New Delhi: India is a country with one of the highest number of tuberculosis (TB) cases i.e. one fifth of the global incidence annually. Although pulmonary TB is most common, there has been also significant number of cases of extra-pulmonary TB reported annually. Among these, female genital tract TB poses a diagnostic challenge. It is one of the major causes for severe tubal disease leading to infertility.
Talking about the symptoms, Dr Kiran Arora, consultant, obstetrics and gynaecology, Gurgaon IVF Clinic, said, “Symptoms can be very vague; it can begin with abdominal pain, discharge, weight loss, irregular bleeding, fever etc leading towards infertility.”
Dr Sonia Malik, director, Southend Fertility and IVF Centres, Delhi, said, “Female genital tract TB is one of the major causes of infertility but other than that it may also cause excessive bleeding, or it may lead to no menstrual bleeding at all, abdominal pain related or unrelated to period. Then there can be vaginal discharge, if the tuberculosis bacteria is active inside the body then they may have same symptoms of any other pulmonary tuberculosis people i.e. loss of weight, loss of appetite, fever etc. But in many cases, women may not complain of all these symptoms, except infertility complain. Due to this disease, the patient may not be able to conceive or may conceive but may not be able to carry forward the pregnancy resulting in abortion. In some cases, women may have no conceiving problem but missed or irregular periods.”
Unlike pulmonary tuberculosis, the clinical diagnosis of GTB is difficult because in majority of cases the disease is either asymptomatic or has varied clinical presentation. Routine laboratory values are of little value in the diagnosis. An absolute diagnosis cannot be made from characteristic features in hysterosalpingogram (HSG) or laparoscopy. Due to the paucibacillary nature of GTB, diagnosis by mycobacterial culture and histopathological examination (HPE) have limitations and low detection rate.
Dr Arora said, “There is a section in society where it is under diagnosed and also sections where it is over diagnosed because diagnosis criteria are not uniform. The bacteria being very atypical bacteria, laboratory techniques may not be able to identify it. Bacteria lives within the cell and it is very difficult to isolate the bacteria. This is the most debated topic in infertility right now. There are two schools of thought on this topic — one school promotes its detection and diagnosis as sufficient but the other school will think that it might be costlier given the treatment is not simple as it involves 6-9 months of therapy, there should not be any loop during the diagnosis. Guidelines are still awaited on the issue. One definite test is culture for TB, mycobacterium and the endometrial biopsy. The culture will not become positive unless there is significant number of bacteria in the sample.”
Talking about the research and study conducted on the genital tuberculosis, Dr Malik said, “There is a study from one of our colleagues from Odisha, Dr S N Tripathy, which was published in the Indian Journal of Tuberculosis in the year 1991. In that study, she tried to find out the co-relation between pulmonary tuberculosis and genital tuberculosis. In her set of patients, what she found was, if a patient is suffering from pulmonary tuberculosis, in 25% of such patients the genital tract is going to be affected i.e. one-fourth of these patients will suffer from genital tuberculosis.”
Dr Malik further said, “In our own studies, about 3-10% of women who consult in gynae set-up are affected by tuberculosis but if you are talking about the infertility clinic, about 10-39% women suffering from tuberculosis have been reported.”
As per Dr Arora, research in genital tuberculosis varies from group to group. She said, “The research in this field has been very poor and everybody is doing what they like. There is no national level of research happening. ICMR is dealing with it but they might have their own biased criteria. It is one of the most serious and difficult areas in female fertility.”
Although the disease is curable but the damage can be controlled only if it is detected at an early stage. Dr Malik explained, “If it’s delayed, then the permanent damage is done and infertility then cannot be cured. The patient has to resort to other ideas such as test-tube baby, IVF etc. Even for some patients, the test-tube baby is not very encouraging because they have lots of issues in conceiving but it is when the disease is found late. If you found the disease early then yes condition can be reversed and the patient can then conceive.”
A recent study by the Indian Journal of Medical Research through its survey stated that the number of women with genital tuberculosis in India has increased to 30 per cent in 2015 from 19 per cent in 2011. Although there are no concrete guidelines made available on this. Dr Malik said, “We are active in the process of making the guidelines, WHO has stepped in to make the guidelines for genital tuberculosis and all other extra pulmonary tuberculosis. Dr S K Sharma from AIIMS is leading this research group. He has been assigned this task of framing the Indian guidelines for the extra pulmonary tuberculosis. Also the problem is the topic of early diagnosis is still a matter of debate. There are tests but we are not fully convinced whether the tests are correct or not. There can be false positive and false negative in the early tests, we need to recheck before giving the final verdict that we can use this report confidently to say yes this is the tuberculosis and this one is not.”
There have been some technical and medical advances on this issue but the results are not satisfactory. Dr Malik explained, “Medical advances are working towards finding all kinds of tuberculosis. Pulmonary tuberculosis advances are being used or extrapolated even to genital tuberculosis. Most of the diagnostic techniques which are validated for the pulmonary tuberculosis have not yet been validated for genital tuberculosis. Till the time we validate all these new technologies for genital tuberculosis we cannot say that they are absolutely correct and we can use them. But most of the diagnosis and most of the treatment is the same because the disease is the same, the bacteria is the same, it is coming from pulmonary tuberculosis, whatever is being used in pulmonary tuberculosis, we are trying to replicate and use it in genital tuberculosis as well. The other advancement is that we are using a lot of laparoscopic diagnosis, hysteroscopy that means we are putting telescope in the abdomen to look at the tuberculosis in their genital track; we are also using ureteroscopy to check the pigments of the genital tuberculosis in the uterus. These kinds of tests are only done by us because genital tuberculosis belongs to the gynaecologists so we are looking at it through the laparoscope as well as endoscope. The other advancement in technology is that we are also using a lot of imaging, ultrasound is also quite helpful in the diagnosis — at least we can suspect the tuberculosis through the ultrasound.”
Spreading the awareness and basic knowledge on genital tuberculosis can surely make some difference. Giving a parallel example, Dr Malik said, “Carcinoma cervix had been the prime cancer killer in this country for a very long period. Then a pharma company came with a vaccine and started creating awareness. It was the pharma company who started creating awareness amongst the patients as well as doctors because they wanted to sell their vaccine. I feel we should take clue from this and need to do something like that to make people aware of it but we need a lot of public funding to create the awareness programme. And people from media coming and taking interest in TB programme will start to make a difference if we use this platform to create awareness among public and doctors. Doctors are now quite aware of this issue but public still has to be made aware of it.”
Dr Malik further said, “In the year 2010, I hosted a standalone national conference on the genital tuberculosis. I invited the national TB control programme people, I invited WHO as well, so that they could be made aware of the issue. That definitely created a difference as you can see the genital tuberculosis is also notifiable now. WHO is also interested and as I said, we are forming the guidelines as well. So from all these I can say yes there is help available, most of the government agencies are paying attention to it, they are also ready to provide us subsidy for diagnostic technology as well.”
But spreading awareness needs funding. “We need funding to create public awareness, continuously upgrade ourselves, to do some research in this area, to try and make the diagnostic more positive and robust so that people don’t have problem in diagnosing tuberculosis. The private sector needs to be involved in this majorly because the bulk of patients, especially infertility patients, are coming to the private sector mainly. I am not saying that they don’t go to government hospitals, they do. In the private sector, all grades of treatment is available, if you are talking about infertility you will have IVF centres also, there are not so many IVF centres in the government sector yet. So, the private sector needs to be involved in decision making as well as in research. Now, the ICMR has taken a leap and they have a group — a task force — the TB taskforce where I am also a member and I am a private doctor, so basically we have started to take this kind of initiatives but it needs to be increased. We need more and more public-private partnerships specially in this case because basically pharma companies who are actually the bulk financers of any research project in the country are not interested in TB because the medicine does not have too much of profit margin but government agencies and WHO must do it. We do need to have more funding and research in this area,” Dr Malik said.
by Rajni Pandey