1. HYSTEROSCOPIC MARKERS FOR ENDOMETRIAL TUBERCULOSIS Dr. PAAYAL CHOBE

2. Dr. Paayal Chobe MBBS (gold medalist), MD OBGY MBBS (gold medalist), MD OBGY Clinical fellowship in Gynae -Laparoscopy- Mumbai BEAMS Clinical fellowship in Gynae -Laparoscopy- Mumbai BEAMS Diploma in Gynae Laparoscopy KIEL & GIESSEN GERMANY Diploma in Gynae Laparoscopy KIEL & GIESSEN GERMANY Presented poster in AICOG 2003 BANGALORE Presented poster in AICOG 2003 BANGALORE Presented paper use of Misoprostol prior to hysteroscopy AMOGS 2009-Aurangabad Presented paper use of Misoprostol prior to hysteroscopy AMOGS 2009-Aurangabad Faculty in state conference AMOGS 2009 Faculty in state conference AMOGS 2009

3. GENITO URINARY TUBERCUOSIS Always secondary to Tuberculosis elsewhere in the body usually in the Lungs, Peritoneum, Lymph Glands and Bone. 1 st case was recorded by Morgagni on autopsy.

4. INCIDENCE: Involvement of organs –Norries Involvement of organs –Norries Site % Fallopian tubes 85-90 Endometrium 35-50 Ovaries 5-6 Cervix 3 Vagina & vulva 2

5. Involvement of Endometrium Involvement of Endometrium Extensive Extensive The Endometrium is replaced by hyalanized connective tissue thereby --------obliterating the cavity. The Endometrium is replaced by hyalanized connective tissue thereby --------obliterating the cavity. Patients present as Oligomenorrhoea to Amenorrhoea. Patients present as Oligomenorrhoea to Amenorrhoea.

6. HYSTEROSCOPY- Purely visual method of investigation. Purely visual method of investigation. Gives better overall view of all the pathological conditions and changes of the Gives better overall view of all the pathological conditions and changes of the endometrium. endometrium. Better tissue perception as compared to hysterosalphingography(HSG) Better tissue perception as compared to hysterosalphingography(HSG) Should ideally be coupled with laparoscopy Should ideally be coupled with laparoscopy

7. Pre-Requisites Proper counseling Proper counseling Detailed history taking and P/S P/V examinations Detailed history taking and P/S P/V examinations Pre-menstrual Pre-menstrual Role of Misoprostol prior to hysteroscopy Role of Misoprostol prior to hysteroscopy Paper presented at AMOGS 2009 study conducted at Gauravi Centre For Laparoscopy by Dr. Paayal Chobe Paper presented at AMOGS 2009 study conducted at Gauravi Centre For Laparoscopy by Dr. Paayal Chobe

8. Diagnostic Hysteroscopy Distension medium-normal saline Distension medium-normal saline Sites to look for markers-endocervix Sites to look for markers-endocervix Uterine cavity Uterine cavity Endometrium Endometrium Tubal ostium Tubal ostium

9. Hysteroscopic Pictures Normal endometrial cavity on hysteroscopy

10. Normal ostium and endometrium

11. Normal findings on hyteroscopy

12. Hysteroscopy Markers Usually os stenosed –so difficulty in passing hysteroscope---misoprostol can be used prior Usually os stenosed –so difficulty in passing hysteroscope---misoprostol can be used prior Endocervical canal-narrow Endocervical canal-narrow Endometrial cavity-obliterated,adhesions and distorted. Endometrial cavity-obliterated,adhesions and distorted. Endometrial lining-pale,patchy Endometrial lining-pale,patchy Advanced cases tubal ostia not visualised. Advanced cases tubal ostia not visualised.

13. Scanty Endometrium

14. Obliterated Endometrial Cavity

15. Fibrosed Endocervical canal & Cavity

16. Obliterated cavity Due to adhesions

17. Narrow endocervical canal

18. Confirmatory test Endometrial biopsy- Endometrial biopsy- However negative endometrial biopsy is not an indication for discontinuing AKT as HPE of endometrium does not necessarily reflect the state of fallopian tubes However negative endometrial biopsy is not an indication for discontinuing AKT as HPE of endometrium does not necessarily reflect the state of fallopian tubes

19. Endometrial biopsy

20. Other confirmatory tests TB PCR-polmerase chain reaction TB PCR-polmerase chain reaction Senitivity 80-90% Senitivity 80-90%

21. Newer horizons TB Interferon-gamma release assays TB Interferon-gamma release assays Most recent available test Most recent available test

22. Summary- Endometrial tuberculosis-important cause of infertility Endometrial tuberculosis-important cause of infertility Hysteroscopy better than HSG to diagnose Hysteroscopy better than HSG to diagnose Hysteroscopy should ideally be coupled with laparoscopy Hysteroscopy should ideally be coupled with laparoscopy Endometrial biopsy-confirmatory test Endometrial biopsy-confirmatory test