Chronic Pelvic Inflammation Diminished Ovarian Reserve as Indicated by Serum Anti Mülerrian Hormone

Pelvic inflammatory disease (PID), responded to infection, irritation, or injury, has become a public health problem because of its deleterious effects on female reproductive system. Fallopian tubal occlusion, responsible for 42.3% of female infertility, is the commonest sequela of PID. It has been reported that 61.1% of infertile women with tubal factor resulted from non-specific PID [ 1 ]. As is well known, PID has direct deleterious effect on pelvic environment and endometrial receptivity However, it is unclear whether chronic pelvic inflammation will destroy ovarian reserve and impair follicles quantitatively and qualitatively. Patients with Crohn’s disease or dermatomyositis had decreased anti-Müllerian hormone (AMH) and antral follicle count (AFC) [ 2 , 3 ], which suggested that inflammation adversely affect ovarian reserve. However, there is no clear mechanism elucidating the role of inflammation on follicle. Here, we compared the basal FSH, estradiol (E 2 ), testosterone (T), AMH and AFC between patients with tubal occlusion and normal fallopian to explore the potential effect of chronic pelvic inflammation on ovarian reserve.

Clinical characteristics of all participants were presented in Table 1 . The ages [31.43±4.94 yrs vs. 30.85±5.11 yrs, P = 0.31] and prevalence of childbearing history [51.60% vs. 45.60%, P = 0.29] between two groups were comparable. Compared with controls, patients with tube obstruction had higher BMI [22.89(4.44) kg/m 2 vs. 21.64(4.12) kg/m 2 , P = 0.03]. Data were presented as mean± standard deviation for age, median (interquartile range) for BMI, and incidence (positive numbers) for categorical variable. BMI: body mass index. a : Statistical significance was found between cases and control subjects(P<0.05). Lower AMH level was observed in patients with bilateral tube occlusion than controls [2.62(2.95)ng/ml vs. 3.37(3.11)ng/ml, P = 0.03], even after adjustment with BMI [P adjust = 0.04]. However, no difference was found in AFC, FSH, LH, E 2 , and T between two groups ( Table 2 ). Data were presented as mean± standard deviation for normality distribution variables and median(quartile interval) for non-normality distribution variables. Difference of the means between two groups was determined after lg-transformation using Students’ T test. Analysis of covariance (ANCOVA) was used for adjustment of the covariance. FSH: follicle stimulating hormone; LH: luteinizing hormone; E 2 : estradiol; T: testosterone; AMH: anti-müllerian hormone P adjust : adjustment for BMI a : Statistical significance was found between cases and control subjects(P<0.05).

Bilateral tubal occlusion showed decreased AMH level, suggesting that chronic pelvic inflammation may diminish ovarian reserve. Therefore, more caution should be paid when evaluating the detriment of PID on female fertility.

A total of 122 women with bilateral tube occlusion diagnosed by hysterosalipingography (HSG) were enrolled. Other causes of infertility, such as ovulatory dysfunction, endocrinopathy, male factor, have been excluded. 217 age-matched women, asking for infertility treatment because of male factor, with normal fallopian tubes were recruited as controls. All subjects were from the Center for Reproductive Medicine, Shandong University. Women with abdominal or pelvic surgery, other disorders affecting ovarian reserve, including endometriosis, thyroid dysfunction, hyperprolactinemia, polycystic ovary syndrome (PCOS), premature ovarian insufficient (POI), and exposure to chemotherapy or radiotherapy previously were excluded. All subjects were subjected to anthropometric data, including height and weight. Body mass index (BMI) was calculated using weight (kg)/height 2 (m 2 ). Menstrual cycle, surgical history, and other diseases were recorded. Trans-virginal ultrasound was performed to evaluate AFC and hysterosalpingogram (HSG) to evaluate the status of fallopian tubes. Blood was sampled after 8 hours of fasting on day 3 to day 5 of menstruation for measuring AMH, FSH, luteinizing hormone (LH), E 2 , and T, using enzyme-linked immunosorbent assay (Ansh Labs Webster, USA; for AMH) and chemiluminescence immunoassays (Roche Diagnostics, Germany; for other serum parameters), respectively, all with intra- and inter-assay coefficients of variation<10%. All the data were listed in S1 Table . Written informed consents were obtained from all participants, and the study was approved by the Institutional Review Board of Reproductive Medicine of Shandong University. Data analysis was performed using Statistical Package for the Social Sciences for Windows (version 20.0; SPSS Inc., Chicago, IL, USA). Normality test was performed first for continuous variables of both groups using Kolmogorov-Smirnov test. Data were presented as mean± standard deviation for normality distribution variables and median(quartile interval) for non-normality distribution variables. Lg-transformation was used in comparison of the latter. Difference of the means between two groups was determined using Students’ T test. Analysis of covariance (ANCOVA) was used for adjustment of the covariance. Chi-square analysis was used for categorical variables comparison. Statistical significance was set at P<0.05.

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