Discussion
Fifty to sixty percent of FGTB patients will have endometrial
tuberculosis. Hematogenous, lymphatic, or contagious transmission is the
norm. Ulceration caused by tuberculosis may damage the uterine cavity’s
structure, especially in the disease’s latter stages. (13) Epithelioid
cell granuloma predominates as the primary histological finding in
tuberculous endometritis. The granuloma may have a localized, limited
size and prominence in the middle of the body. (13) Proliferative solid
epithelioid granulomas, giant or beaded cells, dense polymorphonuclear
cells, lymphocytic infiltrations, accumulation of plasma cell, and
enlarged lymphoid cells are all histopathological findings indicative of
chronic inflammation or lesions that are suggestive of tuberculosis.
Goel et al. found that none of the currently available tests for genital
tuberculosis could detect all cases, despite their use of a wide variety
of diagnostic methods (including HPE, AFB smears, Lowenstein-Jensen (LJ)
culture, BACTEC culture, and CBNAAT/ Xpert MTB/RIF assay) in diagnosing
endometrial tuberculosis in infertile women. (14) Automatically
detecting M. tuberculosis DNA in an endometrial sample and reporting
rifampicin resistance is the goal of the gene-Xpert MTB/RIF, a nucleic
acid amplification (NAA) test. (15) This test had 33-50 percent
sensitivity and 100 percent specificity for diagnosing FGTB (16).
Although there are no gold standard diagnostic methods for FGTB
detection, traditional histopathology evidence, AFB on the microscope,
and positive culture of M. tuberculosis are considered proven diagnostic
methods for FGTB. (17) Molecular techniques, including PCR, LAMP, Xpert
MTB/RIF, and line probe assays, have shown promise and are now being
researched to enhance the diagnostic algorithm of FGTB; however, culture
and HPE remain crucial contributors. (18) An evaluation of the Composite
Reference Standard (CRS) for the diagnosis of FGTB that includes various
clinicopathological findings have also been proposed by Sharma et al.
(19) to make a diagnosis of FGTB more secure way.
On hysteroscopy, the most significant findings were periosteal fibrosis,
pale endometrium, and micro-polyp, which are seen in over 30% of
patients with positive evidence on histopathology. This is in contrast
to most studies where major findings were intrauterine adhesions,
shrunken cavities, and normal uterine cavities. (20–23). The most
common site of tubercular Infection is in the fallopian tube; hence,
foci of Infection remain in ostia more commonly than the endometrium,
which every month shades during menstruation. This corresponds to our
most common finding, periosteal fibrosis. In the event of endometrial
destruction, the uterine cavity will fill up with formations that have
the appearance of cotton and spread throughout the whole endometrial
surface, leading to the development of pale endometrium. A prospective
observational study by Sharma et al. that looked at hysteroscopic
findings in patients with FGTB found that 54.31 % of women had a pale
endometrial cavity. (22) Another common finding in our study of women
with proven endometrial tuberculosis is the presence of endometrial
micro polyps, defined as polyps measuring less than 1 mm in size. In our
experience, they are linked to stromal edema, endometrial thickness, and
periglandular hyperemia, all of which point to the presence of chronic
endometritis. (24) Intrauterine adhesions (Figure 2) are a dreadful
finding of tuberculosis as they often have poor fertility outcomes.
(25,26) Infection of the endometrium occurs on many levels, including
the basalis layer, which is destroyed by endometrial ulceration. As a
result, the endometrium loses its regeneration capacity, and
intrauterine adhesions form over time as the lesion heals with fibrosis.
Intrauterine adhesions are present in 1 in 4 patients (25.24%) with
proven endometrial tuberculosis, according to our study. According to
the European Society for Hysteroscopy (ESH) classification of
intrauterine adhesions type IIa (16/88, 18.18%) and type IV(16/88,
18.18%) was most common followed by type III(14/88,15.90%) and this
findings are more or less similar to previous published
literature.(20,21) We are aware that tubercle and caseation are two
important diagnostic findings in tuberculosis(27) but are not usually
encountered, and this is also true for patients with histopathological
proven endometrial tuberculosis. In all the patients with caseation,
caseous material was seen coming out through ostia. After prolonged
Infection, considerable fibrosis arises in the uterus as a sequela leads
to a shrunken uterine cavity that is difficult to distort with fluid
media during hysteroscopy. In rare instances there may be formation of
dystrophic calcification. (Figure 10) According to a study conducted by
Song et al., the presence of endometrial hyperemia, micro-polyps,
adhesions, periosteal fibrosis, or endometrial interstitial edema during
a hysteroscopic examination should raise suspicion for the presence of
chronic endometritis; however, the overall accuracy of a hysteroscopic
examination concerning the diagnosis of is only 67%. (28) An
endometrial biopsy should be performed on women when a diagnosis of
chronic endometritis or TB is suspected. Initiating anti-tubercular
treatment (ATT) early improved the menstrual cycle and endometrial
thickness and decreased the incidence of grade I adhesions;
nevertheless, the prognosis is frequently poor for women with advanced
endometrial involvement. (29)
The fallopian tubes are often impacted on both sides when genital
tuberculosis is present. Salpingitis tuberculosis may affect the tubes
in several different ways, such as endo salpingitis, exosalpingitis,
interstitial salpingitis, or Salpingitis isthmic nodosa(SIN).
Endosalpingitis caused by tuberculosis often spreads throughout the body
through the hematogenous pathway and may also spread via other routes.
The fallopian tube has become more extensive, thicker, and twisted. (30)
Caseation in the tubal wall and collecting of chees like material in the
lumen with blockage of both ends of fallopian tubes owing to fibrosis
may cause pyosalpinx to develop unilaterally or bilaterally. A woman can
be at increased risk for ectopic pregnancy and infertility if her
endosalpinges are hyperplastic, edematous, or wholly destroyed, or if
there is a fusion of papillae in the endo salpinx. (30,31) In
tuberculous exosalpingitis, the disease spreads from the intestines or
peritoneum and begins in the muscularis mucosa layer of the tube. The
fallopian tubes, ovaries, and peritoneum of the Douglas pouch are
initially hyperemic, with weak adhesions and miliary tubercles on their
surface. (Figure 5) Beaded tubes, characterized by calcification and
tubal blockage, tubo-ovarian masses because of peri oophoritis,
hydrosalpinx, pyosalpinx, or extensive adhesion development, occur
later. (6,30) In our study, most of the patients (96.11%) with proven
endometrial tuberculosis had abdominal-pelvic adhesions ranging from
mild scattered adhesions to severe adhesions that can give rise to a
frozen pelvis. Fitz-Hugh-Curtis syndrome or perihepatitis (Figure 4),
i.e., inflammation of the liver capsule, without the involvement of the
liver parenchyma resulting in adhesion formation, is a chronic
manifestation of pelvic inflammatory disease (PID)(32) and often seen in
patients with tuberculosis. Miliary tubercle, encysted fluid collection,
caseous material, and isthmo-ampulary junction block are considered a
major endoscopic findings to establish the diagnosis of FGTB, but they
are not easy to find. (27,33) In the present study, the tubercle (Figure
6) was seen almost half of the cases of biopsy-proven endometrial
tuberculosis, and around one-third of patients had the isthmo-ampulary
block, encysted fluid collection, and caseous material. Nodular growth
in the isthmic section of the fallopian tube is called salpingitis
isthmic nodosa (SIN) (34), which is often endoscopically seen as an
isthmo-ampullary block or nodule. It is common in underdeveloped
countries and is caused by TB, which invades the isthmic region of the
fallopian tube directly between the lumen and the serosa, affecting the
muscularis layer. Hydrosalpinx was present in 31.39% of patients in our
study, and after anti-tubercular therapy, if hydrosalpinx is present
often managed by salpingectomy or delinking. A comparative study of
laparoscopic findings before and after anti-tubercular therapy (ATT)
showed that ATT improves most laparoscopic findings like pyosalpinx,
beaded tube, and non-visualization of tubes, but no improvement on
advanced lesions like agglutinated or destructed fimbria. (35) Ovarian
tuberculosis may manifest as a variety of findings,
including tubo-ovarian cyst or mass (TO mass) (Figure 8), adhesions, and
caseation formation(Figure 7). TO mass of various sizes (from 2.7 cm to
13.4 cm; mean size 4.67cm) was seen in 31.07% of patients with proven
endometrial tuberculosis. We prefer not to do any intervention for TO
mass and only give ATT; unless the TO mass is associated with pain,
fever, or any obstructive symptoms. It is widely considered that
tuberculosis decreases ovarian blood flow, and involvement of the cortex
decreases ovarian reserve. A study was done to know the effect of
anti-tubercular therapy (ATT) on ovarian function, such as ovarian
reserve, ovarian dimensions, and ovarian stromal blood flow showed that
a significant increase in AMH (2.68 ± 0.97 ng/ml to 2.8 ± 1.03 ng/ml)
pre- to post-ATT, nonsignificant increase in FSH (7.16 ± 2.34 mIU/ml to
7.26 ± 2.33 mIU/ml) post-ATT, significant increase in mean AFC (7.40 ±
2.12-8.14 ± 2.17), PSV in the right ovary (6.015-6.11 cm/s) and left
ovary (6.05-6.08 cm/s). (36) In women with genital TB, ATT enhances
ovarian function (AMH and AFC) and ovarian blood flow. (36,37)
Endo-ovarian tissue biopsy can also be used to diagnose FGTB. A study
showed that MTB DNA was observed in 49.5% of endometrial biopsies and
33.17% of ovarian tissue biopsies on the same sample. (13) In rare
instances, the disease may completely destroy the ovary and tubes.
(Figure 10)