Have you ever wondered why sexually transmitted diseases (STDs) can lead to infertility problems? An important part of the answer is pelvic inflammatory disease (PID). PID is an infection of the vagina and upper genital tract. It affects millions of women worldwide every year. 12.5% of women experience infertility after PID and about 25% will develop chronic pelvic pain.
What is pelvic inflammatory disease (PID)?
PID also known as an “ascending” infection – starts in the lower genital tract (vagina and cervix) and progresses to the upper genital tract (fallopian tubes, uterus, ovaries) as it spreads. How PID is categorized depends on how it presents, persists, and whether a clinical cause has been identified:
- Acute PID: When symptoms appear suddenly or severely, it is defined as acute PID. It can cause long-term and short-term symptoms such as pelvic and abdominal pain, infertility and an increased risk of ectopic pregnancy.
- Subclinical PID: When PID is largely asymptomatic or presents atypically, it is called subclinical PID. It is often diagnosed when there are indicators of pelvic inflammation, such as blocked fallopian tubes due to scarring, disease or injury.
- Recurrent PID: Multiple cases of PID can occur if the original infection is not adequately treated or if the patient is reinfected with a primary infection.
What causes PID?
In at least 85% of cases, PID is caused by untreated chlamydia and gonorrhea – two of the most common sexually transmitted infections (STDs). The remaining 15% of cases may be caused by a mixture of other types of bacteria that have traveled to the reproductive tract and caused infection, such as the bacteria mycoplasma genitalium (a less common STD) and pathogens that lead to bacterial vaginosis (the most common vaginal infection). When a woman develops pelvic inflammatory disease, the damage caused by the infection can make her more vulnerable to future infections in the same area, further increasing the risk of infertility.
What are the symptoms of PID?
While subclinical PID often initially presents with no symptoms or atypical, nondisruptive symptoms, acute PID is more likely to have clinically measurable symptoms. This could mean that subclinical PID is, unfortunately, more likely to go undetected.
Common symptoms of PID include:
- Pain in the lower abdomen
- "Unusual" vaginal discharge with an odor
- Pain and/or bleeding during sex
- Burning during urination
- Bleeding between periods
Can PID have long-term, chronic effects?
Complications caused by PID include chronic pelvic pain, infertility, ectopic pregnancy, and a high susceptibility to recurrence of PID. These complications are usually associated with damage and scarring of the reproductive organs and prolonged inflammation, including:
- Scar tissue formation both outside and inside the fallopian tubes that can lead to blockage of the fallopian tubes (associated with fallopian tube factor infertility)
- Ectopic pregnancy (pregnancy outside the womb) which can be life-threatening
- Chronic pelvic/abdominal pain
- Tubo-ovarian abscess
- Hydrosalpinx: Blockage and swelling within the fallopian tubes, a major cause of tubal factor infertility (TFI).
- The inability to get pregnant is often the first noticeable symptom and this condition also negatively affects the results of IVF.
How is PID diagnosed and treated?
PID is diagnosed with a pelvic exam, tests for sexually transmitted diseases, and tests for other infections. Tests may include genital swabs, blood samples, ultrasounds, and biopsies.
- A positive smear result confirms PID, but a negative smear result does not necessarily indicate that PID is not present.
- Mild and moderate PID is usually treated with antibiotics. More severe and long-term cases may require surgery, drainage of an abscess, or extensive antibiotic therapy.
Does PID affect fertility?
Although PID is treatable, the scarring it can cause to the genital tract, and sometimes the resulting infertility, often is not. Both acute and subclinical PID can lead to infertility by damaging the reproductive organs, causing blockages, or disrupting reproductive processes. Some of these lesions, for example in the tiny cilia lining the fallopian tubes, are not visible to the naked eye. The infertility effects of PID can be difficult to treat as the structural changes to the reproductive system that PID sets in motion (such as blockage of the fallopian tubes due to scar tissue) are usually permanent. About 15% of female infertility is estimated to be related to PID. This becomes more likely once the infection has spread beyond the cervix and when there is permanent damage to the fallopian tubes, such as loss of radial function, fibrosis and blockage of the fallopian tubes.
Risk factors for PID-related infertility
Among the causes of PID, chlamydia appears to carry the greatest risk of infertility because it is often asymptomatic. Some studies suggest that this could also be linked to individual immune responses to chlamydia and a greater inflammatory response. Infertility becomes significantly more likely after the onset of either subclinical or clinical PID.
The risk of infertility increases when:
- Care for PID is delayed
- There is an increased number of PID episodes
- The infection is more serious
- Fallopian tube damage occurs:
Can you have PID while pregnant?
Although uncommon, when PID coincides with pregnancy, it is more likely to occur in the first trimester. If caught early, it can still be treated with antibiotics, probably intravenously (although some types are best avoided in pregnancy). However, PID during pregnancy is still a risk factor for serious complications, including an increased risk of: pregnancy loss, ectopic pregnancy, especially if PID was present at conception, premature birth, maternal death in severe cases, especially when an untreated ectopic pregnancy, caused by PID, leads to a ruptured fallopian tube and dangerous internal bleeding. PID can also occur as a postpartum infection within six weeks of giving birth, usually as inflammation of the lining of the uterus. This is more likely to happen after a C-section, with a prevalence rate of only 1-3 in 100 women giving birth vaginally.
Can PID be prevented?
All women who are sexually active are potentially at risk of developing PID, although there are steps you can take to limit your exposure. If you're sexually active and not trying to conceive yet, using barrier methods during intercourse is a great preventative step. Ovulatory people whose partners use condoms consistently and correctly are less likely to develop recurrent PID or infertility. Although it does not provide absolute protection, the use of condoms can reduce the chance of infection by 30-60%.
Importantly, the Centers for Disease Control and Prevention recommends that all health care providers screen for:
- All women who are sexually active
- They have a new sexual partner
- They have more than 1 romantic partner
- They have a romantic partner with simultaneous partners
- They have a sexual partner who has a sexually transmitted disease
- All pregnant women under the age of 25
- Review all women approximately 3 months after treatment
- Screening for chlamydia rectal testing based on reported sexual behaviors
Pelvic inflammatory disease (PID) can lead to both chronic pain and infertility. And subclinical PID can pose an increased risk to fertility because it often goes undetected. Additionally, the diagnostic tools for subclinical PID are not as clear until a woman presents with unexplained infertility or tubal obstruction. Sexually transmitted infections are the most common cause of PID and can often be asymptomatic. Getting tested for STIs (and encouraging any sexual partners to do the same) and using protective methods, such as condoms, are two of the best ways to protect against PID.
Finally, finding a qualified and experienced gynecologist to achieve early detection and treatment of the disease is the key to avoiding future effects of the disease on your fertility. To learn more about pelvic inflammatory disease and its treatment, contact the Center for Reproductive and Fetal Medicine – Dr. Alexander Trajan for a consultation.