Director, Fortis Bloom IVF Centre, Fortis Bloom IVF Centre
Part 9 of 13 in Diagnosis and Management of Infertile Couple - Latest Guidelines by WHO
Genital Tuberculosis: The Infertility Cause the WHO Guideline Misses
August 28, 2026
Of all the gaps Dr. Pai identified in WHO's 2025 guideline, genital tuberculosis drew the sharpest criticism. It is common across India and many African countries, he told the room, and missing it does not just delay a diagnosis, it can make every subsequent round of IVF fail for a reason nobody has looked for.
A diagnosis that hides behind normal periods, and behind none
The clinical picture is usually amenorrhoea or very scanty periods, occasionally heavy bleeding instead. Dr. Pai's standard workup is TB-PCR and dilation and curettage with histopathology, but he treats laparoscopy as the more reliable step, since PCR testing can return a false negative even when disease is present. His fuller checklist includes a chest X-ray, palpation of cervical and groin lymph nodes, a family history of tuberculosis, sputum testing for acid-fast bacilli across three consecutive days where indicated, interferon-gamma release assays and a Mantoux test. Where suspicion is high but confirmation is elusive, he will start anti-tubercular therapy empirically rather than wait for a test that may never turn positive.
Why the guideline's silence worries him
Doctors trained in the United States or Europe, Dr. Pai argued, rarely consider tuberculosis at all, since they see so little of it; a patient who fails IUI there moves directly to IVF. In India and much of sub-Saharan Africa, where exposure is common because of crowding and socioeconomic conditions, skipping that possibility can mean repeated IVF failures with no clear cause. Once tuberculosis is confirmed, treatment is AKT-4 for two months followed by AKT-2 continuation therapy, nine months of treatment in total, and he was emphatic that stopping early, which he said many patients do once symptoms ease, risks the organism becoming drug-resistant. Completed properly, many patients conceive on their own once treatment finishes, without needing further fertility intervention at all.
This guide is based on a live Jivo Masterclass — Dr. Hrishikesh Pai taught doctors across Africa on February 15, 2026.
FROM THE LIVE Q&A
Dr. Ivan Ipavu (Uganda)
A woman with blood group O negative delivered her first child and received anti-D prophylaxis, then had a miscarriage at 16 weeks. How should such couples be managed?
Dr. Hrishikesh Pai
If antibody titres are very high, management becomes difficult. Where it is legally available, Dr. Pai suggested surrogacy carried by an Rh-negative surrogate as a way to avoid maternal antibody-mediated complications and repeated interventions such as cord blood transfusion, rather than risking complications like kernicterus in the baby.
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Frequently Asked Questions
Is letrozole considered more effective than clomiphene for ovulation stimulation?▼
Not universally. Dr. Pai calls clomiphene his master drug and reserves letrozole specifically for PCOS patients. His practice stratifies by AMH and antral follicle count: normal responders (AMH 2 to 3.5 ng/ml, AFC 7 to 15) receive clomiphene or clomiphene plus HMG; poor responders (AMH under 1.5, AFC under 7) also receive clomiphene plus HMG; hyper-responders with PCOS (AMH over 3.5, AFC over 15) receive letrozole; pure HMG is reserved for IVF cycles.
What is the referral process for sending a patient's case in for review?▼
Answered by the Jivo Healthcare coordination team rather than Dr. Pai directly: each referring doctor is assigned a relationship manager who collects and documents the case file, shares it with the Fortis coordinator and Dr. Pai's team, and returns a review with further guidance within 48 to 72 hours.
Can you say more about the injectable medications you mentioned for weight loss and obesity management?▼
Three drug classes now exist: GLP-1 agonists (semaglutide), GLP-1/GIP combinations (tirzepatide, marketed as Mounjaro), and a GLP-1/GIP/glucagon combination about to be released. Injectable semaglutide starts at 0.25 mg subcutaneously, rising gradually to 2.4 mg; an oral form (Rybelsus) is also available but must be taken daily rather than weekly. Mounjaro, launched in the US two years earlier at roughly $1,000 a month, was released in India at about one-sixth of that cost (roughly Rs 15,000 to 20,000 a month) because of the scale of global obesity; with semaglutide's patent expiring in March and around eleven companies preparing to launch competing versions in India by April, prices are expected to fall further.
There is a lot of misinformation online about Ozempic and similar drugs. What class of drug is this, and how real are the risks?▼
Ozempic is semaglutide. Untreated obesity itself carries heart, kidney, liver, joint and psychological risks that dwarf the drug's own side effects, which Dr. Pai compared to the rare risk of a plane crash or of liver failure from paracetamol, neither of which stops those products being used. He attributed the outsized scrutiny to how much public attention weight-loss drugs attract, not to an unusual risk profile compared with other common medications such as blood pressure drugs.
Does the drug create dependency, so that someone who loses weight once and regains it later has to keep using it?▼
These drugs are not used during pregnancy. Dr. Pai's protocol is to bring the patient's weight down, stop the drug, wait about a month for it to wash out, then begin ovarian stimulation, retrieve eggs, freeze embryos, and transfer roughly a month later. He noted that around 50,000 unplanned pregnancies occurred among women on Ozempic in the US with no reported harm, and drew a parallel to metformin, once considered risky in pregnancy and now used throughout it.
Why might a doctor trained outside India or Africa fail to consider genital tuberculosis as a cause of infertility?▼
Doctors trained in the United States or Europe rarely consider tuberculosis at all, since they see so little of it, so a patient who fails IUI there typically moves directly to IVF. In India and much of sub-Saharan Africa, where exposure is common because of crowding and socioeconomic conditions, skipping that possibility can mean repeated IVF failures with no clear cause identified.
What happens if a patient stops anti-tubercular therapy before completing the full course?▼
Stopping early, which many patients do once symptoms ease, risks the tuberculosis organism becoming drug-resistant.
How long does treatment for genital tuberculosis take once it is confirmed?▼
Treatment is AKT-4 for two months followed by AKT-2 continuation therapy, nine months of treatment in total.
Can a patient conceive naturally after completing tuberculosis treatment?▼
Completed properly, many patients conceive on their own once treatment finishes, without needing further fertility intervention at all.
In This Series: Diagnosis and Management of Infertile Couple - Latest Guidelines by WHO
- 1.Diagnosis and Management of the Infertile Couple
- 2.The WHO's 2025 Infertility Guideline: What Changed and Why It Matters
- 3.Diagnosing Infertility: The Female Workup, Step by Step
- 4.Male Factor Infertility: Semen Testing and Varicocele Treatment
- 5.PCOS and Ovulatory Dysfunction: Diagnosis Through Stepped Treatment
- 6.Weight-Loss Pharmacotherapy in Fertility Care: Semaglutide and Tirzepatide
- 7.Tubal Disease and Hydrosalpinx: Management and Ectopic Pregnancy Vigilance
- 8.Unexplained Infertility: From Expectant Management to IUI
- 9.Genital Tuberculosis: The Infertility Cause the WHO Guideline Misses
- 10.When to Move to IVF: Success Rates, Freezing and Genetic Testing
- 11.Fertility Preservation: Egg Freezing Before the Window Closes
- 12.Cross-Border Fertility Care: Treating Fibroids, Adenomyosis and Long-Distance Patients
- 13.The Next Frontier: AI-Driven ICSI and the Future of ART