A 33-year-old woman comes to a fertility clinic for evaluation. The patient has been attempting to conceive for a year. She has been monogamous for 5 years with a male partner and he has had a semen analysis with adequate sperm motility, volume, and count. The patient used oral contraceptives for 15 years but stopped a year ago. Since then, her menses have occurred every 27-31 days with 4-6 days of bleeding. Seven years ago, she was treated with ceftriaxone after presenting to the emergency department with fever, abdominal pain, and vaginal discharge. Which of the following is the most likely factor contributing to this patient's infertility?

Question

A 33-year-old woman comes to a fertility clinic for evaluation.  The patient has been attempting to conceive for a year.  She has been monogamous for 5 years with a male partner and he has had a semen analysis with adequate sperm motility, volume, and count.  The patient used oral contraceptives for 15 years but stopped a year ago.  Since then, her menses have occurred every 27-31 days with 4-6 days of bleeding.  Seven years ago, she was treated with ceftriaxone after presenting to the emergency department with fever, abdominal pain, and vaginal discharge.  Which of the following is the most likely factor contributing to this patient's infertility?

Quizplus · Accepted Answer

11ec160b_3ad1_76bb_9249_7757ce565259_MD0001_00 In women age <35, infertility is the lack of conception after ≥12 months of unprotected intercourse (Choice C). In women, causes of infertility are often classified into disorders of the uterus, fallopian tubes, or ovaries. In this patient with a history of fever, abdominal pain, and vaginal discharge, the cause of infertility is most likely fallopian tube obstruction from prior pelvic inflammatory disease (PID). PID occurs when a lower genital tract infection (eg, Neisseria gonorrhoeae, Chlamydia trachomatis) compromises the endocervical barrier, allowing polymicrobial vaginal bacteria to ascend and infect the normally sterile upper genital tract (ie, uterus, fallopian tubes). When infection spreads to the fallopian tubes, it creates an inflammatory exudate that promotes tubal wall adhesion and damage; prolonged infection can result in permanent tubal scarring and obstruction that impede the fertilization and/or implantation of future pregnancies (ie, tubal factor infertility, ectopic pregnancy). To prevent these complications, patients with PID require a broad-spectrum antibiotic regimen with coverage for N gonorrhoeae, C trachomatis, and polymicrobial vaginal flora. Treatment typically consists of a cephalosporin (eg, ceftriaxone), doxycycline, and metronidazole. Ceftriaxone covers gram-negative bacteria (eg, N gonorrhoeae), doxycycline covers gram-positive and atypical organisms (eg, C trachomatis), and metronidazole covers anaerobic bacteria (eg, Gardnerella vaginalis). This patient received incomplete antibiotic treatment (ceftriaxone only), which likely led to a persisting or prolonged infection and increased risk for tubal scarring. (Choice A) Advanced maternal age (ie, age ≥35) is associated with decreased fertility due to the diminishing quantity and quality of oocytes as women approach menopause (average age: 51). (Choice B) Chronic ovulatory dysfunction (eg, polycystic ovary syndrome) is a common cause of infertility; however, this diagnosis is unlikely in this patient with regular, monthly (ie, ovulatory) menses. (Choice D) Long-term oral contraceptive use is not associated with infertility. Shortly after oral contraceptives are discontinued, patients typically resume menses and return to their baseline fertility level. Educational objective: Tubal factor infertility, which occurs due to tubal scarring and obstruction, is a complication of pelvic inflammatory disease. The risk for permanent tubal scarring increases with inadequate antibiotic treatment due to persisting or prolonged infection of the upper genital tract. __________ References: Update to CDC's treatment guidelines for gonococcal infection, 2020. (http://www.ncbi.nlm.nih.gov/pubmed/33332296) Pelvic inflammatory disease: diagnosis, management, and prevention. (http://www.ncbi.nlm.nih.gov/pubmed/31524362)

A 33-Year-Old Woman Comes to a Fertility Clinic for Evaluation