Upper genital tract infections (UGTI), commonly grouped under pelvic inflammatory disease (PID), include infections of the uterus, fallopian tubes, ovaries, and surrounding pelvic structures. These infections usually result from ascending sexually transmitted pathogens, particularly Chlamydia trachomatis and Neisseria gonorrhoeae, but polymicrobial infections are frequent, especially in advanced disease stages [1][2]. When these infections progress, they can lead to severe complications like tubo-ovarian abscess (TOA), pelvic peritonitis, and generalized peritonitis, collectively termed complicated UGTI (CUGTI). These conditions are gynecological emergencies associated with considerable morbidity, risk of mortality, and a well-documented deleterious effect on tubal function and future fertility [3][4].

In high-income countries, early diagnosis and prompt antibiotic treatment have substantially reduced the incidence of severe complications. In contrast, in low- and middle-income countries, delayed presentation, limited access to healthcare, high prevalence of sexually transmitted infections (STIs), challenges in implementing comprehensive reproductive health services, sociocultural barriers, and self-medication often lead to advanced infectious forms such as tubo-ovarian abscesses, pelviperitonitis, and generalized peritonitis [1]. Surgical intervention often becomes necessary for diagnostic confirmation, source control, and treatment of complications like visceral perforations [5].

Although several studies have described the clinical management and microbiological aspects of PID, data on surgical management and long-term fertility outcomes following complicated UGTI in Africa remain scarce. Most available studies focus on acute management, with limited follow-up on reproductive outcomes. Previous studies from Cameroon have reported on the prevalence and general management of pelvic infections [6]-[8], but a detailed analysis of surgical strategies and their impact on fertility is lacking. Understanding fertility prognosis after surgery is crucial for counseling patients and guiding postoperative care.

This study aimed to describe the surgical management of complicated UGTI at a tertiary referral hospital in Yaoundé, Cameroon, and to describe subsequent fertility outcomes among affected women.

This study provides a detailed overview of the severe spectrum of CUGTI requiring surgical intervention in a Cameroonian tertiary center. Our findings paint a sobering picture of cPID as a disease of young, often nulliparous women, presenting late with severe systemic illness and carrying a dismal prognosis for future fertility.

The demographic profile of our patients, with a mean age of 29.5 years and a high proportion of nulliparous women (32.1%), underscores that cPID strikes women squarely in their peak reproductive years. This aligns with patterns observed across Sub-Saharan Africa, where PID is a leading cause of tubal factor infertility [1][2][6][7][9][10]. The high prevalence of self-reported STI history (43.4%), particularly Chlamydiatrachomatis and Mycoplasma, is consistent with the established microbial etiology of PID [3][11]. However, the strikingly low rate of consistent condom use (15.1%) highlights a critical gap in preventive sexual health practices, a recurring theme in similar settings [12].

The clinical presentation was marked by severity. The high frequency of fever, peritoneal signs, and a WHO performance status of 3 in over a third of patients indicates advanced infection and systemic compromise. This late presentation likely explains the overwhelming preference for laparotomy (88.7%) over laparoscopy. In resource-constrained environments, laparotomy often remains the safest and most expeditious approach for managing generalized peritonitis, large abscesses, and associated visceral injuries, which were present in nearly half of our patients [5][13]. In contrast, laparoscopy is increasingly favored in high-resource settings due to reduced morbidity and faster recovery [14]. According to Hüseyin et al, the choice of an open or laparoscopic surgical approach should be largely based on operator skill, experience, and ability to perform the necessary surgical maneuvers [15]. The finding of uterine perforation in 32% of cases is notably high and warrants special attention. This likely reflects complications from clandestine or unsafe uterine instrumentation, a significant public health challenge in regions with restrictive abortion laws and limited access to safe reproductive health services [16]. The high rate of preoperative antibiotic administration reflects standard care for sepsis source control, although the choice of regimens was varied.

The intraoperative findings further illustrate the destructive nature of delayed cPID. The high rate of pelvic adhesions (60.4%) and the large volume of purulent collections are direct consequences of prolonged, untreated infection, leading to extensive tissue inflammation and fibrosis [9]. These adhesions are a primary pathological substrate for subsequent infertility and chronic pelvic pain. The postoperative mortality rate of 5.6% contrasts sharply with near-zero mortality reported in high-income countries where earlier PID are largely managed medically in earlier stage without surgical intervention, emphasizing persistent disparities in timely access to care and intensive postoperative support [17].

Tubo-ovarian abscess and pelviperitonitis were the most frequent intraoperative diagnoses, in line with African literature identifying these entities as the most common complications of untreated pelvic inflammatory disease [18]. Digestive involvement, observed in over 10% of cases, further illustrates the advanced stage at which patients present.

A key strength of our surgical management strategy was the predominance of conservative procedures. Salpingectomy was rarely performed, and no oophorectomy was recorded. This approach aligns with international recommendations emphasizing organ preservation whenever feasible in women of reproductive age [17][19]. The high rate of conservative surgical management observed in this study reflects a deliberate fertility-preserving strategy in a context where access to assisted reproductive technologies, particularly in vitro fertilization, remains extremely limited and financially inaccessible for most patients. Despite the known risk of persistent hydrosalpinx and tubal dysfunction, organ-preserving surgery was favored whenever feasible to maintain any residual reproductive potential, especially in young nulliparous women.

The most impactful finding of our study relates to fertility outcomes. A subsequent pregnancy rate of only 20% among eligible women starkly quantifies the devastating toll of cPID on reproductive potential. This rate is lower than some reports following conservative surgical management of isolated TOA in high-income settings, where pregnancy rates between 30% - 40% have been described [20][21]. However, it aligns closely with studies from Low-and Middle-income Countries and is reflective of the advanced disease stage (high rates of peritonitis and adhesions) in our cohort [4]. The fact that all pregnancies were spontaneous and most occurred within two years suggests that if conception does not happen relatively early, the likelihood diminishes significantly, possibly due to persistent tubal damage or adhesion reformation. The occurrence of an ectopic pregnancy (12.5% of pregnancies) is a classic, feared complication of tubal damage from PID, reinforcing the link between infection and adverse reproductive outcomes [4][22].

Our findings must be interpreted in the context of the healthcare landscape in Central Africa. The limited use of laparoscopy is a significant constraint. In high-resource settings, laparoscopy is the gold standard for diagnosing and treating cPID, offering advantages in visualization, adhesion lysis, and fertility preservation, with potentially better reproductive outcomes [23]. The high rate of uterine perforation points to an urgent need for improved access to safe family planning and post-abortion care services. Furthermore, the low condom use despite STI history indicates that behavioral change communication and integrated STI/PID prevention programs remain inadequate.

The main strength of this study lies in its 5-year follow-up and the exhaustive nature of the recruitment in a major tertiary center, providing a realistic portrait of CUGTI management in Cameroon. However, its retrospective design may have led to under-reporting of minor complications and a potential recall bias during fertility interviews. The absence of systematic hysterosalpingography also limited objective assessment of tubal patency. The sample size, while representative of a single center, may limit the generalizability to rural areas.

Complicated pelvic inflammatory disease in our setting represents a severe condition with major implications for both maternal survival and future fertility, as reflected by the low rate of subsequent pregnancy. These findings highlight the need for a comprehensive response that integrates prevention, early diagnosis, and improved care. Strengthening sexual health education, promoting condom use, and expanding STI screening, particularly for Chlamydia are essential to reduce disease incidence. Early recognition and appropriate medical management of acute PID by trained healthcare providers are crucial to prevent progression to complicated forms. Improving surgical care, including the development of laparoscopic capacity and fertility-preserving techniques, could help mitigate long-term reproductive damage. In addition, structured post-treatment counseling and timely referral for fertility evaluation and assisted reproductive technologies are needed. Finally, public health policies should address unsafe uterine instrumentation by improving access to safe abortion services and post-abortion care in accordance with national regulations and WHO recommendations.

All authors who contributed to this work have declared that they have read and approved the final version of the manuscript.