Pelvic inflammatory disease and tubal infertility: the preventable conditions.

Abstract

There are three clear links in the causal pathway for pelvic inflammatory disease (PID): lower genital tract sexually transmitted disease (STD) followed by upper genital tract PID and then tubal infertility. This pathway also entails two clear relationships that have a temporal lag in clinical expression: STD leading to PID and PID leading to tubal infertility. The genital microbial environment the individual behavioral environment (e.g. sexual behavior) and the sociogeographic environment have overlapping effects on these relationships. Neisseria gonorrhoeae Chlamydia trachomatis and anaerobic bacteria are the most common pathogens associated with upper genital tract infection. STD organisms initially infect the cervix endometrium and tubal mucosa and prepare the tissue for subsequent polymicrobial infection. A concurrent prolonged inflammatory response and latent chlamydia infection of the endometrium and/or fallopian tube may further predispose infection with aerobic and anaerobic bacteria. The anaerobic bacteria cause damage by both direct effects of virulence factors and secondary effects on host defenses. Risk factors for PID and infertility include age contraceptive choice and cigarette smoking. Other PID risk factors are race frequency of intercourse timing of coitus sex practices age of onset of sexual activity previous episodes of gonococcal PID and douching. Other risk factors for infertility are number of previous PID episodes severity of pelvic inflammation and chlamydia infection. Asymptomatic PID accounts for more than 50% of all PID cases. Atypical symptoms (e.g. oligomenorrhea) or biochemical (e.g. metabolic or immunologic) markers may need to be used to identify PID. Tubal infertility occurs in 10-30% of couples seeking infertility services in developed countries. All studies show a strong relationship between STD/PID and infertility. The pathogenesis of infertility includes postinfectious scarring microbiologic virulence and host immune factors. The most cost effective way to reduce tubal infertility is prevention of lower genital tract STDs.