Gynecologists seem to be diagnosing
endometrial TB at the drop of a hat
for all infertile women.
Tuberculosis is endemic in India
Genital TB can cause infertility
Can cause symptoms ( amenorrhea, pelvic
pain, abnormal uterine bleeding)
Is often silent
Hard to confirm this diagnosis in the lab,
because it's very difficult to grow the TB
bacillus in vitro.
Culture in L-J media
Guinea pig inoculation
Lots of false negatives
Empiric TB treatment based on clinical
findings. If patient improves clinically,
diagnosis is confirmed
“Suspect” tuberculosis on clinical grounds
Thin endometrium on scans
Adhesions on laparoscopy
Repeated failed IVF cycles
While in the past the diagnosis was often
missed, today the problem is exactly the
Gynecologists are overdiagnosing genital TB,
based on a positive endometrial TB PCR
( polymerase chain reaction) test result.
Detection is based on multiplication not of
whole bacilli, as in culture, but of their
genetic material, chromosomal DNA or
In principle, from one target sequence, of
one bacillus, the reaction can produce
millions of copies and thus yield a positive
Simple , Rapid and Sensitive
Amplifies a DNA sequence which is unique to
Positive test = Presence of mycobacterial
DNA is present in the endometrium.
If TB PCR of endometrium is positive =
patient has endometrial TB
Extremely logical , but very flawed. Let's see
why by starting from first principles.
It does NOT mean the patient has genital TB !
All it tells us that a few molecules of
mycobacterial DNA was found in the sample
processed in the lab.
The type of mycobacteria
The DNA sequence amplified is not specific only
to M tuberculosis - it is found in many other
mycobacterial species as well.
Are the mycobacteria alive or dead?
Where did the mycobacteria came from ?
(contaminant from the OT or the lab)
Not just Mycobacterium tuberculosis or
Mycobacteria are a diverse group of rod-
shaped bacteria that include more than 100
different species. The others which are far
commoner, are called Nontuberculous
mycobacteria (NTM), environmental
mycobacteria, atypical mycobacteria and
mycobacteria other than tuberculosis (MOTT).
Environmental mycobacteria are found
practically everywhere - even in the water in
the lab which is used to clean the instruments
Fools both pathologists and gynecologists
Pathologists are forced to report what they
see – do not provide any clinical
Gynecologists – knee jerk reflex ! Positive test
result = disease = treat !
Fail to realize that a positive PCR report is
very non specific
It’s because it so sensitive that it gives rise to
so many false positives, which mislead both
doctors and patients.
With a positive TB PCR, the odds are that a
positive result ( in an asymptomatic patient)
means that there is something wrong with
the test, not with the patient .
These mycobacteria have created iatrogenic
harm - Non pathogenic Ubiquitous
Mycobacteria - NUM !
When the TB PCR test is positive,
gynecologists then rely on even more
unreliable tests ( such as Quantiferon Gold,
TB PAMP testing, and TB IgG and IgM
antibody tests) to "confirm" their diagnosis ,
even though the Government of India has
banned many of these tests because they are
so unreliable !
New class of in vitro
assay that measure
released by sensitized T
cells after stimulation by
reactivity to M.tb.
What happens if they give conflicting
For example, one test may be positive and
the other is negative !
Which should you trust ?
Clinical suspicion confirmed !
Patient is happy that the doctor has finally
found out why the endometrium is thin; or
why the IVF cycles have failed .
Few patients may get pregnant after starting
the antiTB medicines, this doesn't mean that
there was a cause and effect relationship
between the treatment and the pregnancy.
Tragic ! Most of these patients don't have TB
Overdiagnosis causes havoc in the life of
Unnecessarily exposed to nine months of
Time wasted , during which her ovarian
reserve and fertility will go down.
Harming the country's TB control program
The misuse of antiTB drugs leads to drug-
resistant TB ( MDR and XDR) , which is the
man-made result of interrupted, erratic, or
inadequate TB therapy.
Can’t hurt !
Why take a chance ?
Patients want you to do something !
It’s expected that doctors will always
prescribe medicines !
Doctors are scared that if they “do nothing”
they will lose their patient
Pressure to test and treat – from both patient
and doctor !