Female genital tuberculosis and infertility: Symptoms, diagnosis and treatment

In women, the most common site of extrapulmonary TB is genital TB. Female genital tuberculosis (FGTB) can affect the fallopian tubes, uterine lining, ovaries, cervix and vagina/vulva. A doctor spills the beans on its signs and symptoms, how does it lead to infertility and treatment.

About one-quarter of the world’s population has a tuberculosis infection, which means people have been infected by TB bacteria but are not (yet) ill with the disease and cannot transmit it but all age groups are at risk of TB while over 95% of cases and deaths due to tuberculosis are in developing countries. It is amongst the top 10 communicable diseases in the world as in spite of vaccine coverage and major improvements in antibiotic regimens, TB remains a major global health problem. 

Most commonly, TB affects the lungs (pulmonary TB) but it can spread and cause secondary infection to the kidneys, gastrointestinal tract, brain and pelvic (genital) organs. In women, the most common site of extrapulmonary TB is genital TB and female genital tuberculosis (FGTB) can affect the fallopian tubes, uterine lining, ovaries, cervix and vagina/vulva.

Signs and symptoms and how does it leads to infertility:

Female genital TB is of an insidious nature and most patients develop no symptoms at all, especially in the early stages. Often times, infertility is the only presenting symptom. If not treated in the initial stages, tuberculosis can severely and irreparably damage the fallopian tubes leading to infertility.

It can also damage the lining of the uterus and lead to the development of adhesions within the womb which can sometimes be severe (Asherman’s syndrome). Patients are likely to also have problems with ovulation, poor ovarian reserve, poor oocyte (egg) quality, implantation failure, lower pregnancy rate, and a higher abortion rate.

Some women with genital TB can have symptoms like irregular periods, blood stained vaginal discharge, pain during intercourse and chronic pelvic pain. Sometimes, the condition mimics other gynaecological conditions like ovarian cysts, ectopic pregnancy or even genital cancer.

How is genital TB diagnosed?

In spite of being known to be the third most common site for the infection (after the lungs and lymph nodes), genital TB often goes undetected and diagnosis is still a challenge despite the various tests available. She highlighted, “Clinical suspicion based on medical history, a complete physical examination, use of imaging modalities, surgical and histopathology findings and tests like PCR or Gene expert are required for diagnosis.

Explaining how the tubal blockage associated with FGTB can be diagnosed by a hysterosalpingogram (HSG) where a radio-opaque dye is introduced through the cervix into the uterus, Successive x-rays are then taken to track passage of the dye into the uterus and then through the fallopian tubes into the pelvic cavity. HSG may show obstruction of the tubes or uterine cavity constriction representing adhesions. Tubal blockage can occur anywhere along the course of the fallopian tube/s. In some cases the damaged tubes develop blockage at the distal end and become distended with tubal secretions and fluid (known as hydrosalpinx).

Treatment:

Suggesting multi drug anti-tubercular medical therapy in consultation with a TB specialist, This treatment is a four-drug regimen for 6 months as follows: initial 2-month treatment with daily rifampicin, isoniazid, pyrazinamide, and ethambutol; followed by 4-month treatment with daily isoniazid, rifampicin, and ethambutol. If this first-line treatment fails, (e.g., in patients with HIV co-infection or multidrug-resistant TB), a second-line treatment is adopted.

Currently, role of surgery as a treatment modality is limited. It may be suggested in patients with pelvic mass, pyosalpinx (pus filled fallopian tubes/s), recurrent pelvic pain or excessive bleeding.

Treatment for infertility:

The fallopian tubes are affected in almost all women with genital TB, while an impaired endometrium is found in half of the cases. For women with blocked or damaged tubes, In Vitro Fertilization and Embryo Transfer (IVF-ET) remains the treatment of choice. Women with thin uterine lining or Ashermans syndrome may need to undergo hysteroscopy before planning their IVF cycle.

In patients with hydrosalpinges (fluid filled damaged fallopian tubes) success rates with IVF reduce drastically if the IVF- ET is done in the presence of the hydrosalpinx. For such women, Hysterolaparoscopy with removal of the affected tube/s or (at the very least) clipping of the affected tubes/s as they emerge through the uterine wall is recommended prior to IVF. Pregnancy rates with IVF depend on several factors such as the severity of the disease, extent of damage to the endometrial lining, the woman’s age, her ovarian reserve, any coexisting male factor infertility etc.

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