Thursday, May 12, 2016

Fuzzy thinking about pelvic tuberculosis

I just attended an infertility conference in Goa, and I am struck by how much fuzzy thinking and confusion there is about genital tuberculosis. I think this is one of the most over-diagnosed, mis-diagnosed, over-treated and mis-treated disease in infertile women in India today. There are some doctors who believe that every woman who is infertile has tuberculosis ! They label this as either hidden tuberculosis; latent tuberculosis; inactive tuberculosis; or dormant tuberculosis, terms which are badly defined. Most doctors then use these words to mean whatever they want it to be, which means when two doctors make a " diagnosis " of dormant tuberculosis , they're often talking about completely different things.

Not only are they confused themselves, they end up confusing patients and other doctors as well, because they are so confident and authoritative about what their viewpoint.

There are many reasons for this confusion and uncertainty, but the biggest issue seems to be prejudice. A lot of doctors practise medicine based on their personal clinical experience. They remember a particularly memorable  patient , and build up their entire picture about what genital tuberculosis is , and how it should be treated based on these individual cases. However, anecdotes mean very little , because it's so easy to fool yourself .

Unfortunately, there have been very few good studies about TB of the reproductive tract, and the confusion grows day by day. There are lots of questions which stump doctors in their daily practice. How does one make a diagnosis of dormant tuberculosis? And even if you do make the diagnosis, what does it really mean? What's the point of doing a TBPCR test? Is there any need to treat these patients? When you treat them with 9 months of toxic anti-tuberculosis drugs , what is the harm which you're causing them?

All these are difficult questions, and the biggest tragedy is that no medical college in India is willing to perform a clinic study to answer them definitively . It would actually be quite a simple study to do , where infertile patients are randomised and treated, but because no pharma company is going to sponsor such a study, the tragedy is that it will never be done .  This is why doctors continue sticking to their personal convictions.  One lazy knee-jerk reflex response - " TB is rampant in India, and because it's so hard to make the diagnosis, let's just treat every infertile woman with anti TB medicines.   Others will run an entire panel of tests to try to clinch the diagnosis, in order to confirm their " clinical " suspicion. Thus, if the TB DNA PCR of the endometrium is negative, then  let's do a TB RNA PCR. And if this is also negative then let's do a TB PAMP test. Some doctors will even go the extent of running all the tests at one time - and it's obvious that the more the tests you do , the better your chances of getting at least one  positive result.  Thus , if you do 5 tests and even 1 of them is positive , you go ahead and make the diagnosis of tuberculosis and treat the patient, even though this is highly likely to be a false positive.

Because so many of these tests do come back as positive, this is why a lot of doctors believe that genital tuberculosis is epidemic in India, and that if we " treat the TB ", the pregnancy rates will increase.

It's not that doctors have bad intentions - after all, we do want our patients to get better. However, we need to remember that we can harm our patients inadvertently as a result of this sloppy thinking. It's high time that we started doing good quality, randomized studies in order to be able to define what the right treatment plan is. There's been too much confusion about the entire field of tuberculosis, and this has been going on for years. The sad thing is that we seem to be making no progress towards achieving clarity.  This is why even those tests which  have been proven to be completely useless ( for example, the TB blood tests for  IgG, IgM ) and have been banned by the Government still continue to be ordered by gynecologists !

 The big problem with this diagnosis of latent tuberculosis is that every doctor can define it as he pleases.  This means that dormant tuberculosis can be anything you want it to be ! Thus, even if a patient has no symptoms and no signs , just because her test result is positive you can say, "Oh, she has dormant tuberculosis and she needs treatment because if I don't treat it , it will become active and will flare up , and this can cause her to miscarry, or will reduce her chances of IVF success."

How can one go about disproving this hypothesis? This is where the sloppiness comes in - because you have now created  a hypothesis which is not falsifiable. If you cannot prove that what you're saying is wrong ( disproving the null hypothesis) , then this is unscientific thinking, according to Karl Popper.

The trouble is that doctors continue deluding themselves and believe they are offering their patients, the right treatment. They are blissfully unaware of how flawed their thinking is, and how much harm they are causing their patients. Practising doctors attend conferences in the hope that some expert will shed light on this contentious issue, but their confusion just gets worse , because you typically have to listen to 5 different experts saying 5 different things ! What's even worse is that infectious disease specialists , who are TB experts, have refused to put a brake on the overtreatment which gynecologists continue to indulge in.

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