• Users Online: 222
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 16  |  Issue : 4  |  Page : 599-602

Comparison of laparoscopic findings with tuberculosis polymerase chain reaction in the diagnosis of genital tuberculosis among subfertile women


Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences University, Wardha, Maharashtra, India

Date of Submission03-Sep-2021
Date of Decision28-Sep-2021
Date of Acceptance10-Oct-2021
Date of Web Publication24-Jun-2022

Correspondence Address:
Dr. Deepti Shrivastava
Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences University, Sawangi (M), Wardha, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_325_21

Rights and Permissions
  Abstract 


Background: Female genital tuberculosis (FGTB) is an important cause of infertility. The Fallopian tubes are involved in almost 90% of the cases. Materials and Methods: All 50 participants were women with complaints of infertility to whom FGTB was suspected as a cause of infertility or women with infertility of unknown etiology. After selecting the patient according to inclusion criteria, women were posted for diagnostic laparoscopy and endometrial aspirate/biopsy was sent for TB polymerase chain reaction (TB PCR). Results: In our study, infertile women who had clinical and hysterosalpingography findings suggestive of genital TB underwent endometrial biopsy for TB PCR and hysterolaparoscopy for further evaluation. Among them, 7 (14%) endometrial TB PCR-positive cases were found in the study. Clinical and hysterolaparoscopy findings in these cases were carefully reviewed, although laparoscopic findings were suggestive of TB in 9 (18%) women. Conclusion: Direct visualization of the female genital tract by laparoscopy is most confirmatory and should be considered for starting the antitubercular treatment on the basis of laparoscopic findings.

Keywords: Female genital tuberculosis, laparoscopy, tuberculosis polymerase chain reaction


How to cite this article:
Shrivastava D, Jain J. Comparison of laparoscopic findings with tuberculosis polymerase chain reaction in the diagnosis of genital tuberculosis among subfertile women. J Datta Meghe Inst Med Sci Univ 2021;16:599-602

How to cite this URL:
Shrivastava D, Jain J. Comparison of laparoscopic findings with tuberculosis polymerase chain reaction in the diagnosis of genital tuberculosis among subfertile women. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2022 Aug 16];16:599-602. Available from: http://www.journaldmims.com/text.asp?2021/16/4/599/348107




  Introduction Top


Genitourinary TB is a common form of extrapulmonary TB (EPTB) worldwide (27%), with genital TB alone accounting for 9% of all EPTB cases.[1] A survey by the Indian Council of Medical Research (ICMR) reported that the prevalence of female genital tuberculosis (FGTB) in India has increased from 19% in 2011% to 30% in 2015. A multicentric ICMR study team is working on developing a nationally applicable algorithm for the diagnosis and management of FGTB.[3]

TB not only has pulmonary manifestations but also has serious extrapulmonary manifestations, which are at times difficult to diagnose and hence left untreated; one such is or FGTB which was first diagnosed by Morgagni in 1744 during the autopsy of a woman who died of TB peritonitis.[4],[5],[6]

There is no single diagnostic test available to confirm the diagnosis of FGTB. High degree of clinical suspicion, elaborate history taking, systemic examination, a battery of tests to document Mycobacterium tuberculosis as well as imaging methodologies for characteristic structural changes are essential for the diagnosis.

As per the WHO definition of EPTB, the diagnosis of EPTB should be made on the basis of "one culture positive specimen", or positive histology or strong clinical evidence consistent with active EPTB.[2] A general examination to exclude a TB focus elsewhere in the body, X-ray chest, tuberculin skin test, erythrocyte sedimentation rate and complete blood count. The two imaging techniques useful in the diagnosis of FGTB are hysterosalpingography (HSG) and ultrasonography (USG). HSG evaluates the internal structure of the female genital tract and tubal patency, whereas USG allows simultaneous evaluation of ovarian, uterine, and extrapelvic involvement. The laparoscopic findings suggestive of genital TB may vary from normal appearance to tubercles on the surface, fimbrial block, fimbrial phimosis, tubal beading, peritubal adhesions, periovarian adhesions, tubo-ovarian mass, hydrosalpinx, and rigid tubes.

Histopathology of the specimens shows typical features of TB infection in the form of granulomatous caseous lesions. The demonstration of typical caseous granulomas with giant epithelioid cells is suggestive of TB; however, these lesions also appear in fungal infections, syphilis, leprosy, rheumatoid arthritis, systemic lupus erythematosus, pneumoconiosis, and sarcoidosis.

Ideal time for endometrial sampling is the late secretory phase of the menstrual cycle, which is favorable to identify the classic giant cells and tubercles.[7],[8],[9]

An acid-fast bacilli (AFB) smear staining of the endometrial tissue is a rapid test and requires 10 organisms per ml for a positive result.

In Lowenstein–Jensen (LJ) medium cultures, the minimum time-to-positivity is 4–8 weeks. Thangappah et al. showed that, among the 72 infertile women studied, AFB smear positivity and culture positivity were 8.3% and 5.2%, respectively, when endometrial samples were tested.[6] Goel et al. showed that the positivity in LJ medium and BACTEC for premenstrual samples were 1.83% and 8.8%, respectively.[10]

Polymerase chain reaction (PCR) is a rapid molecular method for the identification of nucleic acid sequences specific to M. tuberculosis and other mycobacteria in tissue samples of patients with FGTB. PCR assays can detect <10 bacilli/ml, including dead bacilli, and has a testing time of 8–12 h. Sensitivity of PCR is higher than culture and histopathology and specificity may be as high as 100% in detecting FGTB, but also it gives false-positive results; hence, it cannot alone be used. Molecular techniques for the detection of TB are increasingly evaluated and used nowadays. The nucleic-acid amplification tests provide results in a few hours; as documented in the existing literature with the use of amplification systems, nucleic acid sequences unique to M. tuberculosis can be detected directly in clinical specimens, offering better accuracy than microscopy and greater speed than culture.

Diagnosis of genital TB requires a high degree of suspicion along with a multimodal approach of investigations. In spite of so many technical advances to catch this age-old disease, challenge still persists.

In the present study, we would like to evaluate the role of TB PCR in the diagnosis of genital TB and compare it with laparoscopic findings among subfertile women attending the infertility clinic of Acharya Vinoba Bhave Rural Hospital.


  Materials and Methods Top


Study design

This was a randomized comparative interventional study.

Sample size

The sample size of the study population was 50.

IEC clearance

Approval from the institutional ethical committee was obtained.

Inclusion criteria

All participants were women with complaints of infertility to whom FGTB was suspected as a cause of infertility or women with infertility of unknown etiology.

Exclusion criteria

  • Women who had other explainable causes of infertility such as anatomical and endocrinal.
  • Acute PID.


Place of study

The study was conducted at AVBRH Sawangi (Meghe), Wardha.

Methodology

  • After selecting the patient according to inclusion criteria, women were posted for diagnostic laparoscopy, and endometrial aspirate/biopsy was sent for TB PCR
  • After due collection of samples and obtaining of results, the results were comprehensively gathered and data were analyzed by SPSS version 18 software for the diagnostic tests such as pelvic USG, histopathological examination (HPE), and also laparoscopy and PCR of endometrial aspirate for patients who were affording, after which these modalities was correlated for accurately diagnosing FGTB, by calculating sensitivity, specificity, positive predictive value, and negative predictive value of the same.


Study duration

This study was performed for 1.5 years.

Informed consent

It was obtained from the women who fulfilled the inclusion criteria and were enrolled in the study.

Statistical analysis

The statistical analysis was carried out using the SPSS version 18 software package (SPSS Inc., Chicago, IL, USA).

Ethical clearance

The institutional ethics committee clearance was obtained on December 13, 2019, with reference No. DMIMSU (DU)/IEC/2020-21/8957.


  Results Top


  • In our study, infertile women who had clinical and HSG findings suggestive of genital TB underwent endometrial biopsy for TB PCR and hysterolaparoscopy for further evaluation. Among them, 7 (14%) endometrial TB PCR-positive cases were found in the study. Clinical and hysterolaparoscopy findings in these cases were carefully reviewed, although laparoscopic findings were suggestive of TB in 9 (18%) women
  • Classically, FGTB has been described as a disease of young women. In our study, a maximum number of cases were diagnosed under the age of 30 years
  • In our study, 72% of the patients presented with primary infertility, while 28% presented with secondary infertility
  • Primary genital TB is extremely rare. In our study, a previous history of pulmonary TB was seen in 14% of the patients and abdominal TB was seen in 10% of the patients
  • The menstrual cycle may be regular and undisturbed in many cases of genital TB. In our study, around 50% of the cases had normal menstrual flow. Around 20% of the cases had hypomenorrhea, 10% had oligomenorrhea, while only 6% of the cases had menorrhagia.


[Table 1] and [Figure 1] show the distribution of the study population according to PCR test results. All the study subjects were tested for M. tuberculosis by PCR method. Of 50 study subjects, 7 were found to be positive (7/50, 14%), while in 43 subjects, PCR was found to be negative (86%).
Table 1: Distribution of the study population according to polymerase chain reaction test results

Click here to view
Figure 1: Distribution of the study population according to polymerase chain reaction test results

Click here to view


The results of laparoscopy and specific diagnostic tests on endometrial samples are shown in [Table 2] and [Figure 2]. Only four endometrial samples (8%) revealed AFB on smear examination. Microbiological culture of the endometrium in LJ media showed that M. tuberculosis was positive only in two samples (4%). On HPE, four of 50 (8%) endometrial samples were positive for TB. Of these, four were positive by the conventional methods, one was positive by culture alone, three by histology alone, and only in two patients both histology and culture were positive. PCR on the endometrial samples was done in all 50 women, of these PCR was positive in 7 endometrial samples (14%). Laparoscopy was positive in 9 (18%) cases which was suggestive of genital TB.[11],[12],[13]
Table 2: Comparison of results of laparoscopy and specific diagnostic tests on endometrial samples

Click here to view
Figure 2: Comparison of results of laparoscopy and specific diagnostic tests on endometrial samples

Click here to view


Hence, this study compares the endometrial TB PCR results with laparoscopic findings in a small group comprising 50 patients with subfertility [Figure 3], [Figure 4], [Figure 5].
Figure 3: Laproscopic findings showing caseous nodule in a case of female genital tuberculosis

Click here to view
Figure 4: Laparoscopy showing multiple abdominal and peritoneal adhesions in female genital tuberculosis

Click here to view
Figure 5: Polymerase chain reaction test kit

Click here to view



  Discussion Top


  • Genital TB is an important cause of infertility in women of rural area, and the prevalence is generally underestimated because of the asymptomatic nature of the infection and diagnostic challenges. Large multicentric studies are needed to estimate the magnitude of FGTB and to identify the most sensitive test for diagnosis. Clinicians need to be aware of this important cause of infertility and menstrual dysfunction in women. Screening for genital TB needs to be a part of evaluation of infertility and menstrual abnormalities. Most of the patients present in the advanced stage with scarring, severe fibrosis, and adhesions and treatment outcomes, especially with regard to infertility, are poor. Hence, early diagnosis and correct treatment is vital to avoid complications and to restore fertility
  • Hence, our study compared laparoscopic findings with TB PCR and found that visual findings on laparoscopy for genital TB are more promising for the diagnosis of genital TB as compared to TBPCR
  • This is similar to a study done by Arpitha et al.[11] in which also described and compared laparoscopic visual inspection findings with endometrial TB-PCR positivity to diagnose GTB
  • A similar study by Grace et al.[3] in 2015 compared laparoscopic findings with TB PCR which reported laparoscopic visual inspection to be superior to TBPCR.



  Conclusion Top


In our study, we could find a maximum number, i.e., 9 (18%), of genital TB evident by laparoscopy in comparison to TB PCR which was positive in 7 (14%) of women. Although the smear positive was 8%, but mycobacterium grown in culture was only 4%, so I can conclude that direct visualization of the female genital tract by laparoscopy is most confirmatory and should be considered for starting the antitubercular treatment on the basis of laparoscopy findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Golden MP, Vikram HR. Extrapulmonary tuberculosis: An overview. Am Fam Physician 2005;72:1761-8.  Back to cited text no. 1
    
2.
World Health Organization. WHO Global Tuberculosis Report 2018. Geneva: WHO; 2018.  Back to cited text no. 2
    
3.
Grace GA, Devaleenal DB, Natrajan M. Genital tuberculosis in females. Indian J Med Res 2017;145:425-36.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Welfare; 2018. Central TB Division, Directorate General of Health Services. India TB. Report: Revised National Tuberculosis Control Programme: Annual Status Report.  Back to cited text no. 4
    
5.
Pesut D, Stojsić J. Female genital tuberculosis – A disease seen again in Europe. Vojnosanit Pregl 2007;64:855-8.  Back to cited text no. 5
    
6.
Thangappah RB, Paramasivan CN, Narayanan S. Evaluating PC, culture & histopathology in the diagnosis of female genital tuberculosis. Indian J Med Res 2011;134:40-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Sharma JB. Tuberculosis and obstetric and gynaecologicalpractice. In: Studd J, Tan SL, Chervenak FA, editors. Progress in Obstetric and Gynaecology. Vol. 18. Philadelphia: Elsevier; 2008. p. 395-427.  Back to cited text no. 7
    
8.
Neonakis IK, Gitti Z, Krambovitis E, Spandidos DA. Molecular diagnostic tools in mycobacteriology. J Microbiol Methods 2008;75:1-11.  Back to cited text no. 8
    
9.
Arora R, Sharma JB. Female genital tuberculosis – A diagnostic and therapeutic challenge. Indian J Tuberc 2014;61:98-102.  Back to cited text no. 9
    
10.
Goel G, Khatuja R, Radhakrishnan G, Agarwal R, Agarwal S, Kaur I. Role of newer methods of diagnosing genital tuberculosis in infertile women. Indian J Pathol Microbiol 2013;56:155-7.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Arpitha VJ, Savitha C, Nagarathnamma R. Diagnosis of genital tuberculosis: Correlation between polymerase chain reaction positivity and laparoscopic findings. Int J Reprod Contracept Obstet Gynecol 2016;5:3425-32.  Back to cited text no. 11
    
12.
Jindal UN, Bala Y, Sodhi S, Verma S, Jindal S. Female genital tuberculosis: Early diagnosis by laparoscopy and endometrial polymerase chain reaction. Int J Tuberc Lung Dis 2010;14:1629-34.  Back to cited text no. 12
    
13.
Sharma JB, Dharmendra S, Agarwal S, Sharma E. Genital tuberculosis and infertility. Fertil Sci Res 2016;3:6-18.  Back to cited text no. 13
  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed629    
    Printed20    
    Emailed0    
    PDF Downloaded96    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]