Tuberculosis is caused by a bacterium known as mycobacterium tuberculosis. It is primarily an infectious process that involves the lungs it is capable of spreading elsewhere (extra-pulmonary TB) It can spread to the woman’s reproductive tract and cause infertility. The commonest site is the Fallopian tubes. From there it can spread to uterine lining (endometrium) and to the ovaries. The lower genital tract (cervix, vagina and vulva can also be affected but this is very rare.
Contrary to popular belief, TB does not spread by surface contact (sharing of utensils or clothes or through touch). Rather it spreads by droplet contamination when you come into contact with an individual who has pulmonary disease, who coughs, spits or sneezes and you come in contact with mycobacterium Tuberculosis. There is a rare form of TB caused by mycobacterium tuberculosis bovis, that spreads through ingestion of infected milk but this usually affects bowel and bone, not the reproductive tract.
While pelvic tuberculosis is a very common cause of infertility in developing countries and in Asia (India in particular), it so rarely causes of infertility in the United States, that the diagnosis is often overlooked here. However, there is good reason to believe that the condition is on the rise in the United States as a result of the influx of immigrants from Asia and other third world countries where tuberculosis is rampant.
Pelvic tuberculosis is often a master of disguise….a silent disease. It may be present for 10 to 20 years without producing any symptoms – the woman remaining in apparent excellent health. Infertility is often one, and sometimes the only, reason that women investigate for the presence of the condition.
In >80% of cases pelvic tuberculosis spreads from a primary focus in the Fallopian tube(s), It usually presents with one or more of the following signs and symptoms:
- Pelvic pain, dysmenorrhea (pain with menstruation), dyspareunia (pain with intercourse), chronic lower abdominal pain or discomfort, and chronic back pain
- Absent or irregular menstruation,
- Abdominal distention, usually due to ascites (collection of free fluid in the abdominal-pelvic cavity
- Tuberculosis-related infertility is most commonly due to tuberculous salpingitis (tubal inflammation) which occurs in 75% of cases, ovulation dysfunction that often presents with absent, excessive or non-cyclical menstruation, largely attributable to ovarian involvement (40% of cases) and uterine (endometrial) tuberculosis (30%)
- Sometimes (albeit rarely), local tuberculous lesions may appear on the external genitalia, cervix, and/or vagina.
The diagnosis is usually based upon a multitude of signs, symptoms and special tests, there being no magic bullet for diagnosing pelvic tuberculosis.
- Clinical suspicion: Evidence of concomitant, pulmonary tuberculosis, the detection of calcifications on pelvic X-rays, a typical tubal pattern on hysterosalpingogram (HSG)
- D&C; laparoscopy/or laparotomy to obtain biopsied material for: analysis by culture histopathologic examination-HPE, and genetic assessment (see below)
- Blood tests such as a differential blood count and erythrocyte sedimentation rate
- Systemic evaluation to detect systemic dissemination of pelvic tuberculosis (primarily to bone and bowel and more rarely to the lungs and elsewhere)
- Dilatation and curettage (D&C) of the uterus is performed a few days prior to menstruation. The surgeon takes care to avoid using an antiseptic to clean the vagina and cervix while preparing for the D&C;, lest the antiseptic kill any tuberculous bacilli present in the specimen thereby rendering a falsely negative culture result. Instead a physiologic salt solution is used to cleanse the operative field. Upon collection, the specimen of uterine curetings is immediately divided into two parts. The first is placed in a physiologic salt solution and expeditiously delivered to the bacteriologic lab for culturing. A specialized culture medium (e.g., Loewenstein Jensen medium) is used for this purpose.Curettings can also be innoculated into a guinea pig for proliferation of tubercous bacteria. The second portion of the specimen is fixed and then stained using the Ziel Mielson staining for the detection of the acid-fast bacterium (AFB), mycobacterium tuberculosis.
- Analysis of biopsied specimens: (from local lesions, menstrual blood and d endometrial curettings. Such biopsied specimens can also be subjected to histopathologic examination (HPE) for microscopic assessment and can be stained, using the Ziel Nielson method for AFB , and polymerase chain reaction (PCR) genetic assessment.
Cuture results and AFB staining and HPE show mild agreement with the clinical criteria, whereas PCR shows a moderate agreement. False negative PCR tests occur in about 40% and false positve results in about 8-10% of cases. It follows that multiple testing is required to make a firm diagnosis of pelvic tuberculosis.
Interpretation & conclusions:
Our results showed that conventional methods of diagnosis namely, HPE, AFB smear and culture have low sensitivity. PCR was found to be useful in diagnosing early disease as well as confirming diagnosis in clinically suspected cases. False negative PCR was an important limitation in this study.
Even in the presence of established tuberculosis, histopathologic examination will only be positive about 50% of the time. Cultures, although more reliable, can also yield false-negative results. And while PCR analysis, conducted under ideal conditions is a highly sensitive and specific method for the detection of the target genes specific to Mycobacterium tuberculosis and has a high positive predictive value, “false positive” results can occur Accordingly, it is often necessary to repeat such tests several times if the diagnosis is strongly suspected.
Treatment of TB primarily directed towards the eradication of the infection by means of specific chemotherapeutics such as Para-amino-salicylic acid (PAS), isoniazid (INH), rifampicin (Rifampin) and streptomycin derivatives.
Given the severity and intractability of fallopian tube-TB, natural conception is very unlikely. Pelvic surgery (other than to remove distended or infected lesions and damaged fallopian tubes) has little therapeutic benefit. Provided that the tuberculous inflammatory process has not totally destroyed the basal uterine endometrium (lining) , leaving it capable of responding adequately to estrogen and progesterone, , in vitro fertilization (IVF) following protracted successful anti-bacterial treatment is the only rational method of treating infertility associated with pelvic tuberculosis.