When to Have an HSG after a Tubal Reversal?

HSG is the best method to determine the tubal patency (if the tubes are open).  It is not recommended to have a HSG too soon after a tubal reversal surgery.  Most will recommended at least 4 to 6 months after a tubal ligation reversal because an HSG relies on increased pressure in the tube, and it the tube is still weak where the tubal ligation reversal occurred, the tube could be damaged. Also, the risk of infection is present whenever a HSG is performed.  It is recommended that patients try for a pregnancy first before going straight to an HSG.  A good number of patients conceive within this early period and will then not need or desire to have a HSG performed.

Get ready for an HSG:

• An HSG is optimally performed after menstruation and before ovulation.  If a HSG is performed after the time of ovulation it may interfere with a pregnancy.
• To diminish the risk of infection, antibiotics and sterile technique are used.
• Gynecologists will mostly recommend a prophylactic pain prescription of 800 mg of ibuprofen one hour before the HSG to minimize discomfort.

What happens in an HSG?

You will be positioned just as if you were having a pap smear performed. The speculum will be placed, and the cervix will be grasped and retracted.  A thin tube will be inserted into the uterus and this may cause some cramping. Dye is then injected through this tube and into the uterus. At the start the dye will fill up the uterine cavity.  It is necessary that the dye in fact enters the fallopian tubes up to the end where the anastomosis was done.  Once past the tubal ligation reversal point, the dye should continue to the end of the tube and be discharged from the end of the tube into the pelvic cavity. Flow through the entire tube may not occur due to a spasm of the muscle at the base of the tubes or a spasm in the tubal segments. As such, some patients who have had a tubal reversal may in fact have a HSG that looks like the tubes are not open. This is very rare.

If the dye passes through the portion of tube that was put back together during the tubal reversal, the fallopian tubes are considered repaired. If the dye spills into the abdominal cavity, the diagnosis of tubal patency is decisive.

Note: Care is taken to note that if in the x-rays show that the dye has passed through the tubal ligation reversal site, but has not yet spilled into the abdominal cavity, this may be due to an inadequate quantity of dye being injected.  The radiologist may incorrectly consider that the tube is blocked when it is in fact open. This also is very rare as the gynecologist performing the HSG should be careful to inject a proper amount of dye.

In the past, ultrasound for infertility was done by placing a transducer on the abdomen.  This required a full bladder for greater accuracy so that the sound waves could be transmitted into the abdomen and pelvis.  However, the standard ultrasound technique used for infertility is now the vaginal, or endovaginal, ultrasound.  The procedure is much more advanced. A long, thin probe is inserted into the vagina. This probe is used for imaging the pelvic organs.  The pictures generated from a vaginal ultrasound are sharper and clearer because having the probe inside of the vagina allows the probe to get much closer to the pelvic structures.

What can be viewed on ultrasound for infertility treatments?

Ovulation scans are important in evaluating follicle size. These ultrasounds allow the gynecologist to more precisely determine when the egg matures and when ovulation occurs.  This is often the fundamental procedure for determining infertility treatments around the time of ovulation.  Daily scans are needed to visualize the emergent follicle, which looks like a black bubble on the ultrasound screen.  Useful information detected and established by these scans is the thickness of the endometrium (the uterine lining).  The ripening follicle produces estrogen, which causes the endometrium to thicken.  The gynecologist can get an excellent approximation of how much estrogen is being produced in the body based on the thickness and clarity of the endometrium on the ultrasound scan.

Multiple follicles look like black bubbles

A triple band of the myometrium in the center of the uterus

When the follicle reaches a certain size (depending on whether or not the patient has been taking fertility medication, this size will vary) a trigger injection can be given. A trigger will lead to ovulation about 36 hours after administration. The treating gynecologist will determine whether there is a need for infertility treatment after a tubal reversal surgery prior to a tubal ligation reversal. It is important that specialists in this very difficult and delicate procedure will determine the likelihood that the patient will even need such treatment BEFORE the tubal reversal surgery. The determination will involve identifying the egg quality to recommend either an IVF procedure or a tubal reversal. This evaluation is based on and mostly determined by the follicles’ growth and ability to ovulate.

Ultrasound has helped transform our method of evaluating infertile patients.  Ultrasound technologies are the most modern addition to the gynecologist’s measures. Ultrasound can provide an image of the internal reproductive structures of the female pelvis.  Ultrasound works by submitting high frequency sound waves similar to SONAR machines in ships used for detecting submarines underwater.  The high frequency sound waves are applied to the pelvic organs and then are reflected back to the computer inside the ultrasound device. Sound waves are reflected back at different speeds to the computer, which then reconstructs the waves into black and white images on the monitor.  These revolutionary ultrasound machines are real-time machines that have real dynamic images.  The ultrasound can construct clear pictures of the uterus, the ovaries, fallopian tubes, and bladder. Gynecologists are able to look for fibroids, ectopic pregnancies, or any ovarian cysts in the pelvis. Gynecologists are able to gain knowledge that helps with even delicate procedures like tubal reversal surgery and tubal ligation reversal.

Ultrasound is also an outstanding device for early diagnosis of pregnancies. However, for some procedures, like tubal reversal, and tubal blockage (hydrosalpinx), the gynecologist may need to perform additional procedures to assess the tubes.  For tubal reversal surgery, before the procedure, it is a normal task of the infertility specialist to have an ultrasound image of the pelvic organs.

Who can perform ultrasound scans?

Ultrasound scans are performed by a radiologist, a gynecologist, or an infertility specialist. Instant decisions about your treatment, based on the images obtained, can then be made.

What is Endometrial Ablation for the management of endometriosis or ovarian cysts?

For a patient with endometriosis, and especially when ovarian cysts related to endometriosis are found (an endometrioma), managing endometriosis and ovarian cysts is effective for both reducing pain and for increasing fertility.  In patients with documented infertility, ablation of the endometriosis implants and removal of the ovarian cysts is the most effective way to restore fertility.

Conventional surgical treatment of ovarian cysts (endometriomas) involves access to the ovaries through an abdominal incision, or via laparoscopy, for drainage of the cyst contents and removal of the cyst membrane or wall.  The procedure has some disadvantages, but generally produces excellent results.  Normal ovarian tissue is unintentionally removed along with the cyst membrane or wall, which may reduce the amount of obtainable oocytes for succeeding fertility treatment.  Other complications may be experienced as a large percentage of these patients have an advanced-stage disease, or may have had multiple previous surgeries with resultant scar tissue.  In the occurrence of pelvic adhesions (scar tissue), visualization of the anatomic structures may be insufficient, and ablation of all implants may not be realized.

After endometrial ablation, patients may try to conceive through natural conception with timed intercourse (during ovulation) or by intrauterine insemination. Patients who have undergone a tubal ligation reversal may have been found to have endometriosis implants inadvertently during the tubal reversal surgery. Dr. Morice will remove any endometriomas found during the course of the tubal reversal surgery.  Since the process is linked with a small possibility of adhesion creation, some patients may form adhesions after their tubal reversal, which could lead to scarring down of the tubes and blockage of the tubes even after tubal ligation reversal. A hysterosalpingogram (HSG) is recommended 3 months after tubal ligation reversal surgery for these patients found to have endometriosis or ovarian cysts.

When is needle aspiration the best option to manage ovarian cyst(s)?

About 6% of women will have an ovarian cyst after menopause.  Factors such as age, menopausal status, size, and type of an ovarian cyst will determine the proper management of such ovarian cysts.  This information in most cases will predict whether the cysts are benign (functional), or likely to be cancerous. One option for benign cysts is needle aspiration.

Needle aspiration of ovarian cysts can sometimes be performed in the physician’s office using ultrasound guidance. The needle aspiration can be made using local anesthetic only, which is less involved than surgical operative intervention, and a patient does not require a hospital admission. Alternatively, aspiration can be done surgically, by either a laparoscopic or classical surgical approach.

There is always the risk of side effects and injury linked to the management of ovarian cysts by either medication or surgery. In the field of assisted reproductive technology (ART), and for patients having ovarian cysts after a tubal reversal, a needle aspiration is often attempted prior to a surgical intervention.  If the cysts are present during the tubal ligation reversal, they can be aspirated or removed at the time of tubal ligation reversal.

Estrogen, the primary female hormone used by a women’s body, depends primarily on ovarian follices for production.  Once there are no ovarian follicles for egg release, the level of estrogen in the body will start to fall.  Because of decreasing ovarian follicles, after a tubal reversal it is important to monitor the ovarian follicles to improve the likelihood of a pregnancy.  Estrogen also helps to control a variety of other bodily functions such as the maintenance of vaginal moisture, bone density, skin temperature, and several brain activities. The decrease of Estrogen causes most of the symptoms associated with the menopause.

Decreased Estrogen is associated with:

1. Hot flashes,
2. Vaginal dryness,
3. Mood changes,
4. Urinary incontinence,
5. Night sweats,
6. Loss of sex drive,
7. Thinning of the bones which can lead to osteoporosis

Most of these symptoms appear within 2-5 years after the initial decline of Estrogen.  The vaginal dryness is likely to worsen in older women if it is not treated.  The risk of osteoporosis also increases with age.

Estrogen as a neurotransmitter

Estrogen plays an essential role in brain activities by increasing the amount of mood-regulating neurotransmitters.  If not available, some breakdown of mood-regulating neurotransmitter triggers may result in depression.  Estrogen has been shown to increase the ability of neurons in the brain to function.  Estrogen also plays a role in the appropriate flow of blood to different parts of the brain.  As such, Estrogen plays an active role in optimizing emotion, memory, and cognitive functions. Following pregnancy, women often have a severe decrease in their Estrogen level.  As a result, 50 -70% women are estimated to have postpartum depression within the first 10 days after their delivery. 10% may suffer a major depression.  According to a study, more than 60% of women with postpartum depression may develop depression later in their lives.  During menopause and perimenopause, the striking decline in estrogen level makes women more susceptible to acute mood swings.  Many studies demonstrate to the close connection between estrogen and mood swings. Patients are often concerned about the relationship between stress and surgery, and how this will affect their Estrogen levels. Most surgeries, such as a tubal ligation reversal surgery, are short outpatient surgeries and should not affect the Estrogen level at all. Tubal reversal surgery alone will not injure the ovaries, and in general any surgery done on the fallopian tubes should not interfere with the production of Estrogen.

The hypothalamus is a small gland found at the base of the brain, which fundamentally operates as a thermostat for reproductive hormones.  It controls the levels of a number of hormones produced by providing responses to and stimulation of the pituitary gland.

How does the hypothalamus works?

The hypothalamus produces gonadotropin-releasing hormone (GnRH), which signals to increase or decrease hormone production throughout the first phase of a women’s ovulatory cycle.  In the feedback response, the pituitary increases FSH production that then causes follicle production in the ovaries. The production of estrogen is then accomplished as the follicle enlarges. As estrogen levels increase, the FSH levels eventually decrease.  Once the follicles are mature, the hypothalamus signals a spike in luteinizing hormone (LH), which leads to ovulation 36 hours later.  If something within this course is uneven or missing, and the process of ovulation does not occur, infertility will result.

Irregular ovulation can be due to numerous factors, but most frequently is secondary to the failure of the ovary to produce a follicle that ovulates.  Anovulation occurs when the ovaries cannot release eggs for fertilization. Although this is a natural consequence of aging associated with menopause, it may occur earlier in some women.

Some factors in irregular ovulation are:

1. Hyperprolactinemia – abnormally elevated prolactin levels. This may be due to a small tumor on the pituitary and may require medications and/or surgery.
2. Thyroid dysfunction – hyperthyroidism or hypothyroidism.  Thyroid levels can cause irregular ovulation. Medications can be used to treat thyroid dysfunction.
3. Adrenal disorders.  Androgens are male hormones, such as testosterone, produced by the ovaries and adrenal gland.  High levels may lead to oligo-ovulation.
4. Environmental factors like pollution, radiation, etc.
5. Excessive exercise, obesity, and/or stress

Fertility treatments are available for such cases.  In these situations, it is assumed that the fallopian tubes are still open, unless the patient has had a tubal ligation surgery. A special test called a hysterosalpingogram can be done to make sure that the fallopian tubes are open. If the patient has had a tubal ligation, she would need to have a tubal reversal performed to open the tubes again. Any patient who will be undergoing a tubal ligation reversal would benefit from a hormonal evaluation prior to the tubal reversal surgery to ensure that once her tubes were reversed, she would not have infertility from a hormonal issue.

What is HCG?

HCG stands for human chorionic gonadotropin, and is known as ‘the pregnancy hormone.’  HCG is formed by trophoblastic cells in the embryo (pregnancy).  These cells occupy the uterine lining and build up into the placenta.

What essential work is done by HCG in the pregnancy?

HCG stimulates the ovary to make progesterone.  Progesterone is the hormone that maintains the endometrial lining of the uterus for carrying the pregnancy.  In the normal menstrual cycle, progesterone made by the ovary only lasts for 2-weeks after ovulation.  After 2-weeks, the progesterone level falls and menstruation begins.  However, if pregnancy occurs, HCG stimulates the ovaries to produce progesterone to prevent menstrual bleeding.

Early pregnancy monitoring after tubal ligation reversal through HCG

Pregnancy tests perceive HCG.  Urine pregnancy tests typically can identify HCG within 14-16 days after ovulation.  Blood pregnancy tests are more receptive for a positive pregnancy and can perceive HCG within 10-12 days after ovulation.

Quantitative tests for HCG

Whether urine or blood tests, are those that actually measure the HCG in the blood stream.  When women become pregnant after tubal ligation reversal surgery, quantitative HCG assays should be performed as soon as a positive home pregnancy test (a qualitative test) is positive.  Once the quantitative serum HCG levels reaches 1500-2000 mIU/ml, a vaginal ultrasound should be able to identify a gestation sac within the uterus.

HCG doubling time

In a normally developing pregnancy, quantitative serum HCG levels increase twofold every 2-3 days during the initial weeks of pregnancy. Repeating HCG tests after a tubal reversal surgery can help indentify normal pregnancies versus ectopic or abnormal pregnancies.

What types of tests are needed for tubal reversal preoperatively?

These tests are needed to assess the preoperative condition of the patient.  These blood analysis are compulsory prior to your tubal ligation reversal.  They can be prearranged by your regular gyneclogist, or can be done at your local laboratory facility (DR. MORICE WILL FAX AN ORDER TO YOUR LOCAL FACILITY):

1. Complete blood count (CBC)
2. Urinalysis
3. Possibly hormonal studies
4. Possibly a semen analysis

Preoperative lab results must be done within 7 days of the surgery date. In the case of abnormal test results, possibly indicative of some medical problems, the surgery will be postponed.

Additional preoperative tests may be needed according to an individual’s prior medical history, such as:

1.       Cycle day 3 FSH – done for women 40 and older. This will assess ovarian function and quality of reserve of eggs.  The “egg quality testing” for patients will ensure their chances if are still good for conceiving after the tubal reversal.

1. Semen analysis for male partner is sometimes ordered.  A semen analysis should be performed prior to your tubal ligation reversal. Although artificial insemination is inexpensive and effortless, you need to know if it will be necessary before you undergo tubal reversal surgery.
2. Urinalysis.
3. Testing of the uterus to ensure there are no problems which would hamper with pregnancy as fibroids or other uterine abnormalities.
4. A baseline mammogram – pregnancy after a tubal ligation reversal complicates treatment for breast cancer and visa versa.
5. AIDS testing if having likelihood.

If egg quality is impaired, then IVF may be the best option rather than tubal reversal.

What is the most appropriate management for ovarian cysts?

Management of ovarian cysts should be done carefully so as to avoid any subsequent effects. In general, cysts can be managed medically with birth control pills or medicines that affect the pituitary gland. If a patient is found to have an ovarian cyst when she is being evaluated for a tubal reversal surgery, the cysts can be removed during the tubal reversal surgery. If the patient is not being evaluated for a tubal reversal surgery, and surgery is not an option, all medical treatments should be exhausted before surgery is considered.

Medical versus Surgical Ways of Managing Ovarian Cysts:

Women who are not taking oral contraceptives, women who are still at a reproductive age and who suffer no pain, and women who are candidates for tubal reversal or have had a tubal reversal should proceed with the conventional medical approach. This will prevent any potential surgical complication, and is the safest way to proceed initially.

Conventional surgery:  For a non-malignant cyst, conventional surgery may be an option.  This may allow a patient to keep her ovaries and simply have the cysts removed.  This operation is called an ovarian cystectomy. Gynecologists will keep the injury to the tissues at a bare minimum, with precise control of bleeding during the surgery. Side effects may include the development of pain and/or painful “adhesions” on the ovaries, infertility, or excessive sensitivity during intercourse.

Laparoscopic method:  This is the most common modality for an ovarian cystectomy. Small cuts are made in the abdomen rather than conventional surgical techniques.  It is an advance that avoids large incisions, reduces pain, and allows for more rapid healing.  If one of the ovaries has been seriously impacted by the cysts, while the other has been intact, the affected ovary may be removed completely.

Hysterectomy: Surgery will allow the gynecologist to see if a cyst has been the result of  edometriosis and results in a collection of old blood. For a woman who has already given birth to her children, this case of “chocolate cysts,” or an endometrioma, can only be cured by a hysterectomy and removal of both ovaries. This is usually necessary rather than optional in order to resolve the problem forever. According to the severity of disease, the patient’s age, and potential other pelvic complaints, removal of the ovary may be the most indicated course.  The surgery is also obligatory for ovarian cancer as the patients have a low rate of survival otherwise.