India is the highest TB burden country accounting for more than one-fourth of the global incidence .Genital TB is found in 5-10% of women with infertility problems, with low rates in Australia (1%) and high rates of up to 19% in India (ICMR,2011)

1. GENITAL
TUBERCULOSIS
DR JAYA KORE -TULASKAR

2. There is a dread disease ….in which life and
death are so strongly blended that death takes
the glow and hue of life and life the gaunt and
grisly form of death
- CHARLE’S DICKENS

3. HISTORY
 In Ancient Vedas tuberculosis
was known as Rakshasman-King
of diseases
 Word ‘TUBERCULOSIS’ was
coined by Johann Lukas
Schönle in 1834.
 -ROBERT KOCH discovered
tubercle bacilli in 1882.

4. MILE STONES --- BEING THE FIRSTS
 First case of genital TB was recognised and
described by Morgagni in 1744.
 First case of tubercular endometritis was reported
by kwisch in 1847.
 Spencer Wales (1862) first operated on clinically
diagnosed ovarian cyst – TB loculated cyst.
 Hegar (1883) removed tubercular tube.
 Sutherland (1943)-tested endometrial biopsy for
TB.
 Raymond described TB cervicitis.

5. INCIDENCE
INDIA IS THE HIGHEST TB BURDEN COUNTRY ACCOUNTING FOR
MORE THAN ONE-FOURTH OF THE GLOBAL INCIDENCE
India
26%
China
13%
Indonesia
6%
Nigeria
5%
South Africa
5%
Bangladesh
4%
Ethiopia
3%
Pakistan
3%
Phillipines
3%
other 13 HBCs
15%
other countries
18%
Source: WHO Geneva; WHO Report 2014:
Global annual incidence = 8.6
million
India annual incidence = 2.2 million
India is 17th among 22 High Burden
Countries (in terms of TB incidence
rate)

6.  In 2013, 8.6 million people fell ill with TB and 1.5
million died from it.(WHO,2014).
 India alone accounted for 26% of total TB cases
globally(WHO,2014).
 HIV has altered the dynamics of TB worldwide
Patients co-infected with HIV contributed about 8.5%
of the increase in tuberculosis cases per
year.(RCOG,2011).

7.  Genital tuberculosis is the second most common
form of extrapulmonary TB after peripheral
lymphadenopathy.
 Genital TB is found in 5-10% of women with
infertility problems, with low rates in Australia (1%)
and high rates of up to 19% in India (ICMR,2011)
 Genital tuberculosis in India has increased to 30 per
cent in 2015 from 19 per cent in 2011(ICMR,2015).

8. PATHOPHYSIOLOGY
Tuberculosis organism is
- non-motile obligate aerobe
replicating cycle of 17-24 hours
(slow growing)
-Non capsulated
-Acid-fast due to the surface
lipids. So resistant to common
antibacterial agents and lytic
enzymes.

9. PATHOPHYSIOLOGY
 AGE GROUP-
-Can occur in any age group, 75% being in the 20–45 yrs .
Postmenopausal women ( 7–11%) .
o if primary infection occurs close to menarche increased chance of
genital T.B
 Mycobacterium tuberculosis of human type.(90–95%)
 Rarely M.bovine.(5-10%).
 Almost always of secondary type.(RCOG,2005)
 If the bacilli are not eradicated, risk of reactivation, especially in
conjunction with diseases (e.g. Hodgkin’s lymphoma, AIDS,
steroids, stress, or malnutrition

10. ORGAN FREQUENCY
Fallopian tubes 90-100%
Endometrium 50-60%
Ovaries 20-30%
Cervix 5-15%
Vulva and Vagina 1%
Schaefer G: Female genital tuberculosis. Clin Obstet Gynecol 19:23, 1976)
Fallopian tubes -primary sites
Mode of spread : Hematogenous (90%)
Lymphatic/ Direct
Ascending
Frequency of tuberculosis in genital organs

11. TUBERCULOSIS OF THE FALLOPIAN TUBES
 Both tubes are involved in 100 % of cases.

12.  Initial: Submucosal layer of Ampulla
Spreads medially Spreads Outwards
Muscle layer
Fibrosis, segmental Perisalpingitis with
Thickening, Tobacco Exudation.( dense
Pouch appearance adhesions)
Pyosapinx Tuboovarian Mass
 Salpingitis Isthmica Nodosa

13. TOBACCO POUCH
APPEARANCECE

14. TYPES OF TUBERCULOUS SALPINGITIS
 Exudative
-Acute phase of the process.
- large pyosalpinx may form. Frequently, the organs contain a large
amount of caseous material plus purulent exudate.
-show few adhesions .
 Productive-Adhesive
-Found most frequently at laparoscopy or laparotomy.
- Tubes are studded with tubercles and are densely adherent to the
surrounding organs.
- The tube wall is thickened and nodular.
- Eventually, when the process starts healing, it results in
calcification and fibrosis.

15.  Productive
 Exudative

16. TUBERCULOSIS OF ENDOMETRIUM
 Uterus
Tubercles at basal layer of
endometrium
Shed at each menstruation
Reinfection
Endometrial ulceration
Asherman’s syndrome

17.  Tubercles at basal layer of endometrium
Myometrium(2-3%)
Caseation
Pyometra(postmenopausal woman)

18. TUBERCULOSIS OF THE OVARY
 The involvement is bilateral.
 Two forms :
 PERIOOPHORITIS
-Extension of the tuberculosis
from the tube
- Most common form of
tuberculosis.
- From the periphery toward the
center
- Resulting in a tuboovarian mass,
which is frequently adherent to
omentum and intestines.

19. OOPHORITIS
-Follows hematogenous spread.
-A relatively rare condition
- Infection starts in the stroma of the
ovary,
-Typical tubercles or larger foci with
caseous centers may be recognized
on cross section in the hilum of the
ovary

20. TUBERCULOSIS OF CERVIX
 Descending infection from fallopian
tubes and uterus.
 Sexual parteners may be source of
infection.
 No macroscopic changes in the
cervix specific for TB.
 The cervix may appear normal or
inflamed, may resemble invasive
carcinoma.
 Three forms
-Ulcerative –most common
-Papillomatous
-Miliary

21. TUBERCULOUS PERITONITIS
 In combination with female genital tract TB approximately 45%
of the time.
 Often extensive adhesions seen.
 Two types
 Serous variety-
- more common
- Characterized by ascitis, signs of peritoneal inflammation, fever,
abdominal pain, weight loss, and anorexia.
 Plastic variety-
- Less common
- Characterized by tender abdominal masses and an abdomen
“doughy” to palpation.

22. TUBERCULOSIS OF THE VULVA AND
VAGINA
 Rarest form of genital TB(1%).
 Sexual partners may be source of
infection.
 In the vulva begins as a nodule on the
labia or in the vestibular region-breaks
down - irregular ragged ulcer.
-sometimes with sinuses discharging
caseous material and pus.
- as a hypertrophic, irregular warty growth.
 In the vagina may simulate carcinoma in
its gross appearance.

23. TB OF PELVIS
 Tubercular adenitis of mesenteric or pelvic lymph nodes.
 Pelvic T.B. is not the same disease as Genital T.B.
 ‘FROZEN PELVIS’
 DDs of frozen pelvis?
Florid genital tuberculosis
Grade III/IV pelvic endometriosis
Advance invasive carcinoma of cervix
Following radiotherapy for invasive carcinoma of cervix

24. CLINICAL FEATURES
 20% have history of T.B. in immediate family.
 Past history of tuberculosis.
 Asymptomatic-10-11%
 Systemic- A history of poor general health persisting over a
period of months or years and associated with weight loss, undue
fatigue, low-grade fever, or vague lower abdominal pain
 Infertility
 Menstrual disturbances
 Abdominal swelling
 Postcoital bleeding
 Vaginal discharge
 Dyspareunia

25. INFERTILITY
 Most common initial symptom.
 In most large studies: Infertility presenting c/o in 40% - 50%
 Past h/o TB /family .
LOWER ABDOMINAL PAIN
 Second common symptom.
 Pain present for several months which is not usually severe.
 M/c associated with swelling of abdomen.
 Episodes of acute lower abdominal pain owing to secondary
infection by pyogenic org.
 In advanced disease pelvic pain becomes severe and gets
aggravated by coitus, exercise & mensus.

26. MENSTRUAL COMPLAINTS
 Third common symptom.
 Menorragia/ Menometrorragia/ Intermenstrual
bleeding/ Oligomenorrhoea/ Postmenopausal
bleeding.
 Menstrual cycle may be normal.
 AMMENORRHOEA
 Advanced active pulmonary T.B. produce amen. but
concomitant genital T.B. is rare.
 Complete destruction of ovary by genital T.B. seldom
occurs so ovarian failure is not the cause.
 ‘End organ failure’ secondary to endometrial caseation

27.  H/o primary infertility with no apparent cause on
examination & family H/o or personal H/o T.B.
 H/o vague lower abdominal discomfort with low grade
fever/undue fatigue/persistent ill health over months to
years associated with weight loss.
 Adolescent female presenting with ascites pain and low
grade fever.
 Menopausal female enlarged uterus that is tense and tender
on examination (pyometra formation)
 Recurrent Pelvic inflammatory disease not responding to
antibiotic therapy.

28. SIGNS
Normal in 50%..
Abdominal examination-doughy feeling.
Abdominal mass
Pelvic mass
Adnexal mass
Abdominal tenderness
Pelvic/adnexal tenderness

29. Ascites
Excessive vaginal discharge
Ulcer in the vulva, vagina, and cervix
Enlarged uterus with pyometra
Fistulal
Lesions of the cervix and external genitalia.

30. DIAGNOSTIC CRITERIA
 Clinical suspicion
 Laboratory evidence
 Histopathological confirmation
 Imaging
 Visual evidence ( laparo / hysteroscopic )

31. CLINICAL SUSPICION
 Unexplained infertility
 Infertility of any duration with
High risk factors
- history of previous pulmonary TB infection.
- contact with a pulmonary TB sufferer.
- recent travel to or migration from high prevalence countries.
- residence in high prevalence areas .
- low socioeconomic background.
- drug abuse.
- HIV positive status.

32. - Generalised s/s
 loss of wt / appetite
 low grade fever / malaise
 night sweats
 persistent vaginal discharge
 non healing of wounds , unexplained ascites
 chronicity of symptoms
 Adnexal disease with ascites in virgins
 Chronic PID refractory to standard antibiotic treatment
 Postmenopausal women with bleeding, persistent leucorrhoea
and pyometra where endometrial neoplasia has been excluded.

33. INVESTIGATIONS
 CBC, ESR
 CXR
 Pelvic ultrasound / hystero-salpingography
 Laparoscopy
 Histopathology
 Microbiology:-
 Mantoux test
 QTG-T
 Serology
 AFB microscopy / culture
 EA / EB / EC / menstrual blood
 Urine c/s
 Molecular tests
 HIV

34.  Hemogram is usually normal,may show lymphocytosis ,low
Hb
 ESR is usually normal but may be raised
 Urine microscopy may show abacteruric pyuria in concomitant
GUTB.
 Raised serum CA125 level

35. CHEST X RAY
 Most chest X-rays are normal
 Old healed scarred lesions
 Current or past tuberculous lesions in
the lungs
o Milliary tubercles if disseminated
tuberculosis.

36. ENDOMETRIAL BIOPSY
 Sampled by endometrial aspiration ,
biopsy Curettage ,premenstrual biopsy/
menstrual blood on1st day within 12 hrs of
menses
 +ive in 50-60 % cases of GTB
 Reveals granulation , caseation , dilated
glands, inflammatory cells
,lymphocytes , plasma cells,
destruction of epithelium , fibrosis
 Microscopic appearance of the granuloma:
Multinucleated giant cells, Langhans cells
Chr. Inflammatory cell,Epitheloid
cells,Central area of caseation necrosis.
 +ive HPE indicates 100% TB salpingitis
 -ive HPE does not rule out endometrial /
tubal TB

37. CULTURE
 Decisive step for diagnosis, treatment & control of TB
 Combination of solid and liquid media-Gold Standard
 For isolation of bacteria – a surest test
 More sensitive requiring 10 -100 org / ml
 Sensitivity is 30-40%
CONVENTIONAL
o Egg based media 3-8 weeks
eg Lowenstein Jensen media
 Agar based < 3 weeks
eg- BACTEC medium
 MGIT: more rapid and sensitive than other methods of
culture.

38. RADIOMETRIC CULTURE METHOD
 BACTEC -- is based on measurement of
carbon dioxide released by bacteria during
growth in liquid medium
 Radioactive carbon labelled substrate like
palmitic acid or formic acid is used as
marker for bacterial growth
 Diagnosis is made in 1-2 weeks
 Sensitivity is 80-90%

39. BACT/ALERT 3D MB
 Fully automated,Non-
invasive,Continuously monitored non-
radiometric system.
 Revised antibiotic supplement kit
 Medium - modified Middlebrook 7H9
broth with supplements
 Direct inoculation
 No processing
 Decontaminated clinical specimen and
sterile body fluid specimen (other than
blood)
-10 ml Middlebrook 7H9 Broth
 BSA, Catalase

40.  For blood and sterile body fluids
-30 ml Middlebrook 7H9 Broth
SPS, Glycerol.
 CO2 released by mycobacteria
detected by sensor
 Colour changes - increase in
reflectance units
 Positive broth - 106-107 orgs/ml
 Mean detection time (days)-11 to15
days.

41. SMEAR MICROSCOPY
 Ziehl-Neelsen
 Fluorochrome - Auramine-rhodamine
(direct fluorescence)
 Simple & rapid procedure
 Higher sensitivity; faster screening
 Requires 10000 mycobacteria/ml for +
ive smear
 Or 1-9 AFB / HPF -- +++
 Or 1-9 AFB / 10 HPF ++
 Or 1-9 AFB / 100HPF +
 - ive smear does not rule out GTB
 Cyto centrifugation enhances
sensitivity

42. TUBERCULIN (MANTOUX) TESTS
0.1 ML PPD IS INJECTED INTRADERMALLY
 Delayed hypersensitivity reaction
 Read between 48 and 72 hours after
the injection
 The tuberculin skin test has a
sensitivity of 55%
and specificity of 80% in patients
with genital
tuberculosis.(RCOG ,2005)

43. SSSSSS

44. QUANTIFERON-GOLD
 In vitro assay that measure interferon (IFN-γ)
released by sensitized T cells after stimulation
by M. tuberculosis antigens.
 FDA-approved in 2001,for detection of latent
tuberculosis infection.
 Indirect test for M. tuberculosis complex
 Tuberculosis disease OR latent tuberculosis
infection (LTBI)- cannot distinguish between
them
 Intended for use in conjunction with risk
assessment, radiography, and other medical
and diagnostic evaluations

45. PRINCIPLE OF QUANTIFERON GOLD
 Fresh heparinised whole blood from sensitised persons
Incubated with mixtures of synthetic peptides
(two proteins present in M. tuberculosis)
 ESAT-6 (early secretory antigenic target-6)
 CFP-10 (culture filtrate protein-10)
 Lymphocytes recognize these mycobacterial antigens –
 Generation and secretion of interferon-γ (IFN-γ)
 Detection and subsequent quantification of IFN-γ by ELISA

46. Result Interpretation
Positive
(ESAT-6 and/or CFP-10
responsiveness detected)
M. tuberculosis infection likely
Negative
(No ESAT-6 or CFP-10
responsiveness detected)
M. tuberculosis infection unlikely,
but cannot be excluded in immunocompromised patients, or
highly probable cases
Indeterminate Test not interpretable

47. ADVANTAGES
 Single patient visit
 Rapid results (within 24 hours)
 Higher specificity than Mantoux
 No booster response (measured by subsequent tests -
which can happen with Mantoux)
 No reader bias (cf Mantoux)
 Not affected by prior BCG vaccination
or Impaired or altered immune function

48. T-SPOT®.TB TEST (T-SPOT)
T-SPOT®.TB test (T-Spot) - Counts the cells releasing IFN-G
visualized as spots with the enzyme-linked immunospot
(ELISPOT) technique.
Clinical Utility:
Can detect both latent and active pulmonary and extra-
pulmonary cases.
Useful for screening person who has symptoms of TB.
Screening suspected Extra-Pulmonary tuberculosis eg: GTB

49. ULTRASONOGRAPHY
 Loculated ascites: The presence of fine lacy strands or
particulate matter in fluid is due to thin fibrin strands
 Bilateral or unilateral tubo-ovarian mass
 Hydrosalpinx
 Fluid in cul de sac , peritoneal cavity
 Mesenteric lymphadenopathy
 Small uterus with atrophic endometrium
 Enlarged uterus with caseous pyometra

50. HYSTEROSALPINGOGRAPHY (HSG)
Hysterosalpingography is contraindicated
-in the presence of recent acute pelvic infection
-If Tuberculosis is suspected.
 Vascular or lymphatic extravasation of the dye
 Rigid (lead-pipe) tubes with nodulations
 Tobacco-pouch appearance
 Leopard skin appearance
 Rosette appearance
 Moth eaten appearance
 Sperm head appearance
 Beaded appearance of the tube
 Distal tube obstruction
 Coiling/ calcified shadows
 Bilateral cornual block
 Irregular, honey-comb appearance of the uterine cavity

51. TOBACCO POUCH
•Tube is enlarged and
distended, ostium remain
patent with recognizable
everted fimbriae.

52. COTTON WOOL PLUG APPEARANCE..
 Focal irregularity and areas
of calcification occur within
the lumen of the fallopian
tubes.

53. TUFTED APPEARANCE..
 Caseous ulceration of the mucosa
of the fallopian tube produces an
irregular contour of the lumen of
the tubes.
 Diverticular cavities may
surround the ampulla and give a
“tuft” like appearance.
 Thick arrow – hydrosalphinx.

54. PIPE STEM APPEARANCE/RIGID PIPE
 Scarring fallopian tubes.
 Irregular and rigid.
 Filling defect in uterine
cavity – adhesion.

55. BEADED APPEARANCE..
 Multiple constrictions along the course of fallopian tube
on HSG due to fibrotic strictures.

56. T-SHAPED UTERINE CAVITY
 Scarring results in a “T”
shaped uterine cavity with
intravasation of contrast.

57. FLASK SHAPED FALLOPIAN TUBES..
 a flask-shaped
dilatation of the
fallopian tubes due to
obstruction at the
fimbria.

58. FILLING DEFECT

59. MOTH EATEN APPEARANCE

60. SPERM HEAD APPEARANCE/GOLF CLUB

61. HYSTEROSCOPY
 Ostia not visualized
 Caseous material coming out of
ostia
 Periosteal fibrosis
 Caseation/ tubercles
 Endometrial calcification
 Scanty endometrium
 Intrauterine adhesions
 Irregular uterine cavity

62. LAPAROSCOPY
 Blue uterus” when chromopertubation test done with
methylene blue.
 Acute salpingitis: red, swollen edematous tubes.
 Tiny tubercles 1-4 mm on surface of organs: tubes,
uterus.
 Hydrosalpinx, pyosalpinx.
 Tobacco-pouch appearance.
 Unilateral / bilateral TO masses.
 Straw colored thick jelly like exudate in POD.
 Fimbrial biopsy, peritoneal fluid may be taken to
confirm the diagnosis .

63. SEROLOGICAL TESTS
 Based on recognition of host response
 Antibodies tested against mycobacterial antigens by ELISA
using mono /polyclonal Abs
 A-60 & 38 kDa –are usual purified Ags tested
 Useful in chronic & inaccessible disease
 Active infection IgM develops before ESR is raised or
Montoux is +ive
 Sensitivity is 80-90% in extra pulmonary TB

64. PCR MOLECULAR DIAGNOSTIC TESTS
PCR based sequencing
- Amplification of DNA using specific primers
- Highly sensitive ( > 90% ) & specific ( 95% )
- Few bacterial cells used for amplification
- Detectable with even 1-10 organisms / ml
- Results available in 2-3 days
- Cumbersome and expensive
- False –ive if contaminated with heparin or high salt
concentration
- False +ive as can not distinguish between live or dead
bacilli

65. MOLECULAR DIAGNOSTIC TESTS
 DNA probes -
- Species specific probes that hybridise with RNA
- Combined with short term culture
- Used for rapid detection of myco TB
- Highly sensitive & specific
 DNA microarrays
- Identify mutation rapidly & accurately
- By Ligase chain reaction where fragmented primers are
amplified

66. PCR GENOTYPIC MOLECULAR TESTS
 PCR assays targetting various gene segments are
 -- a 65 kDa protein encoding gene
-- DNA IS 6110 element -myco TB has 10 -20
copies of this sequence.PCR detect less than 10 pg of DNA =3
genomes
-- mpb 64 gene –a specific Ag -- as patch test . Becomes +ive in
3-4 days & lasts for 1 week (100% specific & 98% sensitive)

67. Advantages:
High specificity and sensitivity, requires only < 10 bacteria/mL
Rapid method, results are available within a day of the DNA being
extracted from the specimen.
Can be applied to sterile fluids like peritoneal fluid where the
culture is difficult due to a low bacterial load.
Disadvantages:
False Negative - absence of even a single AFB in the sample
collected, and high salt concentration of a
specimen which interferes with the PCR results.
False Positive- PCR cannot distinguish between live and killed
bacilli

68. BIOCHEMICAL MARKERS
 Adenosine Deaminase activity
- Tested in associated peritoneal TB
- Levels of > 30 u/L in ascitic fluid significant
- Rapid , highly sensitive & specific
- Pending confirmatory tests - therapy can be initiated
 Tuberculstearic acid test
- Fatty acid present in mycobacteria only
- Gas chromatography /mass spectrometry done with
samples containing small number of bacteria

69. COMPLICATIONS
 Subfertility or Sterility
Even in patients considered to be “cured,” extensive damage
to the fallopian tubes and the endometrium is often
irreversible, and chances of successful intrauterine pregnancy
drop significantly.
 Ectopic Pregnancy
 Congenital Tuberculosis
A rare but potentially serious complication .
transmission from maternal tuberculous endometrium to the
fetus .

70. ANTI TUBERCULAR TREATMENT
 3 basic principles for chemotherapy for T.B.
 Regimen must contain multiple drugs to which
organism is susceptible.
 Drugs are to be taken regularly.
 Drugs should continue for a sufficient period of time.

71. RECENT RNTCP GUIDELINES 2016.

74. `
Drug Bactericidal activity
Isoniazide
Bactericidal in-vivo and in-vitro
Rifampicin
Pyrazinamide
Selectively bactericidal
Streptomycin

75. RESERVE LINE/SECOND LINE DRUGS USED IN
TREATMENT OF TB
Drug <50 Kg >50 Kg
Thiacetazone 150 mg 150 mg
Ethionamide 500 mg 750 mg
Cyclocerine 750 mg 1000 mg
Inj. Kanamycin 750 mg 1000 mg
Inj. Capreomycin 750 mg 1000 mg
Inj. Viomycin 750 mg 1000 mg

76. NEWER DRUGS USED IN THE TREATMENT OF
DRUG RESISTANT TB
Fluoroquinolones: Ciprofloxacin (1500 mg/day), and
Ofloxacin (400-600 mg/day) for 6 months
Anti-leprosy drugs: Clofazimine (100-200 mg/day)
Beta-lactam antibiotics: amoxicillin+ clavulanic acid
(Augmentin)
Macrolides: azithromycin, roxithromycin, and clarithromycin

77. SURGICAL MANAGEMENT
 Tubal reconstructive surgery is contraindicated
because there is usually irreparable damage of tubes
(cilia are destroyed)
 May result in reactivation and dissemination
 Those with infertility must be treated with medical
treatment; and if this does not help artificial
reproductive techniques may be considered.

78. SURGICAL MANAGEMENT
 Indications:-
 Persistent & recurrent disease/pelvic masses/pelvic
pain/abnormal bleeding despite adequate treatment
 Persistent non healing fistula
 Multi drug resistant disease
 Concomitant neoplasia of genital tract
 Chemotherapy should precede surgery by 1-2 weeks.
 Surgery should be done at mid cycle in premenopausal.
 Chemotherapy should be continued for 6-12 months post
op.
 Premenopausal-save ovaries if normal, otherwise TAH
with BSO followed by HRT.
(Glob. libr. women's med., The International Federation of Gynecology and
Obstetrics,2008)

79. GTB & ENDOMETRIAL RECEPTIVITY
Implantation failure reasons are
 Inability to express Integrin molecules in the endometrium
during implantation window
 Inhibition by Myco. TB. Of basal production of progesterone
& stimulatory effect of HCG leading to ovulation failure
 Fibrosis , endometrial atrophy , adhesion formation .

82. UTERINE BIOPHYSICAL PROFILE
Applebaum uterine scoring system for
reproduction
(USSR on USG )
 Endometrial thickness > 7mm in A.P. diameter
 5 lined appearance of endometrium -from D1 to midcycle –
progressive increase in thickness
 Blood flow within zone 3 on color doppler
 Myometrial contractions giving wave like motion of
endometrium
 Uterine arterial blood flow as Pulsatility Index <3.0
 Homogenous myometrial echogenicity
 Myometrial blood flow seen on grey scale exam.
(internal to arcuate vessel)

83. POOR PREDICTORS FOR CONCEPTION
 Poor endometrial receptivity
 Blocked tubes
 Elderly age
 Infertility of longer duration
 Sec. amenorrhea / oligomenorrhea
 Endometrial atrophy , caseation
 Endometrial scarring , synechiae

84. PREDICTORS OF GOOD RECEPTIVITY
 Endometrial thickness
 Endometrial layering
 Myometrial echogenicity

85.  Each parameter is scored as follows:
 1. endometrial thickness
 a. < 7 mm = 0
 b. 7 - 9 mm = 2
 c. 10 - 14 mm = 3
 d. > 14 mm = 1
 2. endometrial layering
 a. no layering = 0
 b. hazy 5-line appearance = 1
 c. distinct 5-line appearance = 3
 3. myometrial contractions (seen as wave-like endometrial
motion high-speed playback from videotape)
 a. < 3 contractions in 2 minutes (real-time) = 0
 b. > 3 contractions in 2 minutes (real-time) = 3

86.  4. myometrial echogenicity
 a. coarse/inhomogeneous echogenicity = 1
 b. relatively homogeneous echogenicity = 2
 5. uterine artery Doppler flow evaluation
 a. PI > 3.0 = 0
 b. PI< 2.5 - 2.99 = 0
 c. PI < 2.2 - 2.49 = 1
 d. PI < 2.19 = 2
 6. endometrial blood flow within Zone 3
 a. absent = 0
 b. present, but sparse = 2
 c. present multifocally = 5
 7. myometrial blood flow internal to the arcuate vessels seen on
gray-scale examination
 a. absent = 0
 b. present = 2