Dr. Ritu Sharma, MD (Obstetrics and Gynaecology).
Genital Tuberculosis and Female Infertility ‑ Is there a correlation?
Extragenital Tuberculosis (TB) is high in a health burden in the developing countries and is caused by the Mycobacterium tuberculosis bacilli. The Extragenital TB can affect female genitals without visible manifestations and could lead to infertility (Sharma et al., 2023). As per the study by Naik, et al., 2022; The prevalence of genital tuberculosis is about 20-25% in infertile women in India and 40–50% of women with genital tuberculosis suffer from infertility. Genital tuberculosis most commonly affects fallopian tubes (92–100%) followed by endometrium (50%), ovaries (10–30%), cervix (5%), and vulva and vagina (<1%). The damaged tubes, poor endometrium, and poor ovarian function subsequently lead to infertility.
The studies indicate the incidence of genital tuberculosis in infertile patients with prior history of extragenital tuberculosis is as high as 30-50%. Whereas, in the infertile patients without prior history of extragenital tuberculosis the incidence ranges from 10-15%. These results clearly conclude that extragenital tuberculosis has a definite impact on female genital tract which is invariably irreversible leading to infertility (Yadav et al., 2022).
Most female extragenital tuberculosis patients have menstrual disturbances. Menstrual abnormalities may be caused by weight loss, Mycobacterium tuberculosis’ antigonadotrophic effect, and rifampicin’s oestrogen catabolism, which affects luteinizing hormone surge. The most common menstrual complaints are menorrhagia, hypomenorrhea, amenorrhoea, and dysmenorrhoea. Menstrual abnormalities persist in 35% of patients after treatment. Young females are most affected due to increased blood circulation and hormone dependence of female genital tract after sexual maturity. In some patients, silent genital tract damage causes delayed infertility (Saxena et al., 2022).
Diagnosing genital tuberculosis remains a challenge due to varied clinical presentation, paucibacillary nature of infection, and lack of sensitive and specific laboratory test. Definite diagnosis is made by histopathology and culture, followed by RT-PCR and other molecular techniques. No Gold standard test for the diagnosis of extragenital TB. Diagnosis is usually made depending on collective evidence from high index of clinical suspicion, serology, histopathology, imaging techniques, and direct visualization on endoscopy (Yang et al., 2022).
In terms of treatment, daily dose of antibiotics including rifampicin is been suggested. Anti-tubercular chemotherapy is the new treatment in the clinical field followed by the surgical removal infested organs. Women with history of extragenital tuberculosis should be counseled regarding the likely impact of their disease on their fertility and that they should not delay evaluation for infertility unnecessarily given a high prevalence of silent genital involvement and subsequent impact on fertility. Timely diagnosis and treatment of genital tract tuberculosis in these patients can prevent further damage and infertility (Yadav et al., 2017).
Author:
Dr. Ritu Sharma, MD (Obstetrics and Gynaecology)
Associate Professor, Department of Obstetrics and Gynaecology, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh.
Updated by:
Sunanda Kulshrestha, Ph.D (Department of Biotechnology, GLA University, Mathura, Uttar Pradesh, India).
References:
Naik, Shilpa N., Ajay Chandanwale, Dileep Kadam, P. W. Sambarey, Gauri Dhumal, Andrea DeLuca, Divyashri Jain, Amita Gupta, Robert Bollinger, and Vidya Mave. “Detection of genital tuberculosis among women with infertility using best clinical practices in India: an implementation study.” Indian Journal of Tuberculosis 68, no. 1 (2021): 85-91.
Saxena, Riden, Kriti Shrinet, Sachchida Nand Rai, Kamal Singh, Shivi Jain, Shuchi Jain, Deeksha Singh, Shampa Anupurba, and Madhu Jain. “Diagnosis of genital tuberculosis in infertile women by using the composite reference standard.” Disease Markers 2022, no. 1 (2022): 8078639.
Sharma, J. B., Shefali Jain, Sona Dharmendra, Urvashi B. Singh, Manish Soneja, Vidushi Kulshrestha, and P. Vanamail. “An evaluation of composite reference standard (CRS) for diagnosis of female genital tuberculosis.” Indian Journal of Tuberculosis 70, no. 1 (2023): 70-76.
Sharma R, Puri M. Extragenital tuberculosis and female infertility – Is there a correlation? A retrospective observational study. IVF Lite 2016;3:7-10. DOI: 10.4103/2348-2907.183439.
Yadav, Siddharth, Prabhjot Singh, Ashok Hemal, and Rajeev Kumar. “Genital tuberculosis: current status of diagnosis and management.” Translational andrology and urology 6, no. 2 (2017): 222.
Yadav, Swati, Manju Puri, Swati Agrawal, and Kamal Chopra. “Genital footprints of extragenital tuberculosis in infertile women: Comparison of various diagnostic modalities.” Indian Journal of Tuberculosis 69, no. 2 (2022): 151-156.
Yang, Yu-Kuan, Hsiao-Wen Chen, Li-Chueh Weng, Kwai-Fong Ng, Hsu-Han Wang, Ming-Li Hsieh, Sheng-Hsien Chu et al. “Incidental tuberculosis epididymitis/epididymo-orchitis: a retrospective analysis at a tertiary center in Taiwan.” Urology 168 (2022): 116-121.