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

2. 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

3. 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 yr:
18,600 chronic pelvic pain
16,800 infertility
8550 EP

4. 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

5. 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

6. 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

7. Risk factors for chronic pelvic pain:
Recurrent PID; strongest predictor (odds ratio [OR] 2.84, 95% CI )
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 )

8. 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.

9. 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.

10. ●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

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

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

13. 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

14. 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.

15. 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 ), with the highest risk in women with multiple episodes of PID (HR 2.46, 95% CI 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.

16. 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

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

18. 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 )

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

20. 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

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