Female Genital TB and Infertility: World Tuberculosis Day, March 24, 2019.
According to World Health Organization “This World TB Day, WHO calls on governments, affected communities, civil society organizations, health-care providers, and national/international partners to unite forces under the banner Find. Treat. All. #EndTB to ensure no one is left behind.”
It’s time for action! It’s time to End TB., Let’s talk about it !
Tuberculosis. If this word evokes the image of a person coughing his lungs out due to Mycobacterium tuberculosis (MTB) (bacterial) infection, then you are partially correct. MTB not only affects lungs but can also reach other parts of your body and cause the “extrapulmonary form” of TB. One such type of extrapulmonary TB is Female Genital TB (FGTB). With an incidence of up to 30% in India it often results in infertility1. So, this year, on world TB day, we dedicate our efforts to educate women about FGTB.
In a case reported from India, a 30-year-old woman sustained long-term FGTB due to lack of knowledge/awareness which unfortunately damaged her uterus lining2. A damaged uterus lining makes it impossible to bear a child and therefore causes infertility. Such lack of awareness led to an increase in the reported cases of FGTB from 19% in 2011 to 30% in 20153. The first step towards fighting FGTB is to become aware and becoming aware is to know the possible signs and symptoms of FGTB which include: fever with night sweats, weight loss, loss of appetite, menstrual dysfunction, abnormally heavy or prolonged menstrual bleeding, postmenopausal bleeding, infrequent menstruation, short periods with light menstrual flow, one or more missed menstruation, painful periods, chronic pain in pelvis, pain in abdomen, abnormal discharge from vagina, vaginal ulcers, swelling in labia, infrequent urination or faeces, lump in abdomen and acute abdomen1.
These symptoms are generally an outcome of secondary infection resulting from pulmonary TB affecting the lungs. Additionally, the chances of having FGTB also increase if one is already suffering from extrapulmonary form of TB such as that of the digestive tract, protective tissues of brain (meninges), kidney, miliary TB or skeletal system. As the causative bacteria travel through the circulatory system, primary infections translate into secondary cases of extrapulmonary TB4. Moreover, women can also acquire MTB directly from their infected male partners suffering from genitourinary TB.
Once MTB infects the female genitalia, it can damage the ovaries, lining of uterus and the cervix, In a majority of cases the fallopian tubes are also deformed1. Fallopian tubes are a pair of tubes in female reproductive system via which the egg travels from the ovaries to the uterus. It is also where the egg and the sperm meet. Therefore, when the fallopian tubes are deformed, there is hindrance to the union/fusion of the egg and sperm and fertilization may not take place.
In order to avoid any damage to one’s reproductive health by Mycobacterium tuberculosis, the infection needs to be detected early. If detected early, timely administration of anti-TB treatment can help avoid infertility. Many a times the infection itself remains latent, that is, symptoms do not appear. Therefore, careful observation of one’s reproductive health and proper awareness may help detect the infection early.
Another challenge associated with FGTB is diagnosis. Diagnosing the condition proves to be difficult as the disease has different clinical manifestations in the body and there is a possibility of diverse results. Diagnosing FGTB accurately involves a combination of different diagnostic tools ranging from blood tests, endometrial biopsy, laparoscopy and the PCR tests5 (DNA based test). It is to be reiterated that even if FGTB is confirmed, it does not necessarily result in infertility Timely medical intervention and treatment can even cure the condition and result in conception6.
However, now is the time to make a switch from diagnosing and treating to compete eradication of TB. TB could be eradicated through better diagnosis, treatment, vaccines and research initiatives and the Indian Government continues to work tirelessly in accordance with the designated objectives of WHO in order to achieve the above. Under the leadership of the honourable Prime Minister Mr. Narendra Modi and the Deputy Director General of WHO, Dr. Soumya Swaminathan, the India TB Research Consortium has been established to promote research, innovation, and partnership to bring an end to TB by 20257. The government is currently conducting clinical trials to validate new drugs, vaccines and diagnostic procedures.
Other innovative measures include actively looking for TB cases among the high vulnerability groups such as antenatal mothers, people suffering from HIV, diabetes, malnourishment, drug abusers, psychiatric cases and others. Through this, the government aims to proactively bring diagnosis to patients and envisions using new technologies of communication to help doctors monitor and report cases efficiently8. Sadly, even in the wake of continuous efforts of eradication, FGTB is usually diagnosed during an evaluation for infertility. This needs to change by educating women about reproductive health and making then more aware.
Women who belong to socioeconomically vulnerable groups frequently contract FGTB. This is gauged from the fact that the tertiary care hospitals in the country report higher rates of FGTB resulting from referrals from primary or secondary healthcare centres. It is indeed a deeply disturbing scenario when a reproductively healthy woman loses her ability to bear children only because a bacterial infection has gone undiagnosed and untreated. Moreover, the stigma associated with TB often results in discrimination against infected women, which denies them the necessary holistic support from society and incapacitates them from receiving quality healthcare. In a country like India, fertility is often given a great deal of importance in society, which in case of a women affected by FGTB could also negatively impact quality of her life and social acceptance. Thus, it is high time to end nonchalance and lack of knowledge and be accountable for spreading awareness to end TB for a healthy society with a viable future.
March 24, 2019
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2. Dutta, R. Genital tuberculosis a major reason for infertility among women. Business Standard (2015).
3. Grace, G. A., Devaleenal, D. B. & Natrajan, M. Genital tuberculosis in females. Indian J Med Res 145, 425–436 (2017).
4. Arpitha, V. J., Savitha, C. & Nagarathnamma, R. Diagnosis of genital tuberculosis: correlation between polymerase chain reaction positivity and laparoscopic findings. Int J Reprod Contracept Obs. Gynecol. 5, 3425–3432 (2016).
5. Mahajan, N., Naidu, P. & Kaur, S. D. Insight into the diagnosis and management of subclinical genital tuberculosis in women with infertility. J Hum Reprod Sci 9, 135–144 (2016).
6. Nadgouda, S. S., Mukhopadhyaya, P. N., Acharya, A., Nagee, A. & Kunjadia, P. D. A study on genital tuberculosis and infertility in Indian population. Arch. Med. 2, (2010).
7. Pai, M. India’s tuberculosis research contributions get international recognition. Nature Microbiology Community (2018).
8. Government of India. India TB Research Consortium. (2019). Available at: http://bmi.icmr.org.in/itrc/index.php.