**4. Infections and female infertility**

#### **4.1. Pelvic inflammatory disease**

PID is a common but vaguely defined complex of signs and symptoms resulting from the spread of pathogenic microorganisms from the vagina and endocervix to the uterus, body of the endometrium, and fallopian tubes. PID can also follow aseptic induced abortion or as a post-partum infection. *C.Trachomatis* salpingitis can be seen in as many as 15% patients who undergo an induced abortion. PID has reached epidemic proportions and according to the CDC, the cost of PID measured in lost earnings and money spent for health services was estimated at \$4.2 billion in 1990.[15] According to a Swedish study[16] tubal infertility occurs in approximately 11% of women who have one episode, in 23% of women who have two episodes, and in 54% of women who have three or more episodes of salpingitis. (Table 2)

As could be seen from Table 2, they found that tubal infertility is directly related to a number of factors present during the initial episode of salpingitis, which include (besides the number of episodes) the initial severity of tubal inflammation, the organisms responsible, and the occurrence of a subsequent ectopic pregnancy. The best predictor of subsequent infertility is the degree of tubal inflammation observed through the laparoscope during the acute phase. Womenwithapelvicabscesshavehadthehighest(85%to90%)rateof subsequentinfertility.[17]


\* Westrom L: Incidence, prevalence and trends of acute pelvic inflammatory disease and the consequences of industrialized countries. Am J ObstetGynecol 135:880, 1980.

† Westrom L: Effects of acute pelvic inflammatory disease on infertility. Am J ObstetGy‐ necol 121:707, 1975

#### **Table 2.** Factors Influencing the Frequency of Tubal Occlusion after Salpingitis

Prompt recognition and vigorous treatment reduce subsequent severe complications of salpingo-oophoritis, such as generalized pelvic peritonitis, abscess formation, and adnexal destruction. However, many patients of PID are often asymptomatic. Approximately 60% to 80% of women with acute salpingitis have a normal temperature or no white blood cell elevation. This finding correlates with the observation that most women with tubal infertility have never been treated for a recognized episode of salpingitis. Epidemiologic studies support the concept of silent PID wherein a strong link exists between serum antibodies to *C. tracho‐ matis* and tubal factor infertility or ectopic pregnancy in patients without a history of clinical PID.[18]

#### *4.1.1. Treatment strategies*

yields abnormal sperm function tests, possibly because of the damaging effects of free radicles of WBCs to the sperms in their journey through the epididymis.[11] There is also substantial evidence that infection contributes to the development of sperm antibodies. Sperm antibodies have been detected in 48% of men with culture-positive asymptomatic infections, 47% of men with a history of urethritis or prostatitis, and in only 5% of men with no infection and a normal

The presence of IgA antibodies was associated with reduced fertility.[12] High concentrations of sperm antibodies can interfere with fertility by several mechanisms. Antibodies on sperm heads or tails may cause sperm to agglutinate. Tail-bound antibodies also interfere with sperm motility. Antibodies anywhere on spermatozoa can lead to sperm phagocytosis through binding to Fc or complement receptors on phagocytic cells. Similarly, antibody-bound sperm react with cervical mucus leading to sperm immobilization and expulsion from the female genital tract. Antibodies on sperm can interfere with sperm binding and penetration of the oocyte.[13] Similar to the situation in women, *C. trachomatis* infection of the male genital tract is often asymptomatic and therefore may persist for a long time. One study using PCR analysis of semen specimens suggested that an asymptomatic unsuspected *C. trachomatis* male genital tract infection may be the cause of previously unexplained infertility.[14] In response to a persistent asymptomatic chlamydial infection and HSP60 production, γδ T cells may be induced in the male genital tract; γδ T cells are capable of releasing proinflammatory cytokines

and could therefore initiate an antisperm immune response within the genital tract.

PID is a common but vaguely defined complex of signs and symptoms resulting from the spread of pathogenic microorganisms from the vagina and endocervix to the uterus, body of the endometrium, and fallopian tubes. PID can also follow aseptic induced abortion or as a post-partum infection. *C.Trachomatis* salpingitis can be seen in as many as 15% patients who undergo an induced abortion. PID has reached epidemic proportions and according to the CDC, the cost of PID measured in lost earnings and money spent for health services was estimated at \$4.2 billion in 1990.[15] According to a Swedish study[16] tubal infertility occurs in approximately 11% of women who have one episode, in 23% of women who have two episodes, and in 54% of women who have three or more episodes of salpingitis. (Table 2)

As could be seen from Table 2, they found that tubal infertility is directly related to a number of factors present during the initial episode of salpingitis, which include (besides the number of episodes) the initial severity of tubal inflammation, the organisms responsible, and the occurrence of a subsequent ectopic pregnancy. The best predictor of subsequent infertility is the degree of tubal inflammation observed through the laparoscope during the acute phase. Womenwithapelvicabscesshavehadthehighest(85%to90%)rateof subsequentinfertility.[17]

**4. Infections and female infertility**

**4.1. Pelvic inflammatory disease**

semen analysis.

6 Genital Infections and Infertility

Prompt treatment is the key in adequate eradication of the responsible organism(s) and preventing long term sequelae like hydrosalpinx, infertility, ectopic pregnancy, and chronic pelvic pain. If the patients with mild symptoms had only cervicitis or endometritis and not salpingitis, prompt treatment before the onset of salpingitis would have a major impact on preventing tubal occlusion. Failure to use doxycycline or azithromycin to inhibit *C. trachoma‐ tis* may contribute to chronic salpingitis.[19] Approximately one half of the women with an ectopic pregnancy have grossly visible tubal damage or a partial occlusion of the tubes. About 7% to 10% of pregnancies that occur after an episode of salpingitis are in an ectopic location, and women with salpingitis have a 10-fold higher rate of ectopic pregnancy than does the general population. Approximately 40% of women who have had an ectopic pregnancy are not able to achieve an intrauterine pregnancy subsequently.[20]
