Tuberculosis (TB) is a major public health concern across the globe. Though effective diagnosis and treatment options are now available, according to the World Health Organization, thousands of people still die of TB every year.
This bacterial infection most often affects the lungs, but extrapulmonary TB can attack other parts of the body, including the lymph nodes or urinary tract. In countries with a high prevalence of TB, such as parts of Southeast Asia, genital tuberculosis can be an important etiological factor for infertility.
How Genital TB Can Affect Fertility
Genital tuberculosis in women generally presents as "a chronic disease with low-grade symptoms," according to the Indian Journal of Medical Research These symptoms can include irregular periods and pelvic pain, but the condition can also be asymptomatic. Under the surface, however, damage to the fallopian tubes and endometrium can cause infertility.
Since genital tuberculosis can mimic other gynecological conditions such as pelvic inflammatory disease (PID) and unexplained infertility, diagnosis is critical to treating the underlying infection. Asymptomatic patients are most often diagnosed during infertility investigations or routine checkups, according to Evidence Based Clinical Gynecology.
Conception rates among women with genital TB are low. The risk of complications such as miscarriage and ectopic pregnancy are high for those who do conceive.
How is Genital Tuberculosis Diagnosed?
Since clinical presentation of genital tuberculosis is nonspecific, gynecologists must consider the prevalence of TB in the area. For example, if a patient has PID that refuses to respond to antibiotics and lives in a country with a high rate of infection, tuberculosis may be the real culprit.
There is currently no definitive diagnostic test for genital TB. Several routine tests provide indirect evidence of acute or chronic infection, including a complete blood count, erythrocyte sedimentation rate and chest X-ray for evidence of active or healed pulmonary TB.
The gold standard for tuberculosis diagnosis is culture on Löwenstein-Jensen medium. Other methods include:
- Examining endometrial biopsy specimens or first-day menstrual blood.
- The Mantoux test or tuberculin skin testing.
- Interferon-gamma release assays.
- Polymerase chain reaction.
If a physician suspects or confirms that a patient has genital TB, they should refer them to someone who can perform hysterosalpingography (HSG) or an ultrasound exam and hysterosalpingo contrast sonography (HyCoSy).
Evaluating Tubal Patency with HSG, HyCoSy and Ultrasound
HSG and HyCoSy can both be used as part of an ordinary infertility work-up to evaluate tubal patency. On HSG, the signs of genital tuberculosis are abundantly clear. These signs include edematous thickening of the tubal walls, tubal dilatation and crowded, torturous or "corkscrew" tubes, according to Evidence Based Clinical Gynecology. Advanced cases of genital TB may reveal fibrosis, scarring and peritubal adhesions.
Ultrasound may show dilated, thickened fallopian tubes filled with a clear fluid called hydrosalpinx, or a thick, caseous material called pyosalpinx. According to the Indian Journal of Medical Research, a sonographer should also look for hyperechoic areas on the endometrium, which could be the foci of fibrosis or calcification.
The condition's appearance on ultrasound varies widely. Other markers may include:
- Distorted uterine cavity.
- Thickened or thin endometrium.
- Cornual obliteration.
- Enlarged ovaries.
- Adnexal fixation.
- Oligemic myometrial cysts.
- Follicles with echogenic rims.
Treating Genital Tuberculosis
Treatment of genital TB is similar to the treatment for pulmonary TB: a six-month antibiotic treatment regimen, following WHO treatment guidelines. With treatment, some women who had infertility due to genital TB are able to spontaneously conceive. One study in Human Reproduction showed an overall pregnancy rate of 60 percent, with more than 90 percent of participants becoming pregnant during tuberculosis treatment or within six months of finishing it.
Genital TB represents a major cause of infertility in women, though its atypical presentation and diagnostic challenges may let it go unnoticed. For patients with infertility, clinicians should consider whether genital TB could be a cause. Early diagnosis and proper treatment is key to preserving or restoring these patients' fertility.
