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.

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.

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.

Female fertility is controlled by reproductive hormones. An imbalance in these may cause an inability to ovulate (release an egg) called anovulation.  Anovulation may lead to symptoms of a hormonal imbalance, or possibly a woman may not ovulate due to a hormonal imbalance.  This cyclic balance between hormones is needed for fertility in women.

After menopause, imbalance is normal due to the aging process. For some younger women, even in their thirties or younger, symptoms of early onset of these hormonal imbalances and the associated disorders has become more and more of a problem.

What factors may present in young female patients?

Hormonal imbalance may be dependent on some continuing factors in a woman’s life, such as:

Nutrition or lack of it,

Basic diet imbalance,

Environmental reasons, including pollution,

Stress,

Contraceptive and birth control medication,

Exercise or lack of it,

Above average consumption of non-organic foods,

Animal products that have disproportionate amounts of estrogen,

Anovulation.

Anovulation may lead to the significant problem of disturbing hormones.  When a woman is not ovulating it means she may be producing too little of one hormone, and/or too much of another.  The production of progesterone from the ovaries does not take place during an anovulatory cycle.  The direct cyclic result is that the normal value or level of progesterone starts to decline. Also, the estrogen level starts to rise.

Note:  The amount of these hormones produced in a woman’s body can fluctuate from one month to the next even in healthy women, but is that there is an incorrect relationship between progesterone and estrogen levels which may lead to infertility.

Some surgical procedures may affect one’s ability to ovulate for a short period of time. For example, after a tubal reversal some women may undergo a temporary phase of hormonal imbalance between progesterone and estrogen levels. This will resolve as the body recovers from the tubal reversal.

About 20-25% of all cases of infertility are related to tubal factor infertility. Tubal factor infertility may be due to one or more of the following reasons:

1. Completely blocked fallopian tubes, either one or both, by scar tissue inside the tube or by prior surgery such as tubal ligation
2. Tubal scarring without blockage of the tube but with damage to the cells that line the inside of the fallopian tube
3. A disturbance in the architecture of the tube such as with a hydrosalpinx (water-filled tube) or scar tissue outside of the tube which distorts the tube

Medical reasons include:

1. Pelvic endometriosis
2. Pelvic infection, such as pelvic inflammatory disease (PID)
3. Scar tissue that forms after pelvic surgery.  Some times after tubal ligation, scar tissue may occur over the blockage site. This can be removed easily during a tubal reversal.  Tubal reversal is an option in such a case to regain fertility.

Does minor tubal damage cause infertility?

In most cases, any minor damage to the tubes does not account for infertility.  It has to be carefully diagnosed whether the infertility problem is only due to tubal damage, or if some other secondary infertility factor also exists.

What standard tests are available for the diagnosis of tubal infertility?

Hysterosalpingogram (HSG) can be performed to investigate the problem.  This is an x-ray exam done in a radiology department.  The dye is injected through the cervix into the uterine cavity.  If the fallopian tubes are open, the dye flows through the tubes and into the abdominal cavity. Sometimes after a tubal reversal, the dye can be seen changing diameters as it passes across the specific site of the tubal reversal.

Does a negative HSG rule out the diagnosis of tubal infertility factor?

Even if the HSG is good (meaning that there is good flow of dye through the tubes), this does not mean that the tubal function is normal.  The inside layer of the fallopian tube can be brutally damaged even if the tube is open.  Tubes that have damage to the inside cell layer may be the factor of the tubal infertility problem even though the tube is ‘open.’ This is particularly important when considering a tubal reversal as the surgeon chosen must be skilled at performing a tubal reversal without damaging the inside of the fallopian tube.

Management of tubal factor infertility

The management of tubal factor infertility is generally done either by a tubal reversal or by in-vitro fertilization (IVF).

The chances of conceiving after having a tubal reversal are considerably better than with IVF, with a 70 to 80% safe success rate for those women who are under 40 years of age.  Most women are able to conceive naturally within a year of their surgery.

When does the ectopic rate after tubal reversal enter in critical risk zone?

There is no set age limit for the risk of an ectopic pregnancy after tubal reversal, but some empirical data suggests that women above 40 have a higher risk in general with tubal reversal, and likewise with ectopic pregnancy after a reanastomosis. The risk of an ectopic pregnancy among the general population is about 1 in 100 and this risk increases to about 5 in 100 after undergoing a tubal reversal.

There is some optimistic analysis of the fertility results observed as well. Although it was demonstrated that age is the most significant predictive factor, for women who had undergone a microsurgical tubal anastomosis procedure (tubal reversal) at age 40 years or older, the reproductive outcomes of the microsurgical tubal anastomosis patients demonstrated a tubal reversal was a justifiable alternative to IVF, even when considering an ectopic pregnancy rate of 2.4 percent.

Managing ectopic pregnancy after tubal reversal

It is important that women are aware about the risk of ectopic pregnancy prior the tubal reversal.  Early diagnosis is needed once a positive pregnancy test is obtained.  If the blood pregnancy test (HCG level) is 1,500 or greater, the contents of the uterus should be seen with a vaginal ultrasound exam. Early diagnosis at this stage is important.  If it is diagnosed that you have an ectopic pregnancy, one or two doses of a prescribed medicine will absorb the ectopic.  Note that time is most important thing, and there are limits to the use of medicine in treating ectopic pregnancy. If the ectopic pregnancy is too far along, the only option may be surgery, and in this case it is extremely important to have a skilled minimally invasive surgeon such as Dr. Morice perform the procedure so that when removing the ectopic pregnancy the fallopian tube suffers minimal damage.

Once you have entered menopause, you will find yourself free of most of the symptoms of pre and peri-menopause, particularly the menstrual problems i.e. irregularity, heavy flow etc. Not only that, but you may even find yourself more energetic and present-minded than in past 5-6 years during peri-menopause.

So you may ask now, if I have overcome of all the symptoms, what exactly is the big deal about being menopausal?

How long does this post-menopause state go on? Forever?

Technically speaking yes, even if you die at the ripe old age of 120, you are still in menopause, but that does not mean that you are still experiencing symptoms. For example, you can still call yourself postpartum years after your child’s birth because technically you are post-partum.

So what is happening to my body in postmenopause?

Your hormonal levels are juggling in order to settle on a fixed level. If you get your FSH levels tested, you will find a higher level of FSH. This means that more FSH is being produced by the pituitary gland, going into an overdrive, in an effort to stimulate follicular formation in your ovaries. This is indeed a futile attempt on the part of the pituitary gland.

Will I have a high level of FSH throughout my life? Isn’t that dangerous for my health?

Yes, you will have a sustained high level of FSH throughout your life, but this is not dangerous at all. It causes no harm. However, if you go for hormone replacement therapy, this high level of FSH will come down.

Are there any other hormonal differences apart from FSH?

Yes, your estrogen production has changed its production site.  While you were in premenopause, estrogen was primarily produced in your ovaries all your life. However, when in menopause, your fat cells take the major role of production of estrogen.

What if I undergo a hysterectomy before menopause?

If you also have your ovaries removed, you will then bring your body into a surgically induced menopause. The effects will still be the same as if your ovaries quit working in a natural way, but the effects will be sudden rather than gradual.

Can a tubal reversal accelerate menopause or perimenopause?

No, tubal reversal surgery is not related with the onset of menopause in any manner. If you are looking to reverse your tubal ligation, do not consider menopause as a risk of tubal reversal surgery.

Are my bones and teeth going to be affected?

There is a potential to develop decreased bone mineral density after menopause. You should continue to follow a healthy lifestyle and have this condition screened on your visits to Dr. Morice. Osteoporosis is a risk that we all face as we age. As such, it is of utmost importance that women adopt a healthful lifestyle, especially before menopause. However, if you have not done so earlier, it is never too late.

You need to develop positive habits and get rid of negative ones i.e. smoking, excessive drinking, overeating etc. You should also take a minimum of 1000 mg of calcium per day in order to avoid significant osteoporotic changes.

There are many nutrient supplements available in the market. Make sure you take adequate vitamins, especially vitamin D and calcium.

You should also work out and exercise regularly. It does not have to be a vigorous routine, but a 15-minute daily walk can do wonders.

Is adjusting to menopausal life hard?

Not at all! It is the peri-menopause that gives women the most trouble. By the time you are in menopause, most of the dreadful peri-menopausal symptoms are gone. You are no longer irritable or moody since you have had ample time to adjust physically and mentally to the end of menstruation. The childbearing years are long gone and you have more time to spend on yourself, your health, and your body. Most of the career women are now settled comfortably into their professional lives and the earlier professional stress is often dissipated as well.

Menopause, for many, is actually the beginning of a life free of stress and tension. Menopause often marks the beginning of a new era in a woman’s life, where she can now concentrate on her own well-being.

Menopause is still considered a taboo subject and is not open to public discussions. Women find it easier to rely on word of mouth than consulting an authority on the subject. Some even look at menopause as a dreaded evil.

Through this section we will try to cover as many random queries related to menopause as possible. These include home remedies as well as issues like pregnancy and menopause.

I am taking hormone replacement therapy. I still experience lethargy and stress. Why?

That is quite a normal occurrence. This also depends on the type of therapy you are taking. Many women find progestin-only therapy much more suitable as compared to a combined pill. As for the stress, you might benefit from lifestyle changes, coping mechanisms, or other medications. Consult Dr. Morice for further advice.

What can I do, without medications, in order to ease the symptoms of menopause?

1. Take better care of your body. It may sound a little trite, but this may offer protection from all sorts of illnesses as well as postmenopausal symptoms.
2. Eat well. Make sure your daily intake of calcium and iron is adequate, since menopause effects bones too. A fiber-rich diet that is low in fat is best.
3. Go for supplements. If you think you cannot cover essential nutrients like calcium or vitamins in your normal diet, take supplements.
4. Exercise regularly. Walk daily. Do cardio exercises for your heart. Try investing a few minutes a week in Yoga or Pilate.
5. Remove stress-inducing factors from your life. Work out the stressful aspects of your life and get rid of them for once and all.

Is pregnancy possible once I am into perimenopause?

Yes. Although not common, it is known to occur. Unless declared menopausal, you can never rule out the possibility of a pregnancy. Make sure you take adequate contraceptive measures if you are not interested in getting pregnant.

I have been having recurrent vaginal infections ever since I entered perimenopause. Are the two related?

There is no direct causal relationship. You may have read earlier, that in perimenopause, there is direct effect on urogenital system and vaginal dryness too. This dryness can be a precipitating factor in vaginal infections, however, menopause does not predispose you to infections in any way.

Is menopause known to be related to neurological disorders?

No. There is no known association of menopause or perimenopause with neurological disorders. However, since this is quite a stressful period in a woman’s life, stress, depression, mood swings, and other psychiatric complaints do occur quite frequently. Many also complain of lack of concentration and a preoccupation with these symptoms.

Does one put on weight in menopause?

Quite a few times, yes. But a lot of it is due to depressive binging of food and lethargy. If you eat healthy and work out regularly, there is no reason why you should put on weight in menopause.

How does one get surgically induced menopause?

Removing the ovaries (oophorectomy), which often occurs with hysterectomy, will result in surgically induced menopause almost immediately. Other procedures such as tubal ligation or tubal reversal do no cause menopause.

Does any clinical condition induce menopause?

Yes, with premature ovarian failure, there can be early menopause.

Understanding your normal physiology

There are numerous popular fads regarding menopause. Some, like getting a tubal reversal after 5 years of tubal ligation can induce menopause, are absurd, while others, such as hot flashes, are certainly true. In order to understand this and pick the truths from the myths, you need to go a bit deeper into the physiology of normal menopause.

An oocyte is an immature cell in the ovary.  A primary oocyte is formed in the ovaries of a woman before her birth. It becomes a secondary oocyte after the onset of menarche (the first menstrual period). This oocyte then becomes an ovum, which is released from the ovary during ovulation and perhaps fertilized by a sperm to form a zygote (a future embryo which then develops into a fetus).

When a female child is born, there are up to 100,000 oocytes in her ovary. Only about 400 are used in her reproductive life. Normal menopause occurs when these oocytes become depleted or non-functional.

A typical menstrual cycle occurs in fixed phases under the effect of various hormones. The following is a simple summary of a menstrual cycle.

A Regular Menstrual Cycle

Follicle Stimulating Hormone FSH and Luteinizing Hormone LH are secreted by the anterior pituitary gland. They are both released under the effect of gonadotropin releasing hormone (GnRH). This GnRH is released by the effect of Estrogen, yet another hormone. This estrogen is released by a mature follicle during the follicular phase. This follicle contains a primary oocyte. When the size of a follicle is big enough, the estrogen triggers a sudden release of LH. LH in turn helps in maturation of the oocyte into secondary oocyte and finally ovum, and it is released from the follicle in the ovary during ovulation. The empty follicle left behind is now called a corpus luteum.  This does not get destroyed right away but persists for some time in the ovary, releasing progesterone.  The progesterone makes a uterus receptive for an embryo to be implanted. This corpus luteum also releases inhibin, which inhibits or suppresses the release of FSH and LH temporarily. The unfertilized egg must then travel through the fallopian tube to reach a sperm coming through the tube from the uterus. (A tubal ligation would prevent this meeting of the egg and the sperm, and a tubal reversal could repair the ligated tube so that the egg and sperm could meet again). If they meet, and fertilization then occurs, the embryo is implanted in the uterus and forms a placenta. The placenta releases hCG which causes the corpus luteum to continue to release progesterone. In case of no fertilization, this corpus is reabsorbed and disappears in most cases. As there is no progesterone now, the mucosal lining of uterus gets destroyed, initiating menstrual bleeding. The effect of inhibin is lifted from FSH and LH, and the increase in FSH causes formation of more follicles to start the process again. Only one follicle matures to become the dominant follicle, the future corpus luteum, holding the primary oocyte.

So this was a normal menstrual cycle, when is normal menopause?

A primary follicle produces estrogen. With age, the oocytes become non-functional. As a result there are fewer primary follicles, reducing the levels of estrogen in the body. Without estrogen there will be no LH surge and no ovulation. No ovulation means no progesterone. That means general thinning of uterine mucosa, vaginal atrophy, and erratic menstruation. Furthermore, the perimenopausal symptoms that you experience i.e. insomnia, irascibility and headaches are due to the lack of estrogen. Post-menopausal urogenital symptoms and osteoporosis are also due to this low level of estrogen. Hormone replacement therapy is often prescribed to cut down the incidence of such symptoms.

Can menopause be induced?

Yes, a hysterectomy can induce menopause if the ovaries are also removed. It will then be called surgically induced menopause.

Will any surgery performed on my uterus induce menopause?

No. Except for removing the ovaries, or some brain surgeries, there are no other surgical procedures that will induce menopause. Neither tubal ligation nor tubal reversal has any effect on menopause.

We can look at 45 as a usual time when premenopausal symptoms first appear.
Unlike the popular misconception, premenopause does not only refer to irritability and mood swings but a whole set of distinct physiological symptoms. These symptoms may be vague independently but together confirm a woman’s ingress into perimenopause.

The symptoms every woman should be able to tell are irregularity of menstruation, hot flashes and associated stress/ irritability. Here irritability is not the primary symptom but an associated one.
There may be associated depression, weight gain, water retention and headaches as well.

At times, these symptoms may cause quite a bit of discomfort, resulting in women thinking of various solutions, many of which are suggested by other peers in small chats and internet chat rooms.

Remember, this is your health we are dealing with. Therefore always consult your gynecologist before considering a drastic measure like hysterectomy or tubal reversal without revealing your true reasons.

How long will this disease last?

Technically speaking, premenopause or menopause is not a disease but merely a switching phase of the body, accompanied with some uncomfortable and, at times, debilitating symptoms. There have been known cases of women who experience sudden cessation of menstruation. However, for the majority, it is the usual grill i.e. approximately 3-6 years of premenopause followed by 2-4 years of postmenopausal symptoms. The symptoms may be mild enough to ignore and severe enough to ask for medications.

Do I need medication?

That is for you and your doctor to decide. If you are experiencing nonadjustable problems, you should seek proper medical advice. The symptoms are basically due to hormonal fluctuations. Most women complain of lack of energy in addition to the above-mentioned symptoms.

In either case, you may consider many alternatives.

How will it affect me in future?

In the best way possible! You will not have to experience menstruation and associated body cramps. You won’t have to worry about unwanted pregnancies. The depression and stress is momentary and will pass away before you even notice. This phase is tough but will be gone soon.

Is there anything that I did to cause this?

No. This is inevitable and unavoidable. You may have accelerated its onset but no matter what you did, this was nonetheless bound to happen. It is a natural process.

What do you mean by my accelerating its onset?

Yes it is a possibility that certain aspects of your lifestyle caused an earlier onset of menopause. Those aspects are:

1. Hysterectomy (as it only removes the uterus, not the ovaries)
2. Smoking
3. No history of pregnancy
4. Treatment history of pelvic radiation or chemotherapy

How do I know when to go to a doctor for my premenopausal symptoms?

In case of unusually heavy bleeding, longer menstruation i.e. more than 9 days, shorter cycle, and spotting in the middle of cycle, you need to see your gynecologist regardless of appearance of other symptoms.

Is this dangerous? Will I have to undergo a surgery? Will the surgery be reversible?

Whoops, lots of questions there. No it isn’t dangerous and you will not necessarily have to undergo a surgery. Most of the times, hormone replacement therapy HRT is advised. This therapy may be a combined pill or a progestin only therapy, depending upon your spectrum of symptoms.

Occasionally endometrial ablation is performed that is destruction of uterine mucosal lining. This is a surgery and not reversible. Even if you opt for a hysterectomy, that is not reversible. The reversible procedure you might be thinking of is tubal reversal which is done to reverse a tubal ligation. That has no effect on menopause at all.