CLINICAL ARTICLE Hysteroscopic findings in women with primary and secondary infertility due to genital tuberculosis Jai Bhagwan Sharma ⁎, Kallol K. Roy, Mohanraj Pushparaj, Sunesh Kumar Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India abstract article info Article history: Received 19 June 2008 Received in revised form 13 August 2008 Accepted 13 August 2008 Keywords: Acid-fast bacilli Asherman syndrome Female genital tuberculosis Hysteroscopy Primary infertility Secondary infertility Uterine adhesions Objective: To evaluate hysteroscopic findings of infertile women with genital tuberculosis. Method: A retrospective study of the records of 94 women who underwent diagnostic hysteroscopy for infertility at All India Institute of Medical Sciences, New Delhi, India. Genital tuberculosis was diagnosed by laboratory studies of an endometrial biopsy and/or laparoscopic findings. Results: For women with primary or secondary infertility, respectively, the hysteroscopic findings were normal in 15 (20.5%) vs 4 (9%) cases; and adhesions were grade 2 in 11 (15.1%) vs 3 (14) cases, grade 2a in 0 vs 1 (1.4%) cases, grade 3 in 11 (15.1%) vs 9 (42.9%) cases, grade 3b in 6 (8.2%) vs 0 cases, and grade 4 in 28 (38.4%) vs 2 (9.5%) cases. Conclusion: Genital tuberculosis causes significant pelvic morbidity due to uterine adhesions and infertility. © 2008 International Federation of Gynecology and Obstetrics. Published by Ireland Ltd. All rights reserved. 1. Introduction Each year 8 million people develop tuberculosis (TB) worldwide and 2 million die from the disease, most (about 90%) in low-income countries, especially Africa and Asia, mainly because they are coinfected with the human immunodeficiency virus [1]. Alarmed by this high toll of human life the World Health Organization (WHO) declared TB a global emergency in 1993 and advocated a directly observed treatment short course (DOTS) strategy for the effective management of this human scourge [2]. Multidrug resistant TB and extremely drug resistant TB cause serious concern throughout the world because they are associated with a high mortality rate [1]. Female genital tuberculosis is common in low-income countries. It is caused by Mycobacterium tuberculosis and is almost always the result of a hematogenous spread from pulmonary or abdominal infection [3,4]. It manifests as menstrual dysfunction (especially oligomenor- rhea or amenorrhea), primary or secondary infertility, lower abdom- inal pain, chronic pelvic pain, and/or a pelvic mass [3–7]. Menstrual dysfunction has been observed even in adolescent girls with pulmonary and extrapulmonary TB [8]. The fallopian tubes are the pelvic organs the most commonly involved in women with genital TB, followed by the endometrium (in 50%–80% of cases) [3,4,9], and the condition is often associated with pelvic, peritubal, and perihepatic adhesions (the Fitz-Hugh-Curtis syndrome) [10]. In the endometrium, TB causes caseation and ulceration in later stages, with uterine cavity adhesions and distortion, sometimes with the complete obliteration of the cavity [11]. Total destruction of the endometrium may result in Asherman syndrome, the failure of the end organ (here, the uterus), which initially manifests as oligomenorrhea or hypomenorrhea, and later in amenorrhea and infertility [11,12]. Endometrial involvement can be diagnosed by hysterosalpingography, but it is usually avoided in women with genital TB because of the risk of disease flare-up [13]. Hysteroscopy is the gold standard for diagnosing uterine adhesions and distortion of the uterine cavity and tubal ostia, and it can also be a prognostic tool [14]. We present findings of hysteroscopic procedures performed in women with genital TB from September 2006 to March 2008 at All India Institute of Medical Science, New Delhi, India. 2. Materials and methods We conducted this retrospective analysis with data from 94 women with or without menstrual irregularity who underwent hysteroscopy as part of a diagnostic protocol for primary and secondary infertility, and who were found to have genital tuberculosis. These patients were not those on whom our study on Asherman syndrome was based and there was no duplication of data [11]. Ethical clearance was not necessary because the study was retrospective. The type and duration of the infertility, a complete personal history and details concerning the symptoms (that included fever, anorexia, weight loss, menstrual irregularities, and abdominal or pelvic pain), and a detailed family history with any history of tuberculosis or anti- tubercular therapy were obtained for all women. All women underwent International Journal of Gynecology and Obstetrics 104 (2009) 49–52 ⁎ Corresponding author. AI/161, Azad Apartments, Sri Aurobindo Marg, New Delhi, 110016 India. Tel.: +91 9818044551, +91 11 26589665; fax: +91 11 26589665. E-mail address: jbsharma2000@gmail.com (J.B. Sharma). 0020-7292/$ – see front matter © 2008 International Federation of Gynecology and Obstetrics. Published by Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2008.08.019 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo