dr dina fisher md, msc, frcpc nar iuatld chicago march 2018 - dina fisher nar2018df (1).pdf · 38...
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Dr Dina Fisher MD, MSC, FRCPC
NAR IUATLD Chicago March 2018
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38 year old female from SouthEast Asia underwent
IVF/ET after standard infertility diagnostic
assessment
Pregnancy was complicated by◦ Premature rupture of membranes
◦ Oligohydraminos
Presented to hospital with new onset seizures
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Urine smear positive and culture positive for fully-
susceptible mycobacterium tuberculosis
Sputum smear negative, culture positive for fully
susceptible mycobacterium tuberculosis
Started on standard TB treatment/steroids with good
clinical outcome
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Infant born at 24 weeks gestation
Treated for congenital TB without culture confirmation
Multiple complications with 14 month hospitalization
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Sharma 2015, J Obst Gyn India
15-20 % of cases of EPTB are GU TB
◦ Fallopian tube involvement (90%)
◦ Endometrial dysfunction (50-70%)
◦ Ovarian dysfunction (20-30%)
10-85 % are infertile (40-60%)
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Sharma 2015, J Obst Gyn India
Attending Infertility Clinics
◦ 1 % in United states
◦ 3 – 26 % High incidence TB countries
◦ 48.5 % tubal factor infertility in high incidence countries
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Several studies have failed to identify history/physical
exam findings that differentiate between TB and non-TB
causes of infertility
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Older, small studies in TB endemic countries have
demonstrate high yield of menstrual fluid sampling for
mycobacterial culture
Margolis et al 1992, SAMJ
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Consider diagnosis based on diagnostic imaging
abnormalities, specifically tubal involvement
Consider diagnosis based on hysteroscopy/laparoscopy
appearance
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Sharma 2015, J Obst Gyn India
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Sharma 2015, J Obst Gyn India
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Sharma 2015, J Obst Gyn India
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Sharma 2015, J Obst Gyn India
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Neelam et al 2005, J Obst Gyn India
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Infertility Clinic India (endometrial and laparoscopic)◦ 40% diagnosed on histopathology
◦ 16% diagnosed on AFB smear
◦ 40% on mycobacterial culture result
◦ 50 % on PCR result
Radhika et al 2016, J of Obstet and Gynaecol
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Al eryani et al 2015, Alexandria Medical Joural
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Variability in incidence of FGTB
Lack of data in best testing/screening strategy for FGTB
Invasive diagnostics to obtain confirmed diagnosis
Treatment of FGTB does not lead to improved fertility
and may delay IVF-ET treatment
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CDC2015 Report ART
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Neelam et al 2005, J of Ob Gyne India
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ASRM ( American Society for Reproductive Medicine)
◦ No comment on investigations for FGTB
◦ No role for routine hysteroscopy/laparoscopy/endometrial biopsy in the assessment of the
infertile female
IFFS (International Federation of Fertility Societies)
◦ Test for infectious diseases associated with infertility
FIGO (International Federation of Gynecology and Obstetrics)
◦ Test for infectious diseases associated with infertility
ICMR (Indian Council for Medical Research)
◦ Consider hysteroscopy/laparoscopy and sampling for MTB
ESHRE (European Society of Human Reproduction and Embryology)
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Flibotte et al 2016, J of Periton
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Better data to inform recommendations
Need to consider pre-test probability of FGTB when
developing guidelines◦ Difficult to develop international guidelines that are applicable to
all countries
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Who to Screen◦ Individuals from high TB incidence countries
◦ Tubal factor infertility
How to Screen◦ Limit invasiveness of testing
Number needed to screen to detect one case of FGTB
Cost of Screening◦ In many countries cost of infertility treatment is borne by infertile
couple and not included in public-payer systems
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