TESTS THAT ARE REQUIRED ARE: >COMPLETE BLOOD COUNT WITH ESR >X-RAY CHEST P/A VIEW MANTOUX

(MX) OR TUBERCULIN TEST :HAS SENSITIVITY OF 55% AND SPECFICITY OF 80% TUBERCULIN +VE TEST MAY BE SUBJECTED TO TO INTERFERON-Y IMMUNONOLOGICAL TEST BUT IS EXPENSIVE &NOT UNIVERSALLY AVAILABLE SEROLOGICAL TEST :DEPEND UPON THE 38kDa ANTIGEN OF M.TBOR MONOCLONAL ANTIBODY BASED ELISA ,BUT NOT SENSITIVE OR SPECIFIC ENOUGH FOR DIAGNOSIS OF FGTB Endometrial biopsy ,curettage or aspirate :Tuberculous endometrites has been observed in 13.6% of infertile women undergoing routine EB.It is done in premenstrual phase One part sent in formalin solution for HPE for granuloma formation Other part sent in NS for AFB smear ,Culture and guinea pig inoculation .and PCR In the absence of typical epitheloid granuloma and caseation of TB,dilataion of glands ,distruction og of epithelium and presence of inflammatory exudates in lumen suggest tuberculous pathology .False negative results may be due to technical failure ,non representative tissue samples ,period of sample collection in relation to disease stage and effect of HIV co-infection .Negative result does not exclude genital TB,if the specimen obtained on first attempt is inadequate , second sampling is recommended . MYOBACTERIUM SMAER AND CULTURE :EB,Aspirate,menstrual blood ,secreation from vagina,cervix ,peritoneal fluid or tubal biopsy from tubercles are subjected to culture and Lowenstein-Jensen(LJ) medium and guinea pig inouculation showed +ve results in 57% and 11% respectively .Since expensive not performed routinely . Polymerase chain reaction (PCR) :is rapid ,sensitive and specific molecular biology method for detecting mycobactrial DNA in both PTBand EPTB.This assay targets genes like 65-kDa,IS6110and mpt64 genes .contamination with heparin and high salt concentration interfers with its results .it cannot distinguish with dead and live bacilli .should not be used for initiating ot stopping ATT.it cannot differentiate between infection and disease ,as most indian show +ve PCR without suffering from disease .

Imaging methods Ultrasonography (USG) Being non-invasive and with no radiation hazard, USG can be used in the diagnosis of FGTB and may show bilateral solid adnexal masses with scattered small calcifications with free fluid in pouch of Douglas However, in the absence of pelvic masses, USG has a very limited role in the diagnosis of genital TB. Computerised axial tomography (CT scan) This is a useful modality for pelvic and abdominal masses especially when the lesion may resemble malignant ovarian tumors. In TB, there is low-density ascites, multiple pelvic, abdominal, hepatic or splenic lesions with or without lymphadenopathy especially in young infertile women. In fallopian tube TB or ovarian TB, CT scan may help in delineation of tubo-ovarian masses. Positron Emission tomograhy (PETscan) It's a useful modality as it demonstrates glucose intake by the diseased area, but the data available on its role in genital tuberculosis is sparse, Magnetic resonance imaging (MRJ) MRI is used increasingly in modern gynecology in the presence of abdominal Blood markers in genital TB It is a non-specific marker , the levels in genital TB are only moderately raised (usually < 200 U /ml). However, there have been case reports with very high levels of CA 125 in disseminated abdominal TB with as high as 18000 U Iml recorded in a proven pelvic TB with disseminated disease. Hence, CA 125 is not a very reliable marker for. diagnosis of FGTB.

Hysterosalpingography (HSG) In a known case of genital TB, HSG is contra-indicated as it may flare up subclinical infection. The abnormalities that are seen includes by synechiae formation, a distorted uterine contour and lymphatic intravasation.The synechiae and intra-uterine adhesions in TB are characteristically irregular, angulated and stellate-shaped with well-demarcated borders. Unilateral scarring may cause obliteration of the uterine cavity on one side giving rise to a pseudo-unicornuate uterus. Scarring in TB may result in conversion of the triangular uterine cavity into a T-shaped cavity. An asymmetric, small-sized, uterine cavity is usually due to TB. Venous and lymphatic intravasation is a good indicator of endometrial TB but is not very specific as it can happen in other conditions also (intra-uterine adhesions or tubal obstruction due to other etiologies). The various diagnostic criteria established for diagnosis of TB of fallopian tubes from HSG are: L 2. 3. 4, 5, 6. Calcified lymph nodes or smaller, irregular calcifications in the fallopian tubes (adnexal area). Obstruction of the fallopian tube in the zone of transition between the isthmus and the ampulla. Multiple constrictions along the course of the fallopian tubes or beaded appearance (salpingitis isthmica nodosa). Ragged and jagged tubal contour with small lumen defects and fistulous tracts, Straight, rigid contour of the lumen with stem-pipe like configuration of the tube. Golf-club appearance: only isthmus and proximal ampulla are visualised and the isthmic segment has a rigid, stove-pipe appearance.

7. Maltese-cross appearance: completely filled tube with rigid and irregular outline (Fig. 5). 8. Rosette type: the distal end of the tube is filled with dye giving a rosettetype image. 9. Leopard skin like speckled appearance of the ampulla due to the tube being partially filled with contrast. Although the tubes are often blocked in genital TB, they may be patent in 37% cases of endometrial TB.5

Endoscopy Hysteroscopy Endoscopic visualisation of the uterine cavity in genital TB may show a normal cavity (if no endometrial TB or early stage TB) with bilateral open ostia. Cavity is partially or completely obliterated by adhesions .Small, shrunken cavity. Presence of intra-uterine synechiae, granulomas and poor distensibility. , Flimsy or thick adhesions with obliteration ofcavity and inability to see ostia or blocked ostia Endometrium is pale looking Laparoscopy Laparoscopy in FGTB in association with other diagnostic modalities like endometrial biopsy, PCR, HSG with or without other tests, has helped in making a correct diagnosis of genital TB in the majority of cases." The final diagnosis is made from good history taking, careful systemic and gynecological examination and judicious use of diagnostic modalities. with imaging methods and endoscopic visualization, especially with laparoscopy. Genital TB can be seen in 5-33.8% of cases of infertility on routine laparoscopy. The various abnormalities of genital TB on laparoscopy are: In the sub-acute stage, there may be (i) congestion, edema and adhesions in pelvic organs with multiple, fluid-filled pockets. (ii)There are miliary tubercles, white, yellow and opaque plaques over the fallopian tubes and uterus. In the chronic stage, there may be following abnormalities: (i) yellow, small nodules on tubes (nodular salpingitis); (ii) short and swollen tubes with agglutinated fimbriae (patchy salpingitis; (iii) unilateral or bilateral hydrosalpinx with retort-shaped tubes due to agglutination of fimbriae;

(iv) pyosalpinx or caseosalpinx where the tube (usually bilaterally) is distended with caseous material with ovoid, white-yellow distension of ampulla with poor vascularization; (v) various types of adhesions may be present in genital TB covering genital organs with or without omentum and intestines. The adhesions are usually vascular and it has been that adhesiolysis in such women may be associated with significant bleeding and there is risk of injury to the bowel in the presence of dense adhesions. Even peritoneal biopsy from the lesions can cause excessive bleeding and needs careful hemostasis with cautery. Various other abnormalities on laparoscopy in genital TB include (1)Adhesions, Granuloma, Plaques, Exudates, Tubo-ovarian masses and pelvic congestion in up to 88.6% of cases (2)Dilated tortuous and blocked fallopian tubes 32.5%. (3) Peritubal and peri-ovarian adhesions 45%. (4)Omental adhesions in 45% and bowel adhesions 37.5% . (5)Fitz-Hugh-Curtis syndrome 48% .

TREATMENT Medical treatment Multiple drug therapy in adequate doses and for sufficient duration is the main-stay in the treatment of TB including FGTB. . The development of short-term, cost-effective chemotherapy for TB was a major achievement for clinical medicine. Short-course chemotherapy for 6-9 months has been found to be effective . Directly observed treatment short course (DOTS) strategy treatment . To prevent MDR and for better results, the DOTS strategy has been proven to be cost effective throughout the world. All women with FGTB should be treated under the DOTS strategy throughout the world for best results In developed countriesDOTS strategy not considered necessary in management of most cases of TB. Genital, TB is classified under category I as being seriously ill, extrapulmonary disease. As M. tuberculosis divides very slowly (18 h), thrice weekly treatment is as effective as daily treatment. However, even one dose should not be missed to avoid development of MDR disease. After diagnosis of FGTB and decision to start ATT , the patient should be sent to a DOTS center (in India, the whole country is now under DOTS strategy). To ensure quality-assured drugs in adequate' doses, a full 6-month course pack is booked for an individual patient in the DOTS center. Intensive phase -woman is given a fixed drug combipack (FDC) of isoniazid (INH), rifampicin, pyrazinamide and ethambutol, 3 times a week for the first 2 months under direct observation in front of a health worker at a DOTS center. Compliance is ensured by the DOTS center providers by contacting the homes. continuation phase, the patient is given a combination blister pack of isoniazid and rifampicin 3 times a week for the next 4 months with at least one of the weekly doses administered under direct observation. Rarely, FGTB cases can have relapse or failure categorizing them into category II , are given treatment accordingly (Table 7) which includes 2 months intramuscular injections of streptomycin thrice weekly along with another four drugs (RHZE) of category I under direct supervision of a DOTS center health worker for the first 2 months followed by four drugs (RHZE) thrice a week for another month (intensive phase). The continuation phase is with three drugs - isoniazid (H), rifampicin (R) and ethambutol (E) thrice a week for another 5 months with at least one of the three times a week dose being administered under direct observation. Minimal genital TB (asymptomatic except for infertility and diagnosed on endometrial biopsy culture) as category III by omitting ethambutol from the first 2 months' regimen, especially in areas where resistance to isoniazid is unlikely. As the exact prevalence of resistance to isoniazid in India is not known (but is probably high), it is apolicy to treat all women with genital TB as category I under the DOTS strategy. The Revised National Tuberculosis Control Programme (RNTCP) of India has achieved a treatment success rate of up to 95% with DOTS for all types of TB including FGTB.4 Alternative treatment (non-DOTS)

Convenient commercial combipacks(AKT-4-contains- one capsule of rifampicin (450 mg), two tablets of pyrazinamide (750 mg each), one tablet of ethambutol (800 mg) plus isoniazid 300 mg : CX-5 at a very economic price 15 per combipack equivalent to 30 US cents or 17 English pence per day). These have to be taken every day for 2 months followed by a combination of rifampicin (450 mg if body weight < 50 kg, 600 mg if > 50 kg) and isoniazid (300 mg; R-Cinex 600 or 450; Lupin: Rimactazid; Novartis, Mumbai (India) as a combipack to be taken daily at a very economic price (Rs. 7 per day).