The other day we had two similar patients in our ward at the same time. Both of them had failed repeatedly to undergo IVF due to infertility, one for the third time and the other for the seventh time. However, both of them had symptoms such as high fever and cough during pregnancy, but they did not take chest X-ray in time because they were concerned about the fetus in their bellies. Later, she developed headache, vomiting, convulsions, coma and other symptoms, and her life was in danger, so she had to take a chest X-ray and undergo lumbar puncture. The fetus, which was less than a month old, had to be taken out by cesarean section to save the mother and the fetus.
In the end, the medical staff did all they could to save the two unfortunate mothers and pulled them back from the ghost gate. However, their precious children were both suffering from congenital tuberculosis, and although a lot of money was spent, neither survived.
It was hard for me to see their devastating experiences and think of their unfortunate families. So I’m writing this article in the hope that I can help those women who may follow in their footsteps, not to repeat the same mistakes, so that the tragedy will not be repeated. If someone can benefit from my article, I will be doubly pleased.
I hope that the following three types of people will read this article.
1. Women who have pelvic tuberculosis and do not know it, especially those who are infertile and want to get pregnant.
2. Obstetricians and gynecologists and doctors in fertility centers, especially those who do IVF.
3. Tuberculosis doctors.
Most patients with extrapulmonary TB are first seen in the appropriate department, such as bone TB in orthopedics, intestinal TB in gastroenterology, and kidney TB in nephrology or urology. The diagnosis and differential diagnosis need to be made in the appropriate department, and treatment in the TB department, which means that it takes the cooperation of both departments to complete the diagnosis and treatment. Patients with pelvic tuberculosis are first seen in obstetrics and gynecology, and the vast majority should also be diagnosed by obstetricians and gynecologists, and then treated in the tuberculosis department.
Many patients with pelvic tuberculosis have no obvious symptoms, but are only infertile, and they turn to OB/GYN or fertility centers for IVF to get pregnant. They do not realize that their infertility is due to pelvic TB and are only concerned about getting pregnant, not realizing that pelvic TB can spread systemically during pregnancy and kill them. It is the doctor’s responsibility to find out what is causing their infertility and treat it, instead of acting like a machine that produces IVF and only knows how to bury their heads in IVF and persevere, even if they fail six times and have to do it a seventh time, and nothing else.
I would like to remind all infertile women, and of course their doctors, that if they want to do IVF, they must first check if pelvic tuberculosis is the cause of infertility. If it is, IVF should never be done directly, but must be treated with anti-tuberculosis treatment first, and only after the TB is cured can IVF be done. Otherwise, either IVF will fail, or even if it is successful and the baby is conceived, it will not be a good thing. During the pregnancy, the TB bacteria can easily spread bloodstream throughout the body and even become life-threatening.
Let’s learn more about pelvic tuberculosis.
Overview.
Inflammation of female genital organs such as fallopian tubes, endometrium, ovaries, pelvic peritoneum and cervix caused by Mycobacterium tuberculosis is called female genital tuberculosis, also known as tuberculous pelvic inflammatory disease or pelvic tuberculosis. It mostly occurs in women aged 20-40 years old, but can also be seen in older women after menopause. Tuberculosis of the fallopian tubes is the most common, accounting for about 85%-95% of female genital tuberculosis, followed by endometrial tuberculosis, accounting for 50%-60%, often spreading from the fallopian tubes to the uterus, with lesions mostly confined to the endometrium. Among the genitalia, the fallopian tubes are the first to be infected with tuberculosis, which can lead to endometrial tuberculosis, especially in the endometrium at the horn of the uterus. If complicated by pelvic peritoneal tuberculosis, there may be scattered nodular lesions in the plasma membrane of the uterus. Other cases such as ovarian, cervical, vaginal and vulvar tuberculosis are rare.
In developing countries, tuberculosis accounts for 40% of the causes of tubal occlusion.
The vast majority of genital tuberculosis is secondary to infection, mainly pulmonary and peritoneal tuberculosis, but also to intestinal tuberculosis, tuberculous foci in the mesenteric lymph nodes, and also to bone or urinary tuberculosis. Primary female genital tuberculosis is rare.
Pathogenesis.
Blood-borne transmission is the main route. The tuberculosis bacilli first invade the respiratory tract and form foci in the lungs, pleura, or nearby lymph nodes, and then spread to the internal genital organs through the bloodstream. In adolescence, when the genitalia are developing and the blood supply is rich, the tuberculosis bacilli are easily transmitted by bloodstream and the genitalia are involved, firstly the fallopian tubes and gradually the endometrium and ovaries. At this time, the tissue reaction is not obvious and there are no clinical symptoms. The tubercle bacilli in the bloodstream can be cleared by the immune system, but because the structure of the tubal mucosa is conducive to the incubation of tubercle bacilli, they can form latent foci in the fallopian tubes for 1-10 years or more. Once the immunity of the body is low, it can be reactivated and develop. The primary lesions in the lungs are often completely absorbed or only calcifications or streaks remain during the latent process, which is almost universal when genital TB is definitively diagnosed. Therefore, most patients have healed primary pulmonary lesions by the time genital tuberculosis is detected later.
Both direct intra-abdominal spread and lymphatic spread are rare.
Clinical presentation.
The clinical symptoms of genital tuberculosis vary in severity, and many patients may be asymptomatic, while others are more symptomatic.
1. Menstrual disorders
is a common symptom. Due to the influence of tuberculosis lesions, excessive menstruation or prolonged menstruation and dripping bleeding may occur in the early stage due to endometrial congestion and ulceration. If the disease is not diagnosed and treated in time, it may develop further. Most of the patients have been suffering from the disease for a long time and are at an advanced stage, and may have scanty menstruation or amenorrhea due to different degrees of endometrial destruction.
2. Infertility
It is a common symptom. Due to the destruction and adhesion of tubal mucosa, the tubal lumen is often blocked, resulting in infertility; or due to adhesion around the tubal lumen, sometimes the lumen is still partially open. However, when the mucosal cilia are destroyed, the fallopian tubes become stiff and peristaltic, and lose their transport function, which also prevents conception. The tubercular lesions in the endometrium destroy the environment for fertilization and development of the egg, resulting in infertility. Therefore, the majority of patients are infertile. Therefore, many patients come to the hospital for examination because of infertility and are finally diagnosed with pelvic tuberculosis. Genital tuberculosis is often one of the main causes of primary infertility.
3. Lower abdominal cramps
Due to pelvic inflammation, congestion, adhesions or abscess formation, lower abdominal cramps of different degrees can occur, which are aggravated during menstruation.
4. Systemic symptoms
Patients with severe pelvic tuberculosis may have systemic symptoms of tuberculosis, such as fever, night sweats, loss of appetite, emaciation, fatigue, and weakness, etc. Sometimes there is only menstrual fever. There may also be no symptoms at all.
5. Physical signs.
Systemic and gynecological examinations vary greatly depending on the degree and scope of lesions. Most patients are found to have endometrial tuberculosis only after diagnostic scraping for infertility, without obvious signs and conscious symptoms.
In more severe cases with peritoneal tuberculosis, there is a tenderness or ascites sign in the abdomen during examination, and a cystic mass can be palpated when an encapsulated peritoneal fluid is formed, with unclear and inactive borders and a hollow sound on percussion due to intestinal adhesions on the surface.
The uterus is generally poorly developed on gynecologic examination, and the uterus is small or malformed. Movement is often limited by the presence of surrounding adhesions.
If the adnexa are involved, the adnexal area is thickened, or a mass of variable size and irregular shape may be palpated, which may be substantial and cystic or cystic solid. There may be positive signs such as pressure pain.
If the pelvis is involved, a large area of sclerotic tissue can be found, which is commonly called “frozen pelvis”. If secondary infection occurs, abdominal pain is more severe.
Examination.
I. General laboratory tests
A positive tuberculin test indicates the presence of tuberculosis infection in the body, and a strong positive test indicates that there is still an active lesion.
Molecular biology methods, such as PCR (polymerase chain reaction) techniques, are quick and easy, but there is a risk of false positives.
T-cell test for tuberculosis infection (T-SPOT): It has been used more and more widely in recent years, but the results should be properly understood.
II. Pathogenetic examination
Various specimens are taken for smear antacid staining to find TB bacilli, or culture of Mycobacterium tuberculosis. The culture results are accurate, but it often takes 1-2 months to get the results, and the culture positivity rate is closely related to the time and number of examinations.
Various specimens include: vaginal film collection of menstrual blood; uterine cavity aspirate; uterine cavity scraping; cervical biopsy; abdominal fluid; pelvic fluid.
III. X-ray examination
1, chest X-ray: the majority of genital tuberculosis is secondary to pulmonary tuberculosis, so chest X-ray should be included as a routine examination, focusing on the presence of active or old tuberculosis foci or pleural tuberculosis signs, positive findings have a certain reference value for the diagnosis of suspicious patients, but a normal chest X-ray cannot exclude the possibility of genital tuberculosis.
If necessary, X-ray examination of the digestive tract or urinary system is performed to detect the presence of primary lesions.
2.Pelvic X-ray examination, which reveals isolated calcified spots, suggests the presence of pelvic lymphatic tuberculosis lesions.
3.Iodine oil imaging of the uterine tubes
Some experts have classified the features of genital tuberculosis on the radiographs of hysterosalpingography into two categories according to their diagnostic value.
One category is the more reliable sign: genital tuberculosis can be basically diagnosed in those with clinical suspicion of tuberculosis and any one of the following features.
(1) Most calcified spots in the pelvis: there are few cases in the gynecological field that lead to pathological calcification of the pelvis. A majority of calcified spots in the area equivalent to the fallopian tubes is very unlikely to be anything other than genital tuberculosis.
(2) Obstruction of the middle part of the fallopian tube with a perfusion defect formed by an ulcer or fistula in the interstitium of the fallopian tube with iodine oil.
(3) Multiple strictures in the fallopian tubes with a rosacea pattern.
(4) Severe stenosis or malformation of the uterine lumen.
(5) Intraluminal perfusion with iodine oil, i.e., iodine oil enters the lymphatic vessels, blood vessels or interstitial tissue. With narrowing or deformity of the uterine cavity.
(6) Ovarian calcification: calcified signs appear in the equivalent of the ovaries.
The second category is possible signs: genital tuberculosis is basically diagnosed when there is clinical suspicion of tuberculosis and any 2 or more of the following signs are present
(1) Isolated calcified spots on pelvic plain film.
(2) The fallopian tubes are stiff and straight with distal obstruction.
(3) Irregularly shaped and obstructed fallopian tubes.
(4) One side of the fallopian tube is not visualized and the middle part of the tube is obstructed with interstitial iodine perfusion.
(5) Distal atresia of the fallopian tubes with a perfusion defect in the lumen.
(6) Bilateral obstruction of the isthmus of the fallopian tubes.
(7) Irregular and jagged margins of the uterine cavity.
(8) Iodine oil perfusion in the uterine interstitium, lymphatic vessels or veins.
(4) Endometrial diagnostic pathological examination
Endometrial pathological examination is the most reliable basis for the diagnosis of endometrial tuberculosis. Both diagnostic scraping and hysteroscopy can take biopsies for pathology. Diagnostic scraping is usually done 2-3 days before menstruation or within 12 hours of menstrual flow and sent for pathology. Since endometrial tuberculosis originates from the fallopian tubes, care should be taken to scrape the uterine horns bilaterally to send all the scrapings for pathological examination. If typical tuberculosis nodules are seen, the diagnosis is confirmed. To prevent the spread, anti-tuberculosis drugs should be used for 3 days before and after scraping.
V. Hysteroscopy
Hysteroscopy is the first choice for diagnosis of endometrial tuberculosis, in which tuberculous lesions can be clearly seen and biopsies can be taken for pathology.
Laparoscopy or dissection
The pelvic cavity can be directly observed, such as whether there are corn-like nodules on the plasma membrane surface of the uterus and fallopian tubes, adhesions around the fallopian tubes, thickening of the fallopian tubes and ovaries, and biopsies can be taken from the lesions for pathological examination and culture of tuberculosis bacteria. The operation should avoid damaging the adherent intestines. If the diagnosis cannot be confirmed by laparoscopy, a caesarean section may be considered. Biopsy specimens must be sent for pathological histological examination.
Seven, puncture examination: when there is encapsulated fluid in the pelvic cavity, centrifugal smear examination can be performed by posterior fornix puncture to find Mycobacterium tuberculosis, and the diagnosis can be made clearly.
Differential diagnosis
1. Non-specific chronic pelvic inflammatory disease
2.Chronic tubal inflammation
3, endometriosis
4.Ovarian tumor
5, Fallopian tube cancer.
6.Fallopian tube pregnancy
Treatment
1.Anti-tuberculosis chemotherapy
Treatment principles: early, combined, appropriate amount, regular and full course.
Early tuberculosis lesions are at the stage of bacterial multiplication, the earlier the lesions are fresh, the better the blood supply, the easier the drugs can penetrate; active treatment can prevent delays and the formation of difficult to treat chronic caseous lesions. The combination of drugs can kill the naturally drug-resistant bacteria or stop the reproduction, and the chance of drug-resistant TB bacteria is greatly reduced. However, because of the long duration of drug therapy, it is often not easy for patients to adhere to it, and premature discontinuation or irregular administration of drugs may lead to treatment failure. For this reason, clinicians should pay more attention to the two principles of regularity and adequacy, pay attention to the patient’s treatment, and strengthen supervision of the patient to avoid stopping or arbitrarily changing medication in the middle of the course, which may result in incomplete treatment and lead to drug resistance and difficult treatment.
Treatment plan (the following plan is for reference and should be adjusted according to the patient’s condition)
(1) Total treatment course of 1 year. The intensive period is 3 months with the combination of four drugs: isoniazid, rifampin, pyrazinamide and ethambutol; followed by the consolidation period of 9 months with the combination of isoniazid, rifampin and ethambutol.
(2) In patients with severe disease, the variety of drugs and the course of treatment are appropriately increased.
(3) Drug-resistant patients: drug-resistant anti-TB regimen based on drug sensitivity results.
Diagnostic scraping at the end of the treatment course, if still not converted to negative continue treatment. If necessary, change the program according to the drug-sensitive results, and if negative after six months, scraping again, two negative, that is, clinical cure.
2.Surgical treatment
Indications for surgery.
(1) Tuberculous abscess in the pelvic cavity is formed and cannot be subsided by drug treatment.
(2) Recurrent attacks after regular and adequate anti-tuberculosis treatment.
(3) Long-term fistula does not heal.
(4) A large encapsulated effusion has formed.
(5) Those who are over 40 years old and have obvious pelvic masses and have difficulty in treatment without the necessary preservation of the uterus.
To avoid the spread of nodules during surgery and to reduce adhesions to the advantage of surgery, anti-tuberculosis drugs should be used for 1 to 2 months before surgery, and postoperative treatment with anti-tuberculosis drugs should be continued to a sufficient course to achieve complete cure. The scope of surgery should be decided according to the age and extent of the lesion. For pre- and post-menopausal women, total bilateral adnexal and hysterectomy is appropriate, and for younger women, ovarian function should be preserved as much as possible. The uterus and adnexa can be removed together when the fallopian tubes and ovaries have formed a large mass and the fallopian tubes and ovaries cannot be separated. Preservation of the ovaries can be considered when there is no caseous necrosis or abscess on dissection of the ovaries.
In cases of pelvic tuberculosis, the adhesions are so extensive and dense that surgical separation is difficult and may cause unnecessary injury if performed reluctantly.
Prognosis
The prognosis is better for the patient if anti-tuberculosis treatment is given promptly, but worse for infertility. Because of the severe tubal destruction by the tubercle bacilli, the chances of obtaining a natural pregnancy are low even after the application of adequate anti-tuberculosis drugs, and artificial fertility techniques can be used if fertility is needed. However, if the endometrium is severely damaged, pregnancy cannot be achieved even with artificial assistance.
Prevention
Enhance physical fitness, get BCG vaccination, and actively prevent and treat tuberculosis, lymph node tuberculosis and intestinal tuberculosis, etc.
Conclusion.
Genital tuberculosis is easily ignored due to its slow course and lack of typical symptoms or asymptomatic. Among the cases that are clinically considered as chronic pelvic inflammatory disease, menstrual disorders or infertility, many of them are found to be genital tuberculosis, so they should be taken seriously. Therefore, the possibility of genital tuberculosis should be considered when the patient has primary infertility, menstrual disorders, especially scanty menstruation or amenorrhea, low fever and night sweats, and chronic pelvic inflammatory disease that has not been cured for a long time. The most important examination methods are iodine oil imaging of the uterine tubes, endometrial biopsy (including endometrial scraping or hysteroscopy), culture of tuberculosis bacteria in menstrual blood and endometrium, laparoscopy or dissection, and T-cell testing for tuberculosis infection. Clinically, since endometrial specimens are easier to obtain and less invasive, pathological examination of the endometrium and iodine oil imaging of the uterine tubes are often helpful in determining the diagnosis of tuberculosis. A definite diagnosis or high suspicion should be treated immediately with regular anti-TB drugs. A period of time must elapse after the regular course of anti-TB treatment before looking at the possibility of artificially assisted pregnancy, such as IVF. If only the fallopian tubes are incompetent and the endometrium is basically normal, IVF may be successful; if the endometrium is so severely damaged that pregnancy is not possible even with IVF, it should not be forced.