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.

Cysts may grow and enlarge without symptoms and go unobserved until they are found on routine examination.  However, some cysts will burst during routine activities such as by sexual intercourse, any injury, or childbirth. Cysts may become bulky enough so that the following symptoms may occur:

• Severe abdominal pain
• Menstrual cycle changes, such as delayed periods, intermittent bleeding between periods, or irregular periods.  This may even occur with corpus luteum cysts and polycystic ovaries.
• Heavy menstrual flow
• Infertility; a symptom occurring in polycystic ovaries and endometrial cysts.
• Internal bleeding may occur with endometrial cysts or hemorrhagic cysts.
• Severe menstrual cramps
• Pain with sexual intercourse
• Pain during a bowel movement
• Weight gain

Note: If a cyst becomes enlarged, the woman may experience intermittent pain.  Unexpected or abrupt sharp pain may indicate that a cyst has ruptured.  The twisting distortion or break of a cyst may add to the likelihood of a torsed ovary or an infection.

Some unexpected onsets need instant medical attention, such as:

• fever,
• abdominal pain,
• vomiting and symptoms of shock such as cold,
• clammy skin
• rapid breathing

Enlarged ovaries, ovarian cysts, or polycystic ovaries are relative concerns to watch after a tubal reversal or any surgical procedure. If the above symptoms exist in a patient who has undergone a tubal reversal, it may be more concerning to the patient, but should be treated as appropriately as medically indicated. Cysts that occur after a tubal reversal should have no effect whatsoever on the likelihood of achieving a pregnancy after a tubal reversal.

How do gynecologists proceed with diagnosing Ovarian Cysts?

Although we do not see an increase in the rate of ovarian cysts after tubal reversal surgery, polycystic or simply cystic ovaries are one of the concerns some patients have expressed after tubal reversal surgery. For most, a thorough exam after the tubal reversal surgery, or close monitoring after the tubal reversal surgery will alleviate these fears.

Predicting whether a cyst is benign or malignant is not always straightforward.  Clinical examination, serum concentrations of CA 125, and ultrasonography are the main diagnostic protocols available.

Clinical examination is often unsatisfactory, with 30-65% of ovarian tumours being unnoticed and mostly overlooked by most doctors.  Ultrasound studies of ovarian cysts will however confirm the presence or absence of cysts in nearly all cases. Combined with a pelvic exam, this will lead to diagnosing close to 100% of all cysts.

Vaginal ultrasonography is the most widely performed and accurate procedure for prediction of the benign nature of a cyst.

How do Gynecologists conduct the evaluation?

1. Gynecologists first take a detailed medical history of the patient and perform a physical examination.  During the physical examination the gynecologist will perform a pelvic exam.

2. In a pelvic exam the gynecologist will place an instrument called a speculum into the vagina and will examine the vaginal walls and the cervix. The gynecologist may take samples of vaginal discharge or perform a Pap smear (removing cells from the cervix with a small brush). Samples are sent to a laboratory for microscopical examination.

3. The gynecologist will then do a bimanual exam by inserting two fingers into the vagina and placing the other hand on the abdomen to examine the size and shape of the uterus and ovaries.  The ovaries may feel larger than normal and this exam may make the patient have discomfort.  If cysts are felt, the gynecologist will suggest additional laboratory and diagnostic tests.

4. Laboratory tests mostly include;

a)        a complete blood count (CBC) and a WBC to perceive any infection and internal bleeding,

b)a pregnancy test to identify uterine pregnancy or ectopic pregnancy.

5. Diagnostic tests include an ultrasound, Doppler studies, Vaginal ultrasonography, and if needed, an x-ray and laparoscopy.

6. An ultrasound test mostly able to shows size, numbers and what the cysts are made of.  If the patient having the cyst is consisted of solid materials or a combination of fluid and solid materials, the gynecologist may suggest an x-ray to find whether it is a benign cyst or a malignant tumor.

7. Gynecologists may recommend later an additional diagnostic test that is laparoscopy if he suspects endometriosis having the cyst enlarged much without fluid.

8. Laparoscopic procedure involves the placing of a laparoscope (a narrow tube with a fiberoptic light at one end) into the lower abdomen.  This is done via a small incision just below the navel to detect the ovaries.  Next if the gynecologist feels the necessity, he may drain the fluid from the cyst, or he can remove the cyst entirely.

Would cysts be discovered during a tubal reversal surgery?

Yes – if you have cysts on either ovary during your tubal reversal surgery, Dr. Morice can remove the cysts at no additional charge.

Why is the diagnosis important?

The search for a diagnosis to explain ovarian cysts should be done with complete awareness of all of the possibilities.  Ovarian cysts can result from a devastating process such as ovarian cancer, or may be simply normal, enlarged follicles in a young patient who is ovulating. The reason for the cyst(s) must be determined in order to provide appropriate medical care.

Do cysts cause problems?

Most ovarian cysts are small and do not cause problems, especially if a woman is in its natural reproductive age. However, larger cysts may cause problems even if they are simply reproductive (physiological) cysts.  Pain and swelling with bloating in the abdomen are the first signs.  A simple pelvic exam can provide information about the size of the cyst(s) and their location. An ultrasound exam can determine the exact size and the relative likelihood of the cyst being a normal, reproductive cysts versus a potential cancer.

Some tests to help the diagnosis include:

1. Radiographic tests including ultrasound, CAT scan, and MRI.
2. Clinical pelvic examination
3. Laboratory tests including CA-125 serum concentrations.  In almost 70% of women who have benign ovarian cysts, the concentration is within average limits.  For malignant cyst(s), there were higher concentrations of serum CA-125 identified.  Unfortunately, 30-65% of ovarian tumors cannot be identified by serum CA-125 concentrations.
4. Vaginal ultrasonography is considered the most accurate modality for diagnosis. In most cases, the prediction of a benign versus a malignant cyst is possible.
5. Ovarian cytology is a very reliable way to know the state of ovaries.  Fluid can be withdrawn from the ovary and sent for special tests.
6. Ovarian pathology – this is the definitive method of determining if the ovary is benign or malignant, but of course this requires a biopsy or removal of the ovary.

Polycystic ovaries are one of the concerns for patients after tubal reversal. Even after a tubal reversal surgery, some patients will have problems with ovarian cysts that cause them to have difficulty in getting pregnant. Some women may not succeed in becoming pregnant after tubal reversal surgery because they do not ovulate regularly. This can be due to cystic ovaries. After tubal reversal surgery, close monitoring is needed to evaluate the fertility of women who have difficulty getting pregnant.

Which is the leading reason of female infertility?

More than 25% of cases of infertility fall in the category of  ovulatory disorders.  Ovulatory disorders, like irregular ovulation or a complete lack of ovulation (anovulation), are usually due to a hormonal imbalance.  Too much prolactin, a milk-producing hormone that suppresses ovulation, or too many androgens (produced mostly by the ovaries and adrenal glands), are considered major reasons behind ovarian dysfunction.  The imbalance of any of these types of hormone may lead to ovulatory dysfunction such that eggs do not develop properly or are not released from the follicles of the ovaries.

Signs of ovulatory disorders:  Women who are suffering from these disorders may not menstruate for several months.  Others may have vaginal bleeding even though they are not ovulating.

Some causes other than hormonal imbalances may involve:

• Eating disorders,
• Other medical disorders,
• Oligo-ovulation is a disorder in which ovulation doesn’t occur on a regular basis, and the menstrual cycle may differ from the normal cycle of 21 to 35 days.
• Exercising or dieting excessively may also stop ovulation.

How is Ovulatory Dysfunction diagnosed?

Medical history is helpful in diagnosing ovulatory dysfunction.

There are some tests that may be required to confirm the dysfunction.  One or more of the following tests will be a diagnostic tool to manage the problem further.

1.  FSH blood level: This is a blood test which is used to evaluate the amount of follicle stimulating hormone (FSH).  It is mostly used to test if a woman is approaching menopause.

2.  Progesterone blood level: A blood test that measures the amount of progesterone in blood to diagnose if ovulation has occurred.

3.  Endometrial biopsy: A sample of endometrial tissue is examined to evaluate if it is developed enough to support a pregnancy.  The endometrial tissue may support the diagnosis of ovarian dysfunction in a woman.

4.  Ultrasound:  A scan may see if the follicles are developing normally.  High frequency sound waves are used to evaluate the follicular size.  Small ovaries with a few small follicles may be a sign of various medical conditions that may affect ovarian function.

Ovulatory dysfunction must be considered when a woman has had a tubal reversal and is attempting pregnancy. Although the chances of conceiving after a tubal reversal are good, even secondary to tubal ligation, disorders of ovulation must be considered.  With a tubal reversal and proper treatment of ovulatory dysorders, most women are able to get pregnant again.

What are glandular problems?

Primary glands are involved in producing reproductive hormones in women.  Hormonal imbalances are sometimes traced back to glandular problems rather than a surgical procedure such as a tubal ligation or tubal reversal.

Primary glands include the hypothalamus, thyroid and pituitary glands.  These glands are constantly sending signals in order to maintain the balance of hormones in the body.  Having a problem with any one of these primary glands in a woman’s body could upset the natural balance of the reproductive hormones estrogen and progesterone.

Primary glands

• Hypothalamus:  The hypothalamus is a small region at the bottom of the brain.  The hypothalamus is responsible for two major jobs.  The first are metabolic processes like controlling body temperature, hunger, thirst, fatigue, and circadian cycles. The second is control of the Autonomic Nervous System.  Hypothalamic-releasing hormones are also responsible for stimulating or inhibiting the secretion of pituitary hormones.  These Hypothalamic-releasing hormones can be affected by birth control pills, stress, and some disease or medications.

• Thyroid:  The thyroid, one of the largest endocrine glands, is found in the neck inferior to the thyroid cartilage, i.e. just below the “Adam’s apple.” Hypothyroidism, in which an underactive thyroid gland can cause excessive levels of the hormone prolactin, can inhibit ovulation.

• Pituitary:  The pituitary gland, or hypophysis, is about the size of a pea and weighs 0.5 g.  Its location is at the bottom of the hypothalamus at the base of the brain.  The pituitary fossa, in which the pituitary gland resides, is located in the sphenoid bone in the middle cranial fossa at the base of the brain.  The pituitary gland secretes hormones for homeostasis, including tropic hormones that stimulate other endocrine glands.  It is functionally connected to the hypothalamus by the median eminence, and rests in a small, bony cavity (sella turcica) covered by a dural fold (diaphragma sellae).  Microscopic tumors or prolactinomas on the pituitary gland can release the hormone prolactin, which may cause infertility by interfering with ovulation.

In some cases hypothyroidism is observed as a postoperative symptom of a surgical procedure on the brain, but not with minor procedures like a tubal ligation or a tubal reversal.  Tubal reversal (tubal reanastomosis) is a surgical procedure that restores the function of the fallopian tubes after a tubal ligation.