“Therapeutic Window” in Acute Gonococcal Salpingitis

Editorial The issue of fertility following acute gonococcal salpingitis has been addressed in less than an optimal manner. The often demographic instability of study patients and the need to publish within specific time frames have partially negated the ability to produce long-term studies of the impact of acute gonococcal salpingitis on subsequent fertility. In his study of acute salpingitis, Heynemann demonstrated that, if antibiotic treatment was started early, before adnexal tumors had formed, the reproductive prognosis for these women was very good. If palpable adnexal masses had developed, the prognosis for fertility was only about 18-20%. Hed-berg and Anberg 2 demonstrated that the risk of infertility varied roughly with the duration of disease before treatment. Similarly, Falk 3 demonstrated that the interval between the onset of pain and the initiation of antibiotics was a major factor in prognosticating the ability of such women to become pregnant. The higher the erythrocyte sedimentation rate (ESR) or the larger the adnexal swelling, the poorer was the prognosis for subsequent reproductive outcomes. Hedberg and Spetz 4 reviewed 216 cases of acute salpingitis. Cultures for Neisseria gonorrhoeae were positive in 96 and negative in 120 patients. These investigators found a better prognosis for fertility in women who had experienced gonococcal salpingitis compared with those with nongonococcal salpingitis. Viberg s surveyed a group of women for voluntary infertility and surgical intervention 21/2-5 years after their discharge from the hospital for acute salpingitis. Again, the incidence of pregnancy was higher for patients with gonococcal vs. those with nongonococcal salpingitis. These studies, done in the 1950s and 1960s, correlate well with our current understanding of the pathogenesis of acute gonococcal salpingitis. 6'7 In the absence of a concomitant Chlamydia trachomatis infection, gonococcal salpingitis is initially monomicrobial in etiology. 6'8-11 With an alteration of the oxidation-reduction potential, the "anaerobic progression" is initiated. 9-11 The current theory is that anaerobic bacteria are primarily responsible for basement-membrane destruction and healing by fibrosis within the fallopian tube. 9 Early monoetiological gonococ-cal salpingitis is associated with a relatively limited elevation of ESR (20-45 mm). 6 With a secondary anaerobic bacterial superinfection, levels >60 mm usually indicate the presence of tubal occlusion or a tubo-ovarian complex. The correlation of cul-de-sac microbiology with clinical response to therapy has demonstrated that, when acute salpingitis was due exclusively to N. gonorrhoeae, there was a predictable clinical response: defervescence in 24-36 h, loss of perito-neal signs and most …