Mrs. X, 35 years old, married for 6 years, case of primary infertility with hypothyroidism on levothyroxine 25 mcg, attended the infertility outpatient department of a tertiary care centre in May 2012. She had already undergone 2-3 cycles of ovulation induction. There was nothing significant in husband's history.
The patient was investigated for primary infertility.
Ultrasound on day 2 of menstrual cycle: uterus of normal size and endometrium thin, with antral follicle count of 3-4 follicles in each ovary and no hydrosalpinx or any adnexal mass.
Premenstrual endometrial biopsy: PCR/TB positive with AFB stain negative. HPE: secretory endometrium and no granulomas.
Hysterosalpingography: not done.
Hysteroscopy: cervical canal was normal. Bilateral ostia seen. Fibrosis in endometrium. Endometrial biopsy taken and sent for HPE.
Laparoscopy: uterus contour was normal. Tubercles were present all over. Biopsy was taken. In the left tube mild hydrosalpinx was present. Right tube was dilated. Both ovaries were stuck in POD. On chromopertubation with saline, bilateral spill was present.
Her endometrial biopsy report showed proliferative endometrium with no granuloma. TB PCR was negative.
Patient was started on category I antitubercular treatment in view of genital Koch's for six months. Treatment as per Revised National TB Control Program, in category I at the initial two months of therapy with INH (600 mg), rifampicin (450 mg), pyrazinamide (1500 mg), and ethambutol (1200 mg) in a thrice weekly schedule followed by INH (600 mg) and rifampicin (450 mg) in a thrice weekly schedule for the period of four months was given. After completion of her ATT course, her ultrasound showed uterus normal size with no evidence of tuboovarian mass or hydrosalpinx. Her antral follicle count was 3-4 follicles in each ovary.
The patient was planned for ovulation induction with intrauterine insemination. Before intrauterine insemination, there were no signs and symptoms of pelvic inflammatory disease. Pelvic examination was normal. She had three cycles of ovulation induction with two cycles of intrauterine insemination.
In her third cycle (August 2013), five days after intrauterine insemination the patient reported to the outpatient department with chief complaint of abdominal pain with fever. Acute pelvic inflammatory disease was diagnosed and the patient was admitted. Her laboratory investigations produced the following results: her blood cell counts were leukocytes of 12,000/muL (4-11000) with neutrophilia, polymorph count of 86, hemoglobin of 10 g/dL (12-16), and platelets of 206,000/muL (150-450,000). Her other serum parameters were within normal limits. Urine culture and blood culture were negative and ultrasound whole abdomen was within normal limits. She was started on intravenous antibiotics/antifungal. She became afebrile after 48 hours of intravenous antibiotics; TLC counts came down to 7700. She responded to treatment and was discharged.
24 days after intrauterine insemination (10 days after discharge from the hospital) the woman presented with low grade fever and abdominal pain. On her vaginal examination the uterus was of normal size. There was fullness and tenderness in pouch of Douglas. On ultrasound, the uterus was normal with endometrial thickness of 9.4 mm, right adnexa: 7 x 5.6 cm? tuboovarian mass. Left adnexa: hydrosalpinx of 7 cm adjacent to left ovary.
There was suspicion of relapse of tuberculosis.
The woman was started on ATT category II from DOTS (Directly Observed Treatment, Short-Course) centre. Treatment as per Revised National TB Control Program, in category II at the initial two months of therapy with streptomycin (750 mg) INH (600 mg), rifampicin (450 mg) pyrazinamide (1500 mg) ethambutol (1200 mg) in a thrice weekly schedule followed by INH (600 mg), rifampicin (450 mg), pyrazinamide (1500 mg), and ethambutol (1200 mg) in a thrice weekly schedule for period of one month followed by INH (600 mg), rifampicin (450 mg), and ethambutol (1200 mg) in a thrice weekly schedule for the period of five months was given. After 2 weeks of ATT the patient again presented with chief complaints of fever with chills and rigor and vomiting. On examination: per abdomen: 14-week palpable mass at the right side. On her vaginal examination uterus size was not made out. There was a firm mass with restricted mobility felt separately from the uterus. The patient was again admitted and started on intravenous antibiotics.
The patient continued to have fever and ultrasound showed persistence of tuboovarian masses with increasing TLC counts from thirteen thousands to twenty two thousands (13,000 to 22,000).
MRI of pelvis showed bilateral tuboovarian masses 8 x 6 cm in right, 9 x 7 cm in left adnexa suggestive of pyosalpinx likely tubercular with septations with endometritis (Figures 1, 2, and 3).
The woman was taken up for exploratory laparotomy after four weeks of ATT. The intraoperative findings were kissing tuboovarian masses with a common cyst wall adherent to intestine and having loculated pus collection. 600 cc pus was drained and sent for AFB culture and Gram staining.
The woman continued on ATT category II and was discharged on same. The purulent discharge culture reported pus cells and Gram negative bacilli. HPE of cyst wall showed fibroconnective tissue with multiple microabscess consisting of neutrophils and macrophages, hemorrhages, and foci of chronic inflammation. Few granulation tissue areas were present.
The woman completed her ATT category II which she was given for one year. Now, she is doing well. Her ultrasound shows poor ovarian reserves with persistent tuboovarian masses (Figure 4). Hence, she is counselled for adoption/IVF with donor oocyte.