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)