Pelvic Infections and InfertilityDr Chaithra S.K

Tubal and peritoneal pathology are among the most common causes of infertility and the primary diagnosis in approximately 30-35% of infertile couples. History of Pelvic Inflammatory Disease (PID), septic abortion, ruptured appendix, tubal surgery, or ectopic pregnancy, suggests the possibility of tubal damage. PID is unquestionably the major cause of tubal factor infertility and ectopic pregnancies. Classic studies in women with PID diagnosed by laparoscopy have revealed that the risk of subsequent tubal infertility increases with the number and severity of pelvic infections. Overall, the incidence is approximately 10-12% after one episode, 23-35% after two, and 54-75% after three episodes of acute PID. The most frequent causes for pelvic infections are sexually transmitted pathogens and intrauterine manipulations like curettage, evacuation, etc. Infertility may also follow blood-borne infections such as tuberculosis, mixed aerobic and anaerobic infections of other pelvic sites, inflammatory complications of surgical trauma, post-abortal and puerperal sepsis, and appendicular rupture. Better recognition and treatment of cervicitis and endometritis before salpingitis develops is even more important in the prevention of infertility than the treatment of salpingitis per se. In choosing between IVF and tubal surgery, the physician must compare success rates (which are best defined by the birth of a live baby) and take into account the patient’s age, presence of a male subfertility factor, the personal priorities of the couple, and the availability of expertise.

The best prevention is to detect and treat early-stage asymptomatic and symptomatic infections. This can be achieved by screening all sexually active reproductive age women and by educating clinicians and patients on the importance of this testing. With the advent of modern DNA amplification tests like Polymerase Chain Reaction (PCR) very sensitive and specific testing on microbes can be done in a matter of hours. This obviates the need of many organisms as is the case with conventional cultures. Also, the newer tests are more specific, yielding a higher positive predictive value thus avoiding unnecessary treatments. Microbes like C. trachomatis, Trichomonas vaginalis, and N. gonorrhoea can be detected in samples obtained from the vaginal introitus, and there is no longer a requirement for a speculum examination. There have been efforts to make chlamydial and gonococcal vaccines, but not met much success.

Early diagnosis and treatment appear to be critical in the preservation of fertility. Current guidelines suggest that empirical treatment should be initiated in at-risk women who have lower abdominal pain, adnexal tenderness, and cervical motion tenderness. Given the diagnostic difficulties and the potential for serious sequelae, the Centers for Disease Control and Prevention (CDC) advises that physicians maintain a low threshold for aggressive patient treatment, with overtreatment preferred to no or delayed treatment. Therapy with antibiotics alone is successful in 33-75% of cases. If surgical treatment is warranted, the current trend is toward conservation of reproductive potential with simple drainage, adhesiolysis, and copious irrigation or unilateral adnexectomy, if possible in case of Tubo-ovarian abscess.

The best hope for reducing the incidence of infertility related to infection lies in the prevention and early detection and treatment of newly acquired asymptomatic or mildly symptomatic infections. By avoiding high-risk sexual behaviour and frequent pelvic infections further, fertility is preserved. In case of pelvic infections, early diagnosis and adequate treatments are recommended to avoid further sequelae. Concomitantly, there must be an increased awareness by health care providers and consumers of the need for intensive screening using the latest and most effective molecular techniques followed by an early effective treatment if positive.