Risk factors for tubal infertility. Influence of history of prior pelvic inflammatory disease

Assisted Reproductive Technology Treatment, the Catalyst to Amplify the Effect of Maternal Infertility on Preterm Birth

OBJECTIVE

To identify the influence of different infertility causes and assisted reproductive technology (ART) treatment on perinatal outcomes and clarify the relationship between the maternal pathophysiological changes and artificial interventions.

METHODS

A total of 1,629 fertile women and 27,112 infertile women with sole infertility causes were prospectively recruited from July 2014 to December 2017, and 9,894 singletons were finally enrolled into the study. Pregnancies with more than one cause of infertility and/or multiple births were excluded. According to the causes of infertility and the exposure of ART treatment, the participants were divided into four groups, namely, fertile naturally conceived (NC) group, infertile NC group, female factor ART group, and male factor ART group. Perinatal outcomes, including gestational age of delivery (GA), birth weight (BW), preterm birth (PTB), low birth weight (LBW), small for gestational age (SGA), and large for gestational age (LGA), were compared among groups. Logistic regression was performed for the adjustment of several covariates.

RESULTS

The birth outcomes of the infertile NC group and fertile NC group, female factor ART group, and infertile NC group were comparable. Compared to the fertile NC group, the female factor ART group had a shorter GA (39.0 ± 1.6 vs. 39.3 ± 1.5 weeks, BW: P < 0.05). An interaction test showed that ART treatment had an interaction on the effect of female infertility on GA (P = 0.023). The female factor ART group also had a higher risk of PTB (OR 1.56, 95% CI 1.18-2.07) and LGA (OR 1.27, 95% CI 1.10-1.47) compared to the fertile NC group. The risk of PTB was increased for tubal factor ART (OR 1.49, 95% CI 1.12-2.00), ovulatory dysfunction ART (OR 1.87, 95% CI 1.29-2.72), and unexplained infertility ART (OR 1.88, 95% CI 1.11-3.17). The risk of LGA was increased for tubal factor ART (OR 1.28, 95% CI 1.11-1.48) and ovulatory dysfunction ART (OR 1.27, 95% CI 1.03-1.57).

CONCLUSIONS

Our findings indicated that ART treatment could amplify the adverse effect of female infertility on neonates. Women with tubal factor infertility, ovulatory dysfunction, and unexplained infertility have a higher risk of PTB after ART treatment. Thus, clinicians should be vigilant in such patients and provide corresponding prevention strategies before and during pregnancy.

Discussions of vaginal douching with family members

PURPOSE

This study examined women's personal douching history and the information they were given by others.

METHODS

Participants in the study (N=199; mean age=28.92) completed a 48-question survey on douching practices and attitudes.

RESULTS

Fifty-seven percent of participants had douched and 39% currently douche. The majority of women reported douching after menstruation, before or after sex, or as needed. Reasons for douching included maintaining cleanliness, feeling good and fresh, eliminating vaginal odor, and removing menstrual blood. Most women (69%) had at least one discussion about douching, with 49% having a discussion with their mother and 22% with a health care provider (HCP). Of the women who currently do not douche, 47% stopped after a HCP instructed them to quit; whereas, 100% of women whose HCP encouraged douching went on to douche. Furthermore, 66% of women planned to discuss douching with a younger girl, with 57% encouraging or being neutral and 43% discouraging it. Women who have previously douched were more likely to discuss and encourage douching than women who had never douched. Also, women who have received a discussion about douching or were encouraged to douche were more likely to douche than women who had not received a discussion or were discouraged.

CONCLUSIONS

Results from this study suggest that younger generations may be taught about or encouraged to douche by their mothers. By giving women accurate information and discouraging douching, women may be less likely to douche or encourage douching in their daughters.

The value of medical history taking as risk indicator for tuboperitoneal pathology: a systematic review

BACKGROUND

Guidelines recommend diagnostic laparoscopy in subfertile women with known co-morbidities in their medical history. Aggregated evidence underpinning these recommendations is, however, currently lacking.

OBJECTIVE

The objective of this study was to perform a systematic review and meta-analysis of the available evidence on the association between items reported during medical history taking and tuboperitoneal pathology.

SEARCH STRATEGY

MEDLINE (from 1966 to May 2007), EMBASE (from 1960 to January 2007) and bibliographies of retrieved primary articles.

SELECTION CRITERIA

All relevant studies that compared medical history with the presence or absence of tubal pathology.

DATA COLLECTION AND ANALYSIS

Studies comparing medical history with the presence or absence of tubal pathology were included. A diagnosis of tubal pathology had to be made by hysterosalpingography, laparoscopy or a combination of both. In the absence of invasive tubal testing, tuboperitoneal pathology was considered to be absent in case of intrauterine pregnancy. Homogeneity between studies was assessed, and the association between medical history and tubal pathology was expressed as a common odds ratio with a 95% CI. No language restriction was applied.

MAIN RESULTS

We included 32 studies. In cohort studies, strong associations were found for a history of complicated appendicitis (OR 7.2, 95% CI 2.2-22.8), pelvic surgery (OR 3.6, 95% CI 1.4-9.0) and pelvic inflammatory disease (PID) (OR 3.2, 95% CI 1.6-6.6), and in case-control studies, for a history of complicated appendicitis (OR 3.3, 95% CI 1.8-6.3), PID (OR 5.5, 95% CI 2.7-11.0), ectopic pregnancy (OR 16.0, 95% CI 12.5-20.4), endometriosis (OR 5.9, 95% CI 3.2-10.8) and sexually transmitted disease (OR 11.9, 95% CI 4.3-33.3).

AUTHOR'S CONCLUSIONS

Subfertile women reporting a history of PID, complicated appendicitis, pelvic surgery, ectopic pregnancy and endometriosis are at increased risk of having tuboperitoneal pathology. In these women, diagnostic laparoscopy should be offered early in the fertility work-up.

Use of IUD and subsequent fertility — follow-up after participation in a randomized clinical trial

PURPOSE

Although the IUD has been a contraceptive method for about 50 years, how it affects subsequent fertility remains controversial. The aim of our study was to examine time to pregnancy, pregnancy outcome and the need for infertility workup in a cohort of previous copper IUD users.

MATERIALS AND METHODS

From May 1993 to April 1995, 957 women were included in a prospective cohort IUD study in the city of Trondheim, Norway. From this randomized clinical trial, we identified 205 women eligible for study participation. Group A comprised 109 women who removed their IUD for purposes of planning to become pregnant, while Group B comprised 96 women who became pregnant or planned pregnancy after a complicated IUD use. Data were collected through a postal questionnaire. All information from the questionnaires was validated against data kept in the medical record at the general practitioner's office or in the hospital record of women who became pregnant or started an infertility workup. All analyses were done using SPSS.

RESULTS

In Group A, 93.6% (102/109) of the women became pregnant. Time to conception was unaffected by parity order, duration of use and age at time for removal of the IUD. Among the seven women who did not conceive, four women cancelled pregnancy plans, while three women started an infertility workup. The distribution of intra-/extrauterine pregnancies did not differ between Groups A and B. However, significantly more pregnancies were terminated as induced abortions in Group B. The two women (2%) who did not conceive in Group B did not start an infertility workup.

CONCLUSION

In line with results from other studies, there is no evidence that prior use of a copper-containing IUD increases the risk for impaired fertility regardless of the reason for removal.

Vaginal douching and risk of preterm birth among African American women

OBJECTIVE

The purpose of this study was to examine how vaginal douching may influence risk of preterm birth.

STUDY DESIGN

We conducted a hybrid cohort study on risk factors for preterm birth. African American women who resided in Baltimore City, Maryland, were enrolled prenatally if they received prenatal care at 1 of 4 Johns Hopkins Medical Institution prenatal clinics or were enrolled after delivery if they delivered at the Johns Hopkins Medical Institution with late, none, or intermittent prenatal care. Interview data were collected on 832 women delivering singleton infants between March 2001 and July 2004.

RESULTS

The preterm birth rate was 16.4%. After adjustment for several potential confounders, those covariates that were associated with either vaginal douching or preterm birth in our sample or that were identified as confounders in the literature, vaginal douching 6 months before pregnancy, and < 3 times per month (prevalence ratio, 0.63; 95% CI, 0.42-0.95) were associated with a reduced risk of preterm delivery. Douching during pregnancy was associated with a trend toward increased risk of preterm birth (prevalence ratio, 1.64; 95% CI, 0.97-2.76).

CONCLUSION

Vaginal douching effects on the risk of preterm birth depend on the timing of the exposure. Douching in the 6 months before pregnancy, but not during pregnancy, appears to protect against preterm birth.

Vaginal douching: personal practices and public policies

BACKGROUND

Vaginal douching is associated with adverse reproductive health outcomes, yet both health providers and women are often poorly informed about details of this practice.

METHODS

We searched the English language articles in the MEDLINE database (1965-March 2004) to describe vaginal douching products, policies of professional organizations, predictors of douching practice, douching methods used, timing of use, and motivation. A key report was obtained from the Food and Drug Administration (FDA) via the Freedom of Information Act. Additional product information was obtained from manufacturers. Primary key terms for the literature search included (vagina OR vaginal) and (douche OR douching). Health effects of douching are reviewed briefly; personal practices and public policies are highlighted.

RESULTS

From the literature search, we identified 432 papers, of which 150 were reviewed in detail. Contrary to the assumptions of many health professionals, douching products are only loosely regulated by the FDA. Few professional organizations have clearly stated policy statements regarding douching. In the United States, the prevalence of douching varies considerably by race (more common among African Americans) and age cohort (more common in women born earlier). Internationally, vaginal douching is common in some cultures and is rare in others. Opinions of mothers, peers, and health professionals, in addition to marketing of commercial products, affect douching behavior.

CONCLUSIONS

Regulation of vaginal douching products and public education efforts on douching behavior need to be reassessed. Because of the preponderance of evidence that suggests an association between vaginal douching and adverse reproductive health outcomes, professional and public health associations should consider educational and policy activities to discourage women from douching.

Douching and endometritis: results from the PID evaluation and clinical health (PEACH) study

BACKGROUND

Douching has been related to risk of pelvic inflammatory disease (PID).

GOAL

To examine the association between douching and PID in a large, multicenter, clinical trial of PID after adjustment for race/ethnicity.

STUDY DESIGN

Interviews were conducted with 654 women who had signs and symptoms of PID. Vaginal Gram stains and upper genital tract pathology/cultures were obtained from all the women. Women with evidence of plasma cell endometritis and/or gonococcal or chlamydial upper genital tract infections were compared with women who had neither endometritis nor upper genital tract infection.

RESULTS

Women with endometritis or upper genital tract infection were more likely to have douched more than once a month or within 6 days of enrollment than women who never douched. These associations remained after adjustment for confounding factors, after analysis of black women only; and among women with normal or intermediate vaginal flora but not bacterial vaginosis.

CONCLUSION

Among a predominantly black group of women with clinical PID, frequent and recent douching was associated with endometritis and upper genital tract infection.

Intrauterine devices and pelvic inflammatory disease: meta-analyses of published studies, 1974-1990

We conducted a meta-analysis of 36 papers published between 1974 and 1990 to estimate the effects of intrauterine device (IUD) use and Dalkon Shield use, in particular, on pelvic inflammatory disease (PID). The number of women studied in each report ranged from 50 to 26,507. For general IUD use, analyses were separated by type of PID (symptomatic or asymptomatic) because of extreme rate-ratio heterogeneity across studies. Dalkon Shield rate ratios were more homogeneous and were considered in a single meta-regression. There was substantial heterogeneity, however, in all three meta-regressions; the rate-ratio estimates ranged from 0.51 to 12 for IUD use and symptomatic PID, from 1.0 to 132 for IUD use and asymptomatic PID, and from 0.32 to 28 for Dalkon-Shield use and PID. This heterogeneity appeared to be due to differences in reference groups, study populations, and characteristics of study design. We observed consistent, positive associations of IUD use with both symptomatic and asymptomatic PID. These associations were largest for the Dalkon Shield.

Vaginal douching and reduced fertility

OBJECTIVES

This study investigated douching and reduced fertility.

METHODS

The monthly probability of conception for douchers and nondouchers was compared in a sample of 840 married, parous women in King County, Washington. Data on the number of months required to conceive were analyzed.

RESULTS

In comparison with nondouchers, women who douched were 30% less likely to become pregnant each month they attempted pregnancy. This relationship remained after adjustment for covariates, and it could not be explained by women douching for medical reasons. The reduction was not related to the type of douching preparation used. Young women who douched had significantly greater reductions in monthly fertility than older women (50% reduction for women 18 to 24 years old, 29% reduction for women 25 to 29 years old, and 6% reduction for women 30 to 39 years old).

CONCLUSIONS

Douching was associated with reduced fertility. Further research is needed to determine whether the relationship is casual and, if so, to what extent it is mediated by pelvic infection. In the meantime, women should be informed that douching may have adverse effects.

Drug therapies for sexually transmitted diseases. Clinical and economic considerations

Sexually transmitted diseases (STDs) are common, and result in immense social and economic costs. In some countries they have a major demographic impact. Because many STDs facilitate the transmission of HIV, the consequences of STDs are further increasing. At the same time, this association between STDs and HIV provides one of the ways in which drug therapy should be very cost effective. The perspective taken in this article is a societal one, and broader issues than those directly related to drug costs and benefits are discussed. However, it is the availability of drugs that has the potential to most quickly and most reliably make a major difference to overall health sector and societal costs as they relate to STDs. For those STDs for which curative therapy is available (particularly Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum, and Trichomonas vaginalis) there have been large decreases in prevalence in many parts of the world. In contrast, those STDs for which curative therapy is not available (particularly HIV, genital herpes and genital human papillomavirus infection) have had stable or increasing prevalence. For these latter infections, each new case increases the overall prevalence. Numerous features of STDs make clinical and economic evaluation difficult. These include the sensitive nature of the topic, the changing epidemiology and drug susceptibility of individual STDs, the fact that a large proportion of those infected are asymptomatic, difficulties in making specific diagnoses, the fact that often consequences are recognised late, sexual re-exposure and reinfection, and inadequate data on which to do clinical and economic evaluations. Furthermore, risk of acquiring an STD roughly correlates inversely with socioeconomic status, and countries or places with the highest rates of STDs may have the least ability to deal effectively with their diagnosis and management. Most of the direct and indirect costs are incurred by women, since they experience the vast majority of the complications of STDs. Many of these only become apparent years later, which makes it very hard to attribute costs and benefits to a specific episode of infection, and to its treatment. The late and indirect costs, plus the costs of prevention, are hard to quantify. That the major burden of STDs is in adolescents and young adults, socioeconomically disadvantaged groups and women has important implications, including for pharmacoeconomic studies.(ABSTRACT TRUNCATED AT 400 WORDS)

Predictors of high-risk behavior in unmarried American women: adolescent environment as risk factor

BACKGROUND

Heterosexual intercourse with two or more partners in a short time period represents a high-risk behavior for acquisition and transmission of sexually transmitted pathogens (STDs). Identification of factors that may predict high-risk sexual behavior can help to focus primary prevention strategies on women at risk for future acquisition of infection.

METHODS

We analyzed survey data obtained in 1988 from a nationally representative sample of 8,450 American women of reproductive age in order to identify such factors.

RESULTS

Of all sexually experienced unmarried women, 6.6% reported having had two or more sexual partners in the preceding three months. Earlier age at first sexual intercourse was associated with multiple recent partners, and with lower reports of abstinence. Birth region in the West, lack of attendance at religious services as an adolescent, and having a mother who had her first child before she was 25 years of age were factors associated with multiple recent partners. Among unmarried white women having a mother who worked full time and not living with both parents during adolescence were associated with multiple recent partners; among unmarried black women, the inverse was true (p for racial difference < .05). Multivariate analysis showed western birth region and earlier age at first sexual intercourse to be significant predictors of having multiple recent sex partners.

CONCLUSIONS

Early environment and race influence later sexual behavior. These factors should be considered in targeting and planning education for STD prevention.

Atypical pelvic inflammatory disease: can we identify clinical predictors?

OBJECTIVE

We used data from a large multicenter case-control study of tubal infertility to analyze further the relationship among demographic variables, behavioral measures, history of previous sexually transmitted diseases, and past contraceptive practices, for women with and without a history of pelvic inflammatory disease.

STUDY DESIGN

We identified 283 white women with tubal infertility who requested care at seven participating institutions. Of these women, 238 (84%) did not have a history of pelvic inflammatory disease ("atypical pelvic inflammatory disease") whereas 45 reported a history of pelvic inflammatory disease ("overt pelvic inflammatory disease"). We compared these groups with 1629 white women without a history of either infertility or pelvic inflammatory disease who were delivered of their first live-born child at the same institutions as the infertile cases.

RESULTS

Women with atypical pelvic inflammatory disease were demographically more like fertile control subjects and had behavioral characteristics midway between those of the overt pelvic inflammatory disease group and the fertile group. Both oral contraceptive and diaphragm use protected against tubal infertility for women with either atypical or overt pelvic inflammatory disease. Atypical pelvic inflammatory disease was related to a history of Trichomonas infection but not to a reported history of gonorrhea, genital herpes, or other vaginitis.

CONCLUSION

Atypical pelvic inflammatory disease is probably more common than its symptomatic counterpart. Whereas this condition is associated with some characteristics of a sexually transmitted infection, clinical predictors remain elusive.