00 : 00 / 05: 00 (Preview)

This discussion has ended. Watch the recording on Medflix app,

Female Genital TB & its Impact on Fertility

Oct 12 | 2:00 PM

According to the Indian Council of Medical Research, the prevalence of Female Genital Tuberculosis (FGTB) has risen from 19 percent in 2011 to 30 percent recently. Infertility, dyspareunia, menstrual irregularities, PID, and other dysfunctions can all be caused by FGTB, but infertility is the most common. Lets learn about FGTB diagnosis, treatment, and fertility outcomes from none other than stalwart of gynecology, Dr. Rishma Pai.

[Music] so i welcome you all thank you very much ma'am for joining us for this wonderful netflix session on particularly genital tuberc losses in impact on an infertility we have with us dr rishma dillon pai who doesn't know her she's a well-known obstetrician gynecologist who has worked for more than almost 29 years in this field and she's an honorary consultant at the lillavati just look in hinduja hospital she is a holy indian who has served as a president of all the three major gynecologists in society that is foxy and iaga she has received numerous national and international awards in the field of obstetric and gynecology as well as as being a legend in the women empowerment field she has also been awarded in that field also she has organized 38 conferences in the capacity of organizing chairperson secretary and has presented more than 70 oration that's huge in addition to being a guest speaker in many national and international conferences she has authored chapters in 30 63 books and 42 articles in a prestigious publications she is also a dedicated educator who has taught many dnb residents in the past few years so uh the topic for today's discussion is like genital tuberculosis and how the impact is there on infertility as we know our india is a typical tuberculosis pandemic in the country so we have faced many times genital tuberculosis patients the most important they are majority time asymptomatic and cannot be diagnosed they are diagnosed when they get a treatment for infertility so i think this is a perfect topic ma'am for us and we are ready to now hear from you the state is yours ma'am thank you thank you so much for the warm words uh look forward to interacting with all of you uh even though it's on a digital platform so let's go ahead and have a sort of a discussion at the end of this presentation so today we're going to be talking about improving fertility outcomes in female genital tuberculosis all of you know that there are some problems which are so complex that you have to be highly intelligent and well informed just to be undecided about them and one such problem really is that of genital tuberculosis we know that the incidence of genetic tuberculosis is very varied depending on which part of the world you come from if you are in usa it may be as low as one percent maybe as high as 16 to 19 if you are in nigeria or in india and of course when you look at the subgroup of patients who are looking uh who are coming to you for treatment of infertility the incidence is very high so essentially 24 percent uh uh the overall incidence and nearly 50 percent of patients who present with tubal factor infertility in your particular infertility center may have tuberculosis so tubal factor one of the commonest causes is uh tuberculosis now we know and a very rough review quick review back to the college days the female genetic tuberculosis is caused by mycobacterium tuberculosis rarely it could be other forms such as atypical mycobacterium it is usually secondary to lung tuberculosis or other organs with infection that spreads through either the hematogenous or the lymphatic root or rarely direct spread from abdominal tuberculosis as well so in most of the cases of human genital tuberculosis uh fallopian tubes are affected 90 of women tubes are affected whereas a uterine endometrium is affected in 70 and ovaries in much lesser like 25 of people will have an ovarian affection so coming to the investigations and you can see this long list of investigations and i have focused a fairly large part of my talk on investigations because this is the most difficult part to even diagnose uh or conclude that this particular patient has genital tuberculosis and so we have a whole lot of tests which really means that there is no perfect test ranging from a simple blood count and esr do the exo chess to the mantu test and many many more and we'll briefly touch upon some of these just to go through and complete the picture so that world health organizations definition of extrapulmonary tuberculosis diagnosis they say should be made on the basis of one culture positive specimen or positive histology or a strong clinical evidence which is consistent with active extrapulmonary tuberculosis so one of these criteria has to be met to conclusively diagnose tuberculosis and of course uh like i said you can do uh you know cbc esr test and x-ray chest and we often end up doing the tuberculin skin test or the mantra test that it's called but all of us know that that has very limited utility because especially in countries like ours where bcg vaccination is fairly common you get a lot of false positives because of a non-tb mycobacterial previous vaccination with pcg or you may get false negative reactions particularly if the patient is on steroids or having some coexisting hiv or chronic renal failure and such other problems so not very reliable the tuberculin test and that's why we have to look for better tests now what about a hysterosalpinography today there is this one test age old test which still has a role to play because you know that the hsg has a very classic pattern in patients with tuberculosis you can see a typical tuber dilatation occlusion irregular contour you see diverticular out pouching what we call the salpingitis is semiconductor and you may have a typical hydro salping with a cotton wool plug or you know pipe stem tube which they call so very many different names to describe the pattern where the tube may be patent it may be interrupted patent and at the end you will see some kind of a minimal spillage giving it like a a beaded tube or a cobblestone tube kind of an appearance uh not only that even in the uh you know when you see the uterus there will be a lot of changes in the uterus you may have a cholesterol abscess a t-shaped uterus becomes so narrow because of adhesions or you may have a uh you know like a pseudo unicorn uterus because half the uterus has gotten blocked off with adhesions so uh complete narrowing of the uterus what we call the netter syndrome is very characteristic of genital tuberculosis cervical tuberculosis fortunately is quite rare and you will see like a narrow cervix and you know a feathery kind of an appearance but it is not very often that we see that again sonography only when there is a significant affection of the genetic tract with sonography pick up tuberculosis so in in classic cases you will see the tubes looking thick and dilated and you may see them you know like there's a pious helping something like that could be picked up on sonography and the endometrium will look heterogeneous there may be areas of calcification fibrosis adhesions sometimes are seen on the sonography so when you see very specific uh picture on the ultrasound for example ah an alignment myo material cysts if you see if you see follicles with echogenic rims and you see presence of endometrial fluid this is quite characteristic of tuberculosis hydro salping is present so this then will give you an idea that this is tuberculosis and rarely you may have to do cta mri particularly if they're large tube ovarian muscles there laparoscopy all of us know give us wonderful information the moment we put in a laparoscope and we see the characteristic pictures of either tubercles museum real block embryo thymosis tubal hydrosalpings rigid tubes adhesions everywhere you will start thinking of tuberculosis and if you combine it obviously with a hysteroscopy you would also see the intrauterine narrowing thin uh pale endometrium and the presence of adhesions maybe and i have a film which i'll show you at the end of a very typical laparoscopic hydroscopic so laparoscopically you will see inflamed or even blue colored uterus you will see salpingitis tube ovarian masses you can see sometimes dyes coming out from the tube it's just like dripping out a bit by bit uh you can see adhesions you can see this casiation in the pouch of douglas or you may have even a frozen pelvis and like i said on hysteroscopy synechia is typical thin pale endometrium is typical so classic picture of laparoscopy and hysteroscopy the histopathological examination is extremely important and you can see the typical features of tuberculosis infection granulomatous acious lesions which are showing giant epithelial cells which is suggestive of tuberculosis so remember you have to collect these specimens if you're collecting endometrial sample try to collect it uh just pre-menstrual because that's when you'll get the best amount of material and you try to collect samples from multiple sites because then you get adequate quantity which will give you the uh enough material for histopathological diagnosis the bacteriological evaluation even today years later remains an important test you could do an acid fast bacilli staining and culture and you can really see classic microscopy and culture using either the zeal nielsen staining or you can you know fluorescent methods are used but remember that for zeal needs and staining the sample should contain a large quantity of vessel at 10 to the power of 6 vaseline and the culture for mycobacterium is a little more sensitive so you require 10 to 100 vaseline per ml so very small quantity will not be picked up by these methods remember menstrual blood again for culturing and all that is very very low sensitivity so you don't get a positive report very often you have to have a good quantity of the bacteria to be able to diagnose by these methods so our whs also said that you need a positive culture to label the patient as tuberculosis and so you can do solid cultures which is the on the lj medium we've studied that in college many many years ago and of course the liquid culture and nowadays very often we perform liquid culture which is performed on the uh automated bacter bacteric mycobacterial growth indicator tube and this is a extremely good test the advantages are that you have very good sensitivity specificity you can pick up the mycobacterium you can even do the you know sort of a drug test drug susceptibility test on it the disadvantage however all of us have experience takes a long time to get the report minimum nine to ten days for positive results and up to six weeks you have to wait before you consider that report as negative so long time to get the uh liquid culture reports which is why to overcome this time uh which is which is taking to get the tests uh reports molecular methods have come in so they are becoming easily now available the nucleic acid amplification test the nat test what they call they give you the results in just a few hours uh similarly pcr very rapid molecular method for identifying these nucleic acid sequences which are typical to mycobacterium tuberculosis and these pcr tests can diagnose very minimum less than 10 bacilli per ml but they also pick up the dead bacilli and that is the problem with these pcr tests that they have a very high false positive rate and therefore you cannot base your diagnosis only on this pcr test because you may get too much diagnosis of tuberculosis even when the patient doesn't have an active form of the disease the serology really has not much of a role to play in fact who has said not to use serology to diagnose these tests uh to diagnose this particular condition but we all know that there is no good test so more and more research is going on on finding an ideal test for diagnosis recently the gene expert test has come it which is being endorsed by the who and it's a fairly it's a very good test gives you the result in just maybe less than two hours and it may be one of the future tests but you know none of these tests are perfect so just a little bit about the gene expert we know that how how this is done like for example for pulmonary tuberculosis this putin sample is collected mixed with the reagent and the cartridge is put into this automated gene expert machine so it's all fully automated and just in two hours you get the results out it's basically a pcr uh technique there is also now the interferon gamma release assay these tests are also available and uh the thing with them is that they do not help to differentiate active from latent tuberculosis you cannot differentiate between the two so two of the popular uh interferon gamma release acids which have come in are the uh pontiferon db cold test which is gaining quite a lot of popularity and the t spot test so these tests basically measure a person's immune response to the mycobacterium tuberculosis so the immune response is picked up it is actually uh the fresh blood samples are mixed with antigens and controls and this is how the test actually works so the new tests really are the gene expert and the interferon gamma release assays and um that all of these tests many many of these tests sometimes are required to be able to actually diagnose a patient with tuberculosis so finally when you come to a conclusion that this patient is suffering from tuberculosis what is the way forward the treatment obviously first line of therapy is medical treatment and nowadays the treatment is very very standardized the who guidelines are there most people follow the directly observed treatment short course that is the dots treatment so you can directly observe the patient for compliance because it's a long therapy difficult therapy and patients are not often compliant of course you can also do the uh non-directly observed therapy so most of the female genetic tuberculosis patients fall into the first category category one where you typically give them two uh two months of four drugs iron age rifampicine ethanbitol and paracenamide so four of these drugs are given for two months either daily or three times a week under dots and then this is followed up with two drug regime for four months so inhc and republican are then continued for four months if the patient is in category two which means she has either failed treatment or has relapsed again or it's not responding to your first treatment then you may want to add streptomycin so you'll get two months of five drugs including streptomycin then you'll give one month or four drugs as mentioned earlier and then you'll give five months of two drugs so it's a long therapy and then you'll eventually even see patients who are multiple drug resistant patients and then you have to have a different line of drugs all together for that group of patients so fairly standardized therapy but for the difficult cases i guess we have to refer them to physicians we can't really manage drug resistant tuberculosis surgical treatment is usually avoided in genetic tuberculosis because the medical therapy is very very effective however they can be limited surgery required for example if you're taking up a patient for tuberculosis and she has big hydrocyclines then you may want to do a self-injectomy you want to block or you may want to like block the tubes you may want to clip them or you may want to uh you know remove a teomas or do the diesel lysis so few situations only will you go in for surgical intervention but remember that there are a lot of complications which you can anticipate if you do surgery on a patient with tuberculosis there can be a flaring up of the disease if it's actually not fully treated you can definitely have intestinal injuries etc because of the massive adhesions and really a sort of a word of caution here the tuberoplasty on these patients really does not give good outcome because the entire tube is often affected and even if you manage to have open tubes at the end of your procedure there's a very high incidence of ectopic pregnancy so it's not really recommended to do that so uh the controversy really is in the treatment of latent tuberculosis so if your tuberculosis is only picked up because of a pcr test and there's no other evidence should you treat this to the closest and that is a major question now the one positive feature in treating it is that you will probably stop the disease in the early phase you will prevent progress and possibly get better results because you have got it at a very very early stage however overall recommendations say that if you treat women with a positive pcr only then there is a huge risk of over treatment of these women and therefore it is not recommended just to go by that one test in fact a very good study was done at all india institute a few years ago in delhi where they took 100 patients who were positive on the pcr test on endometrial aspirate so the endometrial aspirate dna pcr test was done and these 100 patients who were positive on this test were divided into 50 which were treated with antituberous therapy and 50 which were not treated and they were observed over a period of time and it was found that the fertility outcomes were same whether they were treated or not treated and even after treatment when they were tested again after a year the same incidence of positivity came up again which means that treating people on only a dna pcr test had no value in terms of improvement in fertility outcomes or making their test negative so uh it is to be avoided now like i said there are so many challenges in tuberculosis patients starting from the diagnosis which we just saw going on to their treatment even if they come for ivf there are huge challenges and basically we know that uh though ivf is often the only treatment if they come with block tubes etc it may be the only treatment available to them yet the results are extremely poor so in ivf also there are huge problems basically because either there is very bad endometrial blood flow endometrium itself is damaged or because the ovarian resolve is low because of some effect of the ovarian reserve by the uh damage to the ovaries with tuberculosis so uh even though you do ivf on these patients the results may be quite work so let's focus a little bit on the ovarian reserve and this um nice study in human reproduction and most of the studies on tuberculosis you notice are from india that if you actually uh you know does latent tuberculosis actually affect ovarian reserve because the question being asked here and it was found that uh you know patients who had uh tuberculosis even if they had mild latent tuberculosis their ovarian reserve the amh test the android follicle count was low and following treatment uh the there was actually an improvement so latent tuberculosis may not really affect your ivf outcomes or the ovarian reserve outcomes but treatment of this definitely helps and this particular study by uh dr sharma really proved that 50 women with genital tuberculosis treated with uh antituberculosis therapy it was found that the anti-malarian hormone levels improve the enteral follicle count improves and all the uh doppler indices actually improved so the pulsatility index the resistant indexes the big systolic velocity all the blood flows going to the ovary actually improved uh with away with the antitubiculus therapy so if you can actually sort of be fairly sure that the patient is having tuberculosis then early therapy will help improve ovarian reserve similarly the endometrium extremely important we all know endometrial thickness is so important because patients who have a good endometrium seven millimeters or more who have a triple line pattern who have good blood flow to the endometrium are the patients who will really become pregnant following treatment and in tuberculosis unfortunately the endometrium is often affected it's pretty thin and avascular and unresponsive so uh that is where the major issues come in and which is why ivf in these patients which in active tuberculosis really gives poor results because often these patients are either poor responders they require a very high dose of connector pins because they just don't respond and of course the endometrial receptivity is poor it may be thin there may be adhesions inside and the egg and embryo quality is fairly low so though ivf is so to say the best treatment for these patients success rates are on an average just uh as low as 17 percent a conception rate so very very poor rate but still it is much better than trying to do a surgery for these patients which gives really dismal success rate so of course we follow the history guidelines when we are doing ivf on these patients for poor responders so you can use either gnrh agonist or antagonist you can use clomiphene along with gonadotropins in these patients there's no logic in increasing your gonadotropins below beyond 300 iu because just giving very very heavy rules to correspondence doesn't make much sense and of course you can do a natural cycle or modified natural cycle that gives you pretty poor results so treat them like poorer sponder patients and eventually your success rates will be anything between as low as nine to ten percent to some of the units giving a better success rate 25 35 38 as well so we looked at the study which actually a little old study 10 years ago which gave good results with ivf and said why are their success rates better and it was found that they tried to pick up the uh cases very very early and treated them with anti-tuberculosis therapy sometimes for long periods of time till they actually became negative up to 6 to 18 months and this is really not recommended now because we've shown you studies saying that you know the pcr may come positive despite treatment so because this is an old study this is what they did and every patient who had a bad endometrium which could not be treated as transphobic yeah these rises could not be done were taken in for surrogacy and that's how the overall success rate was a little higher but typically you can expect 17 20 success rate with ivf in these badly affected patients with tuberculosis so uh not only uh generalized results even depending on which part of the genetic tract is affected your outcomes differ if the endometrium is affected with tuberculosis the outcomes will be really very pathetic because implantation will be very low and success rate will be very low whereas if it's a tubal factor only the tube is damaged but the endometrium is quite good your results with ivf will be very good so you can't give a generalized success rate you have to say is it tuber uh tuberculosis affecting the tubes or is it affecting the endometrium and then you have to take a call as to what your approximate prognosis may be so really when the world says give up in these very difficult patients hope whispers try it one more time and that's what we have to give our patients hope because otherwise it's a very very dismal situation so fortunately we have now new things in our armamentarium to improve success rate in patients so how do you manage in today's times patients who are poor responders who have a poor ovarian results and there are certain strategies which you can easily employ in which we are already doing in our practice one such strategy is the use of uh activated autologous platelet-rich plasma injection into the ovary so uh the prp is directly isolated from the patient freshly made and this is activated with calcium gluconate and 5 ml of this is actually injected into each ovary either under transvaginal sonography guidance or laparoscopically and literally in a period of two months it has been shown that there is an improvement in the antimalarial hormone the number of eggs you can see are more and there is ability of you know getting at least one blastocyst in patients in whom not a single egg was being found earlier so this was one of the early studies and now many people are actually using intraovarian prp another thing you can do is the autologous stem cell ovarian transplant what we call ascot autologous stem cell ovarian transplant so similarly this is ovarian infusion of bone marrow derived stem cells again this is shown to give a significant improvement in ovarian function in patients with very very poor ovarian reserve and patients who are not becoming pregnant at all prior to treatment could become pregnant and have either natural conception or ivf conception in some of these studies in vitro activation is something which we actually tried to um in fact dr rishikesh had actually gone to the us and trained in this but a fairly difficult technique a little more complicated and having intervention and in this but you know the study was so impressive that this study was done in patients who were totally menopausal amenorrhea for four months uh they had fsh which was more than 35 so they were literally in menopause and in these patients laparoscopically uh part of the ovary was removed it was cut into strips and it was frozen whenever it needed to be utilized the ovarian tissue was thought cut into pieces so as to activate the uh you know hippo uh signaling pathway it was put into akt you know which is actually a stimulating uh system and it was washed and laparoscopically again re-inserted underneath the fallopian tubes so little bit of a tedious process but the amazing part was that you could actually see eggs growing uh after this treatment so the ovaries were activated in withdrawal and patients became pregnant three pregnancies were detected in this initial study in patients who were totally menopausal so of course there's lots that is going to be coming up these are some of the recent headlines in newspapers you must have seen them scientists grow human ex to full maturity in a lab and this was recently said that for the maximum period of time from absolutely immature to full majority eggs have been grown in the lab this was recently reported in the media and at the last estuary conference i was there in 2018 this is one of the landmark papers uh that they actually created an artificial ovary so in patients such as those with cancer or those with tuberculosis where the entire ovaries damage you can actually retrieve the eggs and create an artificial ovary with like a mesh material implant the eggs in that and the patient can actually have her eggs growing in an artificial ovary so this is something which they say in five to ten years you may have this as a reality this was far as the ovarian reserve and you know activation was concerned what about endometrium like i said all of us know that the endometrium uh you know needs to be reasonable size good vascularity good pattern and patients with very thin endometrium everything has been tried people try giving estrogen arginine aspirin sildenafil all kinds of things have been tried and sometimes we get literally no benefits in patients who have a thin endometrium especially in patients where the endometrium is damaged by tuberculosis so one of the things which was very uh sounded very hopeful and in fact we've been using it now for quite a few years and that is the role of granulocyte colony stimulating factor for endometrial receptivity improvement this particular study or 2018 of 10 randomized control trials put together a large number of cycles and they found that there was significant improvement in pregnancy rate implantation rate in patients who had gcsf infused into the uterine cavity compared to those who did not so it has definitely a beneficial effect either by local infusion or you can give it subcutaneously and it has some kind of a benefit particularly on the immunological status and the receptivity another thing which can be used similarly is again platelet-rich plasma and this is something again we are using in patients with thin endometrium non-receptor endometrium uh intrauterine infusion of autologous platelet-rich plasma two to three times uh from the menstrual cycle day ten of their fet cycle so when you are doing fpt or in any other patient uh you know if you find that the endometrium is not growing you can do the infusion of the prp and it definitely improve the pregnancy rate and live birth rate so it improves all parameters the intrauterine infusion of prp a combination of the two has also been tried and this study very interesting study uh in 2019 it's a reasonably recent study called the primer whereby they used both combination they used prp uh 0.7 ml of it was given through intrauterine injection 48 hours before the embryo transfer and gcse 300 microgram of 0.5 ml was given subcutaneously uh you know along with the prp and was administered subcutaneously every week and the combination really significantly improved the implantation and pregnancy rates in patients with recurrent implantation failure so primer is another option that we can use here again stem cells are showing uh that they may have a role to play so some endometrial endometrial uh mesenchymal stem cell inoculation produces a significant increase in individual thickness it normalizes the histopathology immunohistochemistry and the endometrial flow cytometry so many parameters improved with the sub endometrial inoculation of the stem cells as well of course this is our final backup plan if all these new techniques everything fails then what do you do you have no option but to resort to surrogacy so as long as cerebral palsy is available in india we we can definitely go ahead and use it and it is typically meant for patients without the severe intrauterine adhesion absolute atrophy of the basal layer the endometrium refuses to uh become more than 70 millimeters in thickness dense pelvic adhesions repeated ivf failures multi drug resistant tuberculosis you will have to think of cerebral seed and obviously with surrogacy there is an excellent pregnancy rate viable delivery rate of more than 50 and never forget adoption as an option if the patient has badly damaged tube and uterus and ovaries may be then nothing is going to work and then in these patients adoption really becomes the only option remember we are talking of female genetic tuberculosis but don't forget and just a touch on the uh problem of the male factor because we've also seen men getting affected by genetic tuberculosis and the characteristic picture that you find in the when is that of ejaculatory fat obstruction that's the kind of picture that you find in these patients so there you'll see a gradually declining volume of ejaculate there will be asospermia progressing to acepermia and that is very characteristic of this tubercular affection of the male counterpart and typical like i said ejaculatory duct obstruction you'll see the non-distended atrophic seminal vesicles this is diagnostic of tuberculosis and they'll be multifocal of obstructions so really you can't do surgery on these people they will benefit only by uh doing a testicular sperm extraction and then doing a xc or mc with these patients so the epidemic is usually involved by the inflammatory process and that's why you have to do a testicular extraction in these patients most commonly remember even when you do ivf in these patients it is not free of problems they have been rare cases where patients have landed up with military tuberculosis because they are still active to the closest when you do the ivf on them and it becomes aggravated and goes on to military tuberculosis there have been reported cases of abscess in the ovary because of aspiration of insights and this is a very long study of many many years even today few cases of congenital tuberculosis are being reported in the babies and these babies are very seriously affected born premature many of them die the newborns actually uh you know lose their lives because of not picking up the diagnosis or not treating them immediately so keep a watch out for these complications though rare it can be there remember that when faced with a challenge always look for a way not for a way out and what are the future that we are looking at in these patients so it's really called halt tuberculosis you hear you act you learn you treat tuberculosis that's what we are looking to do so one of the greatest challenges and we've discussed this today how difficult it is to diagnose latent tuberculosis or whether we should treat platinum tuberculosis or not how to make the patients really comply with the medication which is so difficult and so diagnosing and treating latent tuberculosis has been recognized by the who as an important strategy to accelerate the decline in global tuberculosis and achieve tuberculosis elimination and they're looking to newer tests maybe interferon gamma release assays which will help us diagnose it early they're looking at rifampicin based treatments which are more patient friendly in order to uh uh you know patients should be compliant with her treatment and if we can really use many strategies to pick up tuberculosis very early and treat it only then can we prevent the massive damage which this disease causes the very interesting paper came out in 2019 about the collagen binding basic hyperblast growth factor this particular uh compound was used in burns but there was a lot of scarring they were using this to make that burn skin regenerate and it was found that when this basic fibroblast growth factor 100 microgram was actually administered around scarred endometrium it was you know under ultrasound control every four weeks in 18 patient that was when this trial was done and it was found that the entire endometrium started to regenerate menstrual volume improved the endometrial thickness everything improved the scarring reduced you could actually see more blood vessels growing in that particular area and so it's possible that this may be a good therapeutic approach for very dismal cases completely scarred endometrium how do you regenerate it so even using this basic fibroblast growth factor injection may have a role in the future we know that every conference you go to today there's a lot of focus on the endometrial biome the various bacteria which actually are housed in the endometrial cavity and that will have a huge impact on implantation again a lot of focus on regenerative medicine uh use of stem cells for conditions such as achievement syndrome and of course there are actually studies and a lot of data coming out on a bioengineered artificial uterus and is being used in animals and actually animals have been grown to term in an artificial uterus so probably uh we will have that option in the future what we do have already is uh uterine transplant all of us know that a few years ago the first baby born by uterine transplant was announced in the lancet and that was really an amazing achievement and following that uh two years ago the british journal actually reported 45 detailed cases of uterine transplantation with nine live births and since then we know that even in india we have had a successful uterine transplantation and a baby bond so this is very much a future for patients who've had a completely damaged uterus we've heard of utran transplant not many people have heard of ovarian transplant and you'll be surprised to know that there are excellent results from ovarian transplant as well you can definitely do an auto transplantation where either fresh or cryo preserved ovarian tissue is transplanted in the same person or identical system or else of course you can have an allo transplant where patient receives the ovary from a genetically uh different hla matched donor and uh 70 of patients that underwent ovarian tissue transplant actually started showing restoration of function they started showing follicle growth and pregnancy was reported in 52 of the patients so it's pretty amazing today how uterine transplant ovarian transplant are becoming successful treatments in patients who otherwise had absolutely no hope of conceiving their own child so let me end by saying that if you run into a wall don't turn around and give up figure out how to climb it go through it or work around it so some strategy we have to find to help our patients achieve their goals thank you thank you very much maybe we can now uh have the short movie playing so that we can get a nice visual of the picture of laparoscopy and hysteroscopy in tuberculosis so can we have the movie playing there seems to be an issue let's try for a minute otherwise uh we will sure ma'am can we take some questions meanwhile the movie is going on yeah yeah okay so the first question is how to proceed a patient with complain of hypomenorrhea i think uh many cases of genital tuberculosis have a complaint of less uh menses yes so you know um very often patients get very perturbed uh if they don't have a good menstrual flow because even today in india people believe that menstruation cleanses out system and you know everything will be clean and perfect after menstruation so that's the first thing you have to find out what is the severity of the oligomenorrhea uh some amount i i typically tell them if there's even one day of reasonable bleeding that's more than enough you don't have to have three to five days of heavy blood not required however if there is a significant uh scanty bleeding then of course we have to start investigating and in our country one of the first thoughts will be of tuberculosis are damaging the uterine cavity so um start doing the test we've talked about a few of the tests obviously you can't go through everything but a basic history of tuberculosis in the past i think it's a little difficult to see the video properly but not an issue so we were talking about scanty period and so um you know you do your basic esr you do your basic x-ray and you can do uh ideally speaking uh hysteroscopy uh following the sonography so if your sonography shows that there's a thin endometrium or there may be adhesions you can do a sonosalpingography that will show you presence of adhesions inside or some you know damaged uh intrauterine space and then you can put in a hysteroscope that will be really diagnostic because it will see the typical picture of a pale uh endometrium and you'll see adhesions you could try hysteroscopic it isolyzes at the same sitting and a lot of times if there are a few adhesions you can lyse them you may actually improve menstruation just after that so do a estroscopical visualization put the patient maybe on estrogen for a period of time uh following that and you might see an improvement in the menstrual blood flow other than that you know just giving her estrogens and then giving progesterone and withdrawing and trying to increase the menstrual blood flow really doesn't work so i think this is really pretty much the only solution we can offer them do a good biopsy find out culture uh whether there is tuberculosis it may not even be tubules could be just some kind of a pelvic infection so treat with antibiotics whatever it may be and based on that you can sort of try to solve the problem but it is one of the difficult problems the next question from dr ganshian he's asking please enumerate the percentage of patients seen in your practice with genetic algebra losses and what percentage of success of ivf post recovery from the triple classes yeah so i think we we definitely see quite a few tuberculosis patients because um being very senior in ivf practice now for 25 years uh we get a lot of failure patients from everybody so obviously patients who are very simple unexplained infertility become pregnant easily and then those who don't become pregnant uh are often referred to us so we see quite a lot and you know the success rate really depends it's so individual until i try to explain to you that tubal tuberculosis will get excellent success rate because uh you know there'll be a hydroceles maybe there'll be some adhesions or uh and you can just go in laparoscopically and you can do a salpingectomy prior to the ivf but that will really improve the success rate so you can clip the tube so you can you know just bipolar them and cut them disconnect the tubes and once you've done that if the ovaries are fortunately not often affected into the closest much lesser incidence of ovarian affection so you get aggressive embryos and then you can if you can disconnect the tubes if the uterus is good which is fortunately again many times then you can get an extremely good success rate uh 50 or more almost similar to your normal non-tuberculosis patients uh however if there is endometrial tuberculosis then that's a different story altogether because uh that endometrium is not very receptive so if it's very minimum damage you picked it up very early you've treated the patient you do a hysteroscopy endometrium is quite good they're not many lesions a few adhesions which you can lies and you do a sonography you see the endometrium coming at least seven millimeters good vascularity patient has a very good problem so i think it's all very very individual you know but if on top of it the patient is old she's 40 years old she has a damaged uterus she has bad tubes she has hydrocele things factor so you know obviously the results are going to be low so it all depends really it's very very individual yes uh the next question is ma'am uh what are what are the recommendations for women who are planning to get pregnant after akt she has completed the akt and now what precautions or recommendations so i think it's the important thing is to evaluate obviously at this point after treatment the uterus and the tubes again depending on what a pre tuberculosis treatment situation involved so whether you want to just do an hsg to evaluate the situation or you want to do a hysteroscopy only prior to ivf or a history everything depends on what she came with you initially and once you've done that and things are looking reasonably good i think we can definitely go ahead and expect a fairly good outcome again based on how much damage has uh she suffered from tuberculosis so one secret is over you know there is absolutely and i presented that study only to say to you do not keep on treating the patient till the pcr test is negative because ccr will pick up even dead bacteria you treat her for six months then you do a pcr again is positive again you treat her for six months again it's a never ending story so that is not to be done once you've done your full treatment patient as well uh go ahead and do your treatment yes uh the next question is ma'am what can be the cause of repeated ectopic i think that he's asking in reference to diagnosis yeah definitely especially uh and i did mention that uh if somebody has tried to open a tuberculosis damage too then you actually end up causing more problems because tuberculosis you've seen the typical beaded tube so it's not one block it's not a corner block which you can put in a wire and you can open it is multiple blocks at various levels through the length of the tube uh at the end of the tube as well and so uh even if the tube is patented which it is many times in tuberculosis patients the incidence of a topic is very very high so any patient who has a topic particularly repeated ectopic you should think of disconnecting the tubes or doing a self-injecting and then going ahead with ivf because you know i mean it's a psychological thing for the patient they're not happy to remove the tube though my tube is open while you're removing it you know so that little thing is there so make sure you take a very proper consent and everything otherwise they'll be eating tomorrow for doing a self-injecting when they're tubers so to say patent so um but after a proper counseling and proper consent it may be better for the patient and less incidence of topics my one question from my side like a patient of a repeated pid mam what i have seen that and she had a history of one ectopic and repeated pid had been treated with every uh like dog's recycling uh metroid so every damn antibiotic and still she had complete leukoria every damn time with infertility though her endometrium was perfect her ovulation everything was good she was not getting conceived so just be ahead yeah no my tubes are open and we had just kept her on three months of akd after finishing on akt she get pregnant so you know sometimes empirical akd also works many a time in pid cases what is your ma'am review on this like do you give empirical akt that's because you know in as i said pandemic tb country we used to see many cases which were not not diagnosed in culture or pcr and still we are giving akt so there is also a pandemic of akt in our country yeah ma'am that is one problem right so i think this has to be really a balance because uh and i've seen that in many parts of india every patient of infertility is put on anti-tubular therapy and i think that's really an overkill because uh the treatment is not simple it's a long treatment it's a difficult treatment it has side effects you cannot just you know okay patient of your infertility in india is equal to tuberculosis and yes so i think i think it's a very fine balance for uh for example your patient if you've really treated her for a long time you've seen recurrences you've seen her not improving nothing is working and you have a suspicion at the back of your mind of tuberculosis uh maybe not 100 proven then if you want to treat it uh and see then that is fine but i i absolutely am not in favor of uh because it's sending out a wrong message yes too much over treatment yes yes and in fact i mean i'll tell you personally also we used to like a few years ago we used to do a hysteroscopy for almost all ivf patients and we used to take a tiny endometrial biopsy and do a pcr test for tuberculosis because it's so common in our country and literally majority of the patients used to come positive for tbpcr and you know the histoscope is perfect you do the hysteroscopy it's clean endometrium is nice there are no adhesions and because i sent the pcr and it came positive now i'm stuck the cavity looks good endometrium is good everything is perfect but pcr is positive what do i do now so you know that puts you in a dilemma and then we realize there were too many false positives so we actually stopped doing the test because i mean if you do a test and you have a pcr positive then you're in trouble again because then you have to put the patient for culture the sample for culture and then the culture takes about six weeks at least to come you cannot go in because six weeks for the uh liquid uh culture and uh so you know you are you are actually stuck for a period of time so only if we are suspicious if there's a strong history uh or we put in a hysteroscope and we find the adhesions we find damage endometrium then only now we send acr subculture and only they're not routinely once upon a time you know simple who come with a medication history of incomplete hrz therapy for genital tb and is negative biopsy the only indicator that we should look for before any art akt sorry i think he has written ait but i think akt would be there so for incomplete hrzd therapy how will it proceed and how will we treat for before going for a rt any biopsy negative biopsy is needed yeah because unfortunately that is again something you see often because people don't complete therapy and which is why the you know who and everybody recommends the dots that you have to observe the therapy because people are not compliant and so um even like three times a week therapy is good enough you know it doesn't have to be every single day if it is under observation uh so but if the patient is you know it depends again incomplete means what did she take it for three months four months five months you know what did she do how much was the damage and what is the remaining damage so now you know it it just it's supposed to taken four months of therapy and stop you need not give the whole cycle again if the hysteroscopy is good if ultrasound is good endometrium is good blood flow is okay amh is fine and follicle counts are there so you know then you don't really need to go full on treatment so you have to be careful i think you have to individualize every single case and like i said uh there are also negatives and we spoke about the complications that if you and if you have an untreated patient and you're doing ivf you can have a possibility of aggravating the tuberculosis you may have a ovarian abscess even in some patients you know if it's a ovarian tuberculosis and you missed it and you uh it's aggravated by doing the open pickup that can happen so all these issues are there so i think you need to really individualize the treatment and i think this is last question ma'am mentism hsg as you know it's an age-old treatment or diet the question is ma'am is hsg contraindicated in uh genital tuberculosis and second question is can we go for hsc to look for intrauterine additions uh second question first intrauterine asians i think the best test is dystroscopy so if you have access to astroscopy i would much rather do that than an hsg because not only can you see you can also treat and so immediately nowadays office hysteroscopy is available and many people are doing actual offices you know small small historic scope and no dilatation outpatient you can do and you can even do some degree if it dies like this with an opposite scope or then under anesthesia so uh definitely um i would prefer hysteroscopy as far as active tuberculosis goes i think no intervention is best intervention if you know that the patient has active tuberculosis now if she comes to you with years of infertility and you know uh some various reports from before and you know things like that she has taken history of akt then you can go ahead and do your history so if you suspect active tuberculosis then avoid it but otherwise yes and uh my one last question from my side i think there is no more question over here does genetical tuberculosis effect on spermatogenesis map as you say in a female it reduce ovarian reserve it reduce central count now everything so does it have any effect on spermatogenesis because we know that epididy diamond is happen and it will cause the ejaculatory duct obstruction everything but is there any data which cause there is an effect on spermatogenesis man yeah so the the the um typical feature like what you already mentioned right now is that of a gradual reduction in the quantity of semen as well so not only so it goes from you know like quantity reduces gradually goes on to ace permia completely and uh also isospermia so definitely there is a damage of the testicular tissue as well eventually but more than that it's an ejaculatory duct obstruction so that's why if you can go to the testes and you can get the sperms more often than not you will get them but um unless the test is really damaged which i don't think is that common okay but definitely multiple uh multiple segments get uh obstructed or language it's not just epidemics or not just one area just like the tubes getting affected at various sites so also the male genetic system gets affected at various sites yeah maybe it also cause architects and everything and that will also can hamper the spermatogenesis okay ma'am so i think that's done with the question and answer it was an exhaustive question answer session ma'am but it was very nice academic and splendid uh presentation ma'am i think the video would be more and beautiful if we it would be played yeah it's okay yeah it's okay so just to conclude the session as we know the genetic loss is highly pandemic but and have very very bad impact on the infertility patient especially in the earlier time when only akt was an option the patients have very less chance for the concealment but now as mam has explained there are multiple and newer methods like prp like cgsf like fibroblast growth factor or uh that ovarian transplant uterine transplant we have a wide basket of treatment available for infertile patients so not to be worried with the genital tuberculosis just treat it in a right time and just get the baby i think so mam thank you very very much ma'am for such a wonderful presentation thank you very much thank you thank you you were you were fantastic no no ideal ideal moderating thank you so very much thank you much

BEING ATTENDED BY

Dr. Dhansukh Jain & 628 others

SPEAKERS

dr. Rishma Pai

Dr. Rishma Pai

Honorary consultant Gynaecologist at the Lilavati, Jaslok and Hinduja Health Care Hospitals, Mumbai | She is the only Indian to have served as President of all the three leading gynaecological, infert...

+ Details
dr. Rishma Pai

Dr. Rishma Pai

Honorary consultant Gynaecologist at the Lila...

+ Details

About Medflix

Medflix is a new platform by PlexusMD, India's most active and trusted doctor community. On Medflix, you can discover live surgeries, discussions, conferences and courses from some of the top doctors and institutions across the world. Join clubs in your areas of interest and access hundreds of amazing live discussions everyday.