Pelvc Inflammatory Disease and Infertility

What is PID (Pelvic inflammatory disease)?

An infection of the upper genital tract (uterus, ovaries, fallopian tubes)

What are the risk factors for developing PID?

Previous history of PID

IUD or IUCD

Postabortion

Post childbirth

Douching

Multiple sexual partners

Early sexual contact

PID may manifest after

Pelvis surgery, accompany tuberculosis, or in association with an abscessed appendix or ruptured colonic diverticulum

A common cause of PID is STD’s like

Chlamydia and gonorrhea

The sequela of PID range from negligible infection that is relatively easy to treat to the development of a

Tubo-ovarian abscess

What is tubo-ovarian abscess?

A pelvic abscess involving the fallopian tubes and ovaries that is often caused by PID

What is the evolution of PID

Vaginitis

Cervicitis

Endometritis

Salpingitis

Tubo-ovarian complex

Tubo-ovarian abscess

Clinical findings of ACUTE PID

Possible history of a STD (chlamydia or gonorrhea)

Fever

Chills

Pelvic pain/tenderness

Purulent vaginal discharge

Vaginal bleeding or itchiness

Dyspareunia

Leukocytosis

Sonographic findings of ACUTE PID

Endometritis

Ill-defined uterine borders

Pyosalpinx

Hydrosalpinx

Cul-de-sac fluid

Multicystic and solid complex adnexal mass(es)

Clinical findings of CHRONIC PID

Continual pelvic or abdominal pain

Infertility (resulting from adhesions and scaring of the fallopian tubes)

Possible palpable adnexal mass

Irregular menses

Purulent vaginal discharge

Sonographic findings of CHRONIC PID

Hydrosalpinx

Scars may be noted within the dilated tube and appear as echogenic bands within the tube

Tubo-Ovarian-complex or Tubo-ovarian-abscess

Multicystic and solid complex adnexal mass(es)

What is vaginitis?

It is the inflammation of the vagina. It is the most common initial clinical presentation in the early stages of PID.

Vaginitis can lead to ?

Excessive vaginal discharge, in cases of PID pt may present with purulent, foul-smelling discharge.

The progression of infection into cervix is termed?

Cervicitis

The progression of infection that ascends into the endometrium is termed?

Endometritis

Clinical findings of endometritis

History of recent abortion, postpartum, D&C, PID, surgery or IUD

Pelvic tenderness

Fever

Leukocytosis

Sonographic findings of endometritis

Thickened echogenic or irregular endometrium

Endometrial fluid

Ring-down artifact from gas or air within endometrium (pneumouterus/ pneumometra)

Color doppler may yield hyperemia

The spread of infection beyond endometrium can lead to inflammation of the fallopian tubes termed

Salpingitis, the tubes subsequently distend , allowing it to be seen on sono

Patients suffering from salpingitis from PID can develop a perihepatic infection and subsequent development of adhesions located between liver and diaphragm. Resulting in the liver capsule being inflamed and leading to clinical presentation much similar to gallbladder disease. This event is called?

Perihepatitis or Fitz-Hugh-Curtis syndrome. Therefore RUQ pain, free fluid within hepatorenal space (morrison pouch), and elevated liver function tests may be noticed with salpingitis

Tubal infections may lead to fluid or pus accumulation within lumen of fallopian tubes and ovaries termed

Hydrosalpinx or pyosalpinx

PID is also linked with fertility and ectopic pregnancy secondary to

formation of scars within inflamed opening of fallopian tubes and ovaries

Scar formation in the tubes can

Disrupt the motility and function of the tube and inhibit likelihood of conception. If conception does occur, the scar formations within tube increases risk of ectopic pregnancy

Clinical findings of salpingitis

Findings consistent with PID

Pelvic tenderness

Fever

Leukocytosis

Sonographic findings of salpingitis

Distended fallopian tube filled with echogenic material (pus) or anechoic fluid

Hyperemic flow within or around affected fallopian tubes with color doppler

Nodular thickened wall of fallopian tube

As PID progresses and reaches beyond fallopian tubes, the ovaries and peritoneum become involved termed the?

Tubo-ovarian-complex

What is tubo-ovarian-complex?

Adhesion that develop within pelvis that leads to fusion of the ovaries and dilated tubes

Further progression of PID beyond tubo-ovarian-complex is termed the?

Tubo-ovarian-abscess

Sonographically the distinguishing feature of the two is?

With tubo-ovarian complex, the ovaries and tubes are more readily recognized as distinct structures but ovaries will not be able to be seprated from the tube by pushing with the vaginal probe

Clinical findings of Tubo-Ovarian Complex and Tubo-Ovarian Abscess

Findings consistent with PID

Sonographic findings of Tubo-Ovarian-COMPLEX

‘Thickened, irregular endometrium

Pyosalpinx or hydrosalpinx

Cul-de-sac fluid

Multicystic and solid complex adnexal mass(es)

Ovaries and tubes recognized as distinct structures, but the ovaries will not be separated from the tube by pushing with the vaginal probe

Sonographic findings of tubo-ovarian ABSCESS

Thickened, irregular endometrium

Pyosalpinx or hydrosalpinx

Cul-de-sac fluid

Multicystic and solid complex adnexal mass(es)

Complete loss of borders of all adnexal structures and the development of a conglomerated adnexal (possibly bilateral) mass

What is a common cause of infertility?

PID

Congenital uterine malformations / mullerian anomalies have been linked to female infertility not because it prevents pregnancy but because of

structural abnormalities

What is a common structural defect of the uterus that leads to fertility troubles

Bicornuate uterus

What is another common structural defect of the uterus that leads to repeated abortions/fertility troubles

Septate uterus. It frequently requires surgical intervention to reduce division of uterine cavity.

For patients with a septate uterus, sonography can also aid in resection of septum during

Hysterescopic uterine septoplasty

What is endometriosis

Functional, ectopic endometrial tissue located outside the uterus.

Hemorrhage of this ectopic tissue often occurs resulting in focal areas of bloody tumors called

Endometriomas/ Chocolate Cysts

Endometriosis can be located anywhere throughout pelvis; the most common location being the

Ovaries

The link between endometriosis and infertility

Development of pelvic adhesions thay may alter normal anatomy, preventing ovum pickup or tubal obstruction

Clinical findings of endometriosis

Patient may be asymptomatic

Pelvic pain

Infertility

Dysmenorrhea

Menorrhagia

Dyspareunia

Dyschezia

Sonographic findings of endometriosis

Predominantly cystic mass with low-level internal echoes (may resemble a hemorrhagic cyst)

Anechoic or complex mostly cystic mass with posterior enhancement and may contain a fluid–fluid level

What is PCOS/Stein-Levanthal syndrome

Endocrinologic ovarian disorder linked with infertility. Characterized by chronic anovulation ,amenorrhea, hirsutism and obesity

What is the most common cause of androgen (male hormones) excess

PCOS

Clinical findings of PCOS

Stein–Leventhal syndrome (amenorrhea, hirsutism, and obesity)

Infertility

Oligomenorrhea cycles (<35 days apart)

Hyperandrogenism

Sonographic findings of PCOS

“String of pearls” sign or “necklace” sign: many small follicles along periphery

Bilateral enlargement of the ovaries

Increased stroma and increased stromal echogenicity

One or both ovaries should contain 12 or more follicles that measure between 2 and 9 mm in diameter

Ovarian volume greater than 10 mL

Threshold of 25 small follicles can also be used

Imaging diagnosis of PCOS one or both ovaries should contain

12 or more follicles measuring between 2-9mm in diameter

For imaging diagnosis of PCOS ovarian volume should exceed

10 mL

For imaging diagnosis of PCOS, a threshold of

25 small follicles should be used

What is often the result of fallopian tube obstruction by adhesions

Hydrosalpinx; hysterography or SIS should be used to evaluate patency

The presence of adhesions within tube can prevent what

Normal peristaltic motions that typically occur.

Adhesion development can occur as a result of

Long-standing PID, endometriosis, tubal surgery

What is an endometrial factor that contributes to infertility

Luteal phase deficiency

What is luteal phase deficiency

When endometrium does not develop appropriately in luteal phase of endometrial cycle as a result of reduced progesterone production

What is ashermans syndrome

Presence of intrauterine adhesions or synechiae within uterine cavity typically resulting from scar formation after uterine surgery especially after a d&c

What is ashermans syndrome link to infertility

Ashermans syndrome often prevent implantation or lead to recurrent early pregancy loss

Clinical findings of asherman syndrome

History of D&C, trauma, and uterine surgery

Recurrent pregnancy loss

Amenorrhea or hypomenorrhea

Sonographic Findings of Asherman Syndrome

Bright areas within the endometrium

Sonohysterography findings include bright bands of tissue traversing the uterine cavity

What is the link between uterine leiomyomas/fibroids and infetility

Fibroids that are intracavitary or submucosal may distort endometrium and prevent implantation

Clinical findings of a uterine leiomyoma/fibroid

Pelvic pressure

Menorrhagia

Palpable abdominal mass

Enlarged, bulky uterus (if multiple)

Urinary frequency

Dysuria

Constipation

Infertility

Sonographic findings of a uterine leiomyoma

Hypoechoic mass within the uterus

Posterior shadowing from mass

Degenerating fibroids may have calcifications or cystic components

Multiple fibroids appear as an enlarged, irregular shaped, diffusely heterogeneous uterus

What is follicular aspiration

Technique used for IVF that drains the follicle for oocyte retrieval

What is oocyte retrieval

Removal of oocytes from ovarian follicles by aspiration

What is in vitro fertilization (IVF)

Fertility treatment that requires a mature ovum to be extracted from the ovary, with fertilization taking place outside the body (4-8 embryos are placed into uterus)

IVF can result in multiple gestations, however it can be reduced by

Selective reduction/ multifetal pregnancy reduction

An additional technique of ART (Assisted- Reproductive- Technology) , where fertilization takes place in fallopian tube by means of laparoscopy

Gamete intrafallopian tube transfer (GIFT)

Another method of ART that requires zygote to be inserted into fallopian tube is termed

Zygote intrafallopian transfer

Sonographers should be aware that patients who are being treated with ART are an increased risk for

Ectopic pregnancy

Heterotopic pregnancy (coexisting ectopic and intrauterine pregnancy)

Multiple gestations

Ovarian hyperstimulation syndrome

Ovulatory dyfunction can occur for many reasons including

Thyroid disorders and diabetes mellitus

What is Ovulation induction

Stimulation of ovaries by hormonal therapy to treat infertility

What drugs are used to stimulate pituitary gland to secrete amounts of follicle-stimulating-hormones (FSH) to encourage development of multiple follicles

Clomid or clomiphene citrate

What is pergonal? And when is it used

a fertility drug made from hormones extracted from postmenopausal urine. It is used when clomid administration is not successful. It consists of a mixture of FSH & LH and given in conjuction with hCG

Ovulation induction dramatically increases the risk of

Multiple gestations and OHS

What is ovarian hyperstimulation syndrome

Syndrome resulting from hyperstimulation of ovaries by fertility drugs, resulting in multiple enlarged follicular ovarian cysts. Ovaries can enlarge (5-12cm)

Because of hCG administered as part of ovulation induction, the ovary will contain multiple large follicles known as

Theca lutein cysts

Theca lutein cysts are large so patient could suffer from

Ovarian torsion

OHS can initiate these following conditions:

Renal failure

Thromboembolism

Acute respiratory distress syndrome

Clinical findings of ovarian hyperstimulation syndrome OHS

Fertility treatment, including ovulation induction

Electrolyte imbalance

Oliguria (low urine)

Nausea

Vomiting

Abdominal distension

Ovarian enlargement

Sonographic findings of ovarian hyperstimulation syndrome OHS

Cystic enlargement of the ovaries greater than 5 cm

Ascites

Possible pleural effusion

What are some examples of progestin-releasing IUDs

Mirena

Liletta

Skyla

Kyleena

What is an example of a IUD that utilizes copper

ParaGard

Copper T

Copper 7

IUDs create _____________ and have been described as producing an “________________” on a sonogram

Posterior shadowing, entrance and exit echo

The use of IUDs has been linked with?

PID

Ectopic pregnancy

Spontaneous abortions

Which IUD is used throughout the world besides the US

Lippes loop

Patients who have an IUD that has perforated into uterine wall or myometrium will often complain of

Irregular or heavy bleeding

Cramping

What is female tubal sterilization/ tubal ligation

Permanent form of female sterilization in which the fallopian tubes are severed by clipping or cauterization

What is the procedure for male sterilization

Vasectomy

If a patient presents with a history of tubal ligation and a positive pregnancy test, what should be highly suspected

An ectopic pregnancy

What is a permanent form of birth control that is implanted into the fallopian tubes to block sperm

essure device, no longer used in US