Gonorrhea

There are an estimated 600,000 new cases of gonorrhea in the United States alone each year. In the United States, 75% of reported cases of gonorrhea occur in men and women between ages 15 and 29. The highest rates of infection are found in women age 15 to 19 and men age 20 to 24.

The main site of infection in women is the endocervix. Patients can be asymptomatic, although more frequently symptoms occur, ranging from increased vaginal discharge to bleeding between periods, dyspareunia, and dysuria.

Neisseria gonorrhoeae is a gram-negative coccus that grows in pairs, hence the term diplococcus. N. gonorrhoeae mainly infects columnar or cuboidal cells and not the squamous epithelium of a postpubertal girl. After attaching to the mucosal epithelium, it penetrates through the epithelial cells and into the submucosal tissues. Neutrophils respond and cause sloughing of the epithelium, submucosal microabscesses, and formation of pus. If left untreated, neutrophils are eventually replaced by macrophages and lymphocytes.

Gonorrhea usually spreads along contiguous mucosal surfaces, producing a superficial infection. This is in contrast to staphylococci or streptococci, which tend to penetrate more deeply. Gonorrhea can then extend through the cervical os into the uterine cavity, producing endometritis. It can then spread to the fallopian tubes, causing an acute inflammatory reaction and, if not treated early enough, chronic inflammation, damage to the cilia, and ultimately scarring.

Gonorrhea can also pass beyond the fimbraie of the fallopian tubes and travel up the paracolic gutters and produce an infection around the liver. This is perihepatitis, or Fitz-Hugh–Curtis syndrome (Fig. 33-1). In unusual cases, gonorrhea can produce a disseminated disease with skin rash, infectious arthritis, and rarely endocarditis.

Treatment of a gonococcal infection depends on the location of the infection. If limited to the cervical region, the Centers for Disease Control and Prevention (CDC) recommends treatment with fluoroquinolones, ceftriaxone, or azithromycin (Table 33-3).

Table 33-3 Sexually Transmitted Disease Treatment Guidelines for Adults

Chancroid	Azithromycin 1 g po × 1 or ceftriaxone 250 mg IM in a single dose or ciprofloxacin 500 mg po BID × 3 d or erythromycin base 500 mg po TID for 7 d
Herpes simplex virus — primary	Acyclovir 400 mg po TID for 7–10 d or acyclovir 200 mg po five times a day for 7–10 d or famciclovir 250 mg po TID for 7–10 d or valacyclovir 1 g po BID for 7–10 d
Herpes simplex virus recurrences	Acyclovir 400 mg po TID for 5 days or acyclovir 800 mg po BID for 5 days or acyclovir 800 mg po TID for 2 days or famciclovir 125 mg po BID for 5 days or famciclovir 1000 mg po BID for 1 day or valacyclovir 500 mg po BID for 3 days or valacyclovir 1000 mg po for 5 days.

Herpes simplex virus — suppression Acyclovir 400 mg PO BID or famciclovir 250 mg po BID or valacyclovir 500 mg QD or Valacyclovir 1 g po QD Syphilis — primary and secondary Benzathine penicillin G 2.4 million units IM × 1 Early latent syphilis Benzathine penicillin G 2.4 million units IM × 1 Late latent syphilis Benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM at 1-week intervals Neurosyphilis Aqueous crystalline penicillin G 18–24 million units per day, administered as 3–4 million units q4h for 10–14 d Chlamydia cervicitis Azithromycin 1 g po × 1 or doxycycline 100 mg po BID for 7 d Uncomplicated gonococcal infections of the cervix, urethra, and rectum Ceftriaxone 125 mg IM × 1 or cefixime 400 mg po × 1 or ciprofloxacin^* 500 mg po × 1 or ofloxacin^* 400 mg po × 1 or levofloxacin^* 250 mg po × 1 plus treatment for chlamydia if not ruled out Bacterial vaginosis Metronidazole 500 mg po BID × 7 d or metronidazole gel 0.75% one full applicator intravaginally qd × 5 d or clindamycin cream 2% one full applicator intravaginally qhs × 7 d Trichomoniasis Metronidazole 2 g po × 1 or tiridazole 2 g po × 1 Human papillomavirus — external genital warts Patient-applied: podofilox 0.5% solution or gel BID × 3 d then none for 4 d, repeated up to 4 cycles prn or imiquimod 5% cream qhs 3 × week for up to 16 wk Human papillomavirus — external genital warts Provider-applied: cryotherapy q 1–2 wk or podophyllin resin 10%–25% in tincture of benzoin q wk or trichloroacetic acid q wk or surgical removal

* Should not be used in men who have sex with men or in those with a history of recent foreign travel or partners’ travel or infection acquired in California or Hawaii.¹

Adapted from CDC Sexually Transmitted Diseases Treatment Guidelines 2006. MMWR 55:1–95, 2006.

Fluoroquinolone resistance in gonococci is becoming common in the Far East and Hawaii. Recently, it has begun emerging as a significant problem in some populations in the mainland United States. In men having sex with men, the prevalence of fluoroquinolone resistance has reached nearly 5%, prompting the CDC in 2004 to recommend that ofloxacin is not the drug of choice in this population.¹ The resistance will continue to spread to other populations, and we will undoubtedly see further changes in the recommendations for the general population.

Treatment of gonococcal infections involving the upper genital tract is discussed under Pelvic Inflammatory Disease in this chapter.

Chlamydia

There are an estimated 3 million new cases of chlamydia in the United States each year. As with most sexually transmitted infections, these cases are more common among younger women. According to the CDC 2002 Sexually Transmitted Disease Surveillance Chlamydia Supplement, more than 5% of 15- to 24-year-old women screened at family planning clinics will be found to have chlamydia. For those young women age 15 to 24 entering the National Job Training Program in 2002, the chlamydia prevalence was approximately 10%. For adolescents entering juvenile detention facilities, the prevalence of chlamydia is higher than 16%.

The National Longitudinal Study of Adolescent Health (Wave III), using ligase chain reaction assays on first-void urine specimens, found chlamydia prevalence of 4% among young adults. The prevalence was greatest among minority women, including African Americans, Native Americans, and Latinos.² The rate for young African American women was 6 times greater than for white women. From 1987 through 2002, the reported rate of chlamydial infections among all U.S. women increased nearly sixfold, from approximately 78 to 455 cases per 100,000 women. The etiology of this dramatic increase is likely multifactorial and includes increased screening, the use of the more sensitive nucleic acid amplification test (NAT), and better reporting, in addition to an increased infection rate.²

Chlamydia trachomatis is the pathologic agent of chlamydial cervical and upper genital tract infections, and certain serotypes also cause an ulcerative sexually transmitted infection termed lymphogranuloma venereum.

Chlamydia cervicitis is clinically indistinguishable from gonococcal cervicitis, with symptoms of vaginal discharge, intermenstrual bleeding, dysuria, and dyspareunia. In contrast to gonorrhea, which is usually symptomatic, chlamydia is often carried asymptomatically, and permanent damage to fertility can occur without notice. Chlamydia can ascend from the cervix to the endometrium and continue to progress into the fallopian tubes, producing PID.

Chlamydia can be detected using nucleic acid amplification testing of a cervical swab sample. NAT can also be used to detect chlamydia in first-void urine. This is an effective screening tool, with sensitivities comparable to those seen with cervical swabs and samples much easier to obtain.

Chlamydia can also be detected with serology. This is not useful for acute cervical or upper genital tract infections, but is the only way to diagnose certain serotypes if the diagnosis of lymphogranuloma venereum is considered. The serologic studies are also useful in determining prior exposure of patients presenting with infertility. By the time a patient presents with infertility, NAT results of a cervical specimen will not likely be positive for chlamydia. Positive serology for chlamydia in this setting helps to direct an infertility workup.

Cervical and upper genital tract chlamydial infections are treated with doxycycline, azithromycin, or erythromycin. The patient and all partners must be treated simultaneously. Treatment options are listed in Table 33-3.

Syphilis

Syphilis was referred to as the great pox in the 1500s and affected a vast number of people in Europe. Although the incidence of syphilis saw a major decline from 1970 through 1990 in the United States, there has been a rise recently in the numbers of cases, especially among homosexual and bisexual men. In 2002, there were 6862 cases of primary and secondary syphilis reported to the CDC. There were also 412 cases of congenital syphilis.

Syphilis is caused by the spirochete Treponema pallidum. This bacterium is extremely fragile, and the infection is almost exclusively transmitted by sexual contact with an infected person or from an infected pregnant woman to her unborn child. In rare circumstances, it can be passed through broken skin on other parts of the body.

The course of syphilis is described as being in one of four stages: primary, secondary, latent, and tertiary (or late) syphilis. Primary syphilis begins as a painless ulcer (i.e., chancre) that develops approximately 3 weeks after exposure on the exposed area. This lesion can be difficult to detect if it is on the vaginal wall or cervix.

Secondary syphilis presents on average at 6 weeks after exposure and is manifest by a diffuse skin rash that classically involves the palms and soles, verrucous-appearing genital lesions, or alopecia. This stage, if untreated, is followed by a long asymptomatic, or latent, stage.

Latent syphilis refers to untreated infections that are no longer symptomatic or contagious. In many untreated patients, no further signs or symptoms of the disease will ever occur.

Tertiary syphilis will eventually develop in approximately one third of untreated patients who have had secondary syphilis. Systemic spread of the bacteria can lead to damage of almost any other part of the body, most notably the brain, nervous system, bones, joints, heart, and eyes. This stage can last for decades, and can eventually lead to progressive neurologic dysfunction, cardiovascular disease, bone destruction, blindness, and death.

The effect of syphilis on pregnancy has been well documented. Syphilis clearly produces miscarriages, prematurity, stillbirths, neonatal deaths, and congenital disease in the infant. The effects of syphilis on fertility are not clear, but a study out of Senegal did find that women age 40 or older with past or active syphilis were significantly more likely to have no history of gestation than women without evidence of syphilis infection.³

The diagnosis of syphilis is made using one of two screening nontreponemal blood tests, known as the rapid plasma reagin (RPR) and the Venereal Disease Research Laboratory (VDRL) tests. These tests are measured in titers that can be followed serially to evaluate treatment response. Both the RPR and VDRL usually become positive within 2 weeks of developing the chancre. If positive, one of two available confirmatory treponemal tests is required, either the fluorescent treponemal antibody absorption (FTA-ABS) test or the microhemagglutination assay for Treponema pallidum (MHA-TP) test. These will remain positive lifelong regardless of treatment status.

Although syphilis may have devastating long-term consequences if not treated, this disease is relatively easy to treat once diagnosed. Penicillin is the mainstay of therapy (see Table 33-3).

Trichomonas

Trichomoniasis is a common type of vaginitis that is sexually transmitted and causes approximately 5 million genital infections in the United States each year. Although it is clearly a sexually transmitted infection, it is not a reportable disease; thus, data on its prevalence is an estimate and likely an underestimate.

Trichomoniasis is caused by the single-celled motile protozoa, Trichomonas vaginalis. Infected men rarely have symptoms. In women, trichomonads cause superficial infection of the vagina and ectocervix, resulting in a foamy yellow vaginal discharge, vulvovaginal irritation, dysuria, dyspareunia or, in many cases, no symptoms at all. Although trichomonads may be cultured from the endocervix, they do not cause a clinical cervicitis.

Several studies have found that women with T. vaginalis infections had an increased risk of tubal infertility (up to 1.9-fold), and that this risk increased sixfold with more than four episodes of T. vaginalis infection.^4–6 These organisms have been found in the abdominal cavity of women with acute salpingitis, and there is speculation as to whether or not the motile trichomonads are able to carry bacteria or viruses to the upper genital tract.⁷

Diagnosis is made most frequently using a wet mount prep of the vaginal discharge and visualizing the motile protozoa. Culture of the trichomonad is the gold standard test but is not widely used in clinical practice. A rapid test utilizing an immunochromatographic strip that can be performed rapidly in a clinical office is being evaluated for clinical use, with reported sensitivities near that of culture.

Treatment is with metronidazole 2 grams orally in a single dose. Tinidazole has also been approved in the United States for treatment of trichomoniasis in a 2-gram single oral dose, but is more costly (see Table 33-3).

Human Papillomavirus

Human papillomavirus (HPV) is one of the most common causes of sexually transmitted infections in the world. According to the CDC, there are more cases of genital HPV infections in the United States than any other STD, with at least 20 million people currently infected. At least 5 million new cases of sexually transmitted HPV infections are reported annually.

Human papilloma viruses are small double-stranded circular DNA viruses. Although more than 100 different types of HPV exist, only 30 types are sexually transmitted. Many men and women with HPV infections have no symptoms. Symptomatic HPV infections manifest in women as genital warts, abnormal results on Papanicolau (Pap) smears, and both premalignant and malignant lesions of the cervix, vagina, vulva, and rectum.

There are high-risk and low-risk types of HPV. Low-risk HPV types 6 and 11 are the more common causes of visible external genital warts, although any of the types that infect humans can cause warts. These lesions are often asymptomatic, although they can be painful or pruritic. The lesions can grow large enough to interfere with coitus. Perianal warts can be seen even if a patient does not have anal sex, but intra-anal warts are only seen with receptive anal intercourse. Vaginal and cervical verrucous warts can also be seen.

Nucleic acid amplification testing is widely available for use with Pap smear specimens to determine the presence of high-risk HPV types. However, the external genital warts are not routinely typed. High-risk HPV types 16, 18, 31, 33, and 35 have all been associated with neoplasia, particularly of the cervix. For this reason, the presence of high-risk HPV types warrants further evaluation with colposcopy and cervical biopsies if indicated.

Although HPV has not been shown to directly affect a woman’s fertility, lesions large enough to affect coitus are certainly problematic. The treatments required for localized preneoplastic or neoplastic lesions (i.e., cryotherapy, loop electrosurgical excision; see Table 33-3) can rarely cause scarring or affect the production of cervical mucosa, both of which could hinder the passage of sperm, thus affecting fertility. Invasive cervical neoplasias can require hysterectomy or other significant pelvic surgery.

Treatment does not eradicate the virus; thus prevention becomes especially important for this sexually transmitted infection. Recent advances have shown that a three-dose HPV-16 vaccine prevented the development of persistent HPV-16 infection and HPV-16-related cervical neoplasia in college age women for the first 17 months after vaccination.⁸ This finding will certainly lead to further vaccine developments for all of the major high-risk HPV types.

Herpes Simplex Virus

Genital herpes was described as early as the first part of the 18th century. It is estimated now to affect nearly 50 million Americans and is seen in all age groups. Herpes simplex virus (HSV) type 2 has been considered the main pathogen in genital herpes, but with the transmission of HSV-1 through oral sex, genital infections with that viral strain are rapidly rising.

Initial clinical manifestations vary widely, but usually involve systemic symptoms of fever, malaise, headache, and myalgia that are followed within a few days by painful vesicular or pustular genital lesions that later ulcerate. Genital itching, dysuria, vaginal or urethral discharge, and inguinal lymphadenopathy are also potential clinical manifestations of genital HSV infection.

Herpes simplex virus cervicitis is found in 90% of women with primary HSV-2 infections and in 70% of women with primary HSV-1 infections. The rate of cervicitis usually decreases to less than 20% with recurrent infections.⁹ HSV involves the squamous epithelium of the exocervix, and the ulcerative lesions can often be seen on visual examination. In rare cases, both HSV-1 and HSV-2 have been shown to extend locally and cause PID.¹⁰ Despite the ability of HSV to cause widely disseminated infection and PID, there has been no evidence that this infection contributes to infertility. Treatment is with acyclovir, valacyclovir, or famciclovir (see Table 33-3).

Mycoplasma

Mycoplasma is a general term often used to refer to the class of more than 120 named species of organisms that are phylogenetically between bacteria and viruses. Of the more than 120 named species, Mycoplasma hominis, Ureaplasma urealyticum, and Mycoplasma genitalium are the most frequently recognized in relation to isolation from the human genitourinary tract. M. hominis has been found in the vagina in two thirds or more of women with abnormal vaginal discharge consistent with bacterial vaginosis, as compared with approximately 10% of women without abnormal discharge.¹¹ Although it is strongly associated with bacterial vaginosis, the pathologic role of M. hominis in the disease is unclear.

M. hominis has also been isolated from the endometrium and fallopian tubes of approximately 10% of women with salpingitis diagnosed by laparoscopy.¹¹ The role of M. hominis as a primary pathogen is unclear because it is usually isolated with other pathologic bacteria, such as gonorrhea or chlamydia.

The role of M. hominis in causing tubal infertility is also unclear. There is serologic evidence that antibodies to M. hominis have been found three times more often in infertile women with a history of PID than in controls.¹² X-ray microscopy has been able to show M. genitalium binding directly to human spermatozoa and thus could be carried by motile sperm and cause upper genital tract disease in women.¹³

Ureaplasmas are clearly a cause of nongonococcal urethritis in men. They may cause an acute urethral syndrome in women as well. Ureaplasmas have been isolated from the fallopian tubes of patients with PID but usually in association with other known pathogens. Thus the direct role in PID is unclear.¹¹

The diagnosis of the mycoplasmas is through culture. Serology is available but is not routinely used for clinical application. Treatment consists of doxycycline or azithromycin.

Chancroid

Chancroid is a sexually transmitted infection that produces genital ulcerative lesions. Although chancroid is a significant health issue in underdeveloped nations, it is seen much less frequently in the United States.

Chancroid is caused by Haemophilus ducreyi, a gram-negative anaerobic bacterium. The ulcerative lesions are typically painful and are associated with painful inguinal adenitis. Haemophilis ducreyi does not spread systemically or to distant sites and has thus not been implicated as a cause of infertility.

Diagnosis is often made clinically because culture of the organism is difficult. Recommended treatment regimens include azithromycin, ceftriaxone, ciprofloxacin, and erythromycin (see Table 33-3).

Hepatitis

Hepatitis A, B, and C are DNA viruses that can be sexually acquired.

Hepatitis A is usually acquired through the fecal-oral route. Food-borne outbreaks have clearly been reported,¹⁴ and outbreaks in patients who practice anal receptive intercourse, mainly men having sex with men, have also been seen. Hepatitis A produces only acute infection that is usually self-limited but can be fulminant and fatal. There is no chronic form of hepatitis A.

Hepatitis B is acquired through contact with blood or other body fluids. It produces an acute viral hepatitis as well as chronic disease. The chronic phase can be detected using serology for hepatitis B surface antigen (HBsAg), and the degree of viremia can then be evaluated using hepatitis B polymerase chain reaction (PCR) amplification on the blood. Prevention for hepatitis B is available in the form of a series of three vaccinations, and although vaccination is now mandatory in children, there are still many sexually active adolescents and adults who need to be screened and vaccinated.

Hepatitis C is the most common chronic blood-borne infection in the United States, with nearly 3.9 million persons being infected.¹⁵ In an infertility practice, this infection is usually seen in patients who are being screened for an assisted reproductive technology (ART) procedure. The virus is most frequently acquired through contact with blood and blood products, but has been shown in several studies to be sexually transmitted.¹⁵ The risk of transmission through sexual contact is very low and far less than for HIV or hepatitis B. It is estimated that the risk of sexual transmission of hepatitis C virus from people with chronic infection varies from 0 to 0.6% if there is only one sex partner to 1% if there are multiple sex partners.¹⁶ Approximately 80% of persons exposed will develop chronic infection, with 60% of these developing chronic active liver disease. If a woman develops the chronic form of hepatitis B or C, she can become so significantly ill that ovarian dysfunction such as anovulation or amenorrhea can occur. Chronic carriers of hepatitis B or C can become a logistic issue for the in vitro fertilization laboratory. It is critical to keep viral-contaminated tissue separate from noncontaminated tissue.

Pathogenic Vaginal Flora

Bacterial vaginosis is the clinical syndrome that occurs when the normal vaginal lactobacilli are replaced by other pathogenic flora, such as anaerobes, streptococci, and Gardnerella vaginalis. These pathogens have also been found in the upper genital tracts of women with PID. For this reason, PID is often considered a polymicrobial infection. These bacteria may contribute to the development of PID when a traditional STD such as Chlamydia occurs.

Tuberculosis

Tuberculosis has been found in ancient Egyptian remains, but did not become a widespread problem until the 17th and 18th centuries, when urban overcrowding facilitated the ease of spread of the bacteria through respiratory droplets. This development led to the White Plague.¹⁷

Today, tuberculosis infects 1.7 billion people worldwide, a third of the world’s population, and causes 3 million deaths each year. In the United States, rates of tuberculosis declined to a low in 1984. Since then, though, rates have begun to climb. Part of the reason for the increase is co-infection with HIV.

Although tuberculosis is most commonly a pulmonary disease, it can affect virtually every organ system in the body, including the genitourinary tract. The incidence of genital tuberculosis in infertility clinics in Australia is 0.6% and in India is 19%, but tuberculosis is a rare cause of infertility in the United States.¹⁸

Mycobacterium tuberculosis is an aerobic, nonspore-forming, nonmotile bacillus that stains positively with an acid-fast stain. This bacterium is fairly large, nonmotile, and rod-shaped and is distantly related to the Actinomycetes. M. tuberculosis is an obligate aerobe, and it is for this reason that pulomonary tuberculosis usually occurs in the well-aerated upper lobes of the lungs. The bacterium is a facultative intracellular parasite.

Tuberculosis is usually acquired from respiratory droplets. A pulmonary infection can spread hematogeneously to the endosalpinx, from which it may spread to the endometrium (50%), ovaries (30%), cervix (5% to 15%), or vagina (1%).¹⁷

The most common presentation of genital tuberculosis is infertility. When other symptoms are present, they are usually local and include menstrual disorders and abdominal pain. Amenorrhea may be present due to complete obliteration of the endometrial cavity, or Asherman’s syndrome, caused by postinfectious adhesions. The cervix may have an ulcerating mass that resembles carcinoma.¹⁷

By the time a woman presents with pelvic complaints or infertility, signs of the primary pulmonary infection may be completely resolved. Cultures of menstrual blood and histologic examination of endometrial tissue may be positive, but sampling error may miss the acid-fast bacilli. Tuberculosis produces midtubal occlusion with characteristic hysterosalpingographic signs, described under Fallopian Tubes in this chapter.

Skin testing for tuberculosis is performed as the Mantoux test, wherein purified protein derivative (PPD) is injected intracutaneously in the forearm. The test is read within 48 to 72 hours. A Mantoux test should be performed on all women being evaluated for infertility.

Treatment for tuberculosis with chemotherapy chosen according to local resistance profiles is highly effective. Surgery is rarely needed for large residual lesions or drug-resistant bacteria.

Pelvic Inflammatory Disease

PID is the inflammatory and infectious syndrome caused by the spread of microorganisms from the lower genital tract to the endometrium, fallopian tubes, ovaries, or other pelvic structures. According to the CDC, in the United States more than 1 million women per year experience an episode of acute PID and more than 100,000 women become infertile each year as a result. Annually more than 150 women in the United States die from PID or its complications.¹⁹

Pelvic inflammatory disease is responsible for a large proportion of ectopic pregnancies. It is estimated that of women acquiring PID between ages 15 and 44, almost 1% will develop ectopic pregnancies, 1.7% will develop infertility, and almost 2% will develop chronic pelvic pain.²⁰ It is estimated that after one episode of PID there is a 13% incidence of infertility due to tubal occlusion; after two episodes, the incidence is 35%; and after three episodes of PID, infertility approaches 75%.

The most likely pathogens responsible for PID are the sexually transmitted organisms Neisseria gonorrheae and Chlamydia trachomatis. Other organisms found to contribute to PID are pathogenic vaginal flora, including anaerobes, Gardnerella vaginalis, Haemophilus influenza, enteric gram-negative rods, Streptococcus agalactiae, Mycoplasma hominis, and Ureaplasma urealyticum.

Pelvic inflammatory disease can be symptomatic or subclinical. Symptoms can consist of lower abdominal tenderness, cervical motion tenderness, adnexal tenderness, mucopurulent cervicitis, and fever. Unfortunately, patients may be asymptomatic and still have enough damage to the upper genital tract to cause infertility.²¹

Early diagnosis and treatment are imperative to avoid the long-term complications of PID. Women who have symptomatic PID and delay seeking care (present 3 to 9 days after the onset of symptoms) are twice as likely to experience infertility as those who present within 2 days of symptoms. By 9 or more days after symptom onset, the risk for infertility and ectopic pregnancy increase to 3.5 times.²² The threshold for diagnosis must be low, so as to not miss those women with minimal symptoms.

At the other end of the spectrum, some women are clearly ill enough to warrant hospital admission for PID treatment.²³ Indications for hospitalization include:

The PID Evaluation and Clinical Health (PEACH) trial evaluated inpatient versus outpatient treatment regimens in 831 women with mild to moderate PID.²⁴ This multicenter, randomized study found no difference in reproductive outcomes between women randomized to inpatient treatment and those randomized to outpatient treatment. Treatment recommendations are listed in Table 33-4.

Table 33-4 Treatment of Pelvic Inflammatory Disease

Parenteral treatment Regimen A: Cefotetan 2 g IV q12h or cefoxitin 2 g IV q6h plus doxycycline 100 mg po or IV q12h Regimen B: Clindamycin 900 mg IV q8h plus gentamicin q8h or single daily dosing

Cervix

Cervical mucus is a healthy medium that, during the periovulatory period, allows sperm to move freely through the cervix to the upper genital tract. It is produced by the secretory cells of the endocervical glands and undergoes quantitative and qualitative changes during the menstrual cycle. The cervix also undergoes anatomic changes during the menstrual cycle. The external os progressively widens during the proliferative phase, reaching maximal width just before ovulation occurs. At that time, the cervical mucus is present in large amounts, facilitating passage of the spermatozoa. After ovulation, the cervical os narrows and the mucus produced decreases in amount and becomes thicker.²⁵

Cervical factor infertility is encountered in approximately 5% of cases in clinical practice. Inflammatory processes of the cervix, such as cervicitis, could alter the physiochemical makeup of the cervical mucus and deny sperm penetration. Pathogens include gonorrhea, chlamydia, trichomonas, and G. vaginalis, streptococci (Group B streptococci), and staphylococci. The staphylococcal and streptococcal infections tend to penetrate more deeply into the cervical wall and involve the gland acini. Gonorrhea usually spreads along contiguous mucous membrane surfaces as a superficial infection.²⁵

Cervical stenosis can cause infertility and can be caused by chronic cervicitis and rarely from scarring resulting from treatment for HPV infections (i.e., cryotherapy, laser, or other ablative procedures). Local ablative procedures can also alter the quantity of cervical mucus due to permanent destruction of the endocervical glands. Scarring from large syphilitic chancres or cervical tuberculosis can rarely cause blockage of the cervical os.

Endometrium

An extremely important step in the process of conception is endometrial implantation of the embryo. Abnormalities in the process of implantation are believed to be the basis of many cases of unexplained infertility. Some of these cases may be related to undiagnosed endometrial infections.

Immune cells are part of the normal cellular population of endometrium and subendometrial areas. The cellular type is dependent on the menstrual cycle. Lymphocytes and neutrophils normally appear in the endometrium in the second half of the menstrual cycle. Their presence does not indicate endometritis. Plasma cells, however, are not normal and indicate an immune response, usually to a bacterial infection.²⁵

Most cases of acute endometritis occur when the usually protective cervical mucosal barrier is disrupted during menses, parturition, abortion, and surgical instrumentation. Staphylococci, streptococci, N. gonorrheae, and Clostridium species are the most important causes of acute endometritis. Chronic endometritis has been associated with N. gonorrheae, C. trachomatis, M. tuberculosis, Mycoplasma, fungi, viruses, and parasites.

Salpingitis and endometritis occur together frequently, with 70% to 90% of women with salpingitis also having endometritis.²⁶ Endometrial biopsy can be used as a surrogate marker of tubal involvement and may make laparoscopy less necessary. Clearly, salpingitis has severe implications with regard to future fertility, and therefore accurate diagnosis is important.

The PEACH trial²⁶ found that endometritis itself was not associated with a reduced rate of pregnancy in women with mild to moderate PID. These findings differ from those presented in the landmark study by Westrom²⁷ on PID and fertility on several points. First, the authors concluded that endometritis does not definitively indicate salpingitis. Westrom’s study used laparoscopic evidence of salpingitis as evidence of PID, whereas the PEACH study used endometrial biopsy, not laparoscopy. Second, the antibiotic treatment presently used is more effective than that available during Westrom’s study period, thus likely leading to fewer treatment failures.

Asherman’s syndrome is the presence of intrauterine adhesions, often caused by uterine curettage, especially if performed in the postpartum period. Asherman’s syndrome can also be caused by tuberculosis or schistosomiasis. The dense adhesions, scar tissue, and even obliteration of the uterine cavity can lead to infertility.

Fallopian Tubes

Fallopian tubes must be both patent and structurally functional to maintain fertility. External adhesions from prior infections (e.g., PID, appendicitis) or endometriosis can cause tubal blockage. Prior surgeries for sterilization, tubo-ovarian abscesses, or ectopic pregnancies can also block tubal passage. The fimbrae and cilia can be damaged by infectious agents and inflammation, causing an inability to transport the ovum, sperm, or embryo; thus, although the fallopian tube is open, it is not functioning appropriately.

Chlamydia trachomatis is the leading cause of permanent tubal damage worldwide. Chlamydia ascends from the cervix and preferentially invades columnar epithelial cells, which are found in abundance in the densely ciliated ampullary segment of the fallopian tubes.²⁸ Once intracellular, Chlamydia then release a specific heat shock protein, Ch-hsp60, which is capable of inducing a local inflammatory response.²⁹ The immune response keeps the infection from spreading to other cells, but the intracellular Chlamydia can escape immune destruction, thus setting up a chronic infection resulting in localized scarring. This chronic infection leads to the production of Ch-hsp60 antibodies, which can be detected in sera. Ch-hsp60 is similar in some regions to h-hsp60 (human heat shock protein 60). This is expressed on the decidua and embryo in early pregnancy. Thus, a woman who has developed Ch-hsp60 antibodies as a result of a previous significant fallopian tube infection could reactivate her immune system and potentially impede early embryonic events.³⁰

Tuberculosis produces distinct pathology that can be seen on hysterosalpingography. This may reveal a shriveled uterine cavity, calcified tube or ovary, bilateral cornual block, lead pipe appearance with distension of ampullary region, or distal tubal occlusion with jagged fluffiness of tubal outline.¹⁸

Tubal obstruction caused by schistosomiasis can result in infertility.³¹ Inflammation of the cervix, vagina, and vulva from schistosomiasis may occur and interfere with coitus, fertility, and ability to deliver a fetus vaginally.³² Women from areas where schistosomiasis is endemic (Schistosoma mansoni in Africa, South America, and the Caribbean; Schistosoma japonicum in Japan, China, and the Phillipines; Schistosoma mekongi in Southeast Asia; Schistosoma haematobium in Africa and the Middle East; and Schistosoma intercalatum in West and central Africa) should have this included in the differential diagnosis of their infertility.

Actinomyces israelii is a rare cause of pelvic abscesses, but has been associated with intrauterine device use (see Chapter 27).