Correlation of past tuberculosis with current screening for female genital tuberculosis in infertile women in a tertiary care hospital

ObjectivesTo analyse correlation of past history of tuberculosis with present state of infertility with respect to HSG and diagnostic findings, with a view to assess the frequency of genital tuberculosis in infertile women, its clinical presentation and association with infertility.Materials and methodsThe study is an ongoing study conducted in the Department of Obstetrics and Gynaecology, Kasturba Hospital, Delhi and included 174 infertile women enrolled as OPD patients in our hospital. A detailed history with special emphasis on past history of tuberculosis, thorough clinical examination, all routine investigations for Infertility & special investigations for genital tuberculosis was done. Diagnostic tests and laparoscopy was further performed as per the protocol.ResultsFemale genital tuberculosis has been described as a disease of the younger population. The present study shows that 87.9% patients diagnosed for genital tuberculosis were between 20 and 35 yrs of age. It was observed that amongst 174 infertile patients who attended our OPD, 40 patients had a positive history of present or previous incidence of Koch's, pulmonary or extra pulmonary, namely 22.9% (Group I) and the remaining patient comprising 77.1%, who had no record of any previous tuberculosis (Group II). Active Tuberculosis was seen in 5 patients out of a total of 40 females. Out of the total of 174 infertile patients suffering from tubal disorder 52.5% of Group I patients had evidences of tubal disease as compared to only 27.6% in Group II thus suggesting a strong correlation of tubal destruction and subsequent infertility to a positive history of tuberculosis. Out of the 56 laparoscopies performed, it was seen that 75% of Group I patients with past history of TB had abnormal laparoscopic findings (18 out of 24 patients), as compared to Group II which had only 9 out of 32 patients (28%) showing positive pelvic pathology. This seems to be very significant.ConclusionIn conclusion the results of the present study validate arguments in favour of incorporating screening for genital tuberculosis as a part of the baseline investigation for all patients of infertility, in countries like ours and especially in such patients who have suffered from Tuberculosis sometimes earlier in their lives.     

Detection of genital tuberculosis among women with infertility using best clinical practices in India: An implementation study

BackgroundDiagnosis of genital tuberculosis (TB) as a cause of infertility still remains a diagnostic dilemma for clinicians, as no standard guidelines exist. The recently proposed best practices for genital TB diagnosis have not been evaluated yet in India.ObjectivesTo implement best practices to diagnose and treat likely genital TB as a cause of infertility.MethodsBetween April 2016 and June 2018, consenting women seen at a tertiary hospital infertility clinic were assessed by thorough TB related clinical history, ultrasonography, tuberculin skin test (TST), and ESR. Those with suspected genital TB underwent laparohysteroscopy. Clinical and laboratory characteristics were compared between likely (microbiologically confirmed or probable TB) and unlikely (possible and no genital TB) genital TB. Fertility outcome was assessed among women initiated on anti-TB treatment (ATT).ResultsOf 185 women seeking infertility care, likely genital TB was identified among 29 (15.7%) women, with 6 (21%) confirmed and 23 (79%) probable genital TB. Compared to unlikely genital TB cases, the likely genital TB group were found to have past history of TB (p < 0.001); positive TST (p = 0.002) and elevated ESR (p = 0.001). Among the likely genital TB group, all 6 confirmed genital TB were started on ATT and 2 (33.3%) conceived. Of 5 probable genital TB started on ATT, 3 (60%) conceived.ConclusionApproximately 1/6th of women seeking infertility care met the criteria for likely genital TB. Conception among over-half of treated probable genital TB cases provides preliminary evidence that best clinical practices can be utilized, but needs further confirmatory studies.     

Genital footprints of extragenital tuberculosis in infertile women: Comparison of various diagnostic modalities

BackgroundGenital tuberculosis (TB) continues to remain an important cause of infertility in women, especially in developing countries. It is mostly consequent to a primary infection elsewhere in the body. The diagnosis is challenging, considering its paucibacillary nature. Although there are many studies on association of genital tuberculosis with infertility, there is paucity of literature on impact of extragenital tuberculosis on fertility of women through involvement of female reproductive organs. The various diagnostic modalities available have limitations and quest is ongoing for the best diagnostic test.MethodThis was a prospective observational study conducted at the infertility clinic of a tertiary care health facility where 60 infertile women with either tubal factor or unexplained infertility with or without past history of extragenital tuberculosis were enrolled as study subjects or controls respectively. Mantoux test was performed in all women and diagnostic laparo-hysteroscopy was performed in all women to look for any evidence of uterine and/or tubal damage. The peritoneal fluid was sent for GeneXpert and Liquid culture for mycobacterium tuberculosis. Results of Mantoux test, GeneXpert and liquid culture were compared with the laparohysteroscopic findings.ResultOf the thirty infertile women in the study group, 27/30 (90%) had a history of pulmonary tuberculosis and 3/30 (10%) had history of tubercular cervical lymphadenopathy. It was observed that Mantoux test was positive (induration >10 mm) in 27/30 (90%) of women in the study group as compared to only 4/30 (13.3%) controls. Abnormal hysteroscopic findings were documented in 26.6% (8/30) study group women as compared to 6.6% (2/30) women in the control group. Similarly, 60% (18/30) of women in the study group had abnormal laparoscopic findings compared to 33% (10/30) in the control group. Seven out of thirty (23.3%) women were positive for GeneXpert in the study group compared to only 1/30 (3.3%) in the control group. Similarly, liquid culture was positive in 6/30 (20%) of women in the study group as compared to 1/30 (3.3%) in the control group. All the above differences were statistically significant. We observed that the sensitivity of Mantoux test (75.8%) stand alone was higher than the other tests combined (50%). However, specificity and positive predictive value (PPV) increases markedly (up to 100%) to when all the three tests are combined.ConclusionThe authors conclude that all women presenting with infertility should be screened for a past history of tuberculosis and actively worked up for genital tuberculosis in case the history is positive. The various available tests (Mantoux test, GeneXpert and liquid culture) have their limitations for the diagnosis of genital tuberculosis. Thus an approach of early resort to laparohysteroscopy in suspected patients is desirable so that definitive management may be instituted timely and promptly.     

Prise en charge diagnostique et thérapeutique de la tuberculose urogénitale

Genito-urinary tuberculosis is the fourth most common manifestation of the disease, but it is often underestimated by clinicians because of few and non-specific symptoms and insidious disease course. The most common urinary findings are multiple ureteral stenosis. The most common genital involvement is an epididymal nodule for men and a chronic salpingitis for women. The definite diagnosis of genito-urinary tuberculosis is obtained on the basis of culture studies. Due to the paucibacillary nature of the disease, especially of genital location in woman, a probable or presumptive diagnosis is frequently considered with several parameters including radiological imaging (abdominal CT-scan, pelvic ultrasound, pelvic MRI). Endoscopic and surgical procedures are frequently required to obtain specimens for histopathologic and bacteriological studies. Medical treatment is the method of choice, with a combination of four drugs, namely isoniazid, rifampicin, ethambutol and pyrazinamide, followed by a two-drug regimen, for a total of six month duration. Surgery might be indicated in complicated genito-urinary tuberculosis (decreased renal function, infertility, urologic complaints).     

Female genital tuberculosis: a review

Female genital tuberculosis is an uncommon type of tuberculosis that can lead to infertility. The present review describes the disease, reports available epidemiological data, and focuses on examinations and procedures necessary for the early diagnosis and the management of this curable disease.     

An algorithmic approach to female genital tuberculosis causing infertility.

SETTING: A private infertility care and in vitro fertilisation (IVF) centre in Northern India. OBJECTIVES: To describe the prevalence, clinical spectrum, management strategy and outcome of infertility due to female genital tuberculosis (GTB) diagnosed with the help of a simplified tuberculosis (TB) algorithm. DESIGN: Data from 150 women with infertility (Group I) and 47 women with general gynaecological problems (Group II) were analysed. RESULTS: GTB was diagnosed in 7.2% of Group I and 2.8% of Group II women. Anti-tuberculosis treatment resulted in resolution of symptoms other than infertility in over 90% of cases. Of the total 20 pregnancies in the group, 10 were obtained in 32 IVF treatment patients. CONCLUSIONS: A definitive bacteriological diagnosis was generally difficult to achieve in GTB before administration of anti-tuberculosis treatment. A high index of suspicion and several other morphological and/or laboratory criteria were employed. It is suggested that a step-wise algorithm can help in the management of these cases.     

Impact of pulmonary tuberculosis on menstrual pattern and fertility

Introduction and Study Objective: The association between pulmonary tuberculosis (TB) and female reproductive health problems is not well addressed. This study was done at Assiut University and Woman's Health University Hospitals to estimate the effect of pulmonary TB on menstrual patterns and fertility of women in childbearing age. Patients and Methods: This study composed of 429 women with pulmonary TB of childbearing age (study group) and 100 age‐matched healthy women (control group). A detailed medical history was obtained, and a clinical examination, routine investigations of pulmonary TB and transvaginal ultrasonography (TVS) were performed for all cases. Hysterosalpingography, combined laparoscopy and hysteroscopy were done for infertile women whenever indicated. Results: Menstrual abnormalities were reported in 66% of women in the study group. Secondary amenorrhea (112 cases, 26.5%, P < 0.001) and hypomenorrhea (86 cases, 20%, P < 0.001) were significantly higher in the study group than controls (2% and 3%, respectively). TVS diagnosed functional ovarian cysts in 85 patients in the study group (19.8%). After completing anti‐tuberculosis treatment, 76% of women with menstrual abnormalities (162/213) resumed normal menstrual cycles. Among the 68 cases who sought fertility within 1 year after completion of treatment, TB peritubal and fine intrauterine adhesions were confirmed by laparoscopy and hysteroscopy in two and one infertile woman, respectively (0.7% of study group). Conclusions: TB had marked reversible effect on the menstrual cycle but minimal association with genital TB and infertility. Pretreatment counseling of pulmonary TB women should include information on these reversible changes. Persistence of menstrual abnormalities or presence of infertility after completion of treatment should stimulate investigation for the possibility of genital tract involvement. Please cite this paper as: Hassan WA and Darwish AM. Impact of pulmonary tuberculosis on menstrual pattern and fertility. The Clinical Respiratory Journal 2010; 4: 157–161.     

The significance of haptoglobin in the differential diagnosis of tuberculosis of the female genital organs]

Study included 115 women with suspicion of genital tuberculosis. Combined clinical, X-ray and laboratory examination made it possible to classify patients into 3 groups: group 1 included 44 patients with active genital tuberculosis, group 2 32 women with clinically cured tuberculosis of internal genitalia and group 3 39 women with nonspecific genital diseases. The haptoglobin-tuberculin test was given to all patients. High haptoglobin parameters before or 72 h after tuberculin administration were found only in the group of patients with active genital tuberculosis. In groups 2 and 3 the haptoglobin level did not exceed normal values both before and after tuberculin administration in a dose of 50 TU. The informative value of serum haptoglobin parameters in patients with active tuberculosis of internal genitalia constituted 88.6%.     

Peripartum genital tuberculosis presenting with ascites

Extra-pulmonary tuberculosis may affect multiple sites within the body. The symptoms vary widely and diagnosis requires a high clinical suspicion. In rare cases, tuberculosis may be manifest in the genitalia, initially presenting as infertility. Here we report a clinical case of a 23-year-old female with peripartum genital tuberculosis who presented at 2 weeks after delivery with fever and increasing abdominal girth.     

Role of microbiological tests in diagnosis of genital tuberculosis of women with infertility: A view

ObjectiveIndia is a country sharing one fourth of the global incidence of tuberculosis. It is much easier to diagnose pulmonary cases, but challenges are with extrapulmonary cases. Genital tuberculosis is considered as an important cause of infertility in young females in India and difficult to diagnose. It requires incorporation of different modalities that should correctly, timely and rapidly diagnose the case.MethodsThis study was conducted retrospectively for a period of 12 months on 438 endometrial samples from females with history of infertility. Three modalities namely Ziehl-Neelsen staining, Automated liquid culture and Nucleic acid amplification technique (TB-PCR) were compared and their sensitivity in diagnosis of genital tuberculosis was ascertained.ResultsOut of 438 samples, 18 samples were found positive with at least one modality. TB-PCR positivity was 3.6% (16 cases) in comparison to culture where positivity was 1.59% (7 cases). Five samples were found culture and TB-PCR positive and only one sample was positive by all three diagnostic tests.ConclusionInfertility in young female per se is usually heart breaking and distressing. Therefore, it is essential to diagnose and treat the cases of genital tuberculosis before irreversible damage of tube may happen. Although, advancement in diagnostic field is there from microscopy to molecular method, but still diagnosis of genital tuberculosis is challenging. Correct diagnosis prevents young female from mental trauma and toxicity of anti-tuberculosis drugs given on suspicion in high prevalence country like India.     

Infertility and coeliac disease.

BACKGROUND: Coeliac women may suffer from gynaecological and obstetric complications. It is possible that these complications are the first symptom of coeliac disease. AIMS: To investigate the occurrence of subclinical coeliac disease in patients with infertility or recurrent miscarriages. SUBJECTS: Women of reproductive age who were attending the hospital because of either primary or secondary infertility, or two or more miscarriages. Women undergoing sterilisation served as control subjects. METHODS: The diagnostic investigation for infertility included the endocrine status, diagnostic laparoscopy, investigation of tubal patency, postcoital test, and semen analysis of the partner. Circulating antibodies against IgA class reticulin and gliadin were used in screening for coeliac disease. In positive cases, the diagnosis was confirmed by small bowel biopsy specimens. RESULTS: Four (2.7%) of 150 women in the infertility group, and none of the 150 control subjects were found to have coeliac disease (p = 0.06). All four women with coeliac disease suffered from infertility of unexplained origin. Altogether 98 women had no discoverable reason for infertility. Thus, in this subgroup the frequency of coeliac disease was 4.1% (four of 98), the difference from the control group being statistically significant (p = 0.02). None of the coeliac women had extensive malabsorption, but two had iron deficiency anaemia. One women with coeliac disease has had a normal delivery. None of the 50 women with miscarriage had coeliac disease. CONCLUSION: Patients having fertility problems may have subclinical coeliac disease, which can be detected by serological screening tests. Silent coeliac disease should be considered in the case of women with unexplained infertility.     

A case control study of active genital Chlamydia trachomatis infection among patients with tubal infertility in northern Nigeria

A case-controlled study of the prevalence of genital Chlamydia trachomatis infection in 120 patients with tubal infertility (study group) and 120 clients of the family planning clinic (control group) attending the Ahmadu Bello University Teaching Hospital, Zaria in northern Nigeria is reported. The prevalence was 38.3%, 95% confidence interval (CI) (29.6-47.6%) in the study group and 13.3%, 95% CI (7.8-20.7%) in the control group. There was a fourfold risk of having genital Chlamydial infection among the cases compared to the controls (odds ratio [OR] = 4.04, 95% CI (2.04 < OR < 8.09). Tubal infertility was found to be significantly associated with genital C. trachomatis infection (P < 0.001). Out of the 58 cases of primary infertility, 22(37.9%) tested positive for genital C. trachomatis compared with 24 of the 62 (38.7%) that had secondary infertility. The infection was not found to be significantly associated with a particular type of infertility (primary or secondary), number of sexual partners or previous sexually transmitted disease (P < 0.05). There is need for provision of facilities to enable screening for genital C. trachomatis infection in view of its high prevalence in the study population.     

Sharma's parachute sign a new laparoscopic sign in abdomino pelvic tuberculosis

AimsTo demonstrate a new laparoscopic sign “Sharma's Parachute sign” in abdominopelvic tuberculosis in women with infertility.MethodsA total of 104 women who were diagnosed to have abdominopelvic tuberculosis, on endometrial sampling or on laparoscopy were enrolled in this ongoing study on tuberculosis in infertility. A new laparoscopic “Sharma's parachute sign” was looked for in these cases on laparoscopy.ResultsThe mean age, pairty and duration of infertility was 27.6 years, 0.58 and 4.1 years respectively. Menstrual dysfuction were common especially hypomenorrhoea (34.61%), oligomenorrhoea (36.53%) along with constitutional symptoms and abdomino pelvic pain or lump. Diagnosis of abdominopelvic tuberculosis was made by identification of acid fast bacilli (AFB) on microscopy or culture of endometrial aspirate or peritoneal biopsy or positive gene Xpert or positive polymerase chain reaction (PCR) or histopathological demonstration of epithelioid granuloma on endometrial or peritoneal biopsy, various laparoscopic findings on pelvic and abdominal organs were tubercles and shaggy areas (white deposits, caseous nodules encysted ascites, abdominal and pelvic adhesions, tubal findings (hydrosalpinx, pyosalpinx, beaded or calcified tubes). A new “Sharma's parachute sign”in which ascending colon was totally adherent to anterior abdominal wall with its mesocolon looking like an open parachute with small caseous nodule was seen in 11 (10.5%) cases.ConclusionDiagnostic laparoscopy is an important investigation for abdominopelvic tuberculosis showing various adhesions including new parachute sign.     

Pelvic tuberculosis continues to be a disease of dilemma--case series

Tuberculosis (TB) has become a global epidemic again with emergence of HIV/AIDS and multi-drug resistant strains of TB. Female genital tuberculosis (GT) is typically a disease of young women and its occurrence in post menopausal women is rare. Amongst the genital disorders, GT is the most baffling especially because of its various presentations. So GT is notorious for evading diagnosis. A series of cases of females GT between the age 25 yrs to 40 yrs is being reported with women having spectrum of clinical features, creating diagnostic dilemma and so final diagnosis by histopathology after laparotomy. So a high degree of suspicion aided by intensive investigations may be required for the diagnosis of GT. Medical therapy is the main treatment, however some do need surgery. Research needs to be continued for early establishment of timely diagnosis of GT and modalities of effective therapies.     

Hysteroscopic observations in 348 consecutive cases of female genital tuberculosis: A prospective study

Study objectiveTo evaluate the hysteroscopic findings in female genital tuberculosis.DesignIt was a prospective study of hysteroscopic findings performed on 348 cases of female genital tuberculosis (FGTB).SettingIt was a prospective cross-sectional study in a tertiary referral centre.PatientsA total of 348 patients with infertility with FGTB on various tests.InterventionA total of 348 patients of infertility found to have FGTB on various investigations were enrolled in the study. A detailed history was taken. Clinical examination, endometrial sampling and diagnostic laparoscopy were performed was also performed in selected cases. All patients underwent hysteroscopy as part of evaluation for infertility and tuberculosis (TB) findings.Measurements and main resultsThe mean age, parity, body mass index and duration of infertility was 28.2 years, 0.31,23.1kg/m² and 3.44 years respectively. Infertility was primary in 81.03% and secondary in 18.96% cases. Diagnosis of FGTB was made by endometrial aspirate findings of positive AFB on microscopy (4.02%), positive culture (4.88%), positive PCR (83.90%), epithelioid granuloma (14.65%), positive AFB on microscopy or culture of peritoneal cytology (1.14%) or epithelioid granuloma on peritoneal biopsy (1.72%), definitive findings of TB on laparoscopy (41.95%) or probable findings of TB on laparoscopy (58.05%). Various hysteroscopic findings observed were normal findings (28.16%), pale endometrial cavity (54.31%), features of active TB (7.47%), features of chronic TB (19.54%), features of TB sequelae like obstructed ostia (both ostia in 13.79%, one ostia 14.94%, periostial fibrosis; (bilateral 4.59%, unilateral 5.17%), endometrial glands atrophy (12.35%), small shrunken cavity (6.32%), distorted cavity (5.17%), various grades of intrauterine adhesions (29.88%). Hysteroscopy in FGTB was associated with increased difficulties and complications like failed procedures, difficult visualisation, false passage and uterine perforation.ConclusionHysteroscopy is useful modality to detect endometrial TB but is associated with increased difficulty and complications.     

Gonadotrophin resistance

Gonadotrophin resistance is caused by inactivating mutations in receptors (Rs) of the two gonadotrophins, i.e. luteinizing hormone (LH) and follicle-stimulating hormone (FSH), presenting as hypergonadotrophic hypogonadism and infertility/subfertility in both sexes. These conditions are extremely rare, but must be kept in mind upon differential diagnosis of disorders of sexual maturation, hypogonadism and infertility. In 46,XY individuals inactivation of LHR causes a disturbance in male-type sexual differentiation that ranges from male pseudohermaphroditism (complete lack of genital masculinization) to mild conditions such as cryptorchidism and hypospadias, depending on completeness of the receptor inactivation. In women, the phenotype is milder, presenting mainly as anovulatory amenorrhoea and hypo-oestrogenization. Inactivation of FSHR causes in otherwise normally masculinized men small testis size and variably reduced spermatogenesis, but not azoospermia or absolute infertility. In women the phenotype is more severe, with primary or early secondary amenorrhoea, arrested follicular maturation and anovulatory infertility. Incomplete forms with milder phenotype and partial responsiveness to FSH have also been described. Although gonadotrophin resistance is a very rare condition, its correct diagnosis is important for the selection of adequate treatment.     

Chlamydia trachomatis infection as a risk factor for infertility among women in Ghana, West Africa

In developing countries, data about the prevalence of genital Chlamydia trachomatis infections and their sequelae, especially tubal infertility, is scarce. A prospective case-control study was performed enrolling 439 Ghanaian women. The case group included 191 patients with primary or secondary infertility. The control group consisted of 248 healthy pregnant women. First-void urine samples were investigated by PCR, and serum specimens were tested for C. trachomatis-specific IgG and IgA antibodies. Demographic and behavioral information were gathered for statistical analysis. The PCR prevalence of C. trachomatis was relatively low and did not differ significantly among both groups (2.4 versus 1.6%). In contrast, significantly higher prevalences of specific IgG (39% versus 19%) and IgA (14% versus 3%) antibodies were found among infertile women. The adjusted odds ratios were 2.1 and 2.8, respectively. Our data suggest that previous C. trachomatis infections may contribute to infertility in Ghanaian women.     

<Emphasis Type="Italic">Mycoplasma genitalium</Emphasis>

Mycoplasma genitalium was initially isolated from men with nongonococcal urethritis in 1980. Subsequent studies to assess the association of M. genitalium with human disease were inhibited however because on repeated attempts the organism proved extremely difficult to culture. Fortunately, the development and use of specific polymerase chain reaction assays allowed progress in this arena and provided evidence of the association between M. genitalium and urethritis, cervicitis, and endometritis. A serologic association has also been noted between M. genitalium antibody and salpingitis and tubal factor infertility. In addition, sexual transmission of M. genitalium in heterosexual partners has also been demonstrated. Currently, studies are underway to further assess these associations and provide additional information about the significance of this organism with regards to sexual transmission, infertility in women, and its association with other genital tract disease processes. Recent studies have suggested that M. genitalium-associated infections are best treated with azithromycin.     

Male genital tuberculosis: a review of the literature with instructive case reports

The prevalence of extrapulmonary tuberculosis, including cases at male genital sites, has remained relatively constant during the past two decades in the United States. The most common genital sites of tuberculous infection are the epididymis and prostate; the testicle is infected in a lower proportion of cases. The usual modes of genital involvement include descending infection from the kidneys, intracanalicular or direct extension from neighboring foci in the genital tract, and hematogenous seeding. Local symptoms are usually insidious and progressive. Systemic manifestations such as fever, chills, and sweats are infrequently present in isolated genital tuberculosis. Tuberculous genital infection can be confused with other bacterial (including nontuberculous mycobacterial) infections, fungal disease, tumors, and cysts as well as with a number of less common illnesses. Although some diagnostic and therapeutic indications for surgical excision still exist, the preferred approach to treatment is primarily multiple-drug antituberculous chemotherapy.     

Pelvic tuberculosis: an uncommon gynaecological problem in Malaysia

Tuberculosis of the genital tract was diagnosed in only 12 patients during the 17 year period from March 1968 to February 1985 at the University Hospital, Kuala Lumpur, which serves as a major referral centre in Malaysia. The incidence was 0.31 per 1000 gynaecological admissions and the peak age incidence was in the age group 26 to 35 years. The surgical management was mainly conservative as infertility was the most frequent mode of presentation (50%). Evidence of previous pulmonary tuberculosis was present in only five cases. Adnexal adhesions were the commonest pelvic finding; the fallopian tubes and endometrium were affected with equal frequency. Positive cultures for Mycobacterium tuberculosis were obtained in only five of the 12 patients. All patients received combination anti-tuberculosis drugs with satisfactory response.