Pelvic inflammatory disease is a general term used to describe infection of uterus (womb), fallopian tubes (tubes that carry egg, sperm, embryo between ovaries and uterus), ovaries and other reproductive organs.
The pelvic organs get infected commonly due to bacterial organisms. These organisms reach the uterus, tubes and ovaries through sexual route i.e. vagina. Gonorrhoea and chlamydia are two common bacterial organisms that cause PID. Tuberculosis can also cause PID. Tuberculosis can be transmitted via the sexual route or through blood when some other organ in body is infected.
While infection of the uterus is called endomyometritis. Salpingitis and salpingoophoritis indicates infection of tube and ovary. Infection may spread to surrounding organs such as intestines (bowel) and bladder. These organs may get stuck to each other to prevent further spread of infection leading to what is called as Pelvic adhesions (similar to fevicol smeared in between fingers) or Tubo-ovarian mass (collection of mass due to sticking together of the surrounding structures).
Adhesions between the bowel and anterior abdominal wall
How does PID cause Infertility?
Untreated, undiagnosed and repeated infections may lead to permanent damage to reproductive organs leading to infertility. This may present with intrauterine adhesions, hydrosalpinx, pelvic adhesions or deforming tubo-ovarian relation. All these leads to altered anatomy of the uterus, fallopian tubes and ovaries leading to difficulty in the egg being picked up by the fallopian tube or the meeting of the egg with the sperm or sometimes the attachment of the embryo in the womb (inner cavity of uterus.)
Video of mid tubal block
In INTRAUTERINE ADHESIONS the two walls of uterus or womb get stuck to each other after infection causing closure of cavity and preventing the lining of womb to grow and therefore the embryo or egg cannot implant (enter the lining). It is like when two pieces of wood get stuck to each other with glue there is no space between them.
HYDROSALPINX (Fluid within the tube) occurs after infection of the tubal lining. The inner lining of the fallopian tube is ciliated i.e it has some finger like projections for movement of the sperm, egg and embryo. This lining is extremely delicate. When there is infection of the fallopian tubes this lining gets affected and inflamed leading to permanent loss of function of the cilias in most cases.
The tube lining gets infected with bacterial organisms and produces a fluid to fight the infection. The infection may get cured but the fluid remains. Also the tube lining may get destroyed due to infection. Fallopian tubes are very important structures through which the ovum or female eggs go from ovary to uterus, the sperms or male eggs go from uterus to tube, also the early embryo develops within the tube and then goes to uterus.
Video of Hydrosalpingx
When the tubes get destroyed with formation of hydrosalpinx these functions are lost and thereby causing infertility. Also the fluid in hydrosalpinx is toxic to embryo so it can also lead to failure of IVF. In such cases separation of tubes (delinking) from the uterus will be required for successful IVF. This procedure delinks (detaches) the fallopian tubes from the uterus and hence prevents the spread of the toxic fluid to the uterus and embryos. This leads to increase chances of pregnancy in cases of IVF /ICSI.
Delinking of the tube from the uterus in case of Hydrosalpinx
(Bowel stuck to the uterus and left tube and ovary)
Video of delinking
Another important complication of PID especially in cases of tubal involvement is ECTOPIC PREGNANCY. It has been seen that the fallopian tubes are involved in almost 90% of cases of PID. If pregnancy results in these cases there is a very high risk of the embryo attaching and implanting in the tubes itself. This is known as ectopic pregnancy. Such pregnancy cannot grow as the tubes are very small and may rupture any time leading to blood in the abdomen and life threatening condition.
Above pictures show right tubal ectopic pregnancy and its laparoscopic excision.
Therefore it is very important to do serial serum beta HCG once you are pregnant. This should be followed by USG to localise the pregnancy. In case of early ectopic pregnancies medical management can be done in the form of methotrexate injections. If the ectopic pregnancy is detected late than surgical removal is the only option. Once methotrexate is used, after the beta HGC values in the blood come to normal , the next pregnancy can be planned in 3 – 6 months.
When infection reaches outside the tube into abdominal cavity, women’s body tries to prevent the spread of infection to other parts of body. When this occurs, the intestine, the fallopian tubes and the ovaries may get stuck to each other, leading to what is called PELVIC ADHESIONS. In the process the normal relationship between tube and ovaries get destroyed. Normally tubes and ovaries are arranged in such a way that when an egg ruptures it is directly transferred to the tube.
Due to the adhesions the tube and ovary may be pulled away from each other and therefore even if there is normal ovulation or rupture of egg, it does not enter the tube.
How do women get PID?
Sexually active women in their childbearing years are at most risk, and those under age 25 are more likely to develop PID than those older than 25. This is because the cervix of teenage girls and young women is not fully matured, increasing their susceptibility to the bacteria that cause PID.
Poor personal hygiene in either or both the couple may increase the incidence of PID.
The sperm (tail of the sperm) and the vaginal flora may also carry the infection into the female reproductive tract i.e. uterus and fallopian tubes.
Women who douche (clean their vagina with jet of water or soap water) may have a higher risk of developing PID compared with women who do not douche. Research has shown that douching changes the vaginal flora (organisms that live in the vagina) in harmful ways, and can force bacteria into the upper reproductive organs from the vagina.
Women who have an intrauterine device (IUD e.g. Copper T) inserted may have a slightly increased risk of PID near the time of insertion. However, this risk is greatly reduced if a woman is examined and, if necessary, treated with antibiotics before an IUD is inserted.
Intrauterine invasive surgeries if not performed using proper antiseptic precautions and under the cover of antibiotics can also lead to PID. Therefore dilatation and curettage, MTP and abortions can also predispose to PID.
What are the symptoms of PID?
Symptoms of PID may vary from none to severe. Those women who have symptoms may have one or more of the following:
Pelvic pain or tenderness
Pelvic pain during intercourse (dysparaeunia)
Smelly yellow or green vaginal discharge
Fever or chills
Mild to severe nausea
Many a times a woman may experience mild symptoms or no symptoms at all, while serious damage is being done to her reproductive organs. Because of unclear symptoms, PID goes unrecognized by women and their doctors about two thirds of the time.
How is PID diagnosed in women with fertility problems?
Women may present with symptoms of vaginal discharge or pain in lower abdomen. However frequently they have no symptoms and chronic PID may be diagnosed on USG (sonography), HSG (hysterosalpingography) or at the time of diagnostic laparoscopy.
Hydrosalpinx and intrauterine adhesions are visualized on USG. Many a time lack of growth of lining of the uterus may be suggestive of old infection. T-shaped uterus seen on USG may also indicate past infection. Non-motile or adherent ovary with probe tenderness may also reflect adhesions in the pelvis.
HSG findings like extravasation of the dye, T-shaped uterus, dilated thick beaded tubes, absent spill in one or both tubes, or loculated spill are suggestive of damage done due to PID.
Many a times a diagnostic laparoscopy and hysteroscopy may be planned for other reasons and hydrosalpinx, blocked tubes or adhesions may be picked at that time. In these cases, we at Ankoor clinic also do adhesiolysis as well, so that the patient does not have to undergo a repeat procedure (only after the couple’s consent).
How can all this be treated?
Acute infection causing severe pain and vaginal discharge is treated with antibiotics. It is always better to treat both the women and her male partner as the infection is usually sexually transmitted.
However most women who come to infertility clinic, have an old infection i.e. chronic PID. These women will have no symptoms. The diagnosis is based on evidence seen on USG, like presence of hydrosalpinx or intrauterine adhesions. This can be treated surgically only.
Laparoscopy and hysteroscopy are gold standard for treatment for chronic PID. On laparoscopy serial examination of the pelvis and upper abdomen is done to see presence of adhesions, hydrosalpinx etc. Under laparoscopic guidance these adhesions can be released, infected fluid drained and normal anatomy can be established. Tubal patency can be checked by pushing a dye through the tubes.
In case of a hydrosalpinx, the tube needs to be either removed or cut off from the uterus. This is done because as explained before these tubes are non functional and would not allow normal conception (pregnancy). In which case the women will finally require IVF or test tube baby. The fluid from the tube is toxic to the embryos which are put in the uterus during IVF and therefore it is better to cut the tubes from the uterus. This will improve the success rates of IVF.
Intrauterine adhesions and T-shaped uterus a sequel of old infection need to be treated hysteroscopically. Adhesiolysis and metroplasty are the surgeries used to treat these. These women may sometimes need more than one surgery to finally restore normal uterine cavity.
What are the complications of PID if left untreated?
Besides causing problem in conceiving, untreated infection can lead to problems like ectopic pregnancy or abortions.
Scar tissue formed in the fallopian tubes, prevents movement of a fertilized egg towards the uterus. This causes the embryo to implant within the fallopian tube itself, which can be life-threatening.
Thin lining of the uterus decreases the blood supply to the implanted embryo and may lead to missed abortion. Also in presence of hydrosalpinx the infective material from the tube can be toxic to embryo and may lead to early pregnancy loss.
Besides this complication, chronic infection can lead to constant dull aching pain in the lower abdomen and may hamper day to day life of a woman. If a woman conceives and the pregnancy continues there are chances of preterm labour and low birth weight of the baby.