In August this year, I visited the chock-o-block clinic at JJ Hospital in Mumbai. As I was sitting in the clinic, a 30-year-old woman was the second patient that day to be diagnosed with female genital tuberculosis—a form of extra-pulmonary tuberculosis that is always secondary to tuberculosis infection elsewhere in the body. It had been less than an hour since the clinic had opened at about 11 am. The woman, desperate to bear a child, joked with the resident doctor examining her, “I will come one day and pick up some child from the hospital. You mark my words.” I found out later that she had been married for about 14 years.
The 30-year-old told me that she had never had a regular menstrual cycle since her periods first began when she 13 or 14-years-old. She was married soon after. “When I got married and came to Mumbai, I realised that my sister-in-law was getting periods every month. I had no idea we were supposed to get it every month. I have been taking medicines to treat this problem. Socho—Think!,” she said. Soon after, she began visitng several doctors—including a few in her hometown at Benaras—to try and understand why she was not able to conceive. More often than not, she would be faced with condescending practioners who did little to help her predicament. “My neighbours taunt me and say I am not able to bear a child. My family also scolds me sometimes, out of love,” she said, before adding, “They are bound to say some things to me, aren’t they?” After she was finally diagnosed that day, she told me that she hoped her disease would not infect others in the house, even though the doctor had informed her that extra-pulmonary tuberculosis was not infectious.
Genital tuberculosis in women is detected by conducting tests on a sample of the endometrium lining. Its symptoms, apart from infertility, include painful sexual intercourse; abnormally long, heavy and infrequent periods; the absence of periods; and abdominal pain. The disease forms close to 12 percent of the total pulmonary tuberculosis cases in India, and represents 15 to 20 percent of the extra-pulmonary cases. Most of these cases are asymptomatic and the diagnosis requires a “high index of suspicion” with experienced clinicians being more likely to spot or diagnose them. The organs that are most commonly affected due to genital tuberculosis are: the fallopian tubes, the lining of the uterus, the ovaries, and the cervix among others.
In India, infertility is the most common symptom of genital tuberculosis among women. According to a study that was published in 2008, around “18 percent of the infertile females in infertility clinics suffer from TB [tuberculosis].” The 30-year-old woman I met was unable to conceive because both her fallopian tubes were blocked due to the tuberculosis, and the doctors did not seem to know for how long. “She is now on anti-TB medicines. We do not know when she got TB. Let’s hope it clears the tubes,” said Dr Ashok Anand, professor of gynaecology at JJ Hospital.
“Whenever a patient complains of infertility we do a TB test using endometrial sampling. If the person’s immunity is good, many times the body handles the infection on its own.” said Dr Kiran Coelho, consulting obstetrician and gynaecologist at Lilavati Hospital in Mumbai. But even a strong immune system is no guarantee of avoiding complications. “TB heals by scarring unfortunately. Therefore, there could be fibrosis of the fallopian tubes leading to a block, preventing the egg or ovum from travelling in the uterine cavity,” she continued. In such a scenario, she went on to tell me, surgery was usually considered, although it is not always possible. In some cases, Jain said, “we can only advise in-vitro fertilisation treatment (IVF) to conceive.”