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Extragenital Tuberculosis and Infertility

PHOTO-2019-03-24-22-21-21Extragenital Tuberculosis and Infertility.

Background: The prevalence of genital tuberculosis is about 5% 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. No doubt association of genital tuberculosis with infertility is well‑recognized worldwide, but various studies have also shown a strong correlation between extragenital tuberculosis and infertility. The review of various studies reveals that the incidence of genital tuberculosis in infertile patients with prior history of extragenital tuberculosis ranges from 1.32% to 20% and in the infertile patients without prior history of extragenital tuberculosis the incidence ranges from 2.43–4.9%. These results clearly conclude that extragenital tuberculosis has a definite impact on female genital tract which is invariably irreversible leading to infertility.

Symptoms:

Genital involvement remains asymptomatic in most of the patients with extragenital tuberculosis however menstrual disturbances occur in 20–50% of females. The reasons for menstrual abnormalities are associated weight loss, possible antigonadotrophic effect of Mycobacterium tuberculosis, and increased enzymatic catabolism of estrogen caused by antitubercular drug rifampicin affecting luteinizing hormone surge. Menorrhagia, hypomenorrhea, amenorrhea and dysmenorrhoea are the most common menstrual complaints.  About 35% of patients continue with menstrual abnormalities even after treatment. Mostly the young females are affected, the reason being increase in blood circulation and hormone dependence of female genital tract after sexual maturity. Infertility, as a result of silent damage of the genital tract is the delayed presentation in some patients.

Diagnosis:

Diagnosing genital tuberculosis remains a challenge due to varied clinical presentation, paucibacillary nature of infection, and lack of sensitive and specific laboratory test. Each test used to diagnose genital tuberculosis has its own limitations. Definite diagnosis is made by histopathology and culture, but both have low sensitivity due to paucibacillary nature of the disease. No single test is diagnostic stand‑alone. Diagnosis is usually made depending on collective evidence from high index of clinical suspicion, serology, histopathology, imaging techniques, and direct visualization on endoscopy.

Treatment and Prevention:

All 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.

Dr. Ritu Sharma, MD (Obstetrics and Gynaecology)

Associate Professor and HOU, Department of Obstetrics and Gynaecology, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh.

March 24, 2019

References:

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.

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