Post Tubal Ligation Syndrome occurs in women who have undergone tubal ligation and endometrial ablation (a minor surgical procedure for abnormal bleeding where the uterine lining is destroyed rather than undergoing a complete surgical removal of the uterus).  Approximately 6 months to 1 year following their ablation procedure or tubal ligation women may experience cyclic pelvic pain.  The pain can be on one or both sides and can be severe.

The symptoms of PTLS (Post Tubal Ligation Syndrome) are the following:

• Hot flashes
• Night sweats
• Flushing
• Chills
• Headache
• Racing pulse
• Dizziness
• Difficulty concentrating
• Irritability
• Anxiety
• Depression
• Mood swings
• Nausea
• Bloating
• Weight gain
• Change in hair growth pattern and thinning fingernails
• Fatigue
• Difficulty sleeping
• Decreased libido
• Breast tenderness
• Decrease in breast size
• Painful intercourse
• Irregular heavy or light bleeding
• Osteoporosis
• Uterine prolapsed, where the uterus becomes misplaced through the vagina

Although it is not entirely clear what causes PTLS, it is correlated with a previous history of tubal ligation.  Some studies have indicated that women who undergo tubal ligation may be at risk factor for hot flashes, chills, night sweats, and other menopause-like symptoms.  These changes are thought to be related to changes in estrogen and other hormone production in the ovaries.  These changes can lead to loss of normal monthly ovulatory cycles as a result of the change in ovarian hormone production that is thought to occur as a result of tubal sterilization and endometrial ablation.

Depending on a patient’s particular situation, tubal ligation reversal surgery has been considered as a method to reduce the pelvic pain symptoms many women experience after a tubal ligation.  For some women, the desire to return to a more normal pattern of menstrual cycles may be reason to consider a tubal reversal.  The ligation reversal gives the woman back not only the option to consider pregnancy in the future but also can help relieve the symptoms associated with Post Tubal Ligation Syndrome.

Although in most cases ovarian cysts are nothing to be concerned about, occasionally they can cause pain, and in rare instances they can be cancerous.  Non cancerous cysts occur as a result of normal process or a minor abnormality that can clear up on its own.  In those circumstances Dr. Morice may recommend that you follow up in a month or two to see if the cyst has resolved on its own.  In certain circumstances Dr. Morice might recommend further imaging, medications,  or even surgery to better understand what is causing the cyst.

Because there are many different types of cysts, Dr. Morice may want to get a better understanding of what is causing yours, particularly if you are undergoing a tubal ligation reversal.  Identification can be done with an ultrasound before the tubal reversal is performed just to make sure that there isn’t anything more concerning occurring prior to your surgery.

The 5 most common types of ovarian cysts are:

-          Functional cysts

-          Endometrial cysts

-          Cystadenomas

-          Dermoid cysts

-          Polycystic ovaries

Functional cysts are the most common among young women who are cycling normally, regardless of wether they have had a tubal ligation reversal. These cysts are a normal process of menstruation and usually clear up on their own without you or Dr. Morice ever even knowing about them. There are 2 types of functional ovarian cysts. The first comes from the Graafian follicle (or sac) where the egg develops every month. It is the most common and occurs if the sac fails to break open and release its egg.  The second type of functional cyst is a simple fluid filled cyst.  Both types typically resolve on their own in one to three months.

Another remnant from the monthly cycle is a corpus luteum cyst. After the egg is released, this portion of the ovary usually disintegrates. However, if the woman becomes pregnant, for example after a tubal ligation reversal, sometimes this cyst can form if the sac seals off. This ‘sealing’ of the cyst wall results in a buildup of fluid.  Again these cysts normally resolve in a few weeks with most women remaining unaware that they’re even there. The likelihood of getting an ovarian cyst is not increased at all by a tubal reversal.

Occasionally the cysts can become enlarged and rupture. This may cause a little bit of bleeding and pain. Sometimes the blood will collect inside of the cyst itself, and this is called a hemorrhagic cyst. Although a hemorrhagic cyst can be quite painful, it is also a benign condition that can be safely watched without intervention and without concern for an underlying cancer.  As always, if you have concerns about pelvic pain or your risk for ovarian cancer you should discuss these concerns with Dr. Morice.

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.

Possible Risks of a Tubal Ligation

The possibility of tubal ligation failure has the greatest risk for ectopic pregnancy. It is debatable and questionable that Post Tubal Ligation Syndrome consists of only a few medical symptoms or that it is possibly a direct side effect and/or another risk of tubal ligation. In most studies, those who do have symptoms after having a tubal ligation consider these symptoms Post Tubal Ligation Syndrome.

What is considered the major cause of these symptoms?

Several of the symptoms of PTLS (Post Tubal Ligation Syndrome) are linked with having estrogen or progesterone imbalance. There are many research and case studies leading to controversies about these hormone imbalances. It is assumed that imbalance may be the direct result of capillary damage and decreased blood supply to the ovaries during the surgery. The damage to the veins and capillaries is quite varied and slight damage may possibly result in a slight estrogen progesterone imbalance.

For a woman who has both of her ovaries still functioning, if blood supply was not damaged to the uterus and ovaries, then she may experience PTLS due to estrogen/progesterone imbalance by some change in her hormonal message relay system.

Hormonal message relay system destruction is questionable

The assumption behind this is destruction of “target” or “receptor” cells that are significant in the relay of hormonal messages for the female reproductive system. It is unspecified that these cells might be injured, damaged, and or detached during the tubal ligation surgery. Having assumed that these target or receptor cells are positioned within the fallopian tube, many people consider a tubal ligation to be the cause of the destruction of some of these cells. For patients who believe this hypothesis, a tubal reversal would not be an option to reverse symptoms of PTLS. Tubal reversal should only be performed for patients who therefore have a strong belief that the symptoms are related to blockage of their fallopian tubes.

A chromosomal abnormality like Down syndrome is associated with advancing maternal age.  A number of diagnostic tests are currently available which may detect Down syndrome during pregnancy.  These include the nuchal translucency ultrasound and Quad marker screening, among others.

What is a Nuchal Translucency Ultrasound?

A nuchal translucency ultrasound is a sonographic prenatal test which can identify a high risk pregnancy during the first trimester.  It is performed between the 11th and 14th  week of gestation.  Aside from Down syndrome, the test can also detect an increased risk for major heart efects and other chromosomal anomalies in the fetus. Because it is performed during the first trimester, compared to the Quad marker test performed during the second trimester, parents are able to know their risk much earlier in the pregnancy.

The test however does not provide a final diagnosis.  If a mother is in the high risk category, she is often advised to undergo an amniocentesis or a chorionic villus sampling.  These procedures are invasive and entail a small risk for miscarriage.  Findings from these two procedures will generally give the parents a definite diagnosis.

How is the Nuchal Translucency Ultrasound performed?

Nuchal translucency ultrasound is performed either by placing an ultrasound probe over the lower abdomen or by gently inserting a thin ultrasound probe into the vagina.  Ultrasound will measure the thickness of the fold located at the back of the fetal neck. Other information needed during the test includes the age of the mother, the gestational age of the fetus, and additional bloodwork.

What are the factors that influence the test results?

The following are important factors that influence the findings from the nuchal translucency ultrasound:

- Age of gestation (should be between the 11th and 14th week

- The scan is obtained with the fetus in the sagittal position

- Hyperflexed or extended position of the fetus may affect results

- The fetal image is enlarged to 75 percent within the screen

- The nuchal lucency should be distinguished from the underlying amniotic membrane

Is a history of tubal ligation reversal a risk factor for a chromosomal disorder?

Tubal ligation reversal has absolutely no adverse affect on the fetus. The correlation between a tubal reversal and any chromosomal disorder is strictly due to the fact that most patients who undergo a tubal reversal are older, and that older patients are inherently at increased risk for a chromosomal disorder in the fetus.

Many women who have had their fallopian tubes ligated are choosing to undergo tubal reversal procedures in order to have one or more children again.  Tubal reversal is a surgical operation that restores a woman’s ligated tubes back to normal and allows pregnancy to occur.  There are some concerns, however, that a woman above the age of 40 who had a tubal reversal has an increased risk of conceiving a child with trisomy 21 or Down syndrome.

Definition of Trisomy 21:

Every cell in the human body contains 23 pairs of chromosomes.  In trisomy 21 individuals an extra chromosome 21 is present. Most cases are due to random mutations occurring during egg or sperm cell formation.   Children with trisomy 21 have common physical features.  They usually have weak muscles, small and flat heads, wide nasal bridges, and a single crease on their palms.  They also have delayed mental growth.  Some affected children have heart defects and gastrointestinal problems as well.

Genetic Epidemiology In the General Population:

Trisomy 21 occurs in one newborn out of every 800 live births.  According to a study from the Center for Disease Control and Prevention, in the US

approximately 95% of all chromosomal abnormalities are due to trisomy 21.  Downs syndrome appears in all ethnic groups and in all economic classes of human race.

Maternal age influence:

Maternal age is an important contributing factor in conceiving a baby with Down syndrome.  At the ages between 20 and 24, the probability of having an affected child is one out of 1,562 live births.  Between the ages of 35 and 39, it is one in 214 live births.  Above the age of 45, this risk increases to 1 in every 19 live births.   Recent studies have also found that paternal age above 42 years could be another risk factor for the development of Downs syndrome.

Severity of Downs syndrome:

Manifestations of Downs syndrome range from mild to moderate to severe forms.  Most affected children present with moderate mental retardations as well as delayed physical and social developments.  Although there is no known therapy to cure the condition, children with Downs syndrome usually live well into their adulthood.

Tubal Reversal and Down Syndrome:

Women who choose to undergo tubal ligation reversal at an older age (40 and above) must explore their options before making a decision. Advanced age increases the risk of conceiving a child with chromosomal abnormalities such as Downs syndrome. Pregnancy at an advanced age, whether by tubal ligation reversal surgery or not, always puts on at increased risk of having a child with a chromosomal abnormality.

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.

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.

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.

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.