Tuberculosis (TB) is a serious, systemic bacterial infection caused by Mycobacterium tuberculosis, which most commonly affects the lungs. Globally, it remains a significant public health issue. While primarily known as a pulmonary disease, the bacteria can travel through the bloodstream and establish infection in almost any other part of the body. When the infection reaches the reproductive organs, it can cause infertility.
The Specific Role of Genital Tuberculosis
Infertility is caused by Extrapulmonary Tuberculosis (EPTB) that localizes in the reproductive tract, a condition called Genital Tuberculosis (GTB). The bacteria usually spread from a primary infection site, frequently the lungs, through the bloodstream or lymphatic system to the genital organs. This secondary infection can remain silent for many years before causing symptoms.
In women, the infection typically targets the fallopian tubes, leading to inflammation and subsequent scarring and complete tubal obstruction, preventing fertilization. Damage to the inner lining of the uterus, the endometrium, is also common. This scarring can cause intrauterine adhesions, known as Asherman Syndrome, which hinders embryo implantation and may lead to menstrual irregularities or the cessation of periods.
In men, GTB commonly affects the epididymis and testes. Inflammation of the epididymis, called epididymitis, causes swelling and scarring that can block the transport ducts, including the vas deferens. This obstruction can lead to obstructive azoospermia, where sperm is produced but cannot be present in the ejaculate. Damage to the testes can also reduce sperm production, compromising male fertility.
Identifying Symptoms in Women and Men
A major challenge with GTB is that it is often a silent disease, remaining asymptomatic for a long time. It is frequently discovered only during an investigation for unexplained infertility. When symptoms do occur, they are non-specific and can mimic other common reproductive tract infections, such as pelvic inflammatory disease.
For women, symptoms may include chronic pelvic or abdominal pain, which can worsen with movement or intercourse. Abnormal uterine bleeding, irregular menstrual cycles, or amenorrhea (absence of menstruation) are common indicators of damage to the uterine lining. Systemic signs of active TB, such as low-grade fever, unexplained weight loss, and fatigue, may also be present.
In men, the infection may present with symptoms related to the swelling of the affected organs. These include pain or a mass in the scrotum or testicles, often due to epididymitis. While general symptoms like fever and weight loss are possible, the infection is frequently localized. Infertility is often the first and only clear sign of the underlying disease.
Medical Confirmation of Genital TB
Confirming a diagnosis of GTB requires specialized procedures, as standard TB tests, such as a chest X-ray, may not be sufficient. The diagnostic process is usually initiated when a patient presents with unexplained infertility, especially in regions where TB is common.
The most definitive diagnosis involves taking tissue samples for analysis. In women, an endometrial biopsy, often performed during a hysteroscopy, is a common technique to collect tissue from the uterine lining. Histopathological examination of the biopsy can reveal characteristic signs of TB, such as granulomas. Culturing the tissue sample attempts to grow the Mycobacterium tuberculosis bacteria.
Molecular methods, such as Polymerase Chain Reaction (PCR) testing and GeneXpert, are used to rapidly detect the bacteria’s genetic material in tissue or fluid samples. Imaging techniques also play a role. A hysterosalpingogram (HSG) visualizes the fallopian tubes to check for blockages or characteristic scarring patterns. Ultrasound can detect thickened fallopian tubes or abnormal fluid collections, helping to guide the diagnosis.
Treatment and Managing Fertility Outcomes
Treatment for Genital Tuberculosis involves a multi-drug course of Anti-Tubercular Therapy (ATT) to eliminate the active infection. The standard regimen typically involves a combination of antibiotics, such as isoniazid, rifampicin, pyrazinamide, and ethambutol. These are administered for six to twelve months. Successful completion of ATT is necessary to cure the infection.
While ATT cures the infection, it generally cannot reverse the extensive physical damage, such as scarring and structural changes, inflicted on the reproductive organs. This permanent damage to the fallopian tubes and endometrium is the primary cause of persistent infertility after the infection is cleared. Consequently, the conception rate after chemotherapy alone is low.
For these patients, Assisted Reproductive Technology (ART) offers the most viable path to pregnancy. In Vitro Fertilization (IVF) is frequently recommended, as it bypasses the damaged fallopian tubes by fertilizing the egg outside the body. However, the success of IVF can be reduced if there is extensive damage to the uterine lining, which compromises the ability of the embryo to implant.