Rampant Tuberculosis and Declining Fertility- How far true -Pitfalls !!

Rampant Tuberculosis and Declining Fertility- How far true -Pitfalls !!

Tuberculosis (TB) is still rampant in India; and TB of the genital tract used to be the commonest cause of tubal infertility in the past. Comparatively today, the occurrence of TB has been reduced, because of improved socioeconomic conditions. However, it is often misdiagnosed in infertile women, leading to a lot of heartbreak and distress.

Effect on Fertility

It is now understood that subclinical (latent) genital tuberculosis (TB) without clinical evidence of TB has a negative impact on fertility by affecting the endometrium. However, it is not known whether latent infection has detrimental effect on ovarian reserve.

Factors to assess Fertility potential:

There are various factors that help the prognosis of TB, like:

  • Biological age
  • Chronological age
  • Biochemical parameters-AMH,FSH,LH,E2
  • Sonological parameters- AFC
  • To add to it previous and present treatment history is also taken into consideration, besides sometimes the extraneous matters and factors may have impact, which is why in-depth information makes it easier to diagnose the condition.

Tuberculosis has been found to be one of the factors leading to infertility – which may be in form of tubal/ovarian factor. But in order to diagnose and treat it at the right time and in the right manner, the question that arises is whether a diagnosis is actually needed or not.

Sometimes false positive tests and obsolete tests may land into diverting the focus so not bearing results, besides wastage of time adding to financial and psychological burden on the society. Through this article, we have shared a few tips that our readers must know and will help couples in getting many answers, especially the affected couples.

Facts and Myths

Let’s start with some basics:

  • Tuberculosis is an infectious disease which is caused by the tubercle bacillus.
  • There is a difference between an infection with the tubercle bacillus and the TB disease. In India, most of us have been exposed to the tubercle bacillus.
  • Causative factor is either because of exposure to patients who have TB; or because of vaccination with the BCG vaccine (which is often given routinely to babies in India) so-it can be acquired or induced. This exposure helps us to become immune to TB and to fight the infection, because it allows us to produce protective anti-TB antibodies which help us to fight off the bacillus in the body.

How does TB cause infertility?

It does so only when it infects the genital tract. This is called genital TB. While the initial exposure to the tubercle bacillus is through the lungs ( because the bacillus is inhaled), most of us can fight off the infection, as a result of which it remains silent in the body, causing no harm. However, sometimes these latent bacilli can get reactivated, and then spread throughout the body through the blood stream. They can then get deposited in any part of the body, causing a TB infection of that part. It is only when it lodges and infects the genital tract, that TB can cause infertility. When a man is infected by genital TB, it causes tuberculous epididymo-orchitis, blocking the passage, as a result of which the man becomes azoospermic (no sperm enter the semen tract because the tract is blocked). Similarly, when a woman is infected by genital TB, it may cause tuberculous endometriosis (infection of the uterus) and salpingitis (infection of the tubes). This infection can often be silent, and may not cause any symptoms or signs at all!! But it may manifest as Infertility.

Science is a continuous evolving tool with the aim to conquer and defeat diseases but some diseases continue to be fatal in general. Tuberculosis is one of those. Various tests can aid to detect and diagnose besides the clinical picture (when it gets too advanced).

Here are few pitfalls:

1. Culture of bacteria by minor techniques-
Tuberculosis is endemic in India, and it’s a disease which can affect practically any organ system, including the lungs, bones, brain and the reproductive tract. While it’s easy to “suspect” TB, it’s also extremely hard to confirm the diagnosis of tuberculosis in the lab, because it’s very difficult to grow the TB bacillus in vitro.

While curettage is an easy procedure to perform, actually growing the bacillus in the lab, even in women with frank genital TB can be very hard, because this is a very temperamental bacillus which grows very slowly in the microbiology lab. So many clinicians may not opt for this.

2. Mantoux test-
The Mantoux (tuberculin) skin test is equally unreliable. It tests merely for the presence of immunity against TB – and can be similarly misinterpreted.

3. Non-specific tests-
TB QuantiFERON Gold test is unreliable and has been discarded by good doctors.

4. PCR test
It is comparatively authenticated with 50% error still there

5. Chest X ray
It’s a non specific test which can only give an idea of underlying pathology but cannot pin point diagnosis

6. Keyhole surgery (Laparoscopy)
Your doctor may come across certain findings via this surgery and recommend you medicines but it may also be empirical.

Tuberculosis is a very difficult and misleading disease and definitely when there has to be treated but question is more hard to solve in infertile population. Definitely it cannot be recommended like a candy or Over the counter medicine as drugs involved have lots of side effects.

Summary

The diagnosis of TB of the genital tract remains notoriously difficult to make. Most patients are misdiagnosed as having TB when in fact they don’t, and many are treated for no good rhyme or reason !If your gynaecologist diagnoses you as having genital TB based on these unreliable tests, then please do NOT start anti-TB medicines. Please better seek a second opinion from a physician, preferably once who is a TB specialist!

If genital tuberculosis has been diagnosed to a stage beyond the possibility of treatment, couples may have to opt for Surrogacy or Adoption. So it’s a must to know the basics and seek an expert opinion at an early stage.

*Disclaimer-Authors don’t suggest you follow this write up as medical advice. This is just sharing of information and awareness based on facts and clinical expertise!!

Author: Dr. Richa Sharma (Senior IVF consultant)

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