Pelvic inflammatory disease (PID) is a condition where inflammation of pelvic structures occurs, as a result of one of the following: sexual transmission via the vagina and cervix, contamination from other inflamed structures in the abdominal cavity (appendix, gallbladder, kidneys, etc.), a foreign body inside the uterus (i.e., the intrauterine device – IUD), contamination of retained products of conception following abortion or child birth, or, rarely, as a result of blood-born bacterial transmission (e.g., pelvic tuberculosis) which is common in developing countries but rare in the United States.
It is estimated that about 1,500,000 women develop PID annually in the United States and the number is growing. Less than one-third of these women present with symptoms or signs of acute inflammation (e.g. severe pain, malaise, fever, vaginal discharge). The remaining cases usually go undetected until the woman presents with symptoms or infertility. In fact, more that 60% of patients who undergo surgery or in vitro fertilization and embryo transfer (IVF/ET) for the treatment of infertility secondary to pelvic inflammatory disease, provide no history of a prior acute episode.
Acute PID: Where pelvic inflammatory disease presents as an acute illness with fever, sever lower abdominal pain, accompanied by a yellow or blood stained, nonirritant, vaginal discharge and vomiting which usually prompts the woman to seek urgent medical attention.
Subacute PID: Here, the onset of PID is gradual, less severe, and often goes unnoticed until superimposed acute PID occurs, or chronic incapacitating symptoms prompt the woman to seek medical attention (see below).
Chronic Pelvic Inflammatory Disease: Chronic PID is a consequence of untreated or unsuccessfully managed acute and/or subacute PID. The woman usually presents with symptoms of pelvic pain, heavy and painful menstrual periods, pain with intercourse (dyspareunia) and infertility.
In the vast majority of cases, PID results from the sexual transmission of infecting organisms such as Neisseria Gonorrhea, and Chlamydia Trachomatis, which are readily eradicated through appropriate antibiotic therapy. Sexually transmitted bacteria first infects the cervix (the opening into the uterus) through which it ascends via the uterus to the fallopian tubes, ovaries, and other pelvic structures.
There are several important factors which predispose women towards developing PID:
- Exposure to an infected partner
- Exposure blood provides and excellent growth medium for bacteria, promoting their proliferation and passage into the fallopian tubes
- Relative ill health and poor nutritional status. It is predominantly for this reason that PID is much more prevalent in lower socioeconomic groups
- The fact that previously infected tissues are highly susceptible to re-infection; resulting in women with a past history of PID being highly susceptible to recurrent attacks
While sexually transmitted PID is certainly capable of causing endometritis (inflammation of the uterine lining) the uterus itself is not the main focus of the inflammatory process. Cyclical shedding of most of the uterine lining with menstruation tends to remove infected tissue monthly, thereby preventing the inflammation from taking a hold and causing permanent damage to or scarring of the uterine lining (the endometrium). The main site/target of inflammation following sexual transmitted PID is the fallopian tube via which other pelvic and abdominal structures may be infected.
PID following pregnancy (childbirth or abortion): This primarily targets the uterine lining, causing endometritis. Organisms such as Bacteroides, Peptostreptococcus, Beta hemolytic streptococcus, and E.Coli readily proliferate in the products of conception that are sometimes retained in the uterus following childbirth and abortion. The delayed onset of menstruation after both childbirth and abortion provides an opportunity for the inflammatory process to take hold and progress, sometimes leading to the development of scar tissue in the uterine cavity with the opposing surfaces of the endometrium to fuse together or produce scarring (Asherman syndrome). Sometimes the inflamed endometrium obliterates the opening (in the uterus) into the fallopian tubes and might also damage a small, adjacent segment of the tubes. Less commonly, post-childbirth and post-abortal endometritis infects the entire fallopian tube(s) (salpingitis) as well as causing partial or complete blockage, and/or spreading into the pelvic cavity.
PID from the use of the intrauterine contraceptive device (IUD) for contraceptive purposes: This most commonly occurs in cases where the device is inserted into the uterus of women concurrently infected with Gonorrhea or Chlamydia. The IUD acts as a foreign body causing local irritation which compromises the normal defense mechanisms that normally protect against infection. At the same time, the IUD string which protrudes through the cervix into the vagina may act as a “wick” via which infecting organisms gain entrance to the uterus. As with post-abortal and post-childbirth endometritis, IUD-related uterine infection can cause scarring of the endometrial lining, blockage of the fallopian tubes where they leave the uterus (utero-cornual occlusion, and spread, via the tubes, to other pelvic structures. IUD-related PID is a potentially life endangering condition capable of causing pelvic abscess formation, the development of peritonitis (inflammation of the peritoneum), systemic infection (septicemia), and shock.
How PID Causes Tubal Infertility: Sexually transmitted PID caused by Gonorrhea or Chlamydia rapidly spreads via the cervix and uterus to the fallopian tube(s). These organs are highly specialized and are designed to promote the active passage of eggs, sperm, and embryos in a timely manner to and from the uterine cavity. They contain cells whose function is to protect and nurture eggs, sperm and embryos in transit. At their ends, the fallopian tubes have small delicate finger-like projections (fimbriae) that approximate, envelope, and “pick-up” the egg(s) from the ovary(s) at the time of ovulation. Inflammation due to Chlamydia Trachomatis and Neiserria Gonorrhea, damages and often permanently destroys the specialized lining of the fallopian tube(s) and in severe cases results in fusion of the fimbriae thereby clocking the ends of the tube(s) compromising their mobility and their potential to facilitate timely passage of eggs, sperm and embryos. Pus, which accumulated inside the tube(s), often passes into the pelvic cavity producing peritonitis and results in the formation of scar tissue (adhesions) which further disrupts normal pelvic anatomy as well as the relationship between the tube(s) and the ovary(ies). This may prevent the fallopian tubes from collecting the egg(s) during ovulation.
As previously stated, post-abortal and post-childbirth endometritis causes infertility by causing uterine scarring, occlusion of the fallopian tube at its junction with the uterus, and sometimes producing infection along the full length of the tube with resultant tubal damage.
Sexually transmitted PID: This almost invariably affects both fallopian tubes. Even in cases where a dye x-ray test (hysterosalpingogram) or laparoscopy (a procedure where a telescope-like instrument is passed through the belly button to visualize the pelvic structures) indicates that only one fallopian tube has been infected, the other tube is almost invariably involved. A new procedure called tuboscopy (where a thin fiberoptic telescope is passed into the fallopian tube(s) to evaluate the inner structure) has confirmed that the tubes of PID victims, who seemingly have normal pelvic anatomy, oftentimes have internal scarring and/or adhesion. This could account for the low success rate seen with tubal reparative surgeries and the high ectopic pregnancy rate (8-15%) in PID patients who subsequently conceive.
Ureaplasma Urealyticum Infection: Ureaplasma urealyticum infection is an organism which causes a relatively benign form of PID. Often times neither partner has any symptoms or signs of the condition. It has been implicated as a possible cause of both infertility and early recurrent miscarriages. The organism is sexually transmitted and infects the lining of the cervical canal. It rarely produces symptoms of severe physical complications in its female victims. In men, it sometimes causes nonspecific urethritis and/or prostatitis, but in the majority of cases is asymptomatic. Recent research suggests that infection with Ureaplasma urealyticum might be capable of altering the physico-chemical properties of cervical mucus and/or cervical secretions, so that when a catheter is passed into the uterus to transfer embryos or sperm, the organisms gait entry to the uterine cavity, and produce and environment that is inhospitable to embryos.
Management: Emphases should be placed on the prevention of PID by appropriate population screening for sexually transmitted diseases and through the promotion of condom usage in non-monogamous sexual relationships. Acute PID should be vigorously treated with the appropriate antibiotics. Gonorrhea is usually successfully treated with penicillin derivatives, cephalosporins, erythromycin, ciprofloxin and tetracyclines. Anaerobic organisms such as Bacteroides and Peptostreptococcus are responsive to metronidazole (Flagyl), ciprofloxin and in some cases to doxycycline. Beta hemolytic Streptococcus and E. coli respond to penicillin derivatives, tetracyclines, and cephalosporins and ciprofloxin. E. coli can also be treated with the gentamicin. PID due to Chlamydial infection responds well to doxycycline, erythromycin, and ciprofloxin therapy, but will usually not respond to penicillin derivatives or cephalosporins. Ureaplasma urealyticum infections likewise respond well to the same antibiotics and to Flagyl.
All active sexual contact should be treated concurrently and follow up cultures should always be performed to confirm complete eradication of the disease.
The pain, heavy bleeding, and debilitation associated with chronic PID often necessitates removal of the tube(s) and sometimes even hysterectomy, especially in women who have no childbearing aspirations. Younger women who are desirous of having a child might defer such treatment while enduring ongoing symptoms, in the hope of conceiving in the interim.
Diagnosing Tubal damage due to PID: Tubal blockage can occur anywhere in the fallopian tubes. It sometimes occurs in the part of the Fallopian tube that passes through the wall of the uterus. It can also occur in the mid-section of the tube. Most commonly however, it occludes the far end of the tubes.
A hysterosalpingogram (HSG) is the most widely used screening test for damaged or blocked tubes. It involves the injection of a radio-opaque dye through the cervix into the uterus. Successive x-rays are then taken in rapid succession to track passage of the dye into the uterus and then to determine whether it passes into the Fallopian tubes and then spills into the pelvic cavity. However, a HSG showing patent tubes, cannot usually diagnose tubal damage. All it tells you is whether the petal-like fimbriated ends of the tubes have not fused and blocking their ends. It is especially important to take bear this fact in mind whenever the tubes are found to be open, in spite of there being a history of prior PID. A diagnostic laparoscopy is much more reliable for diagnosing both tubal blockage and damage.
Treating Tubal Damage due to PID: Tubal damage is one of the most common causes of infertility. The Fallopian tubes are not merely “pipes”; they are highly complex structures that pick up the ovulated egg and help move it towards the uterus. Normal fertilization occurs in the tube. And, as stated above, damage to Fallopian tubes is most often caused by PID.
During the 1980’s, surgery was regarded as the mainstay of treatment for infertility secondary to PID. The advent of high success rates with in vitro fertilization as performed in selected centers of excellence has changed all of that. Today, virtually without exception, most fertility specialists would agree that IVF is the treatment of choice for almost all forms of tubal infertility.
Surgery to unblock fallopian tubes or clear adhesions resulting from an inflammatory process due to infections with gonorrhea or Chlamydia is truly an exercise in futility. The chances of pregnancy occurring following such an undertaking is less than 2% per month, and less than 25% in three years.
Then there is the fact that there is a high incidence of ectopic pregnancy following tubal surgery (15-20%) and this can be a life endangering condition. Finally, more than 70% of patients undertaking such an escapade would ultimately need IVF anyway, there is no longer any medical justification to choose tubal surgery over IVF.
Hydrosalpinx: In cases where the ends of the fallopian tubes are blocked, pus may collect and distend the tube(s). The pus is usually absorbed over time and replaced by clear straw-colored fluid. The resulting, occluded, fluid-filled, distended, and often functionless fallopian tube(s) is referred to as a hydrosalpinx.. Such distended Fallopian tubes (hydrosalpinges) can leak fluid back into the uterine cavity where the can destroy transferred embryos upon contact. This is why patients who have hydrosalpinges and are considering undergoing IVF, should first have hydrosalpinges surgically removed or at the very least have the affected tube(s) surgically clipped or tied as they emerge through the uterine wall. This will avoid subsequent back flow when IVF is performed. Understandably, it is often hard for patients to come to terms with the fact that following such surgery they no longer have any possibility of having functional Fallopian Tubes. Such women should be counseled that hydrosalpinges are functionless tubes anyway and that any attempt to open such tubes surgically in an attempt to restore fertility would be an exercise in futility, anyway.
In a nutshell: Tubal surgery is a very poor alternative to IVF. Infertility associated with tubal blockage, especially if due to PID, is an absolute indication for IVF. I would go even further in stating that any tubal damage due to PID, whether or not it is associated with blockage is an indication for IVF.