Autoimmune ooforit — the pathological destruction of ovaries caused by influence of antiovarialny antibodies. It is shown by violations of menstrual function (oligomenorey, amenorey), primary and secondary infertility. At a disease combination to inflammatory processes of the patient complain of pain in the bottom of a stomach. For diagnosis use gynecologic ultrasonography, determination of content of sex hormones, antiovarialny antibodies, interleykin, interferon and FNO. Treatment complex with purpose of glucocorticoid, antibacterial, hormonal medicines and antagonists of interleykinovy receptors. At persistent infertility EKO is shown.
Though autoimmune ooforit is rather rare pathology, this disease often provokes development of resistant forms of an amenorea and infertility. Hereditary forms of a disease are observed extremely seldom and are a part of a poliglandulyarny syndrome at which pathological autoimmune process strikes also other bodies of internal secretion (a thyroid gland, adrenal glands, islets of Langerhans, etc.). Usually this option of an ooforit complicates a current of chronic inflammations of internal genitals. More often patients get sick 30 years with genital infections, invasive diagnostic and medical interventions in the anamnesis are more senior. The importance of timely detection of a disease is connected with the bystry and expressed reduction of quantity of viable follicles, so, decrease in probability of pregnancy.
Damage of tissue of ovaries at autodestruktivny process is caused by education autoantitet to ovarialny fabric. Failure of protective reaction arises under the influence of factors which lead to local patogistologichesky changes in cortical substance, a ferruterous part and Strom of gonads, and also influence elements of cellular and humoral immunity. According to experts in the sphere of gynecology, the autoimmune ovarialny inflammation is caused:
- Genetic defect. Pathology is observed in structure of an autoimmune poliglandulyarny syndrome of the 1st and 2nd types. The first of options is autosomno-recessive, arises at defect of the AIRE gene located in the 21st chromosome. The second — the polygenic pathology associated with HLA-B8 gaplotipa - DR4, - DR5, - R3 which usually develops in several generations of families with hereditary predisposition.
- Inflammation of reproductive organs. The probability of emergence of autoimmune reaction increases at patients with a chronic current of endotservitsit, endometritises, salpingit, adneksit at prescription of a disease more than 5 years, and also at transferred an appendicular and genital syndrome. Autodestruktion of ovaries is more often diagnosed for women to whom were carried out a scraping, abortions, laparotomichesky interventions.
Results of clinical trials show that are more inclined to autoimmune damage of ovaries of the patient in which inflammatory process in bodies of a small pelvis is caused by the microbic associations having as a part of causative agents of genital infections. So, higher incidence is found in groups of women with gonorrhea, genital clamidiosis and trichomoniasis. From nonspecific microbic agents is more often than others korinebakteriya and enterobakteriya are defined.
The mechanism of development of an autoimmune ooforit depends on the reasons which caused it. At hereditary forms of a disease owing to defect of DNA antibodies to the enzymes providing and active cells of ferruterous fabric are formed. At patients with chronic gynecologic pathology long influence of microbic anti-genes activates the pro-inflammatory tsitokinovy cascade. Besides, inflammatory destruction of tissue of ovaries leads to formation of ovarialny anti-genes and development in response to them antiovarialny antibodies. The growing follicles in a stage of recruitment more than 6 mm in size are most sensitive to damage.
Unlike the cyclic changes characteristic of a physiological ovulation, at autoimmune options of ooforit constant high activity of T-lymphocytes which produce interleykin-1 is noted. At the expense of it resident macrophages of ovaries are activated, γ-interferon secretion, transforming α-and β-factors of growth, a α-factor of a necrosis of tumors, a factor of growth of the fibroblast and other tsitokin influencing an atresia of follicular fabric amplifies. Involvement in process of the increasing number of the ripening follicles leads to decrease in synthesis of estrogen, violation of a lyuteinovy phase, emergence hyper - and normogonadotropny primary insufficiency.
The symptomatology of a disease accrues gradually, is defined by extent of defeat of follicular and ferruterous tissue of ovaries. The most characteristic manifestation of an ooforit of an autoimmune origin is violation of an ovarialno-menstrual cycle. At the initial stages the number of bloody allocations decreases. Then duration of periods is reduced, and the period between separate monthly is extended up to 42-60 and more days. The cycle becomes spasmodic. At considerable destruction of ovarialny fabric of periods completely stop.
The pain syndrome at autoimmune injury of ovaries appears only when pathology develops against the background of an exacerbation of inflammatory gynecologic diseases. Patients usually complain of the dull aching ache in the lower part of a stomach and over a pubis. Painful feelings can give to a rectum, a crotch, to arise or amplify during sexual intercourse. Development of an algodismenorea is possible. At the long course of a disease at patients reproductive function worsens that is shown by impossibility to become pregnant at regular sex life without protection.
The most serious consequence of an autoimmune ooforit — the infertility connected with primary ovarialnoy insufficiency. Fertility can be never broken both at earlier becoming pregnant women, and at patients who already gave birth to children. Lack of an ovulation becomes an immediate cause of infertility. By results of researches, in 30-69% of cases of a gipergonadotropny amenorea and approximately a third of patients with normogonadotropny option of ovarilny insufficiency at blood has antibodies to tissue of ovaries. The situation is aggravated in connection with increase in maintenance of antispermalny antibodies (ASAT) at this autoimmune frustration. At 10-15% of patients in the remote period approach of an early climax is possible.
Existence of an autoimmune ooforit can be suspected at patients with permanent violations of a menstrual cycle and infertility, resistant to therapy, which other reasons are authentically not established. During diagnostics the laboratory and tool methods directed to data acquisition about the immune status of the patient, morphological structure and sekretiruyushchy function of ovaries are applied. Are most informative in the diagnostic plan:
- Determination of level of antiovarialny antibodies. The maintenance of antibodies to follicular cages, cages of a granuleza and Strom of ovaries at their autoimmune damage is on average increased by 2,5 times. Approximately at 11-12% examined antibodies to Zona Pellucida (a brilliant cover of an ovum) are defined.
- Assessment of the immune status. In blood concentration interleykinov-1, 4, 6 is increased. Level interleykinov-10 and 12 is at the same time a little reduced. The maintenance of TNF (a tumor necrosis factor) is sharply increased. Also γ-interferon level, the nonspecific immunity reflecting activity increases.
- Content of sex hormones. Oppression of ovarialny sekretorny function is shown by decrease in level of estrogen and progesterone. At 2/3 patients strengthening of production of gonadotropny hormones of a hypophysis, first of all FSG is noted. However the level of gonadotrophins can be not broken.
- Ultrasonography of pelvic bodies. Results of sonografichesky inspection at an autoimmune form of an ooforit demonstrate morphological changes of body. Ovaries are usually reduced in sizes. At initial stages of a disease in them multiple follicular cysts can be defined.
If pathology is connected with existence of genital infections, for the choice of antibacterial medicine it is important to define the activator of inflammatory process. Usually for this purpose apply PTsR-diagnostics, RIF, IFA, bacterial crops of dab from the tservikalny channel. The autoimmune option of an ooforit is differentiated with infectious ooforita, endometriosis, ovarialny benign and malignant tumors, a syndrome of exhaustion of ovaries, solderings in a small basin, other diseases leading to violation of menstrual function, endocrine and tube infertility. If necessary the patient is examined by the endocrinologist, the immunologist, the oncologist, the surgeon, .
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
Medical tactics at the destructive processes caused by antiovarialny antibodies is directed to correction of the immunological status, maintenance of secretion of sex hormones, the longest preservation of an ovulyatorny cycle. As well as other autoimmune processes, ooforit differs in high resistance to the carried-out therapy, demands an integrated approach in treatment. Usually apply the schemes influencing different links of pathogenesis and rendering the following effects:
- Antibacterial action. If ooforit arose owing to infectious damage of reproductive organs, antibiotic treatment is recommended. At the choice of medicine or a combination of antibiotics consider sensitivity of activators.
- Immunnosupressivny influence. Glucocorticoid hormones are considered as medicines of the choice. Their appointment is most effective at early stages of process, however such means oppress all links of immune system and have a number of side effects.
- Antiiterleykinovy effect. In therapy of autoimmune forms of an ooforit for receiving permanent remission receptor antagonists of Interlaken 1L-1 which is one of key links in pathogenesis of a disease even more often use.
- Maintenance of a hormonal background. Replacement therapy estrogen-gestagennymi medicines allows to reduce significantly the violations connected with ovarialny insufficiency. By preparation for EKO often apply anti-estrogen.
According to indications appoint anesthetics and resolvents, with care use immunomodulators. Taking into account the accruing ovarialny destruction the only exit for patients with the broken fertility who plan pregnancy often is extracorporal fertilization after medicamentous induction of an ovulation.
Forecast and prevention
Despite therapeutic resistance of an autoimmune ooforit, early diagnosis of a disease and the correct medical tactics allow to become pregnant to patients with infertility primary genesis. Use of anti-estrogen at gipergonadny option of a disease is effective at 23-24% of patients, at normogonadotropny — at 41-78%. Searches of ways of treatment continue, now developments on application of a system enzimoterapiya and agonists of a lyuliberin which oppress synthesis of gonadotrophins are considered as perspective. Prevention is directed to timely identification and treatment of chronic inflammatory diseases of bodies of a small pelvis, reasonable application of invasive gynecologic interventions, protection from undesirable pregnancy and genital infections.