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The tuberculosis fertility issue you rarely hear about

When you hear the word tuberculosis (TB) what do you think of? Pale and frail 19th century poets coughing languidly into their handkerchiefs? Little Nell lying in her sentimental Dickensian deathbed?

TB causes the most deaths of any infectious disease

Most people would probably consider it far removed from modern life thanks to antibiotics. The truth is that, worldwide, TB causes the most deaths of any infectious disease1. About 10% of latent infections progress to active disease which, if left untreated, kills about half of those affected. And there are a LOT of infections!

TB is spread through the air when people who have active TB in their lungs cough, spit, speak, or sneeze. This allows the mycobacterium, which causes it to proliferate.

95% of TB deaths were in the developing world

In 2017, there were more than 10 million cases of active TB, which resulted in 1.6 million deaths. 95% of these were in the developing world.

So, it is very much a modern disease and it would be foolish to relegate to the past. In 15-20% of active cases, the infection spreads outside the lungs, causing other kinds of TB. These are collectively denoted as “extrapulmonary tuberculosis”, and one of them, urogenital tuberculosis often results in infertility.

Urogenital TB

One of the main problems with urogenital TB is that it passes under the radar. The reason for this is threefold:

  • Non-specific symptoms similar to common cystitis
  • Lack of physician awareness
  • Variable clinical manifestations

The problem is that a delay in diagnosis can result in disease progression, irreversible tissue and organ damage. This is when it becomes a threat to fertility. The infection can attack the ovaries, uterus and tubes leading to infertility problems among women.

The disease can also cause problems in men too. Men suffering with urogenital TB experience epididymo-orchitis, blocking the ureteral passage and preventing ejaculation during intercourse because the tract is blocked.

Diagnosis

Where urogenital TB is suspected, specific diagnosis is made by identification of Mycobacterium tuberculosis (Mtb). This can be through clinical samples examined under a microscope, cultured or through Mtb DNA.

The idea that antibiotics can quickly deal with this problem is also misplaced.

Firstly, Mtb is a tough customer, it is encapsulated in a polysaccharide outer membrane. This protects for against antibodies like macrophages, which find it difficult to engulf Mtb.

Secondly, some strains have developed powerful resistance against conventional antibiotics.

Treatment

A two-prong approach is suggested in terms of antibiotic treatment of urogenital TB2:

  • Treatment of drug-sensitive TB requires 6–9 months of the WHO-recommended standard treatment regimen. Longer therapy is needed for severe disease or in patients in whom immunosuppression is an underlying risk factor
  • Multi drug-resistant TB requires between 12 and 24 months of therapy with toxic drugs and careful monitoring.

As well as drug treatment, surgical intervention may also be called for in unblocking scarred fallopian tubes.

The main challenges for dealing with the problem of urogenital TB are:

  • The need to make an early diagnosis
  • Raising clinical awareness
  • Developing rapid diagnostic tests
  • Improving treatment outcomes in terms of available antibiotics and their application

IVF can still be a successful choice in overcoming infertility due to this condition. Especially for patients who have undergone drug therapy, and for whom fallopian tube repair has not been successful.

References and further reading

  1. The top 10 causes of death. WHO (2019)
  2. Guidelines for the treatment of drug-susceptible tuberculosis and patient care. 2017 update. WHO ( 2017)