Subclinical pelvic infections may impact fertility reports new study

Robin Wulffson MD's picture
pelvic inflammatory disease, PID, subclinical, infertility, STD
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Pelvic inflammatory disease (PID) is an inflammation of the pelvic organs, which can involve the uterus, fallopian tubes, and ovaries. It can cause inflammation and scarring of those structures as well as surrounding areas in the abdomen. It commonly is caused by a sexually transmitted disease STD) such as chlamydia or gonorrhea.

Often, a woman who acquires PID experiences symptoms such as pelvic pain and a vaginal discharge. Sometimes, symptoms are minimal or absent. This is known as subclinical PID. Researchers affiliated with the University of Pittsburgh and the University of California, Davis conducted a study involving the impact of subclinical PID on infertility. They published their findings in the July issue of Obstetrics & Gynecology.

The researchers noted that infertility affects up to 7 million reproductive-aged women in the US. They note that assisted reproductive technology (ART), including in vitro fertilization, now account for more than 1% of all births in the nation. Almost 10% of infertility cases involve fallopian tubes damaged by PID. The authors note that the rate of PID has decreased in the US; however, the rate of tubal infertility has not; this suggests that a large proportion of PID leading to infertility may be undetected. They note rhat subclinical PID is common in women with uncomplicated chlamydial or gonococcal cervicitis or with bacterial vaginosis. The researchers conducted a study to evaluate whether women with subclinical PID are at an increased risk for infertility.

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The study group was comprised of 418 women with or at risk for gonorrhea or chlamydia, or with bacterial vaginosis. Women with acute PID were excluded and were not part of the study group. An endometrial biopsy (biopsy of the lining of the uterus) was performed to identify endometritis (inflammation of the endometrium; subclinical PID). After receiving treatment for gonorrhea, chlamydia, and bacterial vaginosis. The women were followed-up for fertility outcomes.

The researchers found that 146 women achieved a pregnancy during follow-up: 50 pregnancies in 120 (42%) women with subclinical PID and 96 in 187 (51%) women without subclinical PID. Women with subclinical PID diagnosed at enrollment had a 40% reduced incidence of pregnancy compared with women without subclinical PID. However, women with Neisseria gonorrhoeae or Chlamydia trachomatis, in the absence of subclinical PID, were not at increased risk for infertility.

The authors concluded that, despite treatment for a STD, subclinical PID decreases subsequent fertility. They noted that their findings suggest that a proportion of female infertility is attributable to subclinical PID and indicate that current therapies for sexually transmitted diseases are inadequate for prevention of infertility.

Take home message:
This study illustrates the consequences of not practicing safe sex. PID not only impacts fertility but also can cause severe pain requiring a total hysterectomy for relief. Over time, subclinical PID can progress to symptomatic PID. Prevention involves the use of condoms as well as limiting sexual activity to a stable monogamous relationship. An additional complication of PID, both clinical and subclinical is a tubal (ectopic) pregnancy. In these cases, a pregnancy lodges in the damaged tube and begins to develop. Before the pregnancy progresses very far, the tube ruptures, which can result in major, sometimes fatal, internal bleeding.

Reference: Obstetrics & Gynecology

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