What is the most common cause of preventable infertility in the United States?

  1. What is the most common cause of preventable infertility in the United
    Pelvic inflammatory disease (PID).
  2. What is the most likely cause of infertility in a normally menstruating
    woman under the age of 30?
  3. What is PID? How do you recognize it on the Step 2 exam?
    PID is typically due to an ascending sexually-transmitted infection of the upper female
    genital tract that may involve the endometrial cavity (endometritis), fallopian tubes
    (salpingitis), ovaries (oophoritis), parametrial tissues/ligaments (parametritis), and/or
    peritoneal cavity (peritonitis). Look for a female aged 13 to 35 years with the following
    symptoms: (1) abdominal pain, (2) adnexal tenderness, and (3) cervical motion tenderness.
    All three criteria must technically be present. In addition, one or more of the following should
    be present: elevated erythrocyte sedimentation rate/C-reactive protein level, leukocytosis,
    fever, or purulent cervical discharge.
  4. How is PID treated? What are the common sequelae?
    Treat PID with more than one antibiotic (e.g., cefoxitin/ceftriaxone and doxycycline for
    outpatients; clindamycin and gentamicin for inpatients) to cover multiple organisms,
    especially Neisseria gonorrhoeae and Chlamydia trachomatis (the most common organisms).
    Also consider Escherichia coli, anaerobes, and, with a history of intrauterine device use,
    Actinomyces israelii.
    Common sequelae include infertility due to scarring of the fallopian tubes and
    progression to tuboovarian abscess (palpable on exam, may respond to antibiotics alone)
    that may rupture. Treat rupture with emergent laparotomy and excision of the affected tube
    (unilateral disease) or total abdominal hysterectomy and bilateral salpingo-oophorectomy
    for bilateral disease.
  5. Define endometriosis. What are the symptoms and signs?
    Endometriosis is defined as endometrial glands outside the uterus (ectopic). Patients are
    usually nulliparous and over 30 with the following symptoms: dysmenorrhea (painful
    menstruation), dyspareunia (painful intercourse), dyschezia (painful defecation), and/or
    perimenstrual spotting. The most common site for the ectopic endometrial glands is the
    ovaries; look for tender adnexa in an afebrile patient. Other sites include the broad
    (uterosacral) ligament and peritoneal surface. Nodularities on the broad ligament are
    classic findings on physical exam; the classic sequela is a retroverted uterus.