The year 2013 marked the 40th anniversary of the formal establishment of  Maternal-fetal medicine  (MFM) as a specialty, as 16 pioneers took the MFM boards for the first time in 1973. Amongst that group of pioneers was Dr. Edward J. Quilligan, who has gone on to dedicate decades of service to the advancement of women's health, through teaching, research, and leadership. To honour his legacy and his exemplary service to modern  Obstetrics , the  Society for Maternal-Fetal Medicine  and The Pregnancy Foundation created the Quilligan Scholars program, and the first class of five recipients was inaugurated in 2014 at the  Society for Maternal-Fetal Medicine  annual meeting in  New Orleans , Louisiana. [ 3 ]  Though the Quilligan Scholar title confers no monetary reward, the sponsored activities are covered by gracious donations from members of the medical community. The Society for Maternal-Fetal Medicine has agreed to give matching funds to the amount raised by The Pregnancy Foundation up to $125,000 per year for three years. [ 4 ]


The Quilligan Scholar title is traditionally granted to five recipients every year.


The 2014 recipients are: [ 5 ]


The 2015 recipients are: [ 5 ]


The  Ramesseum medical papyri  constitute a collection of  ancient Egyptian   medical documents  dating back to the early 18th century BC, found in the temple of the  Ramesseum . [ 1 ]   As with most ancient Egyptian medical papyri, these documents mainly dealt with ailments, diseases, the structure of the body, and proposed remedies used to heal these afflictions, [ 1 ]  namely  ophthalmologic  ailments,  gynaecology ,  muscles ,  tendons , and diseases of children. [ 2 ]   It is the only well-known papyrus to describe these in great detail. [ 1 ]   Most of the text written in the known manuscripts of this collection are in parts III, IV, and V, and written in vertical columns. [ 1 ]


Papyrus IV deals with issues similar to the  Kahun Gynecological Papyrus , such as  labor , the protection of the  newborn , ways to predict the likelihood of its survival, and ways to predict which  gender  the newborn will be. It also contains a  contraception  formula. [ 3 ]


Papyrus V contains numerous prescriptions dealing with the  relaxation  of  limbs , written in  hieroglyphic  script, rather than  hieratic  script as other medical papyri were. [ 3 ]


This article about a  papyrus  or  papyrology  is a  stub . You can help Wikipedia by  expanding it .


This  history of medicine  article is a  stub . You can help Wikipedia by  expanding it .


Reproductive medicine  is a branch of  medicine  concerning the male and female  reproductive systems . It encompasses a variety of reproductive conditions, their prevention and assessment, as well as their subsequent treatment and prognosis.


Reproductive medicine has allowed the development of  artificial reproductive techniques  (ARTs) which have allowed advances in overcoming human  infertility , as well as being used in  agriculture  and in  wildlife conservation . Some examples of ARTs include  IVF ,  artificial insemination  (AI) and  embryo transfer , as well as  genome resource banking .


The study of reproductive medicine is thought to date back to  Aristotle , where he came up with the “ Haematogenous Reproduction Theory ”. [ 1 ]  However, evidence-based reproductive medicine is traceable back to the 1970s. [ 2 ]  Since then, there have been many milestones for reproductive medicine, including the birth of  Louise Brown , the first baby to be conceived through IVF in 1978. [ 3 ]  Despite this, it was not until 1989 that it became a clinical discipline thanks to the work of  Iain Chalmers  in developing the  systematic review  and the  Cochrane  collection. [ 2 ]


Reproductive medicine addresses issues of  sexual education ,  puberty ,  family planning ,  birth control ,  infertility ,  reproductive system disease  (including  sexually transmitted infections ) and  sexual dysfunction . [ 4 ]  In women, reproductive medicine also covers  menstruation ,  ovulation ,  pregnancy  and  menopause , as well as gynecologic disorders that affect fertility. [ 5 ]


The field cooperates with and overlaps mainly with  reproductive endocrinology and infertility ,  sexual medicine  and  andrology , but also to some degree with  gynecology ,  obstetrics ,  urology ,  genitourinary medicine , medical  endocrinology ,  pediatric endocrinology ,  genetics , and  psychiatry .


Reproductive medicine deals with prevention, diagnosis and management of the following conditions. This section will give examples of a number of common conditions affecting the human reproductive system.


Reproductive tract infections  (RTIs) are infections that affect the  reproductive tract . There are three types of RTIs:  endogenous RTIs ,  iatrogenic RTIs  and  sexually transmitted infections . [ 6 ]   Endogenous RTIs are caused by an overgrowth of bacteria which is normally present. An example of an endogenous RTI is  bacterial vaginosis .


Iatrogenic RTIs are infections contracted as a result of a medical procedure.


Sexually transmitted infections (STIs) are infections spread by sexual activity, usually by  vaginal intercourse ,  anal sex ,  oral sex , and rarely  manual sex . Many STIs are curable; however, some STIs such as  HIV  are incurable. STIs can be  bacterial ,  viral  or  fungal  and affect both men and women. Some examples of STIs are listed below: [ 7 ]


Many parts of the Reproductive system can be affected by  cancer . Below are some examples of Reproductive cancers:


A significant part of reproductive medicine involves promoting fertility in both men and women.


Assessment and treatment of reproductive conditions is a key area of reproductive medicine.


Female assessment starts with a full  medical history  (anamnesis) which provides details of the woman's general health, sexual history and relevant family history. [ 12 ]   A physical examination will also take place to identify abnormalities such as  hirsutism ,  abdominal masses ,  infection ,  cysts  or  fibroids . A  blood test  can inform the clinician of the endocrine status of the patient.  Progesterone  levels are measured to check for  ovulation , and other ovulatory hormones can also be measured. Imaging techniques such as  pelvic ultrasounds  can also be used to assess the internal anatomy. [ 13 ]


Male assessment also starts with a history and physical examination to look for any visible abnormalities. Investigations of  semen  samples also take place to assess the volume, motility and number of  sperm , as well as identifying infections. [ 14 ]


Once the investigations are complete, treatment of identified conditions can occur. For fertility issues, this may involve  assisted reproductive technology  (ART) such as  in-vitro fertilisation  (IVF) or  fertility medication . There are surgical methods that can be used as treatment however these are now performed less frequently due to the increasing success of the less invasive techniques. [ 13 ]  Treatment is also required for sexually transmitted infections (STIs). These can take the form of  antibiotics  for bacterial infections such as  chlamydia [ 15 ]  or  highly active anti-retroviral therapy  (HAART) for the  HIV virus . [ 16 ]


Before starting a career in reproductive medicine, individuals must first obtain an undergraduate degree. The next step is medical school, where they earn a  Doctor of Medicine  (MD) or  Doctor of Osteopathic Medicine  (DO) degree. Specialists in reproductive medicine usually undergo  medical residency  training in  obstetrics and gynecology  followed by  medical fellowship  training in  reproductive endocrinology and infertility . An alternative path to practicing reproductive medicine after medical school involves a medical residency in urology, followed by a medical fellowship in male infertility. The education and training required to practice reproductive medicine is typically 15-16 years in duration. [ 17 ] [ 18 ] [ 19 ]  After completing medical fellowship, physicians can obtain board certification and must maintain  continuing medical education  (CME). [ 20 ]  CME is necessary in reproductive medicine as advancements in technology and treatment options require ongoing learning and skill development.


For reproductive medicine specialists in contraception, other methods of training are possible. Specialists tend to be organized in specialty organizations such as the  American Society for Reproductive Medicine  (ASRM) and  European Society of Human Reproduction and Embryology  (ESHRE).


The  anamnesis  or medical history taking of issues related to reproductive or  sexual medicine  may be inhibited by a person's reluctance to disclose intimate or uncomfortable information. Even if such an issue is on the person's mind, they often do not start talking about such an issue without the physician initiating the subject by a specific question about sexual or  reproductive health . [ 21 ]  Some familiarity with the doctor generally makes it easier for person to talk about intimate issues such as sexual subjects, but for some people, a very high degree of familiarity may make the person reluctant to reveal such intimate issues. [ 21 ]  When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level. [ 21 ]


There are many ethical and legal issues surrounding reproductive medicine. In the UK the  Human Fertilisation and Embryology Authority  (HEFA) regulates many aspects of reproductive medicine in the UK, including  IVF ,  Artificial Insemination , storage of reproductive tissue and research in this field. HEFA was established due to the  Human Fertilisation and Embryology Act  (1990). This act was reviewed and the  Human Fertilisation and Embryology Act  (2008) was passed through parliament as an update to the 1990 act.


For therapies such as IVF, many countries have strict guidelines. In the UK, referrals are only given to women under 40 who have either undergone 12 cycles of artificial insemination, or have tried and failed to conceive for 2 years. [ 22 ]  While NICE recommends NHS  clinical commissioning groups  (CCGs) to provide 3 NHS funded cycles of IVF, many only offer 1 cycle, with some only offering IVF in exceptional circumstances on the NHS. If an individual does not meet the criteria or has gone through the maximum number of NHS-funded cycles, the individual will have to pay for private treatment [ 23 ]


Many reproductive technologies are seen to have ethical problems, including IVF,  mitochondrial replacement therapy ,  germline modification ,  preimplantation genetic diagnosis .


There are many groups around the world which oppose to ARTs, including  religious groups  and pro-life charities such as LIFE.


Sigmoidocele  (also known as  pouch of Douglas  descent) is a medical condition in which a  herniation  of  peritoneum  containing loops of redundant  sigmoid colon  descends (prolapses) into the  rectouterine pouch  (in females), between the  rectum  and the  vagina . [ 1 ] [ 2 ]  This can obstruct the rectum and cause  obstructed defecation syndrome . [ 3 ]


Sigmoidocele may be internal if it is only detectable on  defecography , or external if it detectable without imaging and associated with a  rectocele  or  rectal prolapse . [ 2 ]  It is a type of posterior compartment prolapse. [ 4 ]


Sigmoidocele may be classified according to size relative to the pubococcygeal line. [ 2 ] [ note 1 ]


The severity of sigmoidocele can be described with reference to the position of the lowest loop of the sigmoid relative to lines drawn on defecography:


Sigmoidocele may not cause any symptoms. [ 5 ]


The phenomenon is caused by a weak section of   fascial supports  of the vagina (the uterosacral cardinal ligament complex and rectal vaginal septum), which allows a section of peritoneum containing the sigmoid colon to prolapse out of normal position and descend between the rectum and the vagina. [ 1 ]


The  mesentery  of the sigmoid colon (the structure which attaches the colon to the abdominal wall) is termed the mesosigmoid. This structure is very flexible, which means that the sigmoid colon is very mobile and may change position. During defecation it may be pushed down, eventually causing sigmoidocele. [ 7 ]


Sigmoidocele may be associated with  descending perineum syndrome . [ 8 ]


It is not possible to differentiate between a  rectocele  and a sigmoidocele on  vaginal examination .   Defecating proctography  will demonstrate a sigmoidocele during straining. [ 1 ]


Surgery is considered if there is a significant hernia combined with symptoms of obstructed defecation. [ 9 ]


Laparoscopic  ventral mesh rectopexy  has been used to correct sigmoidocele. [ 7 ]  This procedure involves inserting a mesh between the rectum and the vagina. The mesh is suspended from the sacral promontory without tension. This acts to support the recto-vaginal septum and elevate a deep pouch of Douglas. [ 7 ]  If there is prolapse of the middle compartment,  sacrocolpopexy  may be carried out to surgically correct all pelvic prolapse problems in the same procedure. [ 9 ]


Other treatment options are  anterior resection , [ 4 ]   sigmoidopexy  with rectocele repair, [ 4 ]  or  sigmoidectomy . [ 1 ]


Sigmoidocele normally occurs in females, and is uncommon. [ 1 ]  Sigmoidocele is detected about 4-5% of the time when defecography is carried out. [ 3 ] [ 1 ]


In  gynaecology ,  Sims' vaginal speculum  is a double-bladed  surgical instrument  used for examining the  vagina  and  cervix . It was developed by  J. Marion Sims  out of pewter spoon, [ 1 ]  but nowadays it is manufactured out of stainless steel or plastic. The plastic speculum is disposable, but the stainless steel one is not. Therefore, the stainless steel speculum should be  sterilized  before each use. Sims' speculum is inserted into the vagina to retract posterior vaginal wall. It gives more exposure of the vaginal walls than  Cusco's Speculum  and therefore is preferred for gynaecological surgeries. It is possible to slide the instrument around the vaginal wall to enable better visualization. The groove in the middle of Sims' speculum allows free flow of secretions and blood to the outside, thereby keeping the area dry. Sims' speculum is available in various sizes, and the size appropriate to the vaginal dimensions of the woman is chosen for use. The disadvantage of Sims' speculum is that it is not self-retaining. The examiner might want to use an anterior wall retractor in addition to Sims' speculum for better visualization of the cervix. [ 2 ]


There is a petition campaign to have Sims' name removed from the devices he invented: "Sims uterine curette, uterine sound, vaginal retractor, uterine scissors, and rectal speculum." New names would be chosen by "a committee of POC (People of Color)." [ 3 ]


Sonosalpingography  ( SSG ), also known as  Sion test , is a diagnostic procedure primarily used for evaluating patency of  fallopian tubes . [ 1 ] [ 2 ]   It was introduced as a screening procedure for  infertility  investigations. [ 3 ]  It is becoming more popular among practitioners due to absence of side effects. [ 2 ]


Under  ultrasound  scanning, a slow and deliberate injection of about 200 ml  physiologic saline  into the uterine cavity is accomplished via  Foley catheter . An inflated bulb of the catheter prevents leakage of fluid outside uterine cavity. By visualizing the flow of saline along the tube and observing it as a shower at  fimbrial  end,  tubal patency  can be tested. Presence of free fluid in  pouch of Douglas  also confirms tubal patency.


The term 'Sion test' was popularized by Gautam Allahbadia after the popular government hospital in Sion,  Lokmanya Tilak Municipal General Hospital , locally known as 'Sion hospital', [ 2 ] [ 4 ]  where he invented the test.


A  speculum  (Latin for 'mirror';  pl. :  specula  or  speculums ) is a medical tool for investigating  body orifices , with a form dependent on the orifice for which it is designed.  In old texts, the speculum may also be referred to as a  diopter  or  dioptra . [ 1 ]  Like an  endoscope , a speculum allows a view inside the body; endoscopes, however, tend to have  optics  while a speculum is intended for direct vision.


Vaginal and anal specula were used by the  ancient Greeks  and  Romans , [ 2 ] [ 3 ]  and speculum  artifacts  have been found in  Pompeii . [ 4 ] [ 5 ]  The modern  vaginal  speculum, developed by  J. Marion Sims , consists of a hollow cylinder with a rounded end that is divided into two hinged parts, somewhat like the  beak  of a  duck . This speculum is inserted into the vagina to dilate it for examination of the vagina and  cervix .


The modern vaginal speculum was developed by  J. Marion Sims , a plantation doctor in Lancaster County, United States. Between 1845 and 1849, Sims performed dozens of surgeries, without anesthesia, on at least 12 enslaved women. In these experiments, Sims developed a technique to repair fistula and in the process invented the duckbill speculum. These experiments, and the development of the modern specula, led some to regard Sims as the "father of modern gynaecology." [ 6 ]


By the 1860s, specula were integrated into criminal justice practices in the UK. In Great Britain, examinations of the cervix were made mandatory for all women convicted of prostitution by the country's Contagious Disease Act. [ 7 ]
In the 19th century, the vaginal speculum became a cultural symbol of the tenuous relationship between women and their physicians. Use of the speculum was generally avoided in medical practices, and most vaginal conditions were diagnosed through symptoms or palpating the abdomen. Many practitioners had moral concerns about the use of the speculum, and preferred to diagnose through palpating the abdomen. As late as 1910, physicians believed the vaginal speculum to be inferior to the "educated touch." [ 8 ]


These concerns continued into the early 20th century as the speculum became  commonplace in gynecology practices. Often, nurses played a major role in ensuring the proper use of the speculum during medical exams. [ 8 ]  The 1946 and 1956 editions of a multi-volume gynecology text for nurses required that nurses remain present during examination to protect both the patient and physician from "blackmail by designing persons." [ 9 ]


As of 2015 [update] , 85% of gynecologists are women. [ 10 ]  As a result of this demographic shift, the procedures around speculum use have also changed.


Specula have been made of glass or metal. They were generally made of  stainless steel  and sterilized between uses, but particularly in the 21st century, many — especially those used in emergency departments and doctor's offices — are made of plastic, and are disposable,  single-use  items.  Those used in surgical suites are still commonly made of stainless steel.


Specula come in a variety of shapes based on their purpose, and a variety of sizes; [ 11 ]  in any case the cylinder or bill(s) of the instrument allow the operator a direct vision of the area of interest and the possibility to introduce instruments for further interventions such as a biopsy.


The most common specula used in gynecologic practice are varying sizes of bivalved vaginal speculum; the two bills are hinged and are "closed" when the speculum is inserted to facilitate its entry and "opened" in its final position where they can be arrested by a screw mechanism, so that the operator is freed from keeping the bills apart. [ 12 ]


A cylindrical-shaped speculum, introduced in 2001, the dilating vaginal speculum (also known as the Veda-scope [ 13 ] ) invented by Clemens van der Weegen, [ 14 ]  inflates the vagina with filtered air. [ 15 ]  (see diagram) The device has two main functions: a) to take a normal Pap smear with a cervical brush or a cytology brush; and b) as an internal  colposcope  so that the operator can pivot the Veda-scope to view any part of the vagina barrel and cervix facilitated by an internal light source that can illuminate the vaginal wall and cervix with multi-coloured light filters, which can detect pre-cancerous cells with the aid of  acetic acid  solution and  iodine  solution. It also has a facility to attach a digital camera for viewing and recording. [ 16 ]


A specialized form of vaginal speculum is the weighted speculum, which consists of a broad half tube which is bent at about a 90-degree angle, with the channel of the tube on the exterior side of the angle. One end of the tube has a roughly spherical metal weight surrounding the channel of the speculum. A weighted speculum is placed in the vagina during vaginal  surgery  with the patient in the  lithotomy position . The weight holds the speculum in place and frees the surgeon's hands for other tasks.
A vaginal speculum is also used in fertility treatments, particularly artificial insemination, and allows the vaginal cavity to be opened and observed thereby facilitating the deposit of semen into the vagina.


Vaginal specula are also used for  anal  surgery, although several other forms of anal specula exist.  One form, the  anoscope , resembles a tube that has a removable  bullet -shaped insert.  When the anoscope is inserted into the anus, the insert dilates the anus to the diameter of the tube.  The insert is then removed, leaving the tube to allow examination of the lower rectum and anus.


This style of anal speculum is one of the oldest designs for surgical instruments still in use, with examples dating back many centuries. The  sigmoidoscope  can be further advanced into the lower intestinal tract and requires an endoscopic set-up.


Nasal  specula have two relatively flat bills with handle.  The instrument is hinged so that when the handles are squeezed together the bills spread laterally, allowing examination.


Additionally, the  Thudichum  nasal speculum is commonly used in the outpatient examination of the nose.


Ear  or aural specula resemble a  funnel , and come in a variety of sizes.


For ophthalmic surgery such as  cataract surgery , a speculum designed to retract the eyelids is used.


In veterinary medicine, a McPherson Speculum can be used for oral examination. The speculum helps keep the mouth open during the exam and helps avoid biting injuries.


Specula are used  for sexual pleasure , both vaginally and anally. [ 17 ]


Spinnbarkeit  (English:  spinnability ), also known as  fibrosity , is a biomedical  rheology  term which refers to the stringy or stretchy property found to varying degrees in  mucus ,  saliva ,  albumen  and similar  viscoelastic  fluids. The term is used especially with reference to  cervical mucus  at the time just prior to or during  ovulation . [ 1 ]


Under the influence of  estrogens , cervical mucus becomes abundant, clear, and stretchable, and somewhat like egg white. The stretchability of the mucus is described by its spinnbarkeit, from the  German  word for the  ability to be spun . Only such mucus appears to be able to be penetrated by  sperm . After ovulation, the character of cervical mucus changes, and under the influence of  progesterone  it becomes thick, scant, and tacky. Sperm typically cannot penetrate it.  [ citation needed ]


Saliva  does not always exhibit spinnbarkeit, but it can under certain circumstances. The thickness and spinnbarkeit of nasal mucus are factors in whether or not the nose seems to be blocked.


Mucociliary transport  depends on the interaction of fibrous mucus with beating cilia. [ 2 ]


This  women's health  related article is a  stub . You can help Wikipedia by  expanding it .


Spontaneous conception  is the  conception  and birth of a child naturally, without the use of  in vitro fertilisation  or other forms of  assisted reproductive technology .  There is an overall 18% chance of spontaneous conception after an in vitro fertilization (IVF) treatment, but that chance rose to 37% among younger women (less than 27 years). The likelihood also depends on the  sperm  performance of the man and the egg count of the woman. [ 1 ]


Tannerella forsythia  is an  anaerobic ,  Gram-negative  bacterial species of the  Bacteroidota  phylum. It has been implicated in  periodontal diseases  and is a member of the  red complex  of  periodontal pathogens . [ 1 ]   T. forsythia  was previously named  Bacteroides forsythus  and  Tannerella forsythensis . [ 2 ] [ 3 ] [ 4 ] [ 5 ]


Tannerella forsythia  was discovered by and named after Anne Tanner, who works at  The Forsyth Institute  located in Cambridge, Massachusetts. [ 6 ]


T. forsythia  has been identified in atherosclerotic lesions. Lee et al. found that infecting mice with  T. forsythia  induced foam cell formation and accelerated the formation of atherosclerotic lesions. [ 7 ]   It has also been isolated from women with  bacterial vaginosis . [ 8 ]   The presence of oral  T. forsythia  has been found to be associated with an increased risk of esophageal cancer. [ 9 ]


In the  Trendelenburg position , the body is  lain supine, or flat on the back  on a 15–30 degree incline with the feet elevated above the head. [ 1 ]  The  reverse Trendelenburg position,  similarly, places the body supine on an incline but with the head now being elevated.


The Trendelenburg position is used in  surgery , especially of the abdomen and  genitourinary system . It allows better access to the pelvic organs as gravity pulls the intra-abdominal organs away from the  pelvis . Evidence does not support its use in  hypovolaemic shock , with concerns for negative effects on the lungs and brain. [ 2 ]


The position was named for the German surgeon  Friedrich Trendelenburg  (1844–1924). [ 3 ]


Most recently, the reverse Trendelenburg position has been used in minimally invasive glaucoma surgery, also known as MIGS. This position is commonly used for a superior sitting surgeon that uses a combination of downward patient tilt, of approximately 30 to 35 degrees, microscope tilt towards themselves at the same angle and an intraoperative  goniolens  or prisms that allows them to visualise the inferior trabecular meshwork. Some joysticking of the globe may be required with an appropriate goniolens to bring the meshwork into view. [ citation needed ]


Trotula  is a name referring to a group of three texts on women's medicine that were composed in the southern Italian port town of  Salerno  in the 12th century. The name derives from a historic female figure,  Trota of Salerno , a  physician  and  medical writer  who was associated with one of the three texts. However, "Trotula" came to be understood as a real person in the Middle Ages and because the so-called  Trotula  texts circulated widely throughout  medieval Europe , from Spain to Poland, and Sicily to Ireland, "Trotula" has historic importance in "her" own right. [ 1 ]


In the 12th century, the southern Italian port town of  Salerno  was widely reputed as "the most important center for the introduction of Arabic medicine into Western Europe". [ 2 ]  In referring to the  School of Salerno  in the 12th century, historians mean a school in the sense of a  school of thought : an informal community of masters and pupils who, over the course of the 12th century, developed more or less formal methods of instruction and investigation; there is no evidence of any physical or legal entity before the 13th century. [ 3 ]


Conditions of Women ,  Treatments for Women , and  Women’s Cosmetics  are usually referred to collectively as  The Trotula . They cover topics from childbirth to cosmetics, relying on varying sources from  Galen  to oral traditions, providing practical instructions. These works vary in both organization and content.  Conditions of Women  and  Women’s Cosmetics   circulated anonymously until they were combined with  Treatments for Women  sometime in the late 12th century. For the next several hundred years, the  Trotula  ensemble circulated throughout Europe, reaching its greatest popularity in the 14th century. More than 130 copies exist today of the Latin texts, and over 60 copies of the many medieval vernacular translations. [ 4 ]


The  Liber de sinthomatibus mulierum  ("Book on the Conditions of Women") was novel in its adoption of the  new Arabic medicine  that had just begun to make inroads into Europe. As Green demonstrated in 1996,  Conditions of Women  draws heavily on the gynecological and obstetrical chapters of the  Viaticum ,  Constantine the African 's Latin translation of Ibn al-Jazzar's Arabic  Zad al-musafir , which had been completed in the late 11th century. [ 5 ]  Arabic medicine was more speculative and philosophical, drawing from the principles of Galen. Galen, as opposed to other notable physicians, believed that menstruation was a necessary and healthy purgation. [ 6 ]  Galen asserted that women are colder than men and unable to “cook” their nutrients; thus they must eliminate excess substance through menstruation. Indeed, the author presents a positive view of the role of menstruation in women's health and fertility: "Menstrual blood is special because it carries in it a living being. It works like a tree. Before bearing fruit, a tree must first bear flowers. Menstrual blood is like the flower: it must emerge before the fruit—the baby—can be born." [ 7 ]  Another condition that the author addresses at length is suffocation of the womb; this results from, among other causes, an excess of female semen (another Galenic idea). Seemingly conflicted between two different theoretical positions—one that suggested it was possible for the womb to "wander" within the body, and another which saw such movement as anatomically impossible—the author seems to admit the possibility that the womb rises to the respiratory organs. [ 8 ]  Other issues discussed at length are treatment for and the proper regimen for a newly born child. There are discussions on topics covering menstrual disorders and uterine prolapse, chapters on childbirth and pregnancy, in addition to many others. [ 9 ]  All the named authorities cited in the  Liber de sinthomatibus mulierum  are male: Hippocrates, Oribasius, Dioscorides, Paulus, and Justinus.


De curis mulierum  ("On Treatments for Women") is the only one of the three  Trotula  texts that is actually attributed to the Salernitan practitioner  Trota of Salerno  when it circulated as an independent text. However, it has been argued that it is perhaps better to refer to Trota as the "authority" who stands behind this text than its actual author. [ 10 ]  The author does not provide theories related to gynecological conditions or their causes, but simply informs the reader how to prepare and apply medical preparations. There is a lack of cohesion, but there are sections related to gynecological, andrological, pediatric, cosmetic, and general medical conditions. Beyond a pronounced focus on treatment for fertility, [ 11 ]  there is a range of pragmatic instructions like how to “restore” virginity, as well as treatments for concerns such as difficulties with bladder control and cracked lips caused by too much kissing. In a work stressing female medical issues, remedies for men's disorders are included as well. [ 12 ]


De ornatu mulierum  ("On Women's Cosmetics") is a treatise that teaches how to conserve and improve women's beauty. It opens with a preface (later omitted from the  Trotula  ensemble) in which the author refers to himself with a masculine pronoun and explains his ambition to earn "a delightful multitude of friends" by assembling this body of learning on care of the hair (including bodily hair), face, lips, teeth, mouth, and (in the original version) the genitalia. As Green has noted, the author likely hoped for a wide audience, for he observed that women beyond the Alps would not have access to the spas that Italian women did and therefore included instructions for an alternative steam bath. [ 13 ]  The author does not claim that the preparations he describes are his own inventions. One therapy that he claims to have personally witnessed, was created by a Sicilian woman, and he added another remedy on the same topic (mouth odor) which he himself endorses. Otherwise, the rest of the text seems to gather together remedies learned from empirical practitioners: he explicitly describes ways that he has incorporated "the rules of women whom I found to be practical in practicing the art of cosmetics." [ 14 ]  But while women may have been his sources, they were not his immediate audience: he presented his highly structured work for the benefit of other male practitioners eager, like himself, to profit from their knowledge of making women beautiful. [ 15 ]


Six times in the original version of the text, the author credits specific practices to Muslim women, whose cosmetic practices are known to have been imitated by Christian women on Sicily. And the text overall presents an image of an international market of spices and aromatics regularly traded in the Islamic world. Frankincense, cloves, cinnamon, nutmeg, and galangal are all used repeatedly. More than the other two texts that would make up the  Trotula  ensemble, the  De ornatu mulierum  seems to capture both the empiricism of local southern Italian culture and the rich material culture made available as the Norman kings of southern Italy embraced Islamic culture on Sicily. [ 16 ]


The  Trotula  texts are considered the "most popular assembly of materials on women's medicine from the late twelfth through the fifteenth centuries." [ 17 ]  The nearly 200 extant manuscripts (Latin and vernacular) of the  Trotula  represent only a small portion of the original number that circulated around Europe from the late 12th century to the end of the 15th century. Certain versions of the  Trotula  enjoyed a pan-European circulation. These works reached their peak popularity in Latin around the turn of the 14th century. The many medieval vernacular translations carried the texts' popularity into the 15th century and, in Germany and England, the 16th.


All three  Trotula  texts circulated for several centuries as independent texts. Each is found in several different versions, likely due to the interventions of later editors or scribes. [ 18 ]  Already by the late 12th century, however, one or more anonymous editors recognized the inherent relatedness of the three independent Salernitan texts on women's medicine and cosmetics, and so brought them together into a single ensemble. In all, when she surveyed the entire extant corpus of  Trotula  manuscripts in 1996, Green identified eight different versions of the Latin  Trotula  ensemble. These versions differ sometimes in wording, but more obviously by the addition, deletion, or rearrangement of certain material. [ 18 ]  The so-called "standardized ensemble" reflects the most mature stage of the text, and it seemed especially attractive in university settings. [ 19 ]  A survey of known owners of the Latin  Trotula  in all its forms showed it not simply in the hands of learned physicians throughout western and central Europe, but also in the hands of monks in England, Germany, and Switzerland; surgeons in Italy and Catalonia; and even certain kings of France and England. [ 20 ]


The trend toward using vernacular languages for medical writing began in the 12th century, and grew increasingly in the later Middle Ages. [ 21 ]   The many vernacular translations of the  Trotula  were therefore part of a general trend. The first known translation was into  Hebrew , made somewhere in southern France in the late 12th century. [ 22 ]  The next translations, in the 13th century, were into  Anglo-Norman  and  Old French . [ 23 ]  And in the 14th and 15th centuries, there are translations in  Dutch ,  Middle English ,  French  (again),  German ,  Irish , and  Italian . [ 24 ]  Most recently, a Catalan translation of one of the  Trotula  texts has been discovered in a 15th-century medical miscellany, held by the Biblioteca Riccardiana in Florence. This fragmentary translation of the  De curis mulierum  is here collated by the copyist (probably a surgeon making a copy for his own use) with a Latin version of the text, highlighting the differences. [ 25 ]


The existence of vernacular translations suggests that the  Trotula  texts were finding new audiences. Almost assuredly they were, but not necessarily women. Only seven of the nearly two dozen medieval translations are explicitly addressed to female audiences, and even some of those translations were co-opted by male readers. [ 26 ]  The first documented female owner of a copy of the  Trotula  is Dorothea Susanna von der Pfalz, Duchess of Saxony-Weimar (1544–92), who had made for her own use a copy of  Johannes Hartlieb ’s paired German translations of the pseudo- Albertus Magnus   Secrets of Women  and  Das Buch Trotula . [ 27 ]


Medieval readers of the  Trotula  texts would have had no reason to doubt the attribution they found in the manuscripts, and so "Trotula" (assuming they understood the word as a personal name instead of a title) was accepted as an authority on women's medicine. The physician Petrus Hispanus (mid-13th century), for example, cited "domina Trotula" (Lady Trotula) multiple times in his section on women's gynecological and obstetrical conditions. The Amiens chancellor, poet, and physician,  Richard de Fournival  (d. 1260), commissioned a copy headed "Incipit liber Trotule sanatricis Salernitane de curis mulierum" ("Here begins the book of Trotula, the Salernitan female healer, on treatments for women"). [ 28 ]  Two copies of the Latin  Trotula  ensemble include imaginative portrayals of the author; the pen-and-ink wash image found in an early 14th-century manuscript now held by the  Wellcome Library  is the most well-known image of "Trotula" (see image above). [ 29 ]  A few 13th-century references to "Trotula," however, cite her only as an authority on cosmetics. [ 30 ]  The belief that "Trotula" was the ultimate authority on the topic of women's medicine even caused works authored by others to be attributed to her, such as a 15th-century  Middle English  compendium on gynecology and obstetrics based on the works of the male authors  Gilbertus Anglicus  and Muscio, which in one of its four extant copies was called the  Liber Trotularis . [ 31 ]  Similarly, a 14th-century Catalan author entitled his work primarily focused on women's cosmetics  Lo libre . . . al qual a mes nom Trotula  ("The Book ... which is called 'Trotula'"). [ 32 ]


Alongside "her" role as a medical authority, "Trotula" came to serve a new function starting in the 13th century:  that of a mouthpiece for misogynous views on the nature of women. In part, this was connected to a general trend to acquire information about the "secrets of women", that is, the processes of generation. When the Munich physician  Johannes Hartlieb  (d. 1468) made a German translation of the  Trotula , he not only elevated "Trotula's" status to that of a queen, but also paired the text with the pseudo-Albertan  Secrets of Women . [ 33 ]  A text called  Placides and Timeus  attributed to "Trotula" a special authority both because of what she "felt in herself, since she was a woman", and because "all women revealed their inner thoughts more readily to her than to any man and told her their natures." [ 34 ]   Geoffrey Chaucer  is echoing this attitude when he includes "Trotula's" name in his "Book of Wicked Wives," a collection of anti-matrimonial and misogynous tracts owned by the Wife of Bath's fifth husband, Jankyn, as told in  The Wife of Bath's Tale  (Prologue, (D), 669–85) of  The Canterbury Tales .


The  Trotula  texts first appeared in print in 1544, quite late in the trend toward printing, which for medical texts had begun in the 1470s. The  Trotula  was published not because it was still of immediate clinical use to learned physicians (it had been superseded in that role by a variety of other texts in the 15th century), [ 35 ]  but because it had been newly "discovered" as a witness to empirical medicine by a Strasbourg publisher, Johannes Schottus.  Schottus persuaded a physician colleague, Georg Kraut, to edit the  Trotula , which Schottus then included in a volume he called  Experimentarius medicinae  ("Collection of Tried-and-True Remedies of Medicine"), which also included the  Physica  of  Trota of Salerno 's near contemporary,  Hildegard of Bingen . [ 36 ]  Kraut, seeing the disorder in the texts, but not recognizing that it was really the work of three separate authors, rearranged the entire work into 61 themed chapters. He also took the liberty of altering the text here and there. As Green has noted, "The irony of Kraut's attempt to endow 'Trotula' with a single, orderly, fully rationalized text was that, in the process, he was to obscure for the next 400 years the distinctive contributions of the historic woman Trota." [ 37 ]


Kraut (and his publisher, Schottus) retained the attribution of the text(s) to "Trotula." In fact, in applying a singular new title-- Trotulae curandarum aegritudinum muliebrium ante, in, & postpartum Liber  ("The Book of Trotula on the Treatment of the Diseases of Women before, during, and after Birth")--Kraut and Schottus proudly emphasized "Trotula's" feminine identity. Schottus praised her as "a woman by no means of the common sort, but rather one of great experience and erudition." [ 38 ]  In his "cleaning up" of the text, Kraut had suppressed all obvious hints that this was a medieval text rather than an ancient one. When the text was next printed, in 1547 (all subsequent printings of the  Trotula  would recycle Kraut's edition), it appeared in a collection called  Medici antiqui omnes qui latinis litteris diversorum morborum genera & remedia persecuti sunt, undique conquisiti  ("[The Writings of] All Ancient Latin Physicians Who Described and Collected the Types and Remedies of Various Diseases").  From then until the 18th century, the  Trotula  was treated as if it were an ancient text. As Green notes, "'Trotula', therefore, in contrast to Hildegard, survived the scrutiny of Renaissance humanists because she was able to escape her medieval associations. But it was this very success that would eventually 'unwoman' her.  When the  Trotula  was reprinted in eight further editions between 1550 and 1572, it was not because it was the work of a woman but because it was the work of an  antiquissimus auctor  ("a very ancient author")." [ 39 ]


"Trotula" was "unwomaned" in 1566 by Hans Caspar Wolf, who was the first to incorporate the  Trotula  into a collection of gynecological texts. Wolf emended the author's name from "Trotula" to Eros, a freed male slave of the Roman empress Julia: "The book of women’s matters of Eros, physician [and] freedman of Julia, whom some have absurdly named ‘Trotula’" ( Erotis medici liberti Iuliae, quem aliqui Trotulam inepte nominant, muliebrium liber ). The idea came from  Hadrianus Junius  (Aadrian DeJonghe, 1511–75), a Dutch physician who believed that textual corruptions accounted for many false attributions of ancient texts. As Green has noted, however, even though the erasure of "Trotula" was more an act of humanist editorial zeal than blatant misogyny, the fact that there were now no female authors left in the emerging canon of writers on gynecology and obstetrics was never noted. [ 40 ]


If "Trotula" as a female author had no use to humanist physicians, that was not necessarily true of other intellectuals. In 1681, the Italian historian Antonio Mazza resurrected "Trotula" in his  Historiarum Epitome de rebus salernitanis  ("Epitome of the Histories of Salerno"). Here is the origin of the belief that "Trotula" held a chair at the university of Salerno:  "There flourished in the fatherland, teaching at the university [studium] and lecturing from their professorial chairs, Abella, Mercuriadis, Rebecca, Trotta (whom some people call "Trotula"), all of whom ought to be celebrated with marvelous encomia (as Tiraqueau has noted), as well as Sentia Guarna (as Fortunatus Fidelis has said)." [ 41 ]  Green has suggested that this fiction (Salerno had no university in the 12th century, so there were no professorial chairs for men or women) may have been due to the fact that three years earlier, " Elena Cornaro  received a doctorate in philosophy at Padua, the first formal Ph.D. ever awarded to a woman. Mazza, concerned to document the glorious history of his patria, Salerno, may
have been attempting to show that Padua could not claim priority in having produced female professors." [ 41 ]


In 1773 in Jena, C. G. Gruner challenged the idea that the  Trotula  was an ancient text, but he also dismissed the idea that "Trotula" could have been the text's author (working with Kraut's edition, he, too, thought it was a single text) since she was cited internally. [ 42 ]  (This is the story of  Trota of Salerno 's cure of the woman with "wind" in the womb in the  De curis mulierum .) And so the stage was set for debates about "Trotula" in the 19th and 20th centuries. For those who wanted a representative of Salernitan excellence and/or female achievement, "she" could be reclaimed from the humanists' erasure. For skeptics (and there were many grounds for skepticism), it was easy to find cause for doubt that there was really any female medical authority behind this chaotic text. This was the state of affairs in the 1970s, when  second-wave feminism  discovered "Trotula" anew. [ 43 ]   The inclusion of "Trotula" as an invited guest at  Judy Chicago 's feminist art installation,  The Dinner Party  (1974–79), insured that the debate would continue.


From 1544 up through the 1970s, all claims about an alleged author "Trotula," pro or con, were based on Georg Kraut's Renaissance printed text. But that was a fiction, in that it had erased all last signs that the  Trotula  had been compiled out of the works of three different authors. In 1985,  California Institute of Technology  historian  John F. Benton  published a study surveying previous thinking on the question of "Trotula's" association with the  Trotula  texts. [ 44 ]  That study was important for three major reasons. (1) Although some previous scholars had noted discrepancies between the printed Renaissance editions of the  Trotula  and the text(s) found in medieval manuscripts, Benton was the first to prove how extensive the Renaissance editor's emendations had been.  This was not one text, and there was no "one" author. Rather, it was three different texts. (2) Benton dismantled several of the myths about "Trotula" that had been generated by 19th- and early 20th-century scholarship.  For example, the epithet "de Ruggiero" attached to her name was sheer invention. Likewise, claims about her date of birth or death, or who "her" husband or sons were had no foundation. (3) Most importantly, Benton announced his discovery of the  Practica secundum Trotam  ("Practical Medicine According to Trota") in a manuscript now in Madrid, which established the historic  Trota of Salerno 's claim to have existed and been an author.


After Benton's death in 1988, Monica H. Green picked up the task of publishing a new translation of the  Trotula  that could be used by students and scholars of the history of medicine and medieval women. However, Benton's own discoveries had rendered irrelevant any further reliance on the Renaissance edition, so Green undertook a complete survey of all the extant Latin manuscripts of the  Trotula  and a new edition of the  Trotula  ensemble. [ 45 ]  Green has disagreed with Benton in his claim that all the  Trotula  treatises were male-authored. [ 46 ]  Specifically, while Green agrees with Benton that male authorship of the  Conditions of Women  and  Women's Cosmetics  is probable, Green has demonstrated that not simply is the  De curis mulierum  (On Treatments for Women) directly attributed to the historic  Trota of Salerno  in the earliest known version (where it was still circulating independently), [ 47 ]  but that the text shows clear parallels to passages in other works associated with Trota and suggests strongly an intimate access to the female patient's body that, given the cultural restrictions of the time, would have likely only been allowed to a female practitioner. [ 48 ]


Perhaps the best known popularization of "Trotula" was in the artwork  The Dinner Party  (1979) by  Judy Chicago , now on permanent exhibit at the  Brooklyn Museum of Art , which features a place setting for "Trotula." [ 49 ]  The depiction here (based on publications prior to Benton's discovery of  Trota of Salerno  in 1985) presents a conflation of alleged biographical details that are no longer accepted by scholars. Chicago's celebration of "Trotula" no doubt led to the proliferation of modern websites that mention her, many of which repeat without correction the discarded misunderstandings noted above. [ 50 ]  A clinic in Vienna and a street in modern Salerno and even a  corona on the planet Venus  have been named after "Trotula," all mistakenly perpetuating fictions about "her" derived from popularizing works like that of Chicago. Likewise, medical writers, in trying to indicate the history of women in their field, or the history of certain gynecological conditions, keep recycling outworn understandings of "Trotula" (or even inventing new misunderstandings). [ 51 ]  Nevertheless, Chicago's elevation of both "Trotula" and the real Trota's contemporary, the religious and medical writer  Hildegard of Bingen , as important medical figures in 12th-century Europe, did flag the importance of how historical remembrances of these women were created. [ 36 ]  That it took close to twenty years for Benton and Green to extract the historic woman Trota from the composite text of the  Trotula  was a function of the complicated textual tradition and the broad proliferation of the texts in the Middle Ages. That it is taking even longer for popular understandings of Trota and "Trotula" to catch up with this scholarship, has raised the question whether celebrations of Women's History ought not include more recognition of the processes by which that record is discovered and assembled. [ 52 ]


Since Green's edition of the standardized  Trotula  ensemble appeared in 2001, many libraries have been making high-quality digital images available of their medieval manuscripts. The following is a list of manuscripts of the  Trotula  that are now available for online consultation. In addition to the  shelfmark , the index number is given from either Green's 1996 handlist of Latin manuscripts of the  Trotula  texts, or Green's 1997 handlist of manuscripts of medieval vernacular translations. [ 1 ]


Latin Manuscripts


Lat16: Cambridge, Trinity College, MS R.14.30 (903), ff. 187r-204v (new foliation, 74r-91v) (s. xiii ex., France): proto-ensemble (incomplete),  http://sites.trin.cam.ac.uk/manuscripts/R_14_30/manuscript.php?fullpage=1 [ permanent dead link  ]


Lat24: Firenze [Florence], Biblioteca Laurenziana, Plut. 73, cod. 37, ff. 2r-41r (s. xiii 2 , Italy): intermediate ensemble,  http://www.internetculturale.it/jmms/iccuviewer/iccu.jsp?id=oai%3Ateca.bmlonline.it%3A21%3AXXXX%3APlutei%3AIT%253AFI0100_Plutei_73.37&mode=all&teca=Laurenziana+-+FI


Lat48: London, Wellcome Library, MS 517, Miscellanea Alchemica XII (formerly Phillipps 2946), ff. 129v–134r (s. xv ex., probably Flanders): proto-ensemble (extracts),  http://search.wellcomelibrary.org/iii/encore/record/C__Rb1964315?lang=eng


Lat49: London, Wellcome Library, MS 544, Miscellanea Medica XVIII, pp. 65a-72b, 63a-64b, 75a-84a (s. xiv in., France): intermediate ensemble,  http://wellcomelibrary.org/player/b19745588#?asi=0&ai=86&z=0.1815%2C0.5167%2C0.2003%2C0.1258&r=0 . This is the copy that includes the well-known image of “Trotula” holding an orb.


Lat50: London, Wellcome Library, MS 548, Miscellanea Medica XXII, ff. 140r-145v (s. xv med., Germany or Flanders): standardized ensemble (selections),  http://search.wellcomelibrary.org/iii/encore/record/C__Rb1926717?lang=eng


Lat81: Oxford, Pembroke College, MS 21, ff. 176r-189r (s. xiii ex., England): proto-ensemble ( LSM  only);  DOM  (fragment),  http://digital-collections.pmb.ox.ac.uk/ms-21   Archived  2015-12-16 at the  Wayback Machine


Lat87: Paris, Bibliothèque Nationale de France, MS lat. 7056, ff. 77rb-86va; 97rb-100ra (s. xiii med., England or N. France): transitional ensemble (Group B);  TEM  (Urtext of  LSM ),  http://gallica.bnf.fr/ark:/12148/btv1b9076918w


Lat113: Vatican, Biblioteca Apostolica Vaticana, MS Pal. lat. 1304 (3rd ms of 5 in codex), ff. 38r-45v, 47r-48v, 46r-v, 51r-v, 49r-50v (s. xiii 2 , Italy): standardized ensemble:  http://digi.ub.uni-heidelberg.de/diglit/bav_pal_lat_1304 .


Vernacular Manuscripts


French


Fren1a: Cambridge, Trinity College, MS O.1.20 (1044), ff. 21rb-23rb (s. xiii 2 , England): Les secres de femmes, ed. in Hunt 2011 (cited above),  http://sites.trin.cam.ac.uk/manuscripts/O_1_20/manuscript.php?fullpage=1 [ permanent dead link  ]  (see also Fren3 below)


Fren2IIa: Kassel, Murhardsche Bibliothek der Stadt und Landesbibliothek, 4° MS med. 1, ff. 16v-20v (ca. 1430-75),  http://orka.bibliothek.uni-kassel.de/viewer/image/1297331763218/35/


Fren3a: Cambridge, Trinity College, MS O.1.20 (1044), ff. 216r–235v, s. xiii 2  (England), ed. in Hunt,  Anglo-Norman Medicine , II (1997), 76–107,  http://sites.trin.cam.ac.uk/manuscripts/O_1_20/manuscript.php?fullpage=1 [ permanent dead link  ]


Irish


Ir1b: Dublin, Trinity College, MS 1436 (E.4.1), pp. 101–107 and 359b-360b (s. xv):  https://www.isos.dias.ie/TCD/TCD_MS_1436.html


Italian


Ital2a: London, Wellcome Institute for the History of Medicine, MS 532, Miscellanea Medica II, ff. 64r-70v (ca. 1465):  http://search.wellcomelibrary.org/iii/encore/record/C__Rb1893400?lang=eng


Tubal factor infertility  ( TFI ) is  female infertility  caused by diseases, obstructions, damage, scarring, congenital malformations or other factors which impede the descent of a fertilized or unfertilized ovum into the uterus through the fallopian tubes and prevents a normal pregnancy and full term birth. Tubal factors cause 25-30% of infertility cases. [ 1 ]  Tubal factor is one complication of chlamydia trachomatis infection in women. [ 2 ]


Sexually transmitted chlamydia and genital mycoplasma infections are preventable causes of infertility and negative pregnancy outcomes. When the infections progress and ascend, they can result in TFI. Infertility can have multiple possible causes and may not be recognized for years after a gonorrhea, chlamydia or  Mycoplasma  infection has caused tubal damage, as the affected woman may not have attempted to become pregnant until years later. [ 2 ]


Infertility  is the major symptom of TFI and is generally defined as a woman under 35 who has not become  pregnant  after 12 months without the use of  contraception . Twelve months is the lower  reference limit  for  Time to Pregnancy  (TTP) by the  World Health Organization . [ 3 ]  When the inability to conceive is accompanied by signs and symptoms of  pelvic inflammatory disease  such as  lower abdominal pain , TFI may be present. A history of pelvic inflammatory disease, the  laproscopic  evidence of scarring and a diagnosis of  salpingitis  supports the  diagnosis .


Tubal factor infertility can be due to  chlamydia infection  and testing for  chlamydia antibodies  is one diagnostic tool. [ 4 ]  A  Mycoplasma genitalium  infection has also been linked to TFI. [ 5 ]  Women have difficulty getting pregnant or carrying a baby to term due to the buildup of  scar tissue  in the fallopian tubes causing damage to the cilia on the epithelial cells. [ 6 ] [ 7 ]  TFI can also be due to endometriosis. [ 8 ]


The physician will obtain a medical history and evaluate for tubal obstructions and infections. Obstruction can occur anywhere along the length of the tube.  It can be partially or completely blocked. The extent of obstruction is typically assessed using hysterosalpingogram (HSG). Some use laparoscopy to establish the extent of the disease. Pelvic adhesions can be visualized, if present. [ 4 ]


Distal tubal obstruction is more often observed (70%) than proximal obstruction. It can be caused by hydrosalpinges, pelvic adhesions, or fusion of the fimbriae. Tubal obstruction is caused by infection, endometriosis, myomas, salpingitis isthmica nodosa (SIN), or dried mucus. Because the tube can spasm during the injection of the dye during a hysterosalpingogram, it can be misdiagnosed. [ 4 ]


If tubal factor infertility is suspected to be the cause of the infertility treatment begins with or without confirmation of infection because of complications that may result from delayed treatment. Appropriate treatment depends on the  infectious agent  and utilizes  antibiotic  therapy.  Treating the sexual partner for possible STIs helps in treatment and prevents reinfection. [ 9 ]
Antibiotic administration affects the short or long-term major outcome of women with mild or moderate disease. [ 10 ]


For women with infections of mild to moderate severity, parenteral and oral therapies are prescribed. [ 11 ] [ 12 ] [ 13 ]  Typical antibiotics used are  cefoxitin  or  cefotetan  plus  doxycycline , and  clindamycin  plus  gentamicin . [ 14 ]  An alternative parenteral regimen is  ampicillin / sulbactam  plus doxycycline. [ 14 ]  Once infection has been eliminated, surgery may be successful in opening the lumen of the fallopian tubes to allow a successful pregnancy and birth. [ 15 ]


A  tubo-ovarian abscess  (TOA) is one of the late  complications  of  pelvic inflammatory disease  (PID) and can be life-threatening if the  abscess  ruptures and results in  sepsis . It consists of an encapsulated or confined pocket of  pus  with defined boundaries that forms during an infection of a  fallopian tube  and  ovary . These abscesses are found most commonly in reproductive age women and typically result from upper genital tract infection. [ 1 ] [ 2 ]  It is an inflammatory mass involving the fallopian tube, ovary and, occasionally, other adjacent pelvic organs. A TOA can also develop as a complication of a hysterectomy. [ 3 ] : 103


Symptoms typically include fever, an elevated  white blood cell  count, lower abdominal-pelvic pain, and/or vaginal discharge. Fever and leukocytosis may be absent. TOAs are often polymicrobial with a high percentage of anaerobic bacteria. The cost of treatment in the United States is approximately $2,000 per patient, which equals about $1.5 billion annually. [ 1 ]   Though rare, TOA can occur without a preceding episode of PID or sexual activity. [ 4 ] [ 5 ]


The signs and symptoms of tubo-ovarian abscess (TOA) are the same as with  pelvic inflammatory disease  (PID) with the exception that the abscess can be found with  magnetic resonance imaging  (MRI),  sonography  and  x-ray . [ 1 ]  It also differs from PID in that it can create symptoms of acute-onset pelvic pain. [ 6 ]  Typically this disease is found in sexually active women. [ 4 ] [ 7 ]  Tubo-ovarian abscess can mimic abdominal tumours. [ 8 ]


Complications of TOA are related to the possible removal of one or both ovaries and fallopian tubes.  Without these reproductive structures, fertility can be affected.  Surgical complications can develop and include: [ citation needed ]


The development of TOA is thought to begin with the  pathogens  spreading from the  cervix  to the  endometrium , through the  salpinx , into the  peritoneal cavity  and forming the tubo-ovarian abscess with (in some cases) pelvic peritonitis.  TOA can develop from the  lymphatic system  with infection of the  parametrium  from an  intrauterine device  (IUD). [ 1 ]  Bacteria recovered from  TOAs are  Escherichia coli ,  Bacteroides fragilis , other  Bacteroides  species,  Peptostreptococcus ,  Peptococcus , and  aerobic   streptococci . [ 9 ]  Long term IUD use is associated with TOA. [ 10 ]  Actinomyces is also recovered from TOA. [ 10 ]


Laparoscopy  and other imaging tools can visualize the abscess. Physicians are able to make the  diagnosis  if the abscess ruptures when the woman begins to have lower abdominal pain that then begins to spread.  The symptoms then become the same as the symptoms for  peritonitis .   Sepsis  occurs, if left untreated. [ 3 ] : 103   Ultrasonography is a sensitive enough imaging tool that it can accurately differentiate between pregnancy, hemorrhagic ovarian cysts, endometriosis, ovarian torsion, and tubo-ovarian abscess. Its availability, the relative advancement in the training of its use, its low cost, and because it does not expose the woman (or fetus) to ionizing radiation, ultrasonography an ideal imaging procedure for women of reproductive age. [ 6 ]


Risk factors have been identified which indicate what women will be more likely to develop TOA.  These are: increased age, IUD insertion, chlamydia infection, and increased levels of certain proteins (CRP and CA-125) and will alert clinicians to follow up on unresolved symptoms of PID. [ 12 ]


Treatment for TOA differs from PID in that some clinicians recommend patients with tubo-ovarian abscesses have at least 24 hours of inpatient parenteral treatment with antibiotics, and that they may require surgery. [ 1 ] [ 13 ]  If surgery becomes necessary, pre-operative administration of broad-spectrum antibiotics is started and removal of the abscess, the affected  ovary  and  fallopian tube  is done.   After discharge from the hospital, oral antibiotics are continued for the length of time prescribed by the physician. [ 3 ] : 103


Treatment is different if the TOA is discovered before it ruptures and can be treated with IV antibiotics.  During this treatment, IV antibiotics are usually replaced with oral antibiotics on an outpatient basis.  Patients are usually seen three days after hospital discharge and then again one to two weeks later to confirm that the infection has cleared. [ 3 ] : 103   Ampicillin/sulbactam plus doxycycline is effective against C. trachomatis, N. gonorrhoeae, and anaerobes in women with tubo-ovarian abscess. Parenteral Regimens described by the Centers for Disease Control and prevention are Ampicillin/Sulbactam 3 g IV every 6 hours and Doxycycline 200 mg orally or IV every 24 hours, though other regiments that are used for pelvic inflammatory disease have been effective. [ 14 ]


The epidemiology of TOA is closely related to that of pelvic inflammatory disease  which is estimated to one million people yearly. [ 15 ]


Tumescence  is the quality or state of being tumescent or swollen. Tumescence usually refers to the normal engorgement with  blood [ 1 ]  ( vascular congestion ) of the  erectile tissues , marking  sexual excitation , and possible readiness for  sexual activity . The tumescent sexual organ in males is the  penis  and in females is the  clitoris  and other parts of the genitalia like the  vestibular bulbs .  Arteries  in the penis dilate to increase blood volume. [ 2 ]


Detumescence  is the reversal of this process, by which blood leaves the erectile tissue, returning the erectile tissue to the flaccid state. [ 3 ]


Something that causes an  erection  is sometimes referred to as a tumefier (tumefyer) or tumescer. [ 4 ]


A  ureterovaginal fistula  is an abnormal passageway existing between the  ureter  and the  vagina . It presents as urinary  incontinence . Its impact on  women is to reduce the "quality of life dramatically." [ 1 ]


A ureterovaginal fistula is a result of  trauma ,  infection , pelvic  surgery ,  radiation treatment  and  therapy ,  malignancy , or  inflammatory bowel disease .   Symptoms  can be troubling for women especially since some  clinicians delay treatment until  inflammation  is reduced and stronger tissue has formed. [ 2 ]   The fistula may develop as a maternal birth injury from a long and protracted  labor , long  dilation  time and expulsion period. Difficult deliveries can create pressure  necrosis  in the tissue that is being pushed between the head of the infant and the softer tissues of the  vagina ,  ureters , and  bladder . [ 1 ]


Radiographic imaging can assist clinicians in identifying the abnormality. [ 3 ]  A Ureterovaginal fistula is always indicative of an obstructed kidney necessitating emergency intervention followed later by an  elective surgical  repair of the fistula. [ 2 ]


[UN member states will engage in] Educating individual women and men, girls and boys, communities,
policymakers and health professionals about how obstetric fistula can be prevented
and treated, and increasing awareness of the needs of pregnant women and girls, as
well as of those who have undergone surgical fistula repair, including their right to
the highest attainable standard of mental and physical health, including sexual and
reproductive health, by working with community and religious leaders, traditional
birth attendants and midwives, including women and girls who have suffered from
fistula, the media, social workers, civil society, women’s organizations, influential
public figures and policymakers... [ 4 ]


Many women delay treatment for decades. [ 5 ]  Surgeons often will correct the fistula through major gynecological  surgery . Newer treatments can include the placement of a  stent  and is usually successful. In 0.5-2.5% of major pelvic surgeries a ureterovaginal fistula will form, usually weeks later. [ 2 ]  If the fistula cannot be repaired, the clinician may create a permanent diversion of urine or  urostomy . [ 6 ]  Risks associated with the repair of the fistula are also associated with most other surgical procedures and include the risk of  adhesions , disorders of wound healing,  infection , ileus, and  immobilization . There is a recurrence rate of 5%–15% in the surgical operation done to correct the fistula. [ 1 ]


Birth injuries that result in the formation of fistulas and urinary and fecal incontinence have been found to be strongly associated with economic and cultural factors. [ 4 ]  Teenagers and women who sustain injuries that develop into ureterovaginal fistulas during childbirth suffer significant social stigma. [ 5 ]  Ureterovaginal fistulas related to prolonged, obstructed labor are rare in developed nations but are more common in countries where access to emergent obstetrical care is limited. [ 7 ]


Abele, H (2014).  Atlas of gynecologic surgery . Stuttgart: Thieme.  ISBN   978-3-13-650704-9 .


A  urethral caruncle  is a benign  cutaneous condition  characterized by distal urethral  lesions  that are most commonly found in  post-menopausal women . They appear red, and can be various sizes. They can have the appearance of a  tumor . These epidermal growths are found around the posterior portion of the  urethral meatus . They can bleed and occasionally cause  dysuria  and  dyspareunia . The caruncles can be removed by surgery,  electric cauterization  and then with suture repair.  Pathology  studies are necessary to distinguish  carcinoma of the urethra  from urethral caruncles. Caruncles can grow back in some instances. Urethral caruncles can accompany the skin changes related to lowered  estrogen  levels. They can become a source of chronic  hematuria ,  infection , and  urethritis . [ 1 ] [ 2 ]


A  urethral diverticulum  is a condition where the  urethra  or the  periurethral glands  push into the connective tissue layers ( fascia ) that surround it. [ 1 ] [ 2 ]


Urethral diverticula are often asymptomatic [ 2 ]  and symptoms that are present tend to be nonspecific. [ 1 ]  They can co-occur with cancer, in approximately 6-9% of cases, most commonly  adenocarcinoma , but also including  squamous cell carcinoma  and  transitional cell carcinoma . Approximately 10% of cases co-occur with  kidney stones . [ 3 ]


There are 2 types of urethral diverticulums. Congenital and acquired. In infancy usually the urethral diverticulum is congenital but in rare instances acquired urethral diverticulum can be seen in infancy specially following traumatic catheterization. [ 4 ]


Common symptoms of urethral diverticulum include  incontinence , urinary frequency and urgency,  pain during sex , and  pain during urination . Other symptoms include pain localized to the urethra or pelvis and frequent  urinary tract infection . [ 3 ]


When urethral diverticulum becomes severe, a painful mass can sometimes be felt inside the  introitus  of the vagina, which can discharge  pus . If the mass is hard or bleeds, complications like cancer or  kidney stones  may be present. [ 3 ]


Few urethral diverticula are present at birth; the vast majority are acquired. Acquired urethral diverticula can be caused by trauma and/or infection. [ 1 ]  When the peri-urethral ducts become infected repeatedly, they can become blocked and eventually cause a diverticulum. They are usually found in the middle of the urethra or the end farthest from the bladder. [ 3 ]


Congenital urethral diverticula can arise from several embryological sources. These include defects in the primordial folds and remnants of  Gartner's duct . [ 3 ]


Histopathologically, several characteristics are frequently visible in urethral diverticula. These include  nephrogenic adenoma ,  chronic inflammation  associated with  fibrosis  around the glands, small or absent  epithelium ,  chronic cystitis ,  cystitis cystica ,  cystitis glandularis ,  squamous metaplasia , and  adenomatous metaplasia . [ 3 ]


Approximately 1/3 of diverticula are compound or multiple, and some can extend to surround the urethra. [ 3 ]


Urethral diverticulum is often an  incidental finding . [ 2 ]  It can be diagnosed using  magnetic resonance imaging  and/or  micturating cystourethrography . [ 1 ]  Other studies that can be used to diagnose urethral diverticulum include  intravenous urography ,  urethroscopy , and/or  ultrasound .  Conditions that should be distinguished from urethral diverticulum in a  differential diagnosis  include  overactive bladder ,  Gartner's duct cyst ,  Gartner's duct abscess ,  ectopic caeco-ureterocele ,  interstitial cystitis ,  pelvic inflammatory disease ,  endometriosis , and cancer. [ 3 ]


The primary treatment for urethral diverticulum is surgical. In women, the surgery is conducted transvaginally, usually when there is no acute inflammation to better aid dissection of the delicate tissues. [ 3 ]


Left untreated, urethral diverticulum can cause significant morbidity (sickness). [ 1 ]


During surgery, there is a risk for complications due to the highly vascular nature of the tissue. The urethral sphincters and its smooth muscle, as well as the neck of the bladder, can be injured regardless of the surgical approach. Other complications from surgery can include  urinary incontinence ,  stress incontinence , a  urethrovaginal fistula , or recurrent diverticula. Horseshoe-shaped diverticula and diverticula that completely surround the urethra are both associated with worse outcomes, as are those located close to the bladder, and large (over 3–4 cm) diverticula. [ 3 ]


The incidence of urethral diverticulum has been increasing in the 2000s, likely due to increasing diagnosis and detection of the condition. It is estimated to be present in as low as 0.02% of all women and as high as 6% of all women, and 40% of women with lower urinary tract symptoms. [ 1 ] [ 2 ]  Most symptomatic urethral diverticula are present in women from 30 to 60 years old. [ 3 ]


84% of periurethral masses are due to urethral diverticula. [ 1 ]


Urethral diverticulum can occur in men, and can cause complications including urethral stones and urinary tract infections. [ 5 ]


A urethrovaginal fistula  is an abnormal passageway that may occur the urethra and the vagina. [ 1 ]  It is a sub-set of vaginal fistulas. [ 2 ] [ 3 ]  It results in urinary incontinence as urine continually leaves the vagina. It can occur as an  obstetrical complication ,  catheter  insertion injury or a  surgical injury . [ 4 ] [ 5 ]


It is also called a urethral fistula and may be referred to as UVF. [ 3 ] [ 6 ]  They are quite rare. In the developed world, they are typically due to injuries due to medical activity. [ 7 ]


This article about a disease of the genitourinary system is a  stub . You can help Wikipedia by  expanding it .


Urogynecology  or  urogynaecology  is a surgical sub-specialty of  urology  and  gynecology .


In 1893,  Howard Kelly , a gynecologist and pioneering urogynecologist, invented an air  cystoscope  which was simply a handheld, hollow tube with a glass partition. [ 1 ]  When the American Surgical Society, later the  American College of Surgeons , met in Baltimore in 1900, a contest was held between  Howard Kelly  and  Hugh Hampton Young , who is often considered the father of modern urology. [ 2 ]  Using his air cystoscope, Kelly inserted ureteral catheters in a female patient in just 3 minutes. Young equaled this time in a male patient. [ 3 ]  So began the friendly competitive rivalry between gynecologists and urologists in the area of female urology and urogynecology. This friendly competition continued for decades. In modern times, the mutual interest of obstetricians, gynecologists, and urologists in pelvic floor problems in women has led to a more collaborative effort.


Urogynecologists are medical professionals who have been to medical school and achieved their basic medical degree, followed by postgraduate training in Obstetrics and Gynaecology (OB-GYN).  They then undertake further training in Urogynecology to achieve accreditation/board certification in this subspecialty. Training programme requirements and duration varies from country to country but usually tend to be around 2–3 years in most places. Urogynaecology fellowship programmes are available in some countries, but not all and the levels of formal accreditation and certification vary from country to country.


The International Urogynecological Association (IUGA) is a global body for professionals practising in the field of urogynaecology and female pelvic medicine and reconstructive surgery.  IUGA facilitates training for physicians from countries which do not have formal training programmes by maintaining and publishing a directory of fellowship programmes. IUGA also  provides educational opportunities for urogynecologists both online and in-person, develops terminology and standardization for the field. The International Continence Society (ICS) is another global organization which strives to improve the quality of life for people affected by urinary, bowel and pelvic floor disorders through education, and research.


Urogynecology is a sub-specialty of Gynecology, and in some countries is also known as Female Pelvic Medicine and Reconstructive Surgery.  A urogynecologist manages clinical problems associated with dysfunction of the pelvic floor and bladder.  Pelvic floor disorders affect the bladder, reproductive organs, and bowels.  Common pelvic floor disorders include urinary incontinence, pelvic organ prolapse and fecal incontinence.  Increasingly, Urogynecologists are also responsible for the care of women who have experienced trauma to the perineum during childbirth.


There is some crossover with the subspecialty of Female Urology - these doctors are urologists who undergo additional training to be able to manage female urinary incontinence, pelvic organ prolapse and interstitial cystitis/PBS.  In addition, there are colorectal surgeons who have a special interest in anal incontinence and pelvic floor dysfunction related to rectal function.  Contemporary urogynecological practice encourages multidisciplinary teams working in the care of patients, with collaborative input from urogynecologists, urologists, colorectal surgeons,  elderly care  physicians, and physiotherapists.  This is especially important in the care of patients with complex problems, e.g. those who have undergone previous surgery or who have combined incontinence and prolapse, or combined urinary and bowel problems.  Multidisciplinary team meetings are an important part of the management pathway of these women.


Urogynaecologists manage women with urinary incontinence and pelvic floor dysfunction.  The clinical conditions that a urogynecologist may see include stress incontinence, overactive bladder, voiding difficulty, bladder pain, urethral pain, vaginal or uterine prolapse, obstructed defecation, anal incontinence, and perineal injury.  They may also care for women with  vesicovaginal  or rectovaginal fistulae with specialist training, and in conjunction with other specialties.


Patients will usually be assessed using a combination of history taking, examination (including pelvic examination and assessment of prolapse using validated systems such as the  Pelvic Organ Prolapse Quantification System  and assessment of quality of life impact using validated questionnaires, including the assessment of sexual function, using Pelvic Organ Prolapse/Incontinence Sexual Questionnaire IUGA- Revised [PISQ-IR].  A bladder diary is often used to quantify an individual's fluid intake, and the number of voids per day and night, as well as the volume the bladder can hold on a day-to-day basis.  Further investigations might include urodynamics or a cystoscopy.  Treatment usually starts with conservative measures such as pelvic floor muscle training, fluid and food modification or bladder training.  Drug therapies can be used for overactive bladder, which may include antimuscarinic drugs or beta 3 receptor agonists - both of these help to control the urgency that is the key component of overactive bladder. If medications fail, more invasive options such as injections of botulinum toxin into the bladder muscle, or neuromodulation are other options for symptom relief.  Surgical treatments can be offered for stress incontinence and/or uterovaginal prolapse if pelvic floor muscle training is unsuccessful.


Urogynecological problems are seldom life-threatening, but they do have a major impact on the quality of life of affected individuals.  Urogynecologists will usually use quality of life improvement as a treatment goal, and there is a major focus on optimising symptoms using conservative measures before embarking on more invasive treatments.


Some conditions treated in urogynecology practice include: [ 4 ]


Diagnostic tests and procedures performed include: [ 4 ]


Specialty treatments available include: [ 4 ]


The uterine microbiome refers to the community of  commensal , nonpathogenic microorganisms—including  bacteria ,  viruses , and  yeasts /fungi—present in a healthy  uterus , as well as in the  amniotic fluid  and  endometrium . These microorganisms coexist in a specific environment within the uterus, playing a vital role in maintaining reproductive health. [ 1 ]  In the past, the uterus was believed to be a sterile environment, free of any  microbial life . Recent advancements in microbiological research, particularly the improvement of  16S rRNA gene  sequencing techniques, have challenged this long-held belief. These advanced techniques have made it possible to detect bacteria and other microorganisms present in very low numbers. [ 2 ]  Using this procedure that allows the detection of bacteria that cannot be  cultured  outside the body, studies of  microbiota  present in the uterus are expected to increase. [ 3 ]


In the past, the  uterine cavity  had been traditionally considered to be sterile, but potentially susceptible to be affected by  vaginal bacteria . However, this idea has been disproved. Moreover, it's been shown that endometrial and vaginal microbiota can differ in structure and composition in some women.


The microbiome of the innermost layer of the uterus, the  endometrium , may influence its capacity to allow an embryo to implant. The existence of more than 10% of non- Lactobacillus  bacteria in the endometrium is correlated with negative impacts on reproductive function and should be considered as an emerging cause of implantation failure and pregnancy loss. [ 4 ]


Bacteria,  viruses  and one  genus  of  yeasts  are a normal part of the uterus before and during  pregnancy . [ 5 ]  The uterus has been found to possess its own characteristic microbiome that differs significantly from the  vaginal microbiome , consisting primarily of lactobacillus species, and at far fewer numbers. [ 6 ]  In addition, the  immune system  is able to differentiate between those bacteria normally found in the uterus and those that are pathogenic.  Hormonal  changes have an effect on the microbiota of the uterus. [ 7 ]


The organisms listed below have been identified as commensals in the healthy uterus. Some also have the potential for growing to the point of causing disease:


Other  taxa  can be present, without causing disease or an immune response. Their presence is associated with negative birth outcomes. [ 5 ] [ 7 ]


Prophylactic  antibiotics  have been injected into the uterus to treat infertility. This has been done before the transfer of embryos with the intent to improve implantation rates. No association exists between successful implantation and antibiotic treatment. [ 12 ]  Infertility treatments often progress to the point where a microbiological analysis of the uterine microbiota is performed.  Preterm birth  is associated with certain species of bacteria that are not normally part of the healthy uterine microbiome. [ 5 ]


The uterine microbiome appears to be altered in female patients who experience  endometrial cancer ,  endometriosis , chronic endometriosis, and related gynecological pathologies, suggesting the clinical relevance of the uterine microbiome’s composition. [ 13 ]  Next-generation sequencing has revealed the presence of certain bacterial  taxa , such as  Alteromonas , to be present in patients presenting with gynecological conditions. [ 14 ]


Clinically speaking, there is no universal protocol on how to treat uterine  dysbiosis . However, use of antibiotics has been widespread. In the context of infertility, researchers have studied the effects of a treatment plan of antibiotics in conjunction with prebiotics and probiotics to increase  Lactobacillus  colonization in the endometrium. It was found that, while there was a  Lactobacillus- dominated endometrium correlated with increased pregnancy rates, the data was not statistically significant.  [ 15 ]  Antibiotics have also been used to treat chronic endometritis and endometriosis. [ 13 ]


Interestingly, a link between the oral microbiome and the uterine microbiome has been uncovered.  Fusobacterium nucleatum , a  Gram-negative bacteria  commensal to the oral microbiome, is associated with  periodontal disease  and has been linked with a wide variety of health outcomes, including unfavorable pregnancy outcomes. [ 16 ]   [ 17 ]


The immune response becomes more pronounced when bacteria are found that are not commensal. [ 5 ]


Investigations into reproductive-associated microbiomes began around 1885 by  Theodor Escherich . He wrote that meconium from the newborn was free of bacteria. There was a general consensus at the time and even recently that the uterus was sterile and this was referred to as the  sterile womb paradigm.  Other investigations used sterile diapers for meconium collection. No bacteria were able to be cultured from the samples. Other studies showed that bacteria were detected and were directly proportional to the time between birth and the passage of meconium. [ 1 ]


Investigations into the role of the uterine microbiome in the development of the infant microbiome are ongoing. [ 1 ]  In recent years, the number of articles and review publications discussing the uterine microbiome has grown. Based on a  Web of Science  analysis, the highest number of documents published on the topic was in 2023, with a total of 23 papers.


The  Daunert Lab , based at the  University of Miami ’s Sylvester Comprehensive Cancer Center, focuses on the role of the  microbiome  in  endometrial cancer  and the role the uterine microbiome plays in the success of an  IVF cycle . Similarly, Dr. Maria Walther-Antonio’s lab at the  Mayo Clinic  focuses on the microbiome’s role in endometrial cancer. Notably, Dr. Walther- Antonio has confirmed that  Porphyromas somerae  is able to invade  endometrial cells , indicating a possibility that this microbe contributes to the pathogenesis of endometrial cancer. [ 18 ]


The  Carlos Simon Foundation , based in  Valencia ,  Spain , is an women’s health research organization founded by reproductive endocrinologist  Carlos Simon, MD PhD . A research team led by Dr. Inmaculada Moreno at the Carlos Simon Foundation studies the role of the endometrial microbiome in human reproduction. When research on the uterine microbiome was scarce, Dr. Moreno and her team analyzed the endometrial microbiota and discovered that there was a correlation between certain endometrial microbiota compositions and the outcome of implantation success or failure. [ 4 ]  Six years later, they followed up with a paper revealing that specific pathogenic bacteria and depletion of  Lactobacillus  spp. in the endometrium correlated with impaired fertility. [ 11 ]


In  mammals  and other animals, the  vagina  ( pl. :  vaginas  or  vaginae ) [ 1 ]  is the elastic, muscular  reproductive organ  of the female  genital tract . In humans, it extends from the  vulval vestibule  to the  cervix  (neck of the  uterus ). The  vaginal introitus  is normally partly covered by a thin layer of  mucosal tissue  called the  hymen . The vagina allows for  copulation  and  birth .  It also channels  menstrual flow , which occurs in humans and closely related  primates  as part of the  menstrual cycle .


To accommodate smoother penetration of the vagina during sexual intercourse or other  sexual activity , vaginal moisture increases during  sexual arousal  in human females and other female mammals. This increase in moisture provides  vaginal lubrication , which reduces friction. The texture of the vaginal walls creates friction for the  penis  during sexual intercourse and stimulates it toward  ejaculation , enabling  fertilization . Along with pleasure and bonding, women's sexual behavior with other people can result in  sexually transmitted infections  (STIs), the risk of which can be reduced by recommended  safe sex  practices.  Other health issues  may also affect the human vagina.


The vagina has evoked strong reactions in societies throughout history, including negative perceptions and language, cultural  taboos , and their use as symbols for  female sexuality , spirituality, or regeneration of life. In  common speech , the word "vagina" is often used incorrectly to refer to the  vulva  or to the female genitals in general.


The term  vagina  is from  Latin   vāgīna , meaning "sheath" or " scabbard ". [ 1 ]  The vagina may also be referred to as the  birth canal  in the context of  pregnancy  and  childbirth . [ 2 ] [ 3 ]  Although by its dictionary and anatomical definitions, the term  vagina  refers exclusively to the specific internal structure, it is  colloquially  used to refer to the  vulva  or to both the vagina and vulva. [ 4 ] [ 5 ]


Using the term  vagina  to mean "vulva" can pose medical or legal confusion; for example, a person's interpretation of its location might not match another's interpretation of the location. [ 4 ] [ 6 ]  Medically, one description of the vagina is that it is the canal between the  hymen  (or remnants of the hymen) and the  cervix , while a legal description is that it begins at the vulva (between the  labia ). [ 4 ]  It may be that the incorrect use of the term  vagina  is due to not as much thought going into the anatomy of the female genitals as has gone into the study of male genitals, and that this has contributed to an absence of correct vocabulary for the external female genitalia among both the general public and health professionals. Because a better understanding of female genitalia can help combat sexual and psychological harm with regard to female development, researchers endorse correct terminology for the vulva. [ 6 ] [ 7 ] [ 8 ]


The human vagina is an elastic, muscular canal that extends from the vulva to the cervix. [ 9 ] [ 10 ]  The opening of the vagina lies in the  urogenital triangle . The urogenital triangle is the front triangle of the  perineum  and also consists of the urethral opening and associated parts of the external genitalia. [ 11 ]  The  vaginal canal  travels upwards and backwards, between the urethra at the front, and the rectum at the back. Near the upper vagina, the cervix protrudes into the vagina on its front surface at approximately a 90 degree angle. [ 12 ]  The vaginal and urethral openings are protected by the labia. [ 13 ]


When not  sexually aroused , the vagina is a collapsed tube, with the front and back walls placed together. The lateral walls, especially their middle area, are relatively more rigid. Because of this, the collapsed vagina has an H-shaped cross section. [ 10 ] [ 14 ]  Behind, the upper vagina is separated from the  rectum  by the  recto-uterine pouch , the middle vagina by loose  connective tissue , and the lower vagina by the  perineal body . [ 15 ]  Where the vaginal  lumen  surrounds the cervix of the uterus, it is divided into four continuous regions ( vaginal fornices ); these are the anterior, posterior, right lateral, and left lateral fornices. [ 9 ] [ 10 ]  The posterior fornix is deeper than the anterior fornix. [ 10 ]


Supporting the vagina are its upper, middle, and lower third muscles and ligaments. The upper third are the  levator ani  muscles, and the transcervical,  pubocervical , and sacrocervical ligaments. [ 9 ] [ 16 ]  It is supported by the upper portions of the  cardinal ligaments  and the  parametrium . [ 17 ]  The middle third of the vagina involves the  urogenital diaphragm . [ 9 ]  It is supported by the levator ani muscles and the lower portion of the cardinal ligaments. [ 17 ]  The lower third is supported by the perineal body, [ 9 ] [ 18 ]  or the urogenital and  pelvic diaphragms . [ 19 ]  The lower third may also be described as being supported by the perineal body and the pubovaginal part of the levator ani muscle. [ 16 ]


The  vaginal opening  (also known as the  vaginal introitus  and the Latin  ostium vaginae ) [ 20 ] [ 21 ]  is at the posterior end of the  vulval vestibule , behind the  urethral opening . The term  introitus  is more technically correct than "opening", since the vagina is usually collapsed, with the opening closed. The opening to the vagina is normally obscured by the  labia minora  (inner lips), but may be exposed after  vaginal delivery . [ 10 ]


The  hymen  is a thin layer of  mucosal tissue  that surrounds or partially covers the vaginal opening. [ 10 ]  The effects of  intercourse  and childbirth on the hymen vary. Where it is broken, it may completely disappear or remnants known as  carunculae myrtiformes  may persist. Otherwise, being very elastic, it may return to its normal position. [ 22 ]  Additionally, the hymen may be lacerated by disease, injury,  medical examination ,  masturbation  or  physical exercise . For these reasons,  virginity  cannot be definitively determined by examining the hymen. [ 22 ] [ 23 ]


The length of the vagina  varies  among women of child-bearing age. Because of the presence of the cervix in the front wall of the vagina, there is a difference in length between the front wall, approximately 7.5 cm (2.5 to 3 in) long, and the back wall, approximately 9 cm (3.5 in) long. [ 10 ] [ 24 ]   During sexual arousal, the vagina expands both in length and width. If a woman stands upright, the vaginal canal points in an upward-backward direction and forms an angle of approximately 45 degrees with the uterus. [ 10 ] [ 18 ]  The vaginal opening and hymen also vary in size; in children, although the hymen commonly appears  crescent -shaped, many shapes are possible. [ 10 ] [ 25 ]


The vaginal plate is the precursor to the vagina. [ 26 ]  During development, the vaginal plate begins to grow where the fused ends of the  paramesonephric ducts  (Müllerian ducts) enter the back wall of the  urogenital sinus  as the  sinus tubercle . As the plate grows, it significantly separates the cervix and the urogenital sinus; eventually, the central cells of the plate break down to form the vaginal  lumen . [ 26 ]  This usually occurs by the twenty to twenty-fourth week of development. If the lumen does not form, or is incomplete, membranes known as  vaginal septa  can form across or around the tract, causing obstruction of the outflow tract later in life. [ 26 ]


There are conflicting views on the embryologic origin of the vagina. The majority view is Koff's 1933 description, which posits that the upper two-thirds of the vagina originate from the caudal part of the Müllerian duct, while the lower part of the vagina develops from the urogenital sinus. [ 27 ] [ 28 ]  Other views are Bulmer's 1957 description that the vaginal epithelium derives solely from the urogenital sinus epithelium, [ 29 ]  and Witschi's 1970 research, which reexamined Koff's description and concluded that the  sinovaginal bulbs  are the same as the lower portions of the  Wolffian ducts . [ 28 ] [ 30 ]  Witschi's view is supported by research by Acién et al., Bok and Drews. [ 28 ] [ 30 ]  Robboy et al. reviewed Koff and Bulmer's theories, and support Bulmer's description in light of their own research. [ 29 ]  The debates stem from the complexity of the interrelated tissues and the absence of an animal model that matches human vaginal development. [ 29 ] [ 31 ]  Because of this, study of human vaginal development is ongoing and may help resolve the conflicting data. [ 28 ]


The  vaginal wall  from the lumen outwards consists firstly of a  mucosa  of  stratified squamous epithelium  that is not  keratinized , with a  lamina propria  (a thin layer of  connective tissue ) underneath it. Secondly, there is a layer of  smooth muscle  with bundles of circular fibers internal to longitudinal fibers (those that run lengthwise). Lastly, is an outer layer of connective tissue called the  adventitia . Some texts list four layers by counting the two sublayers of the mucosa (epithelium and lamina propria) separately. [ 32 ] [ 33 ]


The smooth  muscular layer  within the vagina has a weak contractive force that can create some pressure in the lumen of the vagina. Much stronger contractive force, such as during childbirth, comes from muscles in the  pelvic floor  that are attached to the adventitia around the vagina. [ 34 ]


The lamina propria is rich in blood vessels and lymphatic channels. The muscular layer is composed of smooth muscle fibers, with an outer layer of longitudinal muscle, an inner layer of circular muscle, and oblique muscle fibers between. The outer layer, the adventitia, is a thin dense layer of connective tissue and it blends with loose connective tissue containing blood vessels,  lymphatic vessels  and nerve fibers that are between pelvic organs. [ 12 ] [ 33 ] [ 24 ]  The vaginal mucosa is absent of glands. It forms folds (transverse ridges or  rugae ), which are more prominent in the outer third of the vagina; their function is to provide the vagina with increased surface area for extension and stretching. [ 9 ] [ 10 ]


The epithelium of the ectocervix (the portion of the uterine cervix extending into the vagina) is an extension of, and shares a border with, the vaginal epithelium. [ 35 ]   The vaginal epithelium is made up of layers of cells, including the  basal cells , the parabasal cells, the superficial  squamous flat cells , and the intermediate cells. [ 36 ]  The basal layer of the epithelium is the most mitotically active and reproduces new cells. [ 37 ]  The superficial cells  shed  continuously and basal cells replace them. [ 10 ] [ 38 ] [ 39 ]   Estrogen  induces the intermediate and superficial cells to fill with  glycogen . [ 39 ] [ 40 ]  Cells from the lower basal layer transition from active metabolic activity to death ( apoptosis ). In these mid-layers of the epithelia, the cells begin to lose their  mitochondria  and other  organelles . [ 37 ] [ 41 ]  The cells retain a usually high level of glycogen compared to other epithelial tissue in the body. [ 37 ]


Under the influence of maternal estrogen, the vagina of a newborn is lined by thick stratified squamous epithelium (or mucosa) for two to four weeks after birth. Between then to  puberty , the epithelium remains thin with only a few layers of cuboidal cells without glycogen. [ 39 ] [ 42 ]   The epithelium also has few rugae and is red in color before puberty. [ 4 ]  When puberty begins, the mucosa thickens and again becomes stratified squamous epithelium with glycogen containing cells, under the influence of the girl's rising estrogen levels. [ 39 ]  Finally, the epithelium thins out from  menopause  onward and eventually ceases to contain glycogen, because of the lack of estrogen. [ 10 ] [ 38 ] [ 43 ]


Flattened squamous cells are more resistant to both abrasion and infection. [ 42 ]  The permeability of the epithelium allows for an effective response from the  immune system  since  antibodies  and other immune components can easily reach the surface. [ 44 ]  The vaginal epithelium differs from the similar tissue of the skin. The  epidermis  of the skin is relatively resistant to water because it contains high levels of lipids. The vaginal epithelium contains lower levels of lipids. This allows the passage of water and water-soluble substances through the tissue. [ 44 ]


Keratinization happens when the epithelium is exposed to the dry external atmosphere. [ 10 ]  In abnormal circumstances, such as in  pelvic organ prolapse , the mucosa may be exposed to air, becoming dry and keratinized. [ 45 ]


Blood is supplied to the vagina mainly via the  vaginal artery , which emerges from a branch of the  internal iliac artery  or the  uterine artery . [ 9 ] [ 46 ]  The vaginal arteries  anastamose  (are joined) along the side of the vagina with the cervical branch of the uterine artery; this forms the  azygos artery , [ 46 ]  which lies on the midline of the anterior and posterior vagina. [ 15 ]  Other arteries which supply the vagina include the  middle rectal artery  and the  internal pudendal artery , [ 10 ]  all branches of the internal iliac artery. [ 15 ]  Three groups of lymphatic vessels accompany these arteries; the upper group accompanies the vaginal branches of the uterine artery; a middle group accompanies the vaginal arteries; and the lower group, draining lymph from the area outside the hymen, drain to the  inguinal lymph nodes . [ 15 ] [ 47 ]  Ninety-five percent of the lymphatic channels of the vagina are within 3 mm of the surface of the vagina. [ 48 ]


Two main veins drain blood from the vagina, one on the left and one on the right. These form a network of smaller veins, the  vaginal venous plexus , on the sides of the vagina, connecting with similar venous plexuses of the  uterus ,  bladder , and  rectum . These ultimately drain into the  internal iliac veins . [ 15 ]


The nerve supply of the upper vagina is provided by the  sympathetic  and  parasympathetic  areas of the  pelvic plexus . The lower vagina is supplied by the  pudendal nerve . [ 10 ] [ 15 ]