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.

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 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.