1. ‘President’s Medal’ for best medical graduate 1970-75.
‘Dr. B.C Roy’s award’ in 1999 for outstanding contribution towards
medicine and field of specialty,
‘Vikas Ratan Award’Nations economic development & growth society 2002
‘Chiktsa Ratan Award’ International Study Circle , 2007
Felicitated by Agra medical college for ‘Outstanding contribution towards
field of specialty. 2008
Appointed by National Board of Examination as course director to award
post doctoral Fellowship in Reproductive Medicine since 2007, and by
FOGSI for basic as well as advanced infertility training since 2008
Member of Editorial board of ‘Worldwide IVF’ and peer reviewer for
‘Journal of Human Reproductive Sciences’
Over 15 publications in indexed journals and 20 chapters in textbooks for
ob/gyn and reproductive medicine
Over 150 guest lectures and orations in national /international
conferences.
Prof. Dr. Abha Majumdar
Director and Head
Center of IVF and Human Reproduction
Sir Ganga Ram Hospital, New Delhi,
INDIA

2. Pelvic tuberculosis and
infertility
Prof. Dr. Abha Majumdar
Director and Head
Center of IVF and Human Reproduction
Sir Ganga Ram Hospital
New Delhi

3. 2 types of tuberculosis infection
in humans
 Latent TB: Exposure to tuberculosis but
organism is dormant or inactive. Only 5-
10 % of latent TB will progress to active
disease in ones life time
 Active TB: occurs by active
multiplication of the bacteria to cause
disease and tissue destruction in the
body

4. Latent tuberculosis
 Latent TB is a clinical condition defined
by a positive mantoux’s test in people
who have no clinical evidence of active
disease. (CDC definition)
According to an estimate performed in
1999, 1.86 billion, or almost 1/3 of the
world’s population has exposure to
TB.

5. Differences in latent and active
tuberculosis
Latent tuberculosis
 TB bacteria enter humans
and stimulates immune
system to stimulate cell
mediated immunity after
which it remains dormant
as bacteria or its DNA or
antibodies.
Active tuberculosis
 Big pellet of myco-
bacteria enters body to
surpass ones immunity
OR
 Dormant bacteria in body
start multiplying due to
lowered immunity to start
active disease damaging
the cells and tissue
BCG vaccinePrimary
infection (TB
bacteria
enters from
environment
but remains
dormant due
to good
immunity
Treated
tuberculosis

6.  Genital tuberculosis is mostly secondary
to a primary infection in the lungs
 Rarely primary infection can be through
abraded skin, GIT or genitalia.
 Focus of genital tuberculosis is fallopian
tubes which are almost always affected
bilaterally but not symmetrically. This
spreads to endometrium in approx half
the cases
Genital tuberculosis

7.  Hematogenous (most common)
 Lymphatic spread (from hilar LNs to
intestinal LNs to pelvic LNs)
 Direct spread from adjacent
abdominal organs (rare)
 Venereal transmission (very rare)
The routes of spread for genital
tuberculosis

8. How does tuberculosis infection
cause infertility?
TB infection actively affects genital organs, starts
tissue destruction-tubal damage/ blockage-leads to
increased risk of ectopic pregnancy or infertility due to
tubal blockage.
Further involvement of endometrium can lead to
destruction of implantation surface and further
infertility.
Women with pulmonary tuberculosis or of other organs
with no genital involvement get pregnant with ease

9. Tests to suspect genital
tuberculosis
Pelvic Ultrasound
HSG
Laparoscopy and hysteroscopy

10. Pelvic ultrasound
Hydrosalpinx, T-O masses, encysted fluid in
pelvis
Thin endometrium or poor, unclear
endometrium, fluid filled spaces or synechia
Thick endometrium with haphazard
endometrial lining

11. HSG findings in genital
tuberculosis
 Hydrosalpinges with fimbrial blocks
 Blocked or lead pipe tubes
 Scarring leading to irregular uterine
margins, distorted uterine contour,
pseudo-unicornuate uterus, or T shaped
uteri
 Synechia as filling defects, calcification
 Venous and lymphatic intra-vasation of
dye

12. HSG findings in genital
tuberculosis

13. Laparoscopy and Hysteroscopy
(closest to confirmatory tests)
Direct visualization of tuberculous
lesion and its sequele in pelvis and
endometrium
If endometrium is involved tubes
will be involved in almost 100%
cases

14. Advanced endometrial
tuberculosis on hysteroscopy
Normal uterine cavity

15. Advanced pelvic tuberculosis
on laparoscopy
Fitz hugh curtis or
abdominal tuberculosis

16. Direct test or confirmatory
tests for active disease
Histopathology
Visualization of bacteria

17. Epitheloid and langhans giant
cells & lyphocytes
Reliable & specific method of diagnosis of TB
with sensitivity of 70-100% & high specificity
Histopathology

18. Direct visualization of
mycobacterium
 Demonstration of AFB in tissue:
(>10,000 org/ml)
 Ziel Nelson staining
 Fluorescent staining with Auramine
Rhodamine
 Culture (>100 org/ml in sample
 Lowenstein Jenson Media- 6 wks
 Bactec 460 TB system (radiometric
test)-1-3 wks

19. Categories and Rx of Genital TB
Category Description Initial phase
(daily or thrice
weekly)
Continuation
phase (daily or
thrice weekly)
I Severe forms of
Extrapulm TB-
Genital TB
2 HRZE 4 HR
II Relapse /defaulter/
t/t failure
2 HRZES/ f/b
1 HRZE
5 HRE
III Less sev forms of
Extrapulm TB
2 HRZ 4 HR
IV Chronic and
MDR-TB cases
Standard drug
regimen daily- 6-9
months intensive
phase
18 months
continuation phase

20.  Convenient commercial combipacks of
AKT-4 to be taken for 2 months daily.
 One capsule of Rifampicin- 450mg
 Two tablets of Pyrazinamide- 750mg each
 One tablet of Ethambutol – 800mg
 One tablet of Isoniazid 300mg
 Followed by Rifampicin (450mg -
600mg) and Isoniazid 300mg- for
another 4 months.
American Thoracic Society/British thoracic Society/ UK
National Institute for Health & Clinical Excellence
(NICE-2006)

21. Why INDIA is different when the
question of treating latent
tuberculosis arises?
Why can’t we follow western
countries in treating latent
tuberculosis?
Because the prevalence of
latent tuberculosis is different
within these 2 areas

22. Prevalence of Tuberculosis
 High prevalence countries :
 INDIA =40% (800:2000)of population has
been exposed to TB that is 500 million
individuals have latent TB
India TB 2006 RNTCP status report, N. Delhi
D.G.H.S, Ministry of Health & Family Welfare
 Low prevalence countries
 USA < 0.5%(1:2000) of population, 2 lac
individuals in country of 330 million have
latent TB

23. Pitfalls in treatment of Latent
TB in India
 Due to constant exposure to Mycobacterium
tuberculosis in high prevalence areas like India,
even after treating Latent TB, the person
may again get infected and this would
mean repeated courses of
chemoprophylaxis
 Treatment of Latent TBI would only increase the
logistic and financial burden on the health care
system of the country

24. Treatment of tuberculosis in
India
 The priority of TB control program in India
(RNTCP) is treatment of active TB
 Testing and treating of Latent TB is not
recommended in INDIA as it is a high
prevalence zone, unless individual leaves the
country for living in a low prevalence zone
India TB 2006 RNTCP status report, N. Delhi
D.G.H.S, Ministry of Health & Family Welfare

25.  In developed countries- where prevalence of TB
is minimal, most new cases are only due to
activation of latent TB infection
 In such low prevalence countries, treatment of
latent TB is a major component of TB control,
by which 80-90% of active TB in community
can be reduced.
Latent TB in developed
countries with low prevalence

26. Indirect Tests used to detect
tuberculosis
(cannot detect between latent and active
tuberculosis)
 Mantoux Test skin test
 Quantiferon Gold (QFT-G) humoral test
(immunological response to antigen exposure)
 Antibody Detection Test: ELISA
 Antigen Detection Tests such as TB PCR
(Nucleic Acid Amplification Tests)

27. Prevalence of tuberculosis in
India
 Latent tuberculosis 40%
 Active pulmonary tuberculosis 8-10%
 Genital tuberculosis 3-4% of pul tub
LOGISTICS: due to higher prevalence of TB in
India - percentage of pulmonary TB cases will
increase but ratio of pulmonary TB to genital
TB will remain same
(numbers will be more due to higher population
and prevalence
percentage of genital TB cannot exceed that of
pulmonary TB)

28. Changing epidemiology of TB in
INDIA by treatment of L-TB
Urban MDR 51% vs rural MDR 2%
Clin Infect Dis 2003 Jun 15;36(12)
Second line ATT now required for neonates and
infants due to emerging MDR (SGRH pub)
Long term as well as fatal toxicity of ATT
Epigenetic changes in progeny of Indian
immigrants to US (reduction in bone marrow
mass) Boston university US unpub data

29. Some scary facts
 Indiscriminate use of ATT - XDR (extreme) and
TDR (total)
 Need of sanatoriums may re-emerge to
prevent spread of infection with these resistant
strains
 Travel to western world may need to be
quarantined
 TB recently has been declared as notifiable
disease like dengu plague and swine flue

30. TOI
Finally, tuberculosis declared a notifiable disease TOI 09 May
2012, 06:27 IST ...They finally land up in government treatment
programme," said a senior official of the revised national TB control
programme (RNTCP). Multi-drug resistant TB has become a menace
in India. Every year, the country reports 15 lakh new cases of TB.
WHO says around...
In two months, 63 new MDR-TB cases in district TOI 24 Apr
2012, 06:33 IST ...
Paediatric TB a major concern in state TOI 22 Apr 2012, 02:57
IST….
Finally, tuberculosis declared a notifiable disease
Kounteya Sinha, TNN May 9, 2012, 06.27AM IST
NEW DELHI: India has finally declared tuberculosis (TB) a notifiable
disease. The announcement signifies that with immediate effect, all
private doctors, caregivers and clinics treating a patient suffering
from TB will have to report every single case of the air-borne disease
to the government.
The notification was sent to all states on May 7. Till now, doctors in the private
sector were free to treat TB patients, and weren't required to keep a record.
India

31. All the TB-PCR positive women were administered standard 6-
month anti-tubercular chemotherapy only….. There were no
statistical differences in the two groups in the overall
pregnancy rate.
…-4 to 5 ml menstrual blood was collected from the remaining
60 women and subjected to PCR against M.tuberculosis.
Sterilized collection tubes were provided to the patients to
collect menstrual blood.
Type I: suggestive of GTB on all cases of lap visual inspection
1 Confirmatory: clear evidence of GTB in the form of multiple
granulomas, exudates, loculated fluid, adhesions,
hydrosalpinges and beaded blocked tubes
2 Suspicious: subtle signs of chronic inflammation, e.g.,
patent tubes with pelvic congestion, only a few scattered
small granulomas, fimbrial agglutination and phimosis, tubal
sacculation, mild adhesions and straw-coloured fluid in POD....
Some quotes from our publications

32. Indian publications advocating
favorable fertility outcome following
ATT for endometrial PCR positivity
 None of the studies are RCT’s with 2 arms in PCR
positive group: one with and the other without
treatment to compare the benefit of treatment
 The criteria to diagnose TB PCR positivity has been
menstrual blood collection by patient herself
 Any pelvic finding of slightest adhesion also has
been taken as indicator of TB. Apparently all other
pathogens causing tubal factor infertility such as
poly microbes, chlamydia, gonococci etc prevalent
all over the world appear to have been abolished
from Indian women…….

33. Facts about tuberculosis
treatment in Northern India
 500 to 600 laparoscopies done under my care
of urban infertile women attending SGRH
 Evidence of TB seen on laparo/hysteroscopy is
only 3% to 4%
 Young healthy women on ATT on indirect test
approximately 30% to 40% (latent tuberculosis
prevalence in the country is same 40%)
 Popular indirect test done to start ATT
 TB-PCR menstrual blood/endometrium
 ELISA TB
 Montoux and quantiferon gold
 No tests

34. Some facts in my experience
 Centre of IVF SGRH
 1200 IVF cycles/year with a pregnancy rate
of 42% in last 1 year
 2400 IUI cycles/year with pregnancy rate of
>24% in unexplained infertility in the last 1
year
 5000 approximate new and 25000 old
infertility consultations/year
ATT is used in not more than 10
patients per year

35. Our ongoing study at SGRH
 This is the first study of its kind being
conducted in the country as prevalence of TB
PCR has never been validated in fertile
population.
 It is a RCT where endometrial TB PCR is being
done to evaluate its prevalence in infertile
women with clear pelvis undergoing
laparoscopic evaluation vs fertile women
undergoing laparoscopic sterilization with clear
pelvis
 Results indicate so far the same prevalence of
TB PCR positivity in the 2 groups
(18.18% infertile 16% fertile women)