Miliary tuberculosis after in vitro fertilization and embryo transplantation

Case-controlled study of tuberculosis in in-vitro fertilisation-embryo transfer and natural pregnancy

OBJECTIVE

To improve the understanding of the clinical features and imaging characteristics of pregnant women with and without in-vitro fertilisation-embryo transfer combined with pulmonary tuberculosis (TB).

METHODS

A retrospective analysis was conducted involving 50 patients with pregnancy who had pulmonary TB and were admitted to the Third People's Hospital of Kunming (China) between 1 January 2017 and 31 December 2021. These patients were divided into an in-vitro fertilisation and embryo transfer (IVF-ET) conception group and a natural conception group according to the conception method. The clinical and imaging data were then collected and compared.

RESULTS

The mean age of the IVF-ET group (n = 13, 31.85 ± 5.84 years) was higher than in the natural conception group (n = 37, 27.05 ± 5.5 years). The proportions of fever, haematogenous TB and extrapulmonary TB in the IVF-ET group (92.31%, 84.62% and 76.92%, respectively) were higher than those in the natural conception group (40.54%,16.22%,27.03%,respectively). The percentage of patients with pregnancy who had intracranial TB (76.9%) in the IVF-ET group was higher than in the natural conception group (10.8%). The percentage of pregnancy terminations in the IVF-ET conception group (84.62%) was higher than in the natural conception group (48.65%). All the above results had statistically significant differences (p < 0.05).

CONCLUSION

Overall, IVF-ET conception combined with extensive pulmonary TB lesions lead to heavy systemic toxic symptoms, severe disease and poor pregnancy outcomes. Therefore, screening for TB prior to performing IVF-ET is recommended.

Clinical analysis of pregnancy complicated with miliary tuberculosis

BACKGROUND

Pregnancy complicated with tuberculosis is increasingly common. The clinical characteristics of pregnancy complicated with miliary tuberculosis are summarized in this study.

METHODS

A retrospective analysis of pregnant patients with miliary tuberculosis was performed in terms of epidemiology, demography, clinical characteristics, laboratory tests, treatment, and prognosis.

RESULTS

Of the 23 patients that were included, 12 became pregnant after in vitro fertilization combined with embryo transfer (IVF-ET). The average gestational age at symptom onset was 13.96 weeks, and the average time from symptom onset to diagnosis was 33 days. Clinical symptoms included fever, dyspnoea, cough, headache, abdominal pain, and chest pain. Extrapulmonary tuberculosis occurred in 10 patients, respiratory failure in 11 patients, and ARDS in 9 patients. Chest HRCT showed diffusely distributed miliary nodules in all patients. Six patients were on mechanical ventilation, two underwent ECMO, and one died. Symptoms appeared in the first trimester of nine pregnancies after IVF-ET and in the second trimester of seven natural pregnancies.

CONCLUSIONS

Miliary tuberculosis can occur in pregnant patients, especially in patients after IVF-ET. Symptoms often appear in the first trimester of pregnancy after IVF-ET and in the second trimester of natural pregnancy. Lacking specificity, the common clinical characteristics include elevated inflammation markers, anaemia, low lymphocyte count, and multiple miliary nodules shown on a chest HRCT scan. Half of patients with miliary tuberculosis may develop respiratory failure, and some may progress to ARDS. Therefore, infertile patients should be required to undergo TB screening before undergoing IVF-ET, and preventive anti-TB treatment should be given to patients with latent TB infections or untreated TB disease.Key MessageMiliary tuberculosis can occur in pregnant patients, especially in pregnant patients after IVF-ET. Symptoms often appear in the first trimester of pregnancy after IVF-ET and in the second trimester of natural pregnancy. Many patients develop respiratory failure or ARDS.

Association of in vitro fertilization with maternal and perinatal outcomes among pregnant women with active tuberculosis: A retrospective hospital-based cohort study

Background

Study on effect of fertilization methods on maternal and perinatal outcomes with respect to TB during pregnancy was scarce. This study aimed to analyze maternal and perinatal outcomes in active TB cases after in vitro fertilization (IVF) treatment vs. normal pregnancy.

Methods

Clinical data of 80 pregnant women with active TB hospitalized at Shanghai Public Health Clinical Center between June 1st, 2014 and November 30th, 2020 were extracted and retrospectively analyzed. History of receiving IVF was recorded at admission and its association with maternal and perinatal outcomes were assessed using multivariable logistic regression models with adjustment for potential confounders.

Results

Of the 80 pregnant women with active TB, 28 (35.0%) received IVF treatment and 52 (65.0%) did not receive IVF treatment. After adjusting for potential confounders, receiving IVF was associated with worse maternal and perinatal outcomes, including maternal criticality (21.4 vs. 2.0%, adjusted OR = 28.3, P = 0.015), miliary TB (89.3 vs. 13.5%, adjusted OR = 75.4, P < 0.001), TB meningitis (32.1 vs. 7.7%, adjusted OR = 6.2, P = 0.010), and perinatal mortality (64.3 vs. 28.8%, adjusted OR = 9.8, P = 0.001).

Conclusion

The additional risk of TB to women receiving IVF treatment is a public health challenge specific to countries with a high tuberculosis burden. Increased awareness of latent tuberculosis infection in women receiving IVF treatment is needed.

Analysis of Clinical Features and Risk Factors in Pregnant Women With Miliary Pulmonary Tuberculosis After In Vitro Fertilization Embryo Transfer

Purpose

Miliary pulmonary tuberculosis (TB) among pregnant women after in vitro fertilization embryo transfer (IVF-ET) causes poor outcomes but is rarely reported. This study analyzed the clinical characteristics and risk factors of these patients to provide hints for further studies.

Method

The demographic characteristics, clinical manifestations, radiologic features, treatment, and outcomes of six patients diagnosed from May 2012 to August 2021 in Xiangya Hospital and 69 patients that were reported in English or Chinese literature from January 1980 to August 2021 were retrospectively analyzed. Continuous variables were compared between groups by t-test or Mann–Whitney U test, and categorical variables were compared between groups by chi-square test or Fisher exact test. Univariate and multiple logistic regression analyses were used to determine the predictors of respiratory failure.

Results

A total of 75 patients were included. The average age of patients was about 30 years. All patients had tubal obstruction; 5 of them were diagnosed with pelvic TB before. Thirteen cases had a history of pulmonary or extrapulmonary TB, six out of them without any antituberculosis treatment history. All patients were in their first or second trimester during the onset of symptoms. The average interval between onset of symptoms and radiologic examination was about 21 days. The most common abnormalities on chest computed tomography scan were multiple nodules, pulmonary infiltrate, and consolidation. Merely 10 patients obtained bacteriological diagnosis by Mycobacterium tuberculosis culture or polymerase chain reaction test. The other patients were clinically diagnosed. All the patients received antituberculosis treatment. Although 44% of patients had fatal complications, all cases were cured or improved after antituberculosis treatment. Unfortunately, only eight fetuses survived (10.6%). The most frequent and severe complication was type I respiratory failure (20%). Patients with expectoration, dyspnea, coarse breath sounds, ground-glass opacity, and pulmonary infiltrate or consolidation were more likely to have respiratory failure (P < 0.05). Ground-glass opacity (OR = 48.545, 95% CI = 2.366–995.974, P = 0.012) and pulmonary infiltrate or consolidation (OR = 19.943, 95% CI = 2.159–184.213, P = 0.008) were independent predictors for respiratory failure.

Conclusion

Tube infertility with underscreened or untreated TB is a risk factor for miliary TB during pregnancy after IVF-ET. Ground-glass opacity and pulmonary infiltrate or consolidation are predictors of respiratory failure. We demonstrate risk factors for incidence and complications to supply clues for future intervention and improve patient prognosis.

Congenital tuberculosis in a neonate following in vitro fertilization-embryo transfer: A case report

BACKGROUND

Congenital tuberculosis is becoming increasingly common, but congenital tuberculosis infection in neonates following in vitro fertilization and embryo transfer (IVF-ET) has been rarely reported; a diagnosis of congenital tuberculosis is often delayed due to the non-specificity of maternal IVF treatments and clinical manifestations during pregnancy-particularly in low-birth-weight preterm infants.

CASE PRESENTATION

We herein report a case of congenital tuberculosis. The infant was born at 27+5 weeks of gestation and was admitted to the hospital due to hypopnea after birth. Due to a poor response to treatment, we conducted pathogenic microorganism metagenomic analysis to assess the nucleotide sequences within the Mycobacterium tuberculosis complex. After collecting sputum, the strains from the tuberculosis analysis were isolated and confirmed. From a detailed examination of the mother and in accordance with the child's congenital tuberculosis, we confirmed the diagnosis of pelvic tuberculosis.

CONCLUSION

IVF treatment and pregnancy can exacerbate latent tuberculosis, especially in women from a family with a history of tuberculosis infections. We posit that the optimal way to prevent neonatal congenital tuberculosis in IVF-ET is to procure a detailed maternal medical or family history and to identify and treat maternal tuberculosis during IVF treatment.

Disseminated Hematogenous Tuberculosis Following in vitro Fertilization-Embryo Transfer: A Case Report

This study aimed to analyze the diagnosis and treatment process of patients with hematogenous disseminated pulmonary tuberculosis after treatment with in vitro fertilization-embryo transfer (IVF-ET). We retrospectively analyzed the clinical data, including imaging and etiological data, the use of antimicrobials, metagenomic next-generation sequencing (mNGS) results, and the treatment process, of a patient who underwent IVF-ET due to an obstruction in the fallopian tube; after the treatment, she developed a persistent fever with shortness of breath and suffered a spontaneous abortion. Due to the failure of other treatment modalities, fiber optic bronchoscopy was performed, and the alveolar lavage fluid was obtained for mNGS. Tests for Mycobacterium tuberculosis and rifampicin resistance (Xpert MTB/RIF) showed positive and negative results, respectively. Subsequently, anti-tuberculosis treatment with isoniazid, rifampicin, pyrazinamide, and ethambutol was administered. After the patient's condition improved, she was transferred to a specialized tuberculosis hospital for further treatment, where she died one month later from multiple organ failure. From this case, we conclude that clinicians should remain highly vigilant for pulmonary infection with M. tuberculosis in pregnant women, particularly in patients treated with IVF-ET, and check for its presence as soon as possible.

Acute miliary tuberculosis in pregnancy after in vitro fertilization and embryo transfer: a report of seven cases

Background

While miliary tuberculosis (TB) in pregnancy is rare after in vitro fertilization and embryo transfer (IVF-ET), it poses a serious threat to the health of pregnant women and their fetuses. The present study aimed to describe the clinical features of miliary TB and pregnancy outcomes of patients after IVF-ET.

Methods

Data of infertile patients who received IVF-ET at Peking University Third Hospital between January 2012 and December 2017 were retrospectively analyzed. Patients who developed miliary TB during pregnancy were identified, and clinical characteristics of miliary TB were described.

Results

Out of 62,755 infertile women enrolled, 7137 (11.4 %) showed signs of prior pulmonary TB on chest X-ray (CXR). Among the 15,136 women (mean age: 33.2 ± 5.0 years) who successfully achieved clinical pregnancy, seven patients aged 28–35 years had miliary TB during pregnancy, with two patients having a complication of TB meningitis. All these patients presented with fever. Notably, old TB lesions were detected on CXR in six patients before IVF-ET; nevertheless, no anti-TB therapy was administered. Furthermore, salpingography revealed oviduct obstruction in all patients (7/7). Patients received anti-TB therapy following a diagnosis of miliary TB and were clinically cured. However, pregnancy was terminated due to spontaneous (4/7) and induced (3/7) abortion.

Conclusions

TB reactivation, mostly as miliary TB and TB meningitis, is severe in pregnant women after IVF-ET and deleterious to pregnancy outcomes. Signs of prior TB on CXR may be risk factors for TB reactivation during pregnancy.

A woman with disseminated tuberculosis experienced preterm delivery, fallopian tube pregnancy, and delivered successfully following in vitro fertilization: a case report

BACKGROUND

Disseminated tuberculosis (TB) is a fatal disease resulting from hematogenous dissemination of Mycobacterium tuberculosis. Spontaneous pregnancy rate of women with TB is low; furthermore, live birth, spontaneous abortion or ectopic pregnancy may be the outcomes even if pregnancy occurs.

CASE PRESENTATION

We report a case of a woman with disseminated TB who had a series of complications including preterm delivery with congenital TB and infant death of pulmonary TB, fallopian tube pregnancy. She was treated by in vitro fertilization-embryo transfer (IVF-ET), and gave birth to a healthy baby.

CONCLUSION

Disseminated TB has a significant impact on female fertility. We should take more active efforts to diagnose and treat this disease in a timely fashion. Moreover, IVF treatment is a feasible approach for an infertile woman after TB.

A case report of cervical pregnancy after in vitro fertilization complicated by tuberculosis and a literature review

Although female genital tuberculosis may lead to infertility, pregnancy is still possible, especially through in vitro fertilization (IVF). In this eventuality, even latent tuberculosis (TB) infection is prone to reactivate. Because some of the symptoms of TB overlap with those of pregnancy, diagnosis and treatment may be delayed. We report the case of a 30-year-old infertile woman with repeated genital tuberculosis (GTB) who underwent two laparoscopic surgeries and anti-TB treatments. The woman conceived through IVF and, unfortunately, a cervical pregnancy was diagnosed, together with a third recurrence of GTB. When the condition became stable after anti-TB treatment, the pregnancy was terminated using oral mifepristone in combination with an ultrasound-guided local injection of methotrexate. The gestational sac was expelled 4 days later with minimal blood loss. In view of the reciprocal influence and interconnection between IVF, pregnancy, and TB, we conducted a literature review to provide valuable information for early diagnosis and treatment, as well as for routine screening before IVF of TB in infertile patients.

Genital tuberculosis screening at an academic fertility center in the United States

BACKGROUND

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.

OBJECTIVE

This study aimed to characterize the prevalence of female genital tuberculosis in infertile patients at our academic fertility center.

STUDY DESIGN

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.

RESULTS

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.

CONCLUSION

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.

Congenital tuberculosis after in vitro fertilization: suggestion for tuberculosis tests in infertile women in developing countries

Congenital tuberculosis (CTB) after in vitro fertilization (IVF) is a major new problem in developing countries. Only 16 cases of CTB after IVF have been reported, and no tuberculosis (TB) tests were performed before IVF in these cases. However, on the basis of data in the literature and from the World Health Organization, the incidence of CTB has been substantially underestimated. We describe two cases of CTB after IVF in detail in our center and provide new insight into the important issue of controlling TB vertical transmission in developing countries. Performing an early diagnosis of CTB, mostly based on evidence of maternal infection and a high index of clinical suspicion, is a challenge. However, most mothers have no symptoms of TB infection during prepartum, and infertility may be the only symptom. Infertility caused by genital TB is common in countries with a high TB burden, and IVF is considered to be an effective treatment to improve their fertility. Therefore, this may lead to more CTB cases without thorough TB tests before IVF. We suggest that thorough TB tests should be conducted in infertile women before IVF to prevent CTB.