A Quad Screen is a maternal blood screening test that is similar to the Triple Screen Test (also know as AFP Plus, the Kettering test, the Bart’s test, and Multiple Marker Screening). However, the Quad Screen looks for not only the three specific substances evaluated in those tests (AFP, hCG, and Estriol) but also a fourth substance known as Inhibin-A. It is done mainly to determine the risk of the pregnant mother carrying a child with Down syndrome. Many patients who have had a tubal ligation reversal are older and will opt for this screening test. This blood analysis is usually performed between the 16th and 18th week of pregnancy. This is used to categorize a patient as either high-risk or low-risk. A high-risk mother is then advised to have further testing which will analyze cells from the fetus for the presence of structural chromosomal problems.

What is meant by a positive Quad Screen?

A positive test means having a high risk of chromosomal abnormalities or neural tube defects. The Quad Screen can be implicated as an early precursor with an extensive deal of ensuing scientific improvements to deal the underlying problems. Patients with a positive screening are then further recommenced for more insightful and specific procedures. Most tubal reversal patients will elect to undergo invasive procedures such as an amniocentesis.

Sensitivity adjustments of the Quad Screen:

Although 78% sensitivity and 5% false-positive rate of the test makes it widely available in most countries as a common option to classify risk, the estimated sensitivity of the risk is calculated and attuned on certain factors including:

o the expectant mother’s age

o diabetic condition of the mother

o twins or other multiple gestation

o the gestational age

o weight of the mother

o ethnicity may also be adjusted in markers

These factors influence the markers, and thus interpretation is indicated for the increased risk.

Integrated Screening

This involves combined first-trimester nuchal translucency and PAPP –A, plus second-trimester Quad Screening, and improves sensitivity to 90%. As most tubal reversal pregnancies occur in older patients, many will opt for the Integrated Screen.

Limitations of the Quad Screen:

1. The test is not for a definite diagnosis

2. The test is only a precursor for more predictive amniocentesis.

3. The age of the mother is indicative for amniocentesis.

How is Trisomy 13 Diagnosed?

Due to the fact that Trisomy 13 has a distinctive set of physical characteristics, a doctor may be able make a diagnoses simply by performing a physical examination. The risk of Trisomy 13 does not increase as a result of a tubal reversal, but the risk does increase with age. To either rule out or verify this disorder, a small blood test can be performed. This blood test, a chromosomal analysis, allows doctors to ultimately verify the existence of an extra #13 chromosome.

Babies with Trisomy 13 generally have low birth weights and look premature even when they are at full-term. Babies with Trisomy 13 often have a small head with an inclined, or prone, forehead. This abnormality is due to structural malformations in the scull and in the brain. In babies with this particular genetic disorder, these characteristics can be identified after birth. Genetic disorders are not increased by a tubal reversal surgery.

Holoprosencephaly (a disorder that causes the front of the brain to be divided improperly) is also common in babies with Trisomy 13. Holoprosencephaly leads to structural problems in the growth of the baby’s face. These babies tend to have close-set eyes, cleft lips, and cleft palates. Their nostrils are not fully grown and their ears are low-set with abnormal shapes. In many cases, skin problems such as cutis aplasia (a scalp abnormality that looks like ulcers on the scalp), birthmarks (purplish-red in color), or hemangiomas (abnormal blood vessels) are also present.

Other major problems for Trisomy 13 babies include:

• Extra fingers and toes (polydactyly)
• Heart defects
• Kidney problems
• Abdominal wall disorders (omphalocele or gastroschisis)
• Malformations of the uterus

Diagnosis before birth

Any chromosomal abnormality, such as Trisomy 13, can be diagnosed before birth. The cells from the amniotic fluid or from the placenta can show defects. A fetal ultrasound (performed during a pregnancy) is not always 100 percent accurate, but can predict whether or not the fetus is at risk. To confirm the physical findings, a blood test can be taken and chromosomes can be analyzed to determine the presence of an extra #13 chromosome. As most tubal ligation reversal patients are older, and maternal age is a predictor for Trisomy 13, many tubal reversal patients will opt for definitive diagnosis prior to birth.

Correlation between Trisomy 13 and tubal ligation reversal

As a woman’s age increases, her chances of having a baby with a chromosomal abnormality also increases. Most women who desire a tubal reversal are older than the average woman trying to get pregnant. In general, the woman who opts for tubal reversal has previously had at least a couple of children before she decided to have her tubal ligation performed. Since these women are older, they are at increased risk for chromosomal abnormalities due to their age, and not due to the actual tubal reversal surgery. A tubal ligation reversal has no affect whatsoever on the risk of a Trisomy 13 or any other chromosomal abnormality.

If you or someone you know has recently undergone tubal ligation reversal you probably have concerns about how this procedure can influence the health of a pregnancy. Particularly as women get older and undergo procedures like a tubal ligation reversal to allow them to become pregnant again, they want to know more about what risks there are to their health and to the health of their children. In some instances after a tubal ligation reversal, moms may have questions about their baby’s risk for genetic abnormalities like Patau Syndrome (also called trisomy 13). This disorder is caused by the fetus inheriting more copies of chromosome 13 than normal. Although severe, Patau Syndrome is thankfully rare and not more common in mothers who have undergone tubal reversal.

The average rate of Patau Syndrome is about one in 10,000 live births. Patau Syndrome can be detected during a prenatal ultrasound by your obstetrician noticing abnormalities in your baby’s appearance. Again, although women who have undergone tubal reversal are not more likely to experience this disorder, tubal reversal patients are typically older than the average mom and as a result of their age tubal reversal patients are at an increased risk. If you have concerns about your babies health and the affects that tubal ligation reversal can have on your pregnancy be sure to discuss your concerns with your obstetrician or gynecologist.

Signs and symptoms of babies born with trisomy 13 (three copies instead of two):

• Impaired motor coordination
• Mental retardation
• An abnormally small (microcephaly) or large head (macrocephaly)
• Low-set abnormally shaped ears
• Extra fingers (polydactyly)
• Abnormal palm creases
• Brain abnormalities
• Heart defects
• Deformed feet that may have a “rocker-bottom” appearance
• Prominent heels
• Eye defects
• Cleft palate
• Spinal defects
• Intestinal defects with an incompletely formed abdomen
• Abnormal genitalia
• Overlapping of fingers over thumb
• Kidney defects

Because the abnormalities associated with Patau Syndrome are severe, most babies surviving until delivery will die soon thereafter. Eighty percent of affected infants die within the first month of life and only 5 percent survive to be six months. When babies do survive they are likely to have severe intellectual disability, seizures, and difficulty growing and learning new skills.

Most cases of Patau Syndrome are not inherited from a mom or dad directly, like eye color, rather Patau Syndrome occurs randomly as a result of incorrect division of genetic material from either the mom’s egg or the dad’s sperm prior to fertilization. Because there is no inherited cause, the disease is said to be sporadic and is not more likely to occur in another child should the mom become pregnant in the future – regardless of whether she has undergone tubal ligation reversal. Rarely, one parent can be a carrier of this extra genetic material and have just a very mild disease. In those instances, recurrence is higher than the general population as the genetic defect can be directly passed on to the infant. It is also possible that only some of the cells in an infant’s body will have the extra genes in a form called mosaicism. Mosaicism is very rare. The chance of having another trisomy 13 affected child is less than 0.01%.

If a child is diagnosed with trisomy 13 it is important that the parents trust their obstetrician or gynecologist and have open conversation about their concerns and wishes for their child. In situations where the obstetrician or gynecologist and patient have developed a relationship, such as with a prior child or in cases where the mother has undergone a tubal reversal prior to becoming pregnant, any discussion about the decisions facing the family can be comforting. For infants with Patau Syndrome, care is decided based on the specific medical situation and the family’s wishes. Generally, treatment is aimed at providing comfort to the baby and to the family during this difficult time. Although long-term survival is not expected, psychological, physical, medical, occupational, and speech therapy can help families and infants cope and reach their full developmental potential.

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.

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.