Link between infertility and female genital tuberculosis

By Syed Akbar

Hyderabad, July 5: A team of city doctors has established a link between infertility and female genital tuberculosis, which is fast spreading in South India after lying low for many years.

The team has also found easy diagnostic methods to detect genital tuberculosis in women with 100 per cent accuracy. Currently diagnosing female genital tuberculosis is nothing short of a Herculean task. In many countries diagnosis is mainly limited to clinical suspicion based on symptoms. The problem is further compounded as abdominal and vaginal examinations reveal nothing.

Dr Roya Rozati, Dr Sreenivasagari Roopa and Dr Cheruvu Naga Rajashwari of the department of reproductive medicine at Mahavir Hospital and Research Centre have not only solved the diagnosis problem by identifying mycobacterial DNA tests through polymerase chain reaction but also established a link between the disease and infertility.

Genital tuberculosis is an important cause of infertility, more so in endemic zones such as South India. The proportion of extra-pulmonary TB is increasing down the Vindhyas and currently stands slightly higher than smear-positive pulmonary TB. Effective chemotherapy had reduced all forms of TB including FGTB until the HIV epidemic reversed the trend over the last decade.

However, the true epidemiology of this disease remains unknown due to lack of highly sensitive and specific tests. Genital tuberculosis not only causes tubal obstruction and dysfunction but also impairs implantation due to endometrial involvement and ovulatory failure from ovarian involvement.

The prevalence of FGTB in infertility clinics shows marked variations in different countries ranging between 15 and 25 per cent. In India in 80 to 90 per cent of cases, FGTB affects young women between 18 and 38 years of age, besides being an important cause of infertility.

"A high erythrocyte sedimentation rate and a positive mantoux test are non-specific. AFB staining is not sensitive enough and both culdoscopy and laparascopy carry a significant risk of bowel injury. Surgery is disadvantageous as it is highly invasive and carries a risk of activating silent infection. Only histopathological evidence in biopsy of premenstrual endometrial tissue or demonstration of tubercle bacilli in culture of menstrual blood or endometrial curetting can provide diagnosis with certainty," says Dr Roya Rozati.

The doctors investigated biopsy or curettage samples from 65 women clinically suspected to have genital tuberculosis for mycobacterium.

Genital tuberculosis is often a secondary complication as a result of reactivation of a silent bacillemia, primarily from lungs, affecting most commonly the fallopian tubes, ovaries, cervix, endometrium and vagina and vulva, and in some instances also from kidney and intestines.

"Direct inoculation of tubercle bacilli can also take place over vulva or vagina during sexual intercourse with a partner suffering from tuberculous lesions of genitalia," she said.