Laparascopy in chronic PID Dr.Fatemeh Keikha Fellowship o infertility & IVF Valiasr Hospital, IKHC,TUMS

PID Infection of the female upper genital tract  ≥ 1 sequle Endometritis Salpingitis Oophoritis Pelvic peritonitis Perihepatitis Prompt diagnosis and treatment   risk short & long-term complications

Treatment and clinical improvement in symptoms  scarring and adhesion formation ✚ healing of infection- damaged tissues  long-term sequelae: — Chronic pelvic pain — Infertility, — Ectopic pregnancy — Morbidity, suffering, and cost A cohort of 100,000 females with PID 20- 24 yr: 18,600 chronic pelvic pain 16,800 infertility 8550 EP

RECURRENT PID Women with a history of PID  risk of recurrence Low income African American women with mil-moderate PID: 15 % recurrence in 35 month 21% recurrence in 84 months Adolescents: 50% more recurrence than adult women Other populations may have lower/ higher recurrence

HYDROSALPINX After PID resolves; Damaged fallopian tube  blocked  fill with sterile fluid  enlarged Damaged fallopian tube from previous surgery / adhesions  hydrosalpinx Asymptomatic Pain Tubal factor infertility Hydrosalpinx in IVF   rates of pregnancy, implantation, live delivery  Early pregnancy loss  Preterm birth

CHRONIC PELVIC PAIN Menstrual / non-menstrual pain At least 6 month Below the umbilicus Severe  functional disability 1/3of women with PID  chronic pelvic pain Etiology is unknown Infectious process  Inflammation  Scarring & adhesions

Risk factors for chronic pelvic pain: Recurrent PID; strongest predictor (odds ratio [OR] 2.84, 95% CI 1.07-7.54) Non-black race Married status Smoking Poor mental health score A case-control study  correlation between a Hx of PID & painful bladder syndrome as a sequelae of PID (OR 3.69, 95% CI 2.89-4.71)

INFERTILITY Symptomatic /asymptomatic PID  Permanent injury of endosalpinx Loss of ciliary action Fibrosis Occlusion Subclinical PID = histologic endometritis with no symptoms of acute PID  fertility, even in treated for chlamydia, gonorrhea, and bacterial vaginosis Treatment of cervicitis without endometritis does not appear to have this effect. Prevalence of infertility after acute PID:  several-fold. Cohort study of 2501 Swedish women with suspected PID  Diagnostic laparoscopy  followed ≥ 25 yr Among women desiring pregnancy, 16% of those with laparoscopically-confirmed PID (group 1) and 2.7% of those with normal laparoscopic findings (group 2) failed to conceive Tubal factor accounted for 67.6 %of infertility diagnoses, but was not a cause of infertility in any woman in group 2.

Risk factor Chlamydial infection Greatest risk of infertility 1 in 4 women with tubal factor serum antibodies to C. serum titers of C. trachomatis antibodies correlate inversely with pregnancy rates The pregnancy rates in women with the highest and lowest titers were 59 and 73%, respectively, 7 yr post-infection. Infertility after PID may result from the host’s immune response to chlamydial infection A high titer may be associated with a greater inflammatory response.

●Delay in seeking care for PID women with PID who delayed treatment ≥3 days  threefold more infertility In women with chlamydial infection, 17.8 %of those who delayed seeking care had impaired fertility, whereas none of those who sought care promptly suffered sequelae

Increasing number of PID episodes A classic review found that pregnancy rates after: 1 of PID 89% 2 episodes 77% 3 episodes 46%

Severity of infection The cumulative proportions of women achieving a livebirth after Mild PID = 90% Moderate PID =82% severe PID = 57%

ECTOPIC PREGNANCY Tubal damage caused by PID increases the risk of tubal pregnancy, as well as infertility The increased expression of certain proteins involved in implantation may play a role in the pathophysiology

prospective Swedish cohort study; incidence of EP in the first pregnancy after laparoscopically- confirmed PID was 7.8% versus 1.3% in women without PID The risk of EP increased with the number of episodes and severity of PID: •After 1, 2, and 3 episodes of PID, the ratio of EP/intrauterine pregnancy was 1:15, 1:6, and 1:3, respectively. •In women with a single episode of mild, moderate, or severe PID, the ratio of EP/intrauterine pregnancy was 1:35, 1:25, and 1:5, respectively.

OVARIAN CANCER A population-based, case-controlled study from Taiwan: Hx of PID was two-fold increase in the risk of ovarian cancer (HR 1.92, 95% CI 1.27-2.92), with the highest risk in women with multiple episodes of PID (HR 2.46, 95% CI 1.48-4.09 for women who had at least five episodes of PID) Additional studies have reported similar associations. It is not known whether PID is an independent risk factor for ovarian cancer, as PID increases the risk of low parity, nulliparity, nulligravidity, and infertility, which are also risk factors for ovarian cancer.

PREDICTION AND PREVENTION OF LONG-TERM SEQUELAE Signs and symptoms associated with acute PID are poor predictors of the eventual development of chronic sequelae. Clinical and/or microbiologic cure of acute disease does not preclude development of the long-term complications Women with a complete recovery from PID have avoided the increased risk of long-term complications. Recurrent PID  two-fold  infertility ≥ four-fold  chronic pelvic pain prevention of recurrent disease is important

Options to reduce the risk of recurrence include: 1- Condom 2- Progestin 3- OCP

Condoms Women whose partners consistently use condoms are less likely to develop recurrent PID or infertility Condom use protects against acquisition of STD In the PEACH trial; women with PID who subsequently acquired a lower genital tract infection  2.3 times more chronic pelvic pain than those who did not (adjusted OR 2.3, 95% CI 1.2-3.2)

Progestins Progestin-based contraceptives  decrease the risk of PID Thickens cervical mucus  barrier against ascending infection.

Oral contraceptive pills The protective role of oral contraceptives in the acquisition of PID is controversial; some studies found: Use of OCP  protective effect against the development of chlamydial PID while others did not

Laparoscopy gold standard for diagnosis. But not performed as routine Indicated in patients: who do not respond to initial therapy diagnosis is doubtful