had normal menstruation, and 40.7% of those wanting a child achieved pregnancy with live birth. Repeat hysterography and hysteroscopy after several months showed complete normalization of the uterine cavity in 62.5% of the women, and persistence of minimal and moderate adhesions in 25% and 12.5% respectively. Dissection with miniature scissors under visual control, followed by application of an IUD and sequential administration of estrogens and progestins seems at present the most effective therapeutic regimen for intrauterine adhesions.

PIP: 31 cases of intrauterine adhesions were diagnosed over the January 1981-December 1984 period at the First Department of Obstetrics and Gynecology, University of Milan (Italy). Table IV presents the relevant details of the subjects' history prior to diagnosis. Menstrual abnormalities were present in 21 subjects -- amenorrhea in 7 and hypomenorrhea in 14. 27 of the women wanted a child. Their obstetric history showed habitual abortion in 19 cases, secondary sterility in 7 cases, and primary sterility in 1. Amenorrhea was the only reason for seeking consultation in the other 4 cases. A complete and basic screening of the couple showed no other important factors causing infertility. Hysterosalpingography always preceded the endoscopic evaluation. Synechiae were evaluated as severe in 8 cases, moderate in 10, and minimal in 13. A rigid hysteroscope of 4 mm diameter was inserted in a 5 mm diagnostic sheath and a 7 mm opering sheath. The uterine cavity was distended by C02 in 10 cases and with macromolecular dextran in 21. Lysis was performed in 15 cases by multiple pressures of the extremity of the tip of the outer sleeve of the hysteroscope and in 12 with rigid miniature scissors introduced through the operating sheath. In the other 4 cases, intervention could not be completed for technical reasons. An IUD was inserted postoperatively in 7 patients; sequential estrogen-progestin treatment was prescribed for 22 patients. A repeat hysterosalpingography was performed on 16 women; 12 underwent a 2nd-look hysteroscopy. In regard to menstrual function, the results were good overall. Over 2/3 of the patients reported complete normality of menstrual flow, and the number of subjects with hypomenorrhea dropped from 45.2% to 25.8%. Less satisfactory results were obtained in the 7 patients with amenorrhea: eumenorrhea in 2; partial restoration of menstrual flow in 3; and no flow in 2. Reproductive status did not improve along with restoration of menstrual function. The not corrected pregnancy rate was 70%; the pregnancies with live births were under 41%. The number of abortions was substantially reduced but even so 45% of the conceptions underwent spontaneous abortion. After correction of minimal interuterine adhesions, the reproductive prognosis could be regarded as moderately good. The same was not the case for moderate adhesions. In the presence of extensive pathology, no pregnancy was carried to term.