TB and infertility: An unholy nexus

Dr Trupti Mehta, Senior Infertility Consultant, Jaslok Hospital and Research Centre, Mumbai highlights that genital TB can cause infertility and emphasises on early detection and treatment

Dr Trupti Mehta, Senior Infertility Consultant, Jaslok Hospital and Research Centre, Mumbai highlights that genital TB can cause  infertility and emphasises on early detection and treatment

201603ehm26TB can have particularly severe consequences for women, especially during their reproductive years. Worldwide prevalence of genital TB is estimated to be 8-10 million cases. India is a country with one of the highest burden of the infection, accounting for one fifth of the global incidence annually. While pulmonary TB (of lungs) is the most common form of TB, genital TB impacts the fertility of women and men.

The actual incidence of genital TB cannot be determined accurately because it is estimated that at least 11 per cent of the people having TB are asymptomatic and the disease is discovered incidentally during an evaluation for cause of infertility. It’s prevalence varies from 18 per cent in India to less than one per cent in the US.

The causative organism which is usually mycobacterium tuberculosis spreads through the air when an infected person coughs, sneezes, spits, laughs or talks. Once in the body it lodges in the lungs and may cause an infection or stay dormant in the body for years defined as a latent infection. The infective focus in the lung often heals, but can spread elsewhere causing an infection or may again lie dormant for years, only to reactivate later like during times of low immunity.

Genital TB is almost always secondary to TB elsewhere in the body originating in the lungs and sometimes in kidneys, gastrointestinal tract, bone or joints. Increased circulation, hormone dependence of genital organs after sexual maturity may in part explain why the genital system is vulnerable to this infection during this phase. The most common genital sites of infection in women are the fallopian tubes (involved in around 90 per cent cases), endometrium (involved in 50–80 per cent cases), ovaries (involved in 20–30 per cent cases), and cervix (involved in five to 15 per cent cases). Among men, the usual sites of infection are the epididymis, prostate, vas deferens, seminal vesicles, ejaculatory ducts and testis in a lower proportion of cases.

In women the presenting symptoms are generally varied; infertility being the most frequent (43-74 per cent). There are subtle signs that could indicate a problem, especially if a woman has suffered from pulmonary TB in the past. However, some of the symptoms to watch out for include pelvic pain, back pain, irregular menstrual cycle, vaginal discharge stained with blood, bleeding after intercourse and to say the least infertility.

32-year old Nisha was married for eight years and had already undergone three attempts of intra-uterine insemination (IUI) and two attempts of in-vitro fertilisation (IVF) without any demonstrable cause of their problem. The couple had lost all hopes of a child when they were suggested an evaluation of Nisha’s endometrial lining. To their utter dismay, her tests indicated genital TB and she underwent the anti-tubercular treatment. She was delighted to conceive naturally while on the medication and is now a mother to a chubby baby girl. Thus, genital TB is found to be a causative factor in many couples with unexplained infertility. Even latent genital TB may be a cause of repeated IVF failures if the disease is not diagnosed and treated.

Other major presenting complaints are abnormal bleeding, pelvic pain, and amenorrhea. Genital TB can affect the fallopian tubes causing them to get hardened, stiffened (lead-pipe like appearance), obstructed (tubal block), retort-shaped, swollen(hydrosalpinx) which not only causes infertility but also increases chances of an ectopic (pregnancy in the tube) which can prove life threatening if not detected and managed in time. Apart from the tubes, TB also affects ovarian function. Depending upon the severity and stage of disease, there may be tubercles on the ovary, adhesions, caseation, tubo-ovarian cyst or abscess formation. It can reduce the blood supply to the ovaries resulting in a reduced ovarian reserve. Such women would at times need donor eggs to help them conceive. The endometrium which is the uterine lining can get damaged to various degrees resulting in endometritis (inflammation of the lining), calcification (calcium deposits in lining) or in severe cases adhesions in lining. Depending on the extent of damage the couple may be advised assisted reproductive techniques ranging from IUI to IVF to even surrogacy or adoption in cases where there is irreparable damage to the endometrium.

In men it can be present as azoospermia (absence of sperm in semen), aspermia (absence of semen during ejaculation), dysuria (pain while passing urine), tenderness, swelling or abscess in the scrotal area or rarely, a penile ulcer. The cause of male infertility is usually obstruction of the seminal vesicles or vas deferens.

However, the disease poses a great diagnostic challenge. Diagnostic methods include smear and culture of infected tissue. The gold standard for the diagnosis of TB in any site is culture to identify M. tuberculosis. Mycobacteria grow slowly, hence it can take up to six weeks for a culture to be positive. The newer radiometric culture BACTEC has a sensitivity of 80- 90 per cent.

PCR test is now commonly employed for the diagnosis of genital TB. Various other methods for detection are Mantoux Test, Interferon y Release assays, histopathology, intravenous urography (IVU), ultrasonography and CT.

In addition, PCR can detect the genes that confer resistance to drugs; for example, the rpoB gene, which signifies resistance to rifampicin, and can probe for mutations associated with resistance to isoniazid, quinolones and aminoglycosides which are used as anti-tubercular drugs. This process allows early identification of multi-drug resistant (MDR) or extensively drug resistant (XDR) TB. Continuing research is needed for finding simpler and practicable methods for making definitive diagnosis which can help early detection and timely treatment.

Also men and women are usually upset when they learn of the diagnosis to be a cause of their infertility, as the disease carries a social stigma. Many people who have fertility problems feel higher levels of stress. Apart from getting support from family and friends, it can be helpful to see a professional counsellor who has experience working with people dealing with such issues. They can help manage the emotional stress and decision-making challenges during treatment.

Following early diagnosis, multiple regimens of treatment with standard four-drug regimen anti-tubercular drugs are used for a minimum of at least six to nine months. These help restore reproductive function and are favourable for fertility when tissue damage is minimal. Minimally-invasive laparoscopy may be needed to treat/ block hydrosalpinx(ges) and hysteroscopic adhesiolysis or metroplasty to repair the uterine cavity damage. Women without tubal or endometrial damage given early anti-tuberculosis treatment have a good chance of early spontaneous conception. In cases where the organs are more severely involved the outcome is compromised even with specialised assisted reproductive techniques like IVF, ICSI. Studies have shown that even if these women conceive there is a higher chance of having a spontaneous abortion or an ectopic pregnancy.

Damini and Yogesh were both diagnosed with genital TB. They underwent a couple of failed attempts at IVF following which they were advised surrogacy which helped them have Yash in their lives. Thus in some cases, where the illness has damaged the reproductive organs to a great extent, many have to opt for surrogacy or adoption to enjoy the joys of motherhood.

Finally early detection, starting treatment of the core condition soon after it is detected and completion of the course of the treatment are certain ways to help ensure a minimal impact on fertility.

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