Parental Concerns:

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 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.

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.

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 types of tests are needed for tubal reversal preoperatively?

These tests are needed to assess the preoperative condition of the patient.  These blood analysis are compulsory prior to your tubal ligation reversal.  They can be prearranged by your regular gyneclogist, or can be done at your local laboratory facility (DR. MORICE WILL FAX AN ORDER TO YOUR LOCAL FACILITY):

1. Complete blood count (CBC)
2. Urinalysis
3. Possibly hormonal studies
4. Possibly a semen analysis

Preoperative lab results must be done within 7 days of the surgery date. In the case of abnormal test results, possibly indicative of some medical problems, the surgery will be postponed.

Additional preoperative tests may be needed according to an individual’s prior medical history, such as:

1.       Cycle day 3 FSH – done for women 40 and older. This will assess ovarian function and quality of reserve of eggs.  The “egg quality testing” for patients will ensure their chances if are still good for conceiving after the tubal reversal.

1. Semen analysis for male partner is sometimes ordered.  A semen analysis should be performed prior to your tubal ligation reversal. Although artificial insemination is inexpensive and effortless, you need to know if it will be necessary before you undergo tubal reversal surgery.
2. Urinalysis.
3. Testing of the uterus to ensure there are no problems which would hamper with pregnancy as fibroids or other uterine abnormalities.
4. A baseline mammogram – pregnancy after a tubal ligation reversal complicates treatment for breast cancer and visa versa.
5. AIDS testing if having likelihood.

If egg quality is impaired, then IVF may be the best option rather than tubal reversal.

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.

Accurate functioning of fallopian tubes

Accurate tubal function involves:

1.  The fimbria of the Fallopian tube picking up the egg

2.   Transportation of the egg through the Fallopian tube by the cells that line the inside of the tube

3.  Fertilization of the egg by a healthy sperm which can penetrate the egg’s protective covering

4.  Transfer from the fallopian tube into the uterus where the embryo implants

If implantation occurs in the tube, this results in a tubal pregnancy.

For the above processes to occur, the tube must be open. Many patients have undergone a tubal ligation procedure which has closed the tube. Tubal reversal is a challenging surgery that can be done by an experienced surgeon that allows one to regain the previous anatomy and physiology of the healthy tube.  After a tubal reversal, fertility prognosis is based on accurate functioning of the tubes. Other infertility factors may also be present which may hinder conception.

What types of tests are available in the work-up of tubal disease?

Most fertility physicians will examine the history of the patient and may suggest any of the following tests according to the degree and nature of the disease history:

1.  Hysterosalpingography (HSG) is the most commonly used method

2.  Laparoscopic chromopertubation is a more invasive technique standard in the diagnosis of tubal disease

3.  Sonohysterography with the use of contrast medium is not as accurate as HSG in diagnosing tubal blockage

4.  Chlamydia serology is the most cost-effective and least invasive diagnostic test

Various available treatments according to the degree and nature of tubal disease

Treatment depends on degree and nature of the tubal dysfunction, while the age and ovarian reserve of the patient determine what options are available for the patient.

1.  With the existence of a hydrosalpinx, prophylactic surgery can remove the hydrosalpinx

2.  For proximal tubal obstruction, a possible first treatment is transcervical tubal cannulation with tubal flushing

3.  For tubal repair in tubal obstruction, some surgical techniques include salpingostomy and fimbrioplasty

Many patents now prefer in-vitro fertilization and embryo transfer by bypassing the tubal problems altogether.  In certain situations, in combination with in-vitro fertilization and embryo transfer, any above type of treatment may be used in dealing with tubal dysfunction. If the tubal disease is secondary to a history of a tubal ligation, then a tubal reversal may be the best option for restoring fertility. Tubal reversal has a better rate of subsequent pregnancy for those patients with a history of tubal ligation.

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).

What will be different with periods after a tubal reversal?

It all depends. Every patient has a different experience after a tubal reversal.

The very first menstrual cycle after tubal reversal could come early, or more probably, late.  It is not unusual for the first menstruation after your tubal reversal to be heavy and painful.

Management of the pain;

• A normal pain reliever such as Motrin may provide some relief
• Prescription pain medications will be prescribed after a tubal reversal
• Feelings of weakness and fainting may be experienced

Some standard risks of the tubal reversal surgery may include bleeding, infection, anesthesia problems, and injury to other structures in the pelvis and abdomen.  These complications are extremely rare and the tubal reversal procedure is considered a very safe operation.

Patients must continue care with their regular obstetrician / gynecologist after their tubal reversal. Patients are instructed to wait at least two months before attempting pregnancy. Normal signs and symptoms and prior menstrual cycle patterns appear only if you are not having any other secondary medical problems. Regular follow-up is necessary.