Pelvic Inflammatory Disease
Pelvic Inflammatory Disease (PID) refers to conditions that affect pelvic structures including the uterus, fallopian tubes, ovaries, bowel, and the smooth membrane that lines the surface of the pelvic cavity (the peritoneum). PID follows infection which reaches pelvic structures as a result of:
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
quite 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 has been estimated that about 1,300,000 women develop PID annually in the United States. Less than one-third of these women present with acute pelvic inflammatory disease. The remaining cases usually go undetected until the woman presents with symptoms of 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 acute PID.
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 infect the cervix (the opening into the uterus) through which it ascends via the uterus to the fallopian tubes, ovaries, and other pelvic structures.
Resolution of PID-Related Infertility
Most fertility specialists would agree that IVF is the treatment of choice for almost all forms of tubal infertility. One exception that is commonly cited involves surgical reversal of tubal ligation. It is correctly argued that the chance of having a baby being born within a year of such surgery is about 50%. Those who favor surgical tubal reversal over IVF in such cases often site the national IVF birth rate of 25% as an argument in favor of this position. However, in selective IFV centers of excellence, where the anticipated birth rate following a single attempt at IVF in women under 40 years is almost double the national average, and the birth rate following three IVF attempts is in the order of 80%, this recommendation is outdated.
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 chance of pregnancy occurring following such an undertaking is less than 2% per month, and less than 25% in three years. We concur with a recent opinion by the Chairman of Gynecology and Obstetrics at UCLA, that in the modern context, infertility surgery for fallopian tubes damaged by inflammation should be considered an “anachronism”.
Given the high incidence of ectopic pregnancy following tubal surgery (20-25%), the fact that surgery requires hospitalization for a number of days, general anesthesia, associated pain, and a significant risk of post-operative complications make tubal surgery less appealing. Furthermore, greater than 70% of the women that choose tubal surgery ultimately need IVF anyway. To make matters worse, some women have undergone more than one attempt at surgical tubal restoration. Since second and third attempts at surgery are even less likely to result in a pregnancy than the first attempt, such practice is worse than unwise.