Tuberculosis is a difficult disease to diagnose and treat. Despite continued efforts of various world agencies, according to WHO, the disease still figures in the first five communicable diseases in the world killing over 5 million people each year. Female Genital tuberculosis forms an underdiagnosed part of it. It is said to be affecting 5% of women visiting Gynae OPD’S across the world. However, if the infertility segment is seen, this incidence jumps up to 19.2% in a study from India.
This bacterial disease has a slow onset and the bacteria can live silently in the body of the host for years after the first exposure. Within the body, it may cause slow destruction of the tissues, disturbing the function of the organ and later its anatomy. In about 10% of individuals, the disease can activate whenever the immune response of the host is compromised as is seen in patients of HIV. In the female genital organs to it can persist and reactivate during the lifetime of a woman, rendering her infertile. This is also known to happen when the patient is either trying to get pregnant or during pregnancy. We were the first ones to realise this and put forth this hypothesis of immune modulation by tuberculosis in the genital tract in 2003 in a review article on the subject. Since then it has been our philosophy to test for the presence of latent disease in every patient of infertility who comes to our centre. This has helped us to increase our success rate in patients of recurrent IVF failures and pregnancy loss.
The diagnosis of extrapulmonary tuberculosis like genital TB is difficult because the bacteria are present in very small numbers. Conventionally, it has been diagnosed by histopathological( biopsy) samples of the uterine and tubal tissues and culture of the bacillus from the tissues are the gold standard. However, the pickup rate of these tests is very low – to the tune of 2 -5%. Moreover, the results of the culture are obtained in 6weeks. Therefore, a new test was required which could diagnose the disease quickly and in paucibacillary samples!
POLYMERASE CHAIN REACTION or PCR as it is popularly known is a technique that is used to detect DNA/RNA of any kind of organism from alive or dead tissues. This sensitive technique has even been used to detect the presence of bacterial/viral remains from Egyptian mummies! In principle, the DNA/RNA from the tissue is extracted and then amplified many times to produce multiple replicas or copies of the bacterial DNA – very much like the photocopying machine. Thus, even small numbers of the bacteria say 10, can be detected. An amplified sample from a PCR can be sent for a culture of the bacteria - which then becomes the gold standard test.
This test is positive in about 45 -50% of cases of infertility thus raising the incidence of the disease tremendously in the country. Many studies from various parts of the country have corroborated this. Cases of long-standing unexplained infertility have been diagnosed by this test, and treatment has resulted in pregnancies.
The problem with DNA PCR is that it can pick up even dead bacilli and RNA PCR although it detects only live bacilli are very difficult to carry out and the samples may get contaminated during transfer. PCR is also an expensive test.PCR can be positive in both infertile and fertile women. The critique, therefore, is whether treatment should be based solely on the presence of a PCR positive test? The present recommendation is to consider the patient to be having TB if PCR is positive with other signs and symptoms of tuberculosis and other tests like X-ray, ultrasound is also showing some features suggestive of it.
MOTT is the short form for Mycobacterium Other Than Tuberculosis. These are bacteria that may live in the body of the individual like parasites without causing any harm to them. These are called “commensals” No treatment is required if these are not causing a problem. Occasionally MOTT infection may erupt in an operative wound which refuses to heal. Such patients need long term treatment with antibiotics.
At Southend Fertility, we understand the importance of TB testing and the interpretation of all the tests as well. We, therefore, recommend testing to all our patients but selectively treat them depending on the need. However, once put on treatment, it is our philosophy to continue treatment until the disease is cured and then initiate treatment for infertility. From our own experience, we have found that this generally takes 9 months to one year of treatment. Best results of IVF are achieved only after complete treatment.