Chronic Salpingitis Research Articles

Interval changes of an extrauterine adenomyoma on magnetic resonance imaging

Extrauterine adenomyomas are rare tumors that present as uterus-like masses. Uterine adenomyomas can show interval changes according to hormone status. However, interval changes in imaging studies have not been reported in adenomyomas. We report a rare case of an extrauterine adenomyoma showing unique interval changes in magnetic resonance imaging.

Xanthogranulomatous salpingitis as a rare pathologic aspect of chronic active pelvic inflammatory disease

Xanthogranulomatous salpingitis (XGS) is a rare form of chronic inflammation of the fallopian tubes. A 41-year old woman with a history of secondary infertility for 2 years is presented. The patient underwent bilateral salpingooopherectomy with presumptive diagnosis of adnexal mass with cystic component. Intraoperative pathology consultation was done. The diagnosis of bilateral XGS associated with chronic active follicular salpingitis was made. XGS is reported to be caused by an unsuccesfully treated pelvic inflammatory disease. Its association with chronic active follicular salpingitis has not been previously reported. Chronic active follicular salpingitis with xanthogranulomatous inflammation might give the impression of a cystic adnexal mass with septations on preoperative pelvic computed tomography. Frozen sections are necessary to rule out malignancy as done in our case.

Ectopic Pregnancy Complicated by an Arteriovenous Malformation of the Fallopian Tube

Ectopic pregnancy is still correlated with a high incidence of morbidity and mortality. 1 Increasing occurrences of sexually transmitted diseases (gonorrhea and chlamydia), pelvic inflammatory diseases, previous abortions, bitubal ligations, intrauterine devices, assisted reproductive techniques, late primiparity, and previous surgery are associated with chronic salpingitis, which is the most common finding associated with and responsible for ectopic pregnancy. 2 Improvements in the resolution of high-frequency transvaginal sonography have contributed greatly to the diagnosis of ectopic pregnancy, which has already been correlated with the β-human chorionic gonadotropin (β-hCG) level. 3,4 The introduction of 2-dimensional (2D) transvaginal scanning, color Doppler imaging, and nowadays, 3-dimensional (3D) transvaginal sonography can provide information about the location and size of the ectopic mass and impairment of the tube. Evaluation of these factors is important for selecting the best treatment for the patient and choosing among the different therapeutic possibilities (laparoscopy, methotrexate administration, and expectant management). Arteriovenous malformations (AVMs) in the female genital tract are relatively uncommon lesions in which there is direct communication between arterioles and venules. They can be either congenital or acquired. The association between ectopic pregnancy and AVMs is extremely rare; indeed, in the literature we found just 2 cases of ectopic pregnancy associated with an AVM. 5,6 We report a case of an ectopic pregnancy complicated by an AVM in which 2D transvaginal sonography, color Doppler imaging, pulsed wave Doppler imaging, and new 3D modes, including tomographic ultrasound imaging, the glass body mode, and 3D bidirectional power Doppler (HD-Flow) imaging, indicated the diagnosis and the best surgical plan.

Urogenital infections in reproductive medicine

Urogenital infections with Chlamydia trachomatis belong to the most prevalent sexually-transmitted bacterial diseases. In women, they can cause chronic salpingitis with subsequent tubal infertility and ectopic pregnancies. In men, C. trachomatis can cause urethritis, prostatitis and epididymitis. Urogenital infections can be symptomatic or asymptomatic. Symptomatic urogenital infections might impair male fertility. In vitro, C. trachomatis affects sperm motility and viability. However, there is no clear evidence that asymptomatic urogenital infections have an adverse effect on male fertility. Because C. trachomatis can be sexually transmitted and lead to female infertility, it is also of significance in male infertility work-up. Because of their high sensitivity, nucleic acid amplification tests should be used to examine first-void urine specimens. Both partners should be treated. The role of Ureaplasma urealyticum in reproductive medicine has been discussed controversially. There is no evidence that U. urealyticum has a significant impact on female or male infertility.

A IMUNOLOGIA E A IMUNOPATOLOGIA DAS INFECÇÕES CAUSADAS POR

As clamídeas são bactérias intracelulares obrigatórias de células eucarióticas, responsáveis por uma ampla variedade de infecções em humanos e em algumas espécies de animais. Em humanos, as infecções por Chlamydia trachomatis geralmente estão localizadas na superfície de epitélios ou de mucosas, e são freqüentemente assintomáticas, podendo persistir por longos períodos de tempo se não tratadas. Em termos de resposta imune em humanos, observa-se a produção de anticorpos neutralizantes de eficácia moderada, específicos para as principais proteínas do envelope externo, enquanto que o interferon ã (IFN) é clamidiostático e, paradoxalmente, pode exercer tanto uma função facilitadora da ã persistência da infecção quanto de proteção imune. Respostas de hipersensibilidade tardia para clamídea, causadas pela infecção persistente ou re-infecção, são importantes no desenvolvimento de seqüelas graves características do tipo tracoma cicatricial ou salpingite crônica. Proteínas clamidiais de choque térmico dotadas de intensa homologia com proteínas humanas equivalentes, podem ser os alvos principais nas respostas imunopatologicas e sua expressão é estimulada por IFN em infecções persistentes. Este ã trabalho revisa os principais aspectos relacionados à imunologia e imunopatologia das infecções causadas por Chlamydia trachomatis, relacionando os mesmos com a evolução clínica da infecção. Palavras Chave: Chlamydia trachomatis, resposta imune, imunopatologia, evolução clínica da infecção.

Immunohistochemical Detection of Glucose Transporter GLUT1 in Benign and Malignant Fallopian Tube Epithelia, With Comparison to Ovarian Carcinomas

Enhanced expression of GLUT1, a facilitative glucose transporter found on red blood cells, blood-brain barrier, and perineurium, has been described in a large spectrum of epithelial malignancies. We present an immunohistochemical survey of GLUT1 expression in benign and malignant fallopian tube epithelia, and compare serous carcinomas of the fallopian tube and ovary. One hundred two routinely fixed and processed archival specimens (36 benign fallopian tubes, 29 primary tubal adenocarcinomas, and 37 primary ovarian adenocarcinomas) were immunostained with rabbit anti-GLUT1 and developed with streptavidin-biotin/diaminobenzidine. Only distinct membrane staining was scored positively (1+ to 3+). Benign tubes (n = 36) were either negatively stained (58.3%) or displayed rare weak staining (0.5+ to 1+, rarely 2+; 41.7%); of the latter, 4 specimens showed chronic salpingitis, and 6 showed hyperplasia (epithelial tufting and stratification). A case of florid hyperplasia with atypia in a BRCA1-positive patient was GLUT1 negative. Twenty-three (79.3%) of 29 tubal carcinomas were positively stained. Staining ranged from focal/scattered foci (n = 15) to multifocal/extensive (n = 8). Of the 6 nonstaining tubal carcinomas, 3 were undifferentiated. Nineteen tubal carcinoma sections showed residual benign epithelium, which was consistently nonstaining. Very frequently, GLUT1 staining intensified in cells furthest from stroma/ stromal capillaries and/or bordering necrotic zones. On average, GLUT1 staining in primary fallopian tube cancers was less extensive than in primary ovarian adenocarcinomas. GLUT1 immunostaining of fallopian tube adenocarcinomas was substantially stronger and more extensive than staining of benign tubal epithelium, consistent with previously described findings in carcinomas versus benign tissues from many primary sites. The frequent localization of GLUT1 positivity to regions most distal from stroma/stromal capillaries is consistent with known activation of GLUT1 expression by hypoxia-sensing cellular pathways and may constitute a survival advantage under hypoxic conditions present in malignancy. The difference in extent of GLUT1 staining between primary tubal and primary ovarian serous adenocarcinomas is discussed.

DIVERTICULITIS WITH ADNEXAL INVOLVEMENT

Diverticulitis involving the adnexa is a rare occurrence with only sporadic case reports in the literature. We discuss two cases of diverticulitis and associated adnexal infection or abscess seen at our institution in one year. Clinical data are summarized in Table 1.Table 1Although the sigmoid and left adnexa are in proximity to each other, they are not contiguous, and adnexal involvement is an unusual complication of diverticulitis, occurring perhaps via the broad ligament. Adnexal involvement is usually manifest by tubo-ovarian abscess or colosalpingal fistulization. One of our patients had acute and chronic salpingitis, and both had ovarian involvement in the form of abscess or inflammation. Symptoms were nonspecific in one case and “classic” for diverticulitis in the other. Physical examination and laboratory data suggested diverticulitis, whereas CT scanning revealed not only diverticulitis but also adnexal involvement. While rare, this complication of diverticulitis should be diagnosed rapidly, particularly in premenopausal women whose fertility may be adversely affected if adnexal involvement were to be unrecognized and untreated.

The role of parasites and fungi in secondary infertility

Parasite-host relationships can cause diminished or absent ability to conceive, ectopic pregnancy or pregnancy with undesired course. There are reports that some protozoa, helminths and fungi may impair women's reproductive capacity, causing deformities of genital tract, so that conception is impossible, or, if it does occur, normal implantation and development of placenta are impossible. Schistosoma haematobium may cause vulvar papule, swelling, tumors, irregular vaginal hemorrhage, tubular infertility and ectopic pregnancies. Patients with cirrhosis caused by schistosomas have gonadal dysfunction and schistosomiasis itself can lead to tubular infertility. Some authors found microfilaria of Mansonella perstans in follicular aspirates in patients with tubular adhesions. Chronic Entamoeba histolytica infection can cause pelvic pain and dyspareunia in some patients. Although Trichomonas vaginalis is a common cause of tubal inflammation, this protozoa affects semen quality and leads to secondary infertility. Soluble parasite extract of T. vaginalis can lead to impaired motility of 50% spermatozoa in vitro and affects semen quality by increased viscosity and amount of debris, or damage spermatozoid membrane. In enterobiosis, presence of adult worms and eggs in fallopian tube, can be followed by chronic salpingitis and tubal occlusion. Also in ascariosis, presence of adult forms and eggs can lead to acute colpitis. chronic endometritis, salpingitis or ovarian abscess. The consequence of fungal infections, such as colpitis and endometritis, caused by Candida albicans, may be infertility. Also, according to some reports, C. albicans leads to decreased spermatozoan motility. Hence parasites and fungi can cause infertility, we recommend examination of both partners in treatment of infertility.

Extrauterine Lesions of Intermediate Trophoblast

Lesions of intermediate trophoblast arising in the uterus include exaggerated placental site, placental site nodule, placental site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor. Only 12 examples of extrauterine lesions of intermediate trophoblast (ELIT) have been previously reported; 7 new cases are described herein. Six lesions were located in the fallopian tube or paratubal region and one in the ovary. The patients were 25 to 47 (average 36) years of age. The lesions ranged from 0.6 to 4 cm in diameter; four were cystic. The four placental site nodules (three tubal, one paratubal) were composed of small, sharply circumscribed nodules of intermediate trophoblast with no mitotic activity. The three PSTTs (two tubal, one ovarian) exhibited irregular stromal infiltration by intermediate trophoblast, mitotic activity, and necrosis. Chronic salpingitis was seen in the six tubal/paratubal cases, and endometriosis was seen in four cases. Immunoreactivity for human placental lactogen, human chorionic gonadotropin, and cytokeratin in two cases was consistent with an origin from intermediate trophoblast. ELITs presumably arise from previous ectopic pregnancies, a history of which was present in two of these patients. Follow-up, available on two of the three patients with PSTT, was uneventful at 6 and 12 years, but study of additional cases is necessary to reliably determine the behavior of extrauterine PSTTs.

Clues to the pathogenesis of fallopian tube carcinoma: a morphological and immunohistochemical case control study.

The purpose of this study was to identify histopathological fallopian tube changes that might be related to the development of fallopian tube carcinoma (FTCA). Each of 14 unilateral cases of the latter was matched with 2 controls for age, hospital, and year of diagnosis. The uninvolved fallopian tube from patients with FTCA, all of which were of serous type, was compared to fallopian tubes from the same side in 28 matched controls. The features evaluated included plical bridging, trapped gland-like structures, inflammation, epithelial stratification, tufting, nuclear atypia, plical atrophy, luminal dilatation, and presence or absence of in situ carcinoma. The significant changes (p < 0.05) in the contralateral tubes of patients with FTCA were luminal dilatation (p = 0.0004), plical atrophy (p = 0.0015), and chronic inflammation (p = 0.0089). FTCA may therefore develop in tubes demonstrating histologic features of chronic healed salpingitis, findings that reflect bilateral tubal disease which apparently antedates the development of the FTCA. p53 stains were strongly positive in 9 of 14 FTCAs and in 5 of 6 foci of in situ carcinoma found in the tubes with unilateral FTCA. No p53 staining was found in any of the contralateral tubes. Serous FTCAs may be etiologically related to antecedent bilateral healed chronic salpingitis and arise from in situ carcinoma in a background of atrophy.

Detection of chlamydia trachomatis DNA in archival paraffinized specimens from chronic salpingitis cases using the polymerase chain reaction

Objective: To identify Chlamydia trachomatis by the polymerase chain reaction (PCR) in fallopian tube tissues with chronic salpingitis. Design: Retrospective case-control study. Setting: Academic tertiary institution. Patient(s): Women with a pathological diagnosis of chronic salpingitis or normal fallopian tube hospitalized between September 1992 and November 1994. Initial identification of 248 specimens with final analysis of 154. Intervention(s): Paraffin-embedded fallopian tube tissues were analyzed with use of PCR to detect C. trachomatis. Main Outcome Measure(s): Identification of C. trachomatis DNA; demographics of age, ethnicity, parity, history of sexually transmitted disease, and surgical procedure. Result(s): C. trachomatis DNA was detected in 9 of 77 chronic salpingitis cases. Seventy-seven controls were negative for C. trachomatis. No statistically significant difference in age or ethnicity between cases and controls was identified. Nulliparity was more frequent in cases (26 of 74) than controls (14 of 76). Sexually transmitted disease history was more prevalent in cases (24 of 74) than controls (6 of 76). Chlamydia infection was not associated with a particular surgical indication. Conclusion(s): Chronic salpingitis is highly associated with the presence of C. trachomatis infection as detected by PCR.

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.

Study of tubal dysfunction by chronic salpingitis with chlamydia trachomatis

International Journal of Gynecology & ObstetricsVolume 70, Issue S2 p. B134-B134 Infections in obstetrics and gynecology Study of tubal dysfunction by chronic salpingitis with chlamydia trachomatis Y. Noguchi, Y. NoguchiSearch for more papers by this authorK. Nakabe, K. NakabeSearch for more papers by this authorE. Sato, E. SatoSearch for more papers by this authorM. Fujita, M. FujitaSearch for more papers by this authorM. Noguchi, M. NoguchiSearch for more papers by this authorM. Nakanishi, M. NakanishiSearch for more papers by this author Y. Noguchi, Y. NoguchiSearch for more papers by this authorK. Nakabe, K. NakabeSearch for more papers by this authorE. Sato, E. SatoSearch for more papers by this authorM. Fujita, M. FujitaSearch for more papers by this authorM. Noguchi, M. NoguchiSearch for more papers by this authorM. Nakanishi, M. NakanishiSearch for more papers by this author First published: 10 December 2003 https://doi.org/10.1016/S0020-7292(00)83136-7Citations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume70, IssueS22000Pages B134-B134 RelatedInformation

The Case of a Stewardess Suffering from Salpingitis Caused by Stress on Aerial Service Who was Effectively Treated with Psychosomatic Therapy Including Counseling and Medication

A strong association exists between work on board aircraft over a long period and stress in aerial service. There have been a lot of reports on the stress, concerning many complaints of fatigue or fatigue-related symptoms including lower back pain in aircrew, disorders of the menstrual cycle, and psychological performance. On the other hand, there are few clinical studies on results of stress such as salpingitis based on depression in the course of aerial stress. In this report, we discuss a case of chronic salpingitis caused by stress due to aerial service from the viewpoint of occupational health and psychosomatic medicine.

Presence of the major outer-membrane protein of Chlamydia trachomatis in patients with chronic salpingitis and salpingitis isthmica nodosa with tubal occlusion

Objective: To determine the presence of the major outer-membrane protein of Chlamydia trachomatis in fallopian tube tissue specimens of infertile women with chronic salpingitis and/or salpingitis isthmica nodosa with tubal occlusion. Design: Prospective controlled study. Setting: Department of Obstetrics and Gynecology, University of Bochum, Herne, Germany. Patient(s): Fifty-six consecutive infertile women with histologically documented chronic salpingitis and/or salpingitis isthmica nodosa and bilateral tubal occlusions were evaluated. They were compared with 28 fertile women. Intervention(s): Fallopian tube tissue specimens were taken during reconstructive infertility surgery, including cesarean section and tubal ligation. Main Outcome Measure(s): Detection of the major outer-membrane protein of C. trachomatis in fallopian tube tissue specimens by a direct fluorescent antibody test. Result(s): The major outer-membrane protein of C. trachomatis was found in fallopian tube tissue specimens in 11 of 56 infertile patients (20%) with chronic salpingitis and/or salpingitis isthmica nodosa. The median titer of IgG serum antibodies to Chlamydia was significantly higher in women with the major outer-membrane protein of C. trachomatis than in patients without this antigen. In comparison, the major outer-membrane protein of C. trachomatis was not found in any of the fallopian tube tissue specimens of the control group. Conclusion(s): The presence of the major outer-membrane protein of C. trachomatis is associated with chronic salpingitis and/or salpingitis isthmica nodosa with tubal occlusion.

Transvaginal sonographic markers of tubal inflammatory disease.

Since the introduction of transvaginal sonography (TVS), clear pictures of the female reproductive tract have been obtained. These images enable the accurate description of Fallopian tube pathology. However, the current literature on the ultrasound diagnosis of pelvic inflammatory disease (PID) is confusing and contradictory. The goal of our study was to identify sonographic markers of inflammatory disease of the pelvis and to place these in a clinical context. Seventy-seven patients were scanned by TVS. They were divided into two groups, according to their clinical picture, the first group with acute PID and the second with a history of chronic PID or no history at all. The sonographic markers studied were shape, wall structure and wall thickness of the Fallopian tube. Ovarian involvement and the presence of pelvic fluid were also evaluated. The best marker of tubal inflammatory disease, either acute or chronic, was the presence of an incomplete septum of the tubal wall, which was present in 92% of the total cases. A thick wall and the 'cogwheel' sign were sensitive markers of acute disease, whereas a thin wall and 'beads-on-a-string' sign were indicators of chronic disease. Palpable findings and surgical history were not discriminatory, but were present in three-quarters and one-third of the study population, respectively. Three false-positive cases are presented: an ovarian cystadenoma, an appendiceal mucocele and one case with periovarian fluid accumulation. The tubo-ovarian complex and the tubo-ovarian abscess should be considered separate entities that differ in their clinical implications. TVS allows one to distinguish between them. Distinguishing characteristics of acute and chronic salpingitis are presented.

Humoral immune response to the chlamydial heat shock proteins hsp60 and hsp70 in Chlamydia-associated chronic salpingitis with tubal occlusion.

The aim of this study was to evaluate the prevalence of serum immunoglobulin (Ig)G and IgA antibodies to recombinant chlamydial 60 kDa heat shock protein (C-hsp60) and to assess the prevalence of serum IgG antibodies to recombinant chlamydial 70 kDa heat shock protein (C-hsp70) in Chlamydia-associated chronic salpingitis and/or salpingitis isthmica nodosa with tubal occlusion. Infertile patients (n =34) with Chlamydia-associated, histologically documented chronic salpingitis and/or salpingitis isthmica nodosa and bilateral tubal occlusions (group I) were compared with infertile patients (n = 19) without tubal occlusions (group II). The prevalence of chlamydial antigen in endocervical, urethral and urine samples was low in both groups. The median chlamydial serum IgG and IgA antibody titres were significantly higher in group I than in group II (P < 0.0001 and P = 0.0002 respectively). Serum IgG antibodies to C-hsp60 and C-hsp70 were detected in 24 out of 34 patients (71%) in group I compared with 10 out of 19 (53%) and nine out of 19 (47%) patients in group II (not significantly different). There was a significant difference (P = 0.035) between the prevalences of serum IgA antibodies to C-hsp60 in groups I (seven out of 34 patients; 21%) and II (none of the 19 patients). The association between the presence of serum IgA antibodies to C-hsp60 and Chlamydia-associated chronic salpingitis and/or salpingitis isthmica nodosa with tubal occlusion underlies the significance of chlamydial 60 kDa heat shock protein in the pathogenesis of tubal infertility.

The immunobiology and immunopathology of chlamydial infections.

Chlamydiae are obligate intracellular bacterial pathogens of eukaryotic cells responsible for a wide variety of important human and animal infections. In humans, chlamydial infections are generally localised to superficial epithelial or mucosal surfaces, are frequently asymptomatic and may persist for long periods of time if untreated, inducing little protective immunity. Nevertheless, neutralising antibodies of limited efficacy are produced against the main chlamydial outer envelope protein, while gamma interferon (IFN gamma) is chlamydiastatic and paradoxically may play a role both in chlamydial persistence and in protective immunity. Delayed hypersensitivity responses to chlamydiae caused by repeated or persistent infection are thought to be important in the development of the severe scarring sequelae characteristic of cicatricial trachoma and of chronic salpingitis. Chlamydial heat shock proteins bearing close homology with their human equivalents may be major targets for immunopathological responses and their expression is upregulated in IFN gamma induced persistent infection. C. pneumoniae, a common cause of acute respiratory infection in humans, may persist in coronary arteries and is strongly implicated as a risk factor in atherosclerosis and in acute myocardial infarction. This paper reviews the immunology and immunopathology of chlamydial infections in the context of the unique biology of this fascinating but challenging group of organisms.

Selective tubal sterilization in rabbits: experience with a hydrogel combined with a sclerosing agent.

To test a method of nonsurgical sterilization. A hydrogel that forms an in situ plug by phase inversion of a polymer solution was placed into fallopian tubes of eight rabbits by means of transvaginal rabbits by means of transvaginal fluoroscopic fallopian tube catheterization. The rabbits were bred, and the presence of embryos was confirmed with palpation and at autopsy. Seven of the eight rabbits became pregnant. Six of these rabbits contained embryos in the control uterus but not in the uterus on the side of the hydrogel injection. The seventh rabbit had embryos in both uteri, but the hydrogel had been expelled. All seven tubes that contained hydrogel showed evidence of acute and chronic salpingitis and a foreign-body reaction. The tube from which hydrogel had been expelled and the eight control tubes were not inflamed. Transcervical catheter methods of tubal occlusion and sterilization are promising, but a non-reactive material is needed.

Tubal histopathology in ectopic pregnancies

A histopathologic study in eighty six patients with ectopic pregnancy and in eighty six control patients was undertaken to evaluate the association between ectopic pregnancy and tubal pathology in our population. Fifty six (65%) and nine (10.4%) cases with chronic salpingitis (CS) were diagnosed in the study group and in the control group, respectively. This difference was statistically significant (p < 0.001). Twelve of 56 cases with chronic salpingitis were salpingitis isthmica nodosa (SIN) and no patient with SIN was observed in the control group. SIN was always concomittant with chronic salpingitis in our study. Based on these findings, we concluded that chronic salpingitis and SIN have an important role in the etiology of ectopic pregnancy in our population and SIN is significantly associated with chronic salpingitis.