International Journal of Gynecology & Obstetrics 75 2001.

269272

Article

Female genital tuberculosis and infertility

B. Namavar JahromiU,a , M.E. Parsanezhad a , R. Ghane-Shirazi b

a
Department of Obstetrics and Gynecology, Shiraz Uni ersity of Medical Sciences, Shiraz, Iran
b
Tuberculosis Control Unit, Health Center of Fars Pro ince, Shiraz, Iran

Received 1 May 2001; received in revised form 7 August 2001; accepted 8 August 2001

Abstract

Objecti es: This study was performed to evaluate the rate of diagnosed female genital tuberculosis and its
presentational symptoms and methods of diagnosis. Methods: A total of 3088 cases of tuberculosis TB. who had
been registered and treated in the Health Center of Fars Province from 1989 to 1999 were retrospectively studied.
From this group, 46 women were diagnosed as having genital TB. The diagnosis in 41 cases was based on the
standard pathological criteria of tissue specimens. The other five cases were excluded from this study due to the lack
of classical diagnostic criteria. Statistical analysis was performed using the Z-test. Results: The mean age of the
patients at the time of diagnosis was 30.4 years. Seven patients presented with abdominal or pelvic pain 17.07%.. In
this group three cases underwent laparatomy due to abdominal mass and four patients for tubo-ovarian abscess,
which led to the diagnosis. Abnormal uterine bleeding was the cause of diagnostic dilatation and curettage in three
other patients 7.31%.. However, in 31 cases 75.6%. TB was diagnosed during studies performed to evaluate the
cause of their infertility, and the most common diagnostic procedure was endometrial curettage 25 cases.. Female
genital TB accounted for 1.32% of all tuberculous patients in this study. Of these, 75.6% were infertile by definition
Z s 12.13 P- 0.0001.. TB endometritis was detected in 72.03%, tubal involvement in 34.03%, ovarian TB in 12.9%
and cervical TB in 2.4% of the patients. Conclusions: This study confirms the presence of a strong relationship
between genital TB and infertility; therefore genital TB would be more frequently diagnosed if this possibility was
considered in the evaluation of every infertile patient in areas where tuberculosis is endemic. 2001 International
Federation of Gynecology and Obstetrics. All rights reserved.

Keywords: Female genital tuberculosis; Infertility

U
Corresponding author. Tel.: q98-711-627-1329; fax: q98-711-235-9847.
E-mail address: namavarb@sums.ac.ir B. Namavar Jahromi..

0020-7292r01r$20.00 2001 International Federation of Gynecology and Obstetrics. All rights reserved.
PII: S 0 0 2 0 - 7 2 9 2 0 1 . 0 0 4 9 4 - 5
270 B. Nama ar Jahromi et al. r International Journal of Gynecology & Obstetrics 75 (2001) 269272
1. Introduction
Tuberculosis TB. is one of the oldest diseases
known to affect humans w1x. Female genital TB is
a rare disease in some developed countries, but it
is a frequent cause of chronic pelvic inflammatory
disease PID. and infertility in other parts of the
world w2x. Unfortunately, the incidence of TB is
again increasing. Approximately 3.8 million new
cases of TB were reported annually to the World
Health Organization in the early 1990s w1x. How-
ever, it is estimated that a total of 7.96 million
new cases of tuberculosis occurred world-wide in
1997. A total of 1.86 billion people or 32% of the
worlds population are infected with Mycobac-
terium TB w3x. Dramatic outbreaks of multidrug-
resistant TB in some populations have focused
international attention on the seriousness of this
matter, due to its significant threat to TB-control
w4x. It is estimated that patients with pulmonary
TB develop genital infection in 513% of cases
w26x. Therefore cases of TB-associated PID may
also become more prevalent w2x.
The purpose of this study is to evaluate the rate
of diagnosed female genital tract tuberculosis, its
presentational symptoms and methods of diagno-
sis, in a 10-year period 19891999. among the
patients referred to the Health Center of Fars
province. All suspected cases in this area are
referred to this center, for proper diagnosis and
free management.
The actual incidence of genital TB cannot be
assessed accurately in any population since it is
estimated that at least 11% of the patients are
asymptomatic and the disease may be discovered
incidentally w6x. However, the symptoms usually
associated with female genital tuberculosis are
lower abdominal and pelvic pain, infertility and
menstrual abnormalities w1,2x.
A definitive diagnosis of genital TB is depen-
dent on a positive mycobacterial culture from a
diagnostic specimen, although most authorities
today accept a diagnosis based on the standard
histopathological criteria of tissue biopsies w1,7x.
In fact, more than two-thirds of the cases of
genital TB in the literature were diagnosed by
histopathological evidence w2x.
Although characteristic X-ray findings for TB
of the fallopian tubes and uterus have been de-
scribed, an absolute diagnosis of genital TB can-
not be made from a hysterosalpingogram. A posi-
tive chest roentgenogram for healed or active
pulmonary TB, a strong contact history and a
positive standard tuberculin test can also aid di-
agnosis w2,8x.
2. Subjects and methods
A total of 3088 cases of TB who had been
registered and treated in the Health Center of
Fars province during 19891999 were retrospec-
tively studied. There were 1843 cases of pulmo-
nary TB and 1245 patients with extrapulmonary
TB. From this group, 46 women were diagnosed
as having genital tract TB Table 1..
The diagnosis of genital TB in 41 cases was
based on histopathological criteria of tissue speci-
mens. However, empirical treatment had been
started in five cases due to the characteristic
changes in the hysterosalpingograms, positive tu-
berculin tests and strong contact histories. This
last group was excluded from the study due to the
lack of classical diagnostic criteria.
Infertility is defined as 1 year unprotected in-
tercourse without conception w9,10x. The micro-
scopic picture suggestive of genital TB is similar
in all of the pelvic organs with tubercles of granu-
lomatous inflammation, Langhans giant cells, ep-
ithelioid cells and central caseation associated
with chronic inflammation w2,8,1113x. With spe-
cial stains, acid-fast bacilli AFB. can be demon-
strated on careful microscopic examination of the
tubercles w1,1315x, and this evaluation was per-
formed in all cases.
Tuberculin tests were performed for all patients
by intracutaneous injection of 0.1 ml purified
protein derivative-tuberculin 5 tuberculin units.
and assessed for the presence of induration within
4872 h. A positive tuberculin test is defined as
an induration size of more than 10 mm w16x.
All of the cases were evaluated for the pres-
ence of other extragenital foci of tuberculosis
using sputum and urine cultures and chest
roentgenograms at the time of diagnosis.
 B. Nama ar Jahromi et al. r International Journal of Gynecology & Obstetrics 75 (2001) 269272 271

Table 1
Distribution and number of patients

Year Pulmonary Extrapulmonary Female genital Total TB

TB TB TB patients

1989 144 101 8 245

1990 188 32 4 220
1991 234 112 3 346
1992 146 110 5 256
1993 153 139 6 292
1994 134 102 3 236
1995 188 141 6 329
1996 141 122 3 263
1997 162 126 2 288
1998 215 139 3 354
1999 138 121 3 259

Total 1843 1245 46 3088

Statistical analysis was performed by the Z-test.
Significance was defined as a P-value - 0.05.
3. Results
The mean age of the patients at the time of
diagnosis was 30.4 years, with a range of 1670
years. Seven patients presented with abdominal
or pelvic pain 17.07%.. In this group three cases
underwent laparatomy because of the presence of
abdominal mass and ascites and therefore sus-
pected ovarian malignancy 7.31%. while four
patients 9.75%. were operated due to a tubo-
ovarian abscess unresponsive to various medica-
tions, and histopathological examinations showed
tuberculosis. Abnormal uterine bleeding was the
cause of diagnostic dilatation and curettage in
three other patients 7.31%.. However, 31 patients
75.6%., presented with infertility and TB was
diagnosed during studies to evaluate the cause of
their infertility. In this infertile group diagnosis
was established in 25 cases by endometrial curet-
tage and in four patients by biopsies taken from
tubes or ovaries during laparatomy. Diagnostic
laparoscopy in two other cases revealed gross
inflammation and tortusity of the tubes with mul-
tiple strictures and obstruction, when tubal biopsy
led to the diagnosis.
Female genital TB accounted for 1.32% of all
tuberculous patients in this study. Although
82.92% of our patients with genital TB had never
been pregnant, 75.6% of them were infertile by
definition Z s 12.13, P- 0.0001., as compared
with the infertility rate of 11.2% in the general
population in this area w17x.
TB endometritis was detected in 72.03%, tubal
involvement in 34.03%, ovarian TB in 12.9% and
cervical TB in 2.4% of the patients.
Tuberculin tests were positive in all of the
patients with a mean induration size of 17 mm
1424 mm.. Among these 41 patients, seven cases
17.07%. were Afghan immigrants.
All of the sputum and urine cultures performed
for the patients were negative, except in one case
2.43%. whose sputum culture was positive at the
time of diagnosis of genital TB. AFB was seen in
direct smears of tissue biopsies in only five cases
12.19%..
4. Discussion
This study confirms that infertility is the most
common symptom associated with genital TB
w1820x. At present unexplained infertility is diag-
nosed in 1015% of infertile couples w10x. Tuber-
culosis seems to be an important underdiagnosed
factor. Since genital TB often causes no physical
symptom, asymptomatic infertile women should
272 B. Nama ar Jahromi et al. r International Journal of Gynecology & Obstetrics 75 (2001) 269272
be investigated for silent or subclinical genital TB
especially in high risk populations w20x.
Tubal infection was confirmed in 34.3% of the
cases in our study vs. 90100% in other investiga-
tions w2,6x. Their higher incidence may be due to
more frequent laparotomies performed in such
cases.
Tuberculous endometritis occurs in 6070% of
women with genital TB w2,6x and our results were
similar 72.03%.. Endometrial curettage was the
most common route of diagnosis in this study,
perhaps because the uterus is more accessible for
taking biopsies.
As this study shows, direct smears are infre-
quently positive since it has been estimated that
approximately 100 000 mycobacteria per milliliter
must be present in the specimen to give a positive
result. Also as a rule, active extragenital foci of
tuberculosis are rarely present when the genital
lesion is discovered w8x.
Although no significant increase in the diag-
nosed number of patients with tuberculosis or
genital TB was seen in this 10-year survey, data
show that the incidence of TB has begun to
increase in the mid-1980s, even in many industri-
alized countries w1x. In spite of this, in some of the
recently published gynecology textbooks, not more
than a few paragraphs has been attributed to
genital TB. Genital TB is uncommon, so the
clinical index of suspicion among gynecologists is
generally low. It seems that more attention should
be paid to this disease, because proper diagnosis
and early treatment needs more accurate training
and discussion.
5. Conclusion
This study shows that infertility is the most
common initial symptom of female genital TB
and more cases of genital TB would be diagnosed
if this disease is considered in the evaluation of
every infertile patient in areas where tuberculosis
is endemic.
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