First principle: haematogenous, not ascending
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Unlike sexually transmitted ascending PID, genital TB usually spreads through the blood from elsewhere, damaging both tube (transport) and endometrium (implantation) → infertility is a common presenting feature. Especially relevant in high‑prevalence regions.
Investigation clues and one safety rule
- Classic HSG appearances: beaded/pipe‑stem tube, cornual block, "tobacco‑pouch."
- Diagnosis rests on microbiology/histology, not imaging names alone.
- 🚩 Never perform HSG (or elective cavity instrumentation) during active genital TB — you risk dissemination.
Asherman syndrome — the scarred cavity
Endometrial trauma (especially intrauterine instrumentation around pregnancy) or infection (TB) → intrauterine adhesions → hypomenorrhoea/secondary amenorrhoea ± infertility, despite normal ovaries and axis.
Discriminators
- Amenorrhoea with normal FSH/prolactin/TSH + a uterine instrumentation history → think Asherman, not an endocrine cause (Concept 36).
Pitfalls
- Working up "secondary amenorrhoea" endocrinologically while missing an obvious curettage/procedure history.
- Instrumenting an actively infected tract.
Pearls
- 🎯 Genital TB = blood‑borne, scars tube + endometrium → infertility; no HSG in active disease.
- 🩺 Normal hormones + scanty menses after a D&C = Asherman until hysteroscopy says otherwise.
Next → Tubes, ovulation and semen converge on fertility (Concept 29).