Departments of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
Departments of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
Am J Obstet Gynecol. 2020 Nov;223(5):737.e1-737.e10. doi: 10.1016/j.ajog.2020.05.045. Epub 2020 Jun 1.
Infertility is a common presentation of female genital tuberculosis in endemic areas. Female genital tuberculosis-related maternal and neonatal complications have increased in recent years after assisted reproductive technology treatments. Despite rising emigration rates to the United States, guidelines to identify those with latent tuberculosis or female genital tuberculosis in fertility centers do not exist.
This study aimed to characterize the prevalence of female genital tuberculosis in infertile patients at our academic fertility center.
This is a prospective cohort study. All patients presenting for infertility evaluation between January 2014 and January 2017 were assessed for risk factors for latent tuberculosis. Patients at risk for latent tuberculosis underwent screening using QuantiFERON-TB Gold serum assay. QuantiFERON-TB Gold-positive patients underwent further testing for female genital tuberculosis consisting of endometrial biopsy with histopathologic examination by a clinical pathologist, polymerase chain reaction for tuberculosis, and culture for acid-fast Mycobacterium tuberculosis.
Twenty-five of 323 infertility patients (7.7%) screened for latent tuberculosis had positive QuantiFERON-TB Gold results. A greater number of patients with a positive test result for QuantiFERON-TB Gold were foreign born than those with a negative test result for QuantiFERON-TB Gold (92% vs 29%; P<.001). Of note, the QuantiFERON-TB Gold-positive population had a higher incidence of both recurrent pregnancy loss (28% vs 7%; P=.003) and Asherman syndrome (8% vs 0.3%; P<.001). Among those with a positive test result for QuantiFERON-TB Gold, chest x-ray was abnormal in only 2 patients (8.0%). Endometrium evaluation revealed abnormalities in 2 patients (8.0%), in whom chest x-ray was normal, with 1 showing evidence of female genital tuberculosis. This was indicated by histology consistent with chronic granulomatous endometritis and positive endometrial testing for tuberculosis by polymerase chain reaction, acid-fast bacilli smear, and culture for Mycobacterium tuberculosis.
Although the prevalence of female genital tuberculosis in infertile women in the United States seems to be low, this study indicates that it can be underdiagnosed without utilization of multiple diagnostic modalities including endometrial sampling. Given the potential for serious maternal and neonatal morbidity in affected patients utilizing assisted reproductive technology, we propose that all at-risk women seeking infertility care in the United States be screened for latent tuberculosis. In patients who screen positive, endometrial biopsy should be obtained for evaluation by histology, polymerase chain reaction, and culture for Mycobacterium tuberculosis to rule out female genital tuberculosis before infertility treatments are initiated.
在流行地区，不孕是女性生殖器结核的常见表现。近年来，在接受辅助生殖技术治疗后，与女性生殖器结核相关的母婴和新生儿并发症有所增加。尽管移民到美国的人数不断增加，但生育中心确定潜伏性结核病或女性生殖器结核病患者的指南尚不存在。
本研究旨在描述我们学术生育中心不孕患者中女性生殖器结核的流行情况。
这是一项前瞻性队列研究。2014 年 1 月至 2017 年 1 月期间，所有因不孕接受评估的患者均评估了潜伏性结核病的危险因素。有潜伏性结核病风险的患者通过 QuantiFERON-TB Gold 血清检测进行筛查。QuantiFERON-TB Gold 阳性患者进一步进行女性生殖器结核检查，包括由临床病理学家进行组织病理学检查的子宫内膜活检、结核分枝杆菌聚合酶链反应和酸杆菌结核分枝杆菌培养。
在筛查潜伏性结核病的 323 名不孕患者中，有 25 名（7.7%）QuantiFERON-TB Gold 检测结果阳性。与 QuantiFERON-TB Gold 检测结果阴性的患者相比，检测结果阳性的患者中，出生在国外的患者更多（92%比 29%；P<.001）。值得注意的是，QuantiFERON-TB Gold 阳性人群的复发性流产（28%比 7%；P=.003）和 Asherman 综合征（8%比 0.3%；P<.001）发生率更高。在 QuantiFERON-TB Gold 检测结果阳性的患者中，仅 2 名（8.0%）患者的胸片异常。2 名（8.0%）患者的子宫内膜检查结果异常，其中 1 名患者的胸片正常，表现为女性生殖器结核的证据。这表明组织学检查符合慢性肉芽肿性子宫内膜炎，聚合酶链反应、抗酸杆菌涂片和结核分枝杆菌培养均显示子宫内膜检测为结核病阳性。
尽管美国不孕妇女中女性生殖器结核的患病率似乎较低，但本研究表明，如果不利用包括子宫内膜取样在内的多种诊断方法，这种疾病可能会被漏诊。鉴于受影响患者在使用辅助生殖技术时可能会出现严重的母婴发病率，我们建议在美国寻求不孕治疗的所有高危妇女都接受潜伏性结核病筛查。对于筛查阳性的患者，应通过组织学、聚合酶链反应和结核分枝杆菌培养获得子宫内膜活检，以排除女性生殖器结核，然后再开始不孕治疗。
