Thursday, May 29, 2014

Gynecologists , infertility and TB


Indian gynecologists seem to be extremely fond of making  a "diagnosis " of genital TB at the drop of a hat !

I saw an interesting patient today . She was completely confused, because she had been to many gynecologists, each of whom had given her a different opinion.

She had done a workup for her primary unexplained  infertility. All her test results had come back as normal. However, during the testing , the doctor had done an endometrial biopsy for her which was sent for histological and bacteriological examination. These reports  had both come back as normal, so she was relieved. However, hr doctor suspected she may have endometrial TB, because she felt that her uterine lining on the vaginal ultrasound scan was “thin”. She therefore sent the tissue for further TB tests. The  TB PCR test  also came back as normal, but she was so sure of her “clinical diagnosis”, that she sent the tissue to a lab in New Delhi, which does an esoteric ( and very expensive !) test for TB, called PAMP ( pathogen associated molecular pattern, a mouthful which means precious little !) Incidentally, this seems to be the only lab in the world which does this test . Any sensible doctor would immediately smell something fishy with this kind of arrangement. After all, if a test is really useful, then why wouldn’t all labs offer it ? However, this test is cleverly marketed as being a very highly sophisticated and expensive test, which apparently no other doctor in the world has the ability to replicate ! They claim that it is a very specialized test , which only they can do ! They send photographs along with the report, to “prove” how accurate their “ diagnosis “ is !

The doctor is very pleased when the test now comes back as positive. She triumphantly points out to this report and is very pleased that she made such a difficult diagnosis . This proves that her clinical acumen is excellent !  She happily disregards the other negative TB tests results and advises the patient should start a 9 month course of antiTB treatment. When the patient points out that she has no symptoms or signs , and that the other TB tests are negative, she says that this just confirms that she needed to run this expensive test to make the right diagnosis, which was “missed” by the other tests. She “ explains “ that genital TB is often “silent” – and calls this “latent” TB !  In fact, some doctors have even coined senseless neologisms such as non-bacterial tuberculosis for these patients ! It’s now impossible to prove to the patient that she does NOT have TB. The poor patient is petrified, because she has been scared into believing that if her TB is not treated, the IVF cycle will fail, or that she will miscarry even after doing IVF.

The patient is now extremely anxious and worried , and she goes to a second IVF doctor for a second opinion . This doctor agrees that it’s highly unlikely she actually has TB, but that it’s not worth “taking a chance” and that it’s best to treat with a course of antiTB treatment, since the test has come back as positive. He feels it’s better to be safe and suggests that it’s fine to take a course of treatment!

The husband is very concerned because he knows that antituberculosis therapy can be very toxic. It involves taking many powerful drugs for many months.  These have many adverse effects, including liver toxicity , and is very reluctant to put his wife on these medications . He then goes to a leading gynecologist for a third opinion, who agrees that the chances of having TB are very low, but suggests that he should so a laparoscopy in order to check if there is in fact any tuberculosis lurking in the pelvis !

He was fed up and frustrated and could not decide what to do next. This is when he came to me. I sat down and explained to him that it’s quite common to have a thin uterine lining on a vaginal ultrasound scan – especially if the scan is done on Day 7 !  This is hardly the right way of making a diagnosis of TB !

I told him that the chances of his wife having genital TB were zero, since both the bacterial and histological tests were negative. I explained what false positive tests are. This means that the test result is abnormal, but the patient does not have the disease. The more the tests which are done, the higher the chances of getting a false positive result !

We are now doing a research study, where we are doing these TB PCR tests for fertile women, who have completed their families and are going to the doctor for a laparoscopic tubal ligation . It will be interesting to see how many of these test results ( in these women who have proven their fertility !) come back as positive !

The danger with misdiagnosing these infertile women as having genital TB is considerable. They get emotionally upset – and I even know of one husband who divorced his wife, because he was scared that having sex with her would mean that he might get TB too !

What’s even worse is that this epidemic of overdiagnosis will lead to the overuse of powerful antituberculosis drugs. Not only do they have significant side effects for the patient, they will result in the spread of MDR ( multiple drug resistant) TB in the community . The inappropriate use of these powerful antibiotics will accelerate the spread of drug-resistant TB in India.

I think it's high time that doctors and patients realized the limitations of these tests. I wish infectious disease specialist and tuberculosis experts specialists would get up and educate gynecologists that these test results have absolutely no value at all !



Have you been " diagnosed " with genital TB ? Please send me your medical details by filling in the form at http://www.drmalpani.com/free-second-opinion so I can guide you sensibly ?

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