Female genital tuberculosis accounts for a significant propor t ion of extra pulmonary tuberculosis and remains an important cause of infertility worldwide [1]. Despite this, it is frequently underdiagnosed due to its indolent course, nonspecific symp toms, and overlap with common gynaecological conditions such as pelvic inflammatory disease. In infertility practice, failure to recognise genital tuberculosis early may result in repeated inef fective treatments, delayed diagnosis, and unsafe use of assist ed reproductive technologies [2,3]. This case illustrates a com mon diagnostic pitfall and reinforces the clinical importance of systematic evaluation before fertility treatment [4].

A 21-year-old woman presented with primary infertility of f ive years’ duration. She had previously received three cycles of ovulation induction with clomiphene citrate at another centre without success. There was no history of pulmonary tuberculo sis, pelvic inflammatory disease, or previous pelvic surgery. Her medical history was notable only for bronchial asthma. Men strual cycles were regular, and physical examination was unre markable.

Investigations

Transvaginal ultrasonography demonstrated a hypoplastic, subseptate uterus. Hysterosalpingography revealed left-sided hydro salpinx with tubal obstruction. Diagnostic hysteroscopy showed intrauterine synechiae and a T-shaped uterine cavity. Laparoscopy revealed dense pelvic adhesions and a markedly dilated left fallopian tube. A left salpingectomy was performed due to severe tubal damage. Histopathological examination of the excised tube showed granulomas composed of epithelioid histiocytes and lymphocytes with central caseating necrosis and Langhans-type giant cells, consistent with tuberculous salpin gitis. No malignancy was identified. A tuberculin skin test was positive, supporting the diagnosis.

Differential diagnosis

• Chronic pelvic inflammatory disease

• Endometriosis

• Tubal factor infertility of non-infectious origin

• Genital malignancy (excluded histologically)

Treatment

The patient received standard first-line antitubercular thera py consisting of isoniazid, rifampicin, and pyrazinamide during the intensive phase, followed by isoniazid and rifampicin for a total treatment duration of six months.

Outcome and follow-up

Following completion of antitubercular therapy, the patient was referred for assisted reproduction. She underwent IVF, and the first embryo transfer resulted in a successful pregnancy. A healthy infant weighing 2 kg was delivered in July 2022. The neonate required short-term neonatal intensive care but was discharged in good condition. Both mother and child remained well on follow-up.

Although FGTB is well documented in the literature, delayed diagnosis remains common, particularly in infertility settings where empirical ovulation induction may precede thorough eti ological evaluation [1,3]. In this case, repeated ovulation induc t ion without tubal assessment delayed diagnosis and definitive management. This report highlights three clinically important issues. First, unilateral hydrosalpinx in young women from TB endemic regions should prompt consideration of genital tuber culosis. Second, histopathological examination remains crucial for diagnosis, as microbiological tests may have limited sensit ivity in genital disease. Third, assisted reproductive techniques should be deferred until completion of antitubercular therapy due to the risk of disease reactivation and adverse pregnancy outcomes, including congenital tuberculosis. While fertility out comes following FGTB are often poor due to residual structural damage, this case demonstrates that successful pregnancy is achievable when diagnosis and treatment occur before irrevers ible endometrial destruction.

Learning points

• Female genital tuberculosis should be considered in young women presenting with unexplained infertility or hydrosal pinx, especially in TB-endemic regions.

• Empirical ovulation induction without definitive evaluation may delay diagnosis and worsen reproductive outcomes.

• Histopathological confirmation plays a pivotal role in diag nosing genital tuberculosis.

• Assisted reproductive techniques should only be undertaken after completion of antitubercular therapy.

• Early recognition and treatment can result in successful fer tility outcomes despite tubal disease.

Patient perspective: “After years of unsuccessful treatment, receiving a diagnosis explained the cause of my infertility. Com pleting treatment and then achieving pregnancy gave me hope and confidence in my care.”

Consent: Written informed consent was obtained from the patient for publication of this case report.