Chapter 21- PID and Infertility

Pelvic inflammatory disease is an infection of the ___

upper genital tract

6 risk factors for PID

- previous PID

- IUD

- post abortion or post child birth

- douching

- multiple sex partners

- early sexual contact

2 most common causes of PID

chlamydia and gonorrhea

Evolution of PID (6)

vaginitis -> cervicitis -> endometritis -> salpingitis -> tubo-ovarian complex -> tubo-ovarian abscess

Acute PID clinical findings (7)

- fever and chills

- pelvic pain

- cx tenderness

- leukocytosis

- purulent vag discharge with odor

- vaginal itchiness + bleeding

- dyspareunia

Acute PID sono findings (3)

- thick irregular endo

- ill defined uterine borders

- pyo/hydrosalpinx

Chronic PID clinical findings (4)

- continual pelvic/abd pain

- infertility due to scarring

- palpable adnexal mass

- irregular menses

Chronic PID sono findings (3)

- markedly distended tubes

- adhesions between pelvic organs

- signs of tubo-ovarian complex/abscess

What is the most common initial clinical sign of PID?

vaginitis

4 endometritis causes

- postpartum

- post D&C

- post surgery

- IUD

4 sono findings of endometritis

- irregular endo

- possible fluid

- gas with ring down

- hyperemic

Pneumouterus (air in uterus) results from collection of ___

bacteria

Sono findings of salpingitis (3)

- pyosalpinx or hydrosalpinx

- hyperemia

- wall thickening

Symptoms of salpingitis may resemble ___

cholecystitis

What is a perihepatic infection that results in liver capsule inflammation from pelvic infections?

Fitz Hugh Curtis syndrome or perihepatitis

Symptoms of Fitz Hugh Curtis syndrome (4)

- RUQ pain

- fluid in Morison pouch

- elevated LFTS

- adhesions between liver and diaphragm

PID has been linked with ___ and ___ due to ___

infertility; ectopics; scarring within tube

Define: late form of PID where adhesions fuse the ovaries and fallopian tubes

tubo-ovarian complex

Define: late form of PID where abscess forms

tubo-ovarian abscess

How to differentiate between tubo-ovarian complex and tubo-ovarian abscess on ultrasound

- complex: ovaries and tubes are distinct structures but ovaries cannot be separated from tubes

- abscess: complete loss of of borders of ovaries and tubes

Define: infertility

inability to conceive after 1 year of unprotected intercourse

Congenital uterine malformations aka ___ can cause infertility

mullerian anomalies

Define: functional endo tissue outside the uterus that is stimulated by hormones of the menstrual cycle

endometriosis

Endometriosis 2 possible causes

- endo is passed through tubes during menstruation

- surgery scarring such as C section

Hemorrhage of endometriosis tissue occurs resulting in what?

endometriomas / chocolate cysts

What is the most common location of endometriosis?

ovaries

PCOS is also known as...

Stein-Leventhal syndrome

PCOS is the most common cause of ____ excess

androgen

aka hyperandrogenism

Criteria for PCOS diagnosis must be 2 out of the 3 presentations:

- amenorrhea/oligomenorrhea

- hyperandrogenism

- sono findings of PCOS

Clinical findings of PCOS (4)

- chronic anovulation

- amenorrhea

- hirsutism

- obesity

Sono findings of PCOS (4)

- many small cysts along periphery of ovary (string of pearls)

- many small cysts throughout ovary

- ovarian enlargement

- increased stromal echogenicity

PCOS ovaries: ____ follicles measuring between ____

12 or more; 2-9 mm

PCOS ovarian volume exceeds ___

10 mL

PCOS raises the risk for which 2 cancers?

endometrial and breast

Obstruction of the fimbriated end of the tube by adhesions causes ___

hydrosalpinx

Tubal adhesions cause infertility and may be due to (3)

- chronic PID

- endometriosis

- tubal surgery

Define: endo does not develop properly in the luteal/secretory phase due to reduced progesterone by the ovary, causing infertility

luteal phase deficiency

Define: presence of adhesions/synechiae in the uterine cavity that causes infertility

Asherman syndrome

What pelvic mass is thought to impair tubal transport?

fibroids

What is ART?

assisted reproductive technology

Define: mature ovum extracted from ovary and fertilized outside the body, then 4-8 embryos are placed into uterus via catheter

IVF (in vitro fertilization)

Define: when twins, triplets, quads, etc are reduced in number

selective reduction

Define: oocyte and sperm are placed in the fallopian tube via laparoscopy

gamete intrafallopian transfer (GIFT)

Define: zygote is placed into the fallopian tube via laparoscopy

zygote intrafallopian transfer (ZIFT)

Risks for patients on ART (4)

- ectopics

- heterotopics

- multiple gestations

- ovarian hyperstimulation syndrome

Ovulatory dysfunction may occur due to (2)

thyroid disorders or diabetes

Define: stimulation of the ovaries by hormonal therapy

ovulation induction

Clomid is a drug used to stimulate the ___ to secrete a lot of ___

pituitary gland; FSH

___ is a drug used when clomid is not successful

Pergonal

Pergonal is extracted from the urine of postmenopausal women and contains ___ and ___

FSH; LH

Ovulation induction greatly increases the risk for (2)

- multiple gestations

- ovarian hyperstimulation syndrome

Define: syndrome that results from hyperstimulation of ovaries by fertility drugs

ovarian hyperstimulation syndrome (OHS)

OHS ovaries usually measure between ___

5-12 cm

OHS ovaries may contain multiple large follicles known as ____ cysts

theca lutein cysts

Remember - theca lutein cysts occur due to increased ___ which is administered during ovulation induction

hCG

Clinical findings of severe OHS (5)

- nausea

- vomiting

- abdominal distention

- oliguria

- electrolyte imbalance

OHS can cause (3) conditions

- renal failure

- thromboembolism

- acute respiratory distress syndrome

If OHS is really severe, what might you see in the abdomen on US?

- ascites

- pleural effusion

What type of IUD is plastic and releases progestin to impede implantation and produce lighter bleeding?

mirena

What type of IUD uses copper to inhibit sperm transportation and fertilization?

paragard

What type of IUD is older and S shaped that appears sonographically as 5 equally spaced shadowing structures?

lippes loop

IUDs create ____ and an ___ and ___ echo

shadowing; entrance; exit

What symptoms may occur if IUD perforates the myometrium?

- irregular, heavy bleeding

- cramping

IUDs raise the risk for (3)

- PID

- ectopics

- spontaneous abortions

Birth control pills create an ___ cycle by supressing ___

anovulatory; LH by the pituitary gland

What is the female vs male version of sterilization?

female - tubal ligation (tubes are severed)

male - vasectomy (vas deferens is severed)

If a patient with tubal ligation has a positive pregnancy test, ____ should be highly suspected

ectopic