Association of Tuberculous Endometritis with Infertility and Other Gynecological Complaints of Women in India

Abstract

Endometrial biopsy samples derived from 393 patients with assorted gynecological complaints were investigated for mycobacterial infection. By employment of four different techniques, mycobacterial pathogens were detected irrespective of the nature/type of clinical complaint. Mycobacterium tuberculosis was the predominant pathogen detected among the samples investigated.Tuberculosis occurs worldwide and causes widespread morbidity and mortality. Pulmonary and extrapulmonary sites are known to be associated with Mycobacterium tuberculosis infection. In fact, it is well known that pulmonary tuberculosis patients go on to develop extrapulmonary tuberculosis. One such manifestation is the occurrence of female genital tuberculosis (FGTB). The spread of the pathogen to fallopian tubes, endometria, and ovaries, leading to a variety of clinical conditions, has been described previously (1,8,15). The present study was undertaken to detect mycobacterial infection in endometrial biopsy (EB) samples collected from patients registered in the gynecological outpatient department of the All India Institute of Medical Sciences, New Delhi, India.Three hundred ninety-three patients attending the obstetrics and gynecology outpatient department of the All India Institute of Medical Sciences were included in the study. Of these, 285 were infertility patients, 80 had menstrual dysfunction complaints, 17 had chronic lower abdominal or pelvic pain, and the remaining 11 were patients with complaints such as ovarian cyst, fibroid, prolapsed uterus, and postrecanalization. The EB samples were processed as described by Chakravorty et al. (3). Four methods were used to detect mycobacteria in the EB samples. The processed EB extracts were microscopically examined for acid-fast bacilli (AFB), processed for isolation of mycobacteria by inoculation on Lowenstein-Jensen medium, and processed for extraction of target DNA by nested PCR (N-PCR) (12). Culture results at the time of this writing were available for 262 samples. Two hundred ninety-five EB samples were processed for histopathological examination by hematoxylin and eosin staining. The N-PCR for the hupB DNA target was carried out as described previously (10). The N-PCR products were electrophoresed on 10% polyacrylamide gel and stained with ethidium bromide. The amplicon sizes for M. tuberculosis and Mycobacterium bovis were ϳ116 bp and 89 bp, respectively. Species-level identification of the isolates obtained was done by spoligotyping (9) and by standard biochemical tests (16). Randomly selected EB samples showing dual bands (116 and 89 bp) were cloned into the pGEMT vector by using a TA cloning kit (Promega). The clones were sequenced at the DNA sequencing facility, South Campus Delhi University, New Delhi, India.The detection and identification of M. tuberculosis and M. bovis in representative EB specimens are depicted in Fig. 1. N-PCR-amplified products equivalent to 116 bp were obtained for five of the seven samples (lanes 1 to 3, 7, and 8). These samples were considered to be infecte...

Diagnosis of genital tuberculosis: correlation between polymerase chain reaction positivity and laparoscopic findings

“…In few other reports in which mycobacterial cultures were performed, positivity rates were between 10% and 15% of GTB patients diagnosed on clinical and morphological criteria and a positive TB-PCR. [8][9][10][11]29 PCR positive and BACTEC (culture) and smear negative cases could be explained by the fact that even though smear and culture has remained a gold standard in diagnosis of pulmonary TB, the very low sensitivity for diagnosis of paucibacillary disease limits its practical utility in extra-pulmonary TB. [30][31][32][33] Hence the use of PCR is suggested as an alternative test especially in culture-negative GTB.…”

“…[9][10][11][12]24 In India, endometrial TB-PCR is also used as screening method for GTB but it demands more evaluation as it is debatable whether PCR positivity indicates infection or disease of the genital tract. By treating all asymptomatic TB-PCR-positive cases, are patients being over-treated?…”

“…And bacteria take 4-5 weeks to show growth on LJ media. [7][8][9][10][11] Nevertheless, even the liquid culture methods such as BACTEC system or more recent introduction of BacTAlert 3D neither reduce the turnaround time below 12days nor improves the rate of positivity beyond a limit.…”

Diagnosis of Genial Tuberculosis by PCR and other conventional methods

“…Moreover, atypical mycobacteria also take the Z-N stain. Besides M.tuberculosis, other species like 8,24 .…”

Tuberculosis is still a cause of infertility in developing countries

“…1 Today, though it has become much less common, because of improved socioeconomic conditions, it has been suggested that any women with infertility that cannot be attributed to a specific cause should be investigated for tuberculosis. 2 Genital TB is always hard to diagnose, because of the fact that it is a silent invader of the genital tract. The only reliable way of making a diagnosis is by actually culturing the tubercle bacillus from tissue sampled from the genital tract.…”