Tuberculosis bacterium which can affect any part of your body, but most often affects the lungs. When it lodges and infects the genital tract, those TB bacteria can cause genital TB and can cause infertility. The infection can attack the ovaries, uterus and tubes leading to infertility problems among women. Even among men tuberculosis is a major reason for infection. Genital TB is a matter of great concern because the symptoms don’t appear easily and by the time it’s realized it already leaves an impact on the fertility of humans. Proper TB medication can help the women go on and have a successful pregnancy.
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Tuberculosis or TB is a bacterium which can affect any part of your body, but most often affects the lungs. The primary infection in the lungs is known as pulmonary tuberculosis. In some cases the TB infection moves through the blood to other parts of the body. It can thus cause secondary infections in the genital tract, pelvic area, kidneys, spine and brain. When the bacterium reaches the genital tract it causes genital tuberculosis or pelvic TB. It affects the genital tract (in both men and women), fallopian tubes, uterus, and ovaries. In some cases it also affects the cervix, vagina and vulva. Genital tuberculosis is one of the major causes of tubal disease and female infertility in developing countries. Though genital TB is not common, it remains a contagious disease.
Doctors say that nearly 90 percent of women with genital tuberculosis are diagnosed in the 15-40 years age group. Infertility on account of genital tuberculosis is 60-80 percent. Doctors say that usually TB of the uterus and fallopian tubes is the cause for infertility. Recent studies have concluded that till a decade ago only 10 percent of the total tuberculosis patients suffered from genital tuberculosis, but the percentage have now increased to 30 percent due to ignoring the disease in the initial stages and lack of awareness.
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The tuberculosis starts affecting the genitals once the ‘mycobacterium tuberculosis’ enters the human body. Initially it does not affect and remains silent as most of us can fight off the infection. However, later these latent bacilli can get reactivated, and then spread throughout the body through the blood stream. It is only when it lodges and infects the genital tract that TB bacteria can cause genital TB and can cause infertility. The infection can attack the ovaries, uterus and tubes leading to infertility problems among women. The disease is also becoming more evident among men causing infertility. Even among men tuberculosis is a major reason for infection. Detection and treatment of tuberculosis remains a challenge even as it is one of the oldest diseases impacting Southeast Asian countries including India and Bangladesh, where the bacteria is very rampant.
In males, genital tuberculosis causes tuberculous epididymo-orchitis, blocking the ureteral passage, as a result of which the man becomes azoospermic (lack of sperms) and is not able to ejaculate during intercourse because the tract is blocked.
While in the woman the TB causes infection of the uterus and the fallopian tubes, this infection can often be silent, and may not cause any symptoms or signs at all. Later on it leads to infertility. The problems may also include bleeding discharge, ulcers, among other symptoms. Doctors say such tuberculosis infection is often serious as they can damage the complete tube making it difficult for females to conceive. It can lead to hydro salpingitis. If not detected at an early stage, it can lead to severe complications. In some cases, women are never able to conceive after they develop hydro salpingitis. Among 30% of women with any kind of tuberculosis, 5-10% suffers hydro salpingitis, where water enters the tube.
A recent study by the Indian Journal of Medical Research through its survey stated that the number of women with genital tuberculosis in India has increased to 30 percent in 2015 from 19 percent in 2011. The report also stated that Saudi Arabia has the second highest number of genital tuberculosis patients with 21 percent.
Genital TB is a matter of great concern because the symptoms don’t appear easily and by the time it’s realized it already leaves an impact on the fertility of humans. Even sexual intercourse with an infected person is one of the means of getting genital tuberculosis.
As being a silent intruder it’s very difficult to notice the problem in the initial stage. Symptoms like irregular menstrual cycle, vaginal discharge that is stained with blood, pain after intercourse could be noticed in females, while in males symptoms like unable to ejaculate, low sperm motility and pituitary gland not able to produce sufficient hormones can be seen.
The diagnostic dilemma arises because of varied clinical presentation of the disease confounded by diverse results on imaging, laparoscopy, histopathology, bacteriological and serological tests, each of which has its limitation in diagnostic sensitivity and specificity. Diagnosis of GTB has profound implications for asymptomatic women seeking fertility.
Diagnosis of GTB depends on following:
CBC, ESR, RFT, CRP
Pelvic ultrasound / Hystero-salpingography(HSG).
AFB microscopy / culture
Endometrial aspiration / Endometrial biopsy/ Endometrial curettage/ Menstrual blood in females.
Pap smear may offer important provisional diagnosis while histological examination of endometrial biopsy is one of the simplest diagnostic methods. Culture for TB remains the gold standard of all diagnosis for GTB.
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Management of genital TB includes eradication of the infection and treating its consequences. Combination of anti-tuberculous agents for 9–12 months duration provides more than 95% cure rate. Surgical intervention may be needed, namely, total abdominal hysterectomy and bilateral salpingoophorectomy, if there is persistent or recurrent disease, unhealed fistula, or multi-drug-resistant.
Most of the time women worry whether after contracting genital TB will they be able to conceive. Genital tuberculosis and the problem of infertility can be cured if proper TB medication is taken for prescribed time and after follow ups and checks are being done. Proper TB medication can help the women go on and have a successful pregnancy. The course of antibiotics for six to eight months should be completed properly, but it doesn’t guarantee the repair of fallopian tubes. Many doctors perform surgery to repair the tubes, but it’s a futile job. Lastly, the intervention has to be either in-vitro fertilization or Intracytoplasmic sperm injection (ICSI). Most symptoms will disappear within a few weeks of treatment and there is a tendency for patients to stop treatment. Incomplete treatment can end up becoming a drug resistant case which may not only be lethal to the patient, but also be a health hazard to the community. It is very important that the treatment is completed fully.
If women with genital TB are diagnosed late, the infertility risk and other harm done to their tissue are likely to be much more severe. The solution lies in early case detection and providing standard treatment for genital TB without delay. If a family member or colleague is an active TB patient, then people around them need to be cautious and should go for tests like chest X-Ray, tuberculin test to know whether they have been hit by TB or not.
Due to lack of education, awareness and proper access to healthcare system, results in a complicated situation. In an endemic area or in an immuno compromised individual, a higher index of suspicion would allow early recognition and treatment institution to minimise its late consequences as well as disease spreading. Anti-TB medication is the mainstay of treatment. Surgical intervention may be needed in selected cases.
Dr.Gautam N. Allahbadia is the Medical Director of Rotunda – The Center for Human Reproduction, the world-renowned fertility clinic at Bandra, Mumbai, India as also the New Hope IVF Clinic at Sharjah, UAE. Dr. Gautam and his team of doctors including embryologists and fertility specialists knows that facing infertility can be one of the most stressful situations you may encounter, emotionally, physically and sometimes financially. At Rotunda, we work hand-in-hand with you to make every phase of the process from diagnosis to treatment as predictable and comfortable as possible. Together we will map out a plan to determine the cause of your infertility and an appropriate course of action. Infertility test at our clinic also includes the test to check out the option for genital tuberculosis as routine procedure. All the services are offered under one roof and includes basic work-up of the infertile Couple, One Stop Fertility Diagnostic Services including hormonal testing, Diagnostic Laparoscopy & Hysteroscopy, Recurrent Pregnancy Loss Clinic, Reproductive Endoscopic Surgery including Fallopian Tube Recanalization, Minimally Invasive Ultrasound Guided Procedures, Uterine Cavity Assessment (Sonocontrast hysterography), Artificial Insemination, Semen Cryopreservation, Semen processing, Ovulation Induction & Monitoring, Evaluation of male patient, Intrauterine insemination, Gonadotropin Cycles, Fallopian Tube Sperm per fusion, GIFT, ZIFT, In Vitro Fertilization (IVF), Embryo Freezing, BET, Oocyte Donor Program, Surrogacy, Assisted Hatching, Surgical Sperm Retrieval (PESA/MESA/TESA/TESE), & Intracytoplasmic Sperm Injection (ICSI).