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.

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.

What is the most appropriate management for ovarian cysts?

Management of ovarian cysts should be done carefully so as to avoid any subsequent effects. In general, cysts can be managed medically with birth control pills or medicines that affect the pituitary gland. If a patient is found to have an ovarian cyst when she is being evaluated for a tubal reversal surgery, the cysts can be removed during the tubal reversal surgery. If the patient is not being evaluated for a tubal reversal surgery, and surgery is not an option, all medical treatments should be exhausted before surgery is considered.

Medical versus Surgical Ways of Managing Ovarian Cysts:

Women who are not taking oral contraceptives, women who are still at a reproductive age and who suffer no pain, and women who are candidates for tubal reversal or have had a tubal reversal should proceed with the conventional medical approach. This will prevent any potential surgical complication, and is the safest way to proceed initially.

Conventional surgery:  For a non-malignant cyst, conventional surgery may be an option.  This may allow a patient to keep her ovaries and simply have the cysts removed.  This operation is called an ovarian cystectomy. Gynecologists will keep the injury to the tissues at a bare minimum, with precise control of bleeding during the surgery. Side effects may include the development of pain and/or painful “adhesions” on the ovaries, infertility, or excessive sensitivity during intercourse.

Laparoscopic method:  This is the most common modality for an ovarian cystectomy. Small cuts are made in the abdomen rather than conventional surgical techniques.  It is an advance that avoids large incisions, reduces pain, and allows for more rapid healing.  If one of the ovaries has been seriously impacted by the cysts, while the other has been intact, the affected ovary may be removed completely.

Hysterectomy: Surgery will allow the gynecologist to see if a cyst has been the result of  edometriosis and results in a collection of old blood. For a woman who has already given birth to her children, this case of “chocolate cysts,” or an endometrioma, can only be cured by a hysterectomy and removal of both ovaries. This is usually necessary rather than optional in order to resolve the problem forever. According to the severity of disease, the patient’s age, and potential other pelvic complaints, removal of the ovary may be the most indicated course.  The surgery is also obligatory for ovarian cancer as the patients have a low rate of survival otherwise.

Cysts may grow and enlarge without symptoms and go unobserved until they are found on routine examination.  However, some cysts will burst during routine activities such as by sexual intercourse, any injury, or childbirth. Cysts may become bulky enough so that the following symptoms may occur:

• Severe abdominal pain
• Menstrual cycle changes, such as delayed periods, intermittent bleeding between periods, or irregular periods.  This may even occur with corpus luteum cysts and polycystic ovaries.
• Heavy menstrual flow
• Infertility; a symptom occurring in polycystic ovaries and endometrial cysts.
• Internal bleeding may occur with endometrial cysts or hemorrhagic cysts.
• Severe menstrual cramps
• Pain with sexual intercourse
• Pain during a bowel movement
• Weight gain

Note: If a cyst becomes enlarged, the woman may experience intermittent pain.  Unexpected or abrupt sharp pain may indicate that a cyst has ruptured.  The twisting distortion or break of a cyst may add to the likelihood of a torsed ovary or an infection.

Some unexpected onsets need instant medical attention, such as:

• fever,
• abdominal pain,
• vomiting and symptoms of shock such as cold,
• clammy skin
• rapid breathing

Enlarged ovaries, ovarian cysts, or polycystic ovaries are relative concerns to watch after a tubal reversal or any surgical procedure. If the above symptoms exist in a patient who has undergone a tubal reversal, it may be more concerning to the patient, but should be treated as appropriately as medically indicated. Cysts that occur after a tubal reversal should have no effect whatsoever on the likelihood of achieving a pregnancy after a tubal reversal.

How do gynecologists proceed with diagnosing Ovarian Cysts?

Although we do not see an increase in the rate of ovarian cysts after tubal reversal surgery, polycystic or simply cystic ovaries are one of the concerns some patients have expressed after tubal reversal surgery. For most, a thorough exam after the tubal reversal surgery, or close monitoring after the tubal reversal surgery will alleviate these fears.

Predicting whether a cyst is benign or malignant is not always straightforward.  Clinical examination, serum concentrations of CA 125, and ultrasonography are the main diagnostic protocols available.

Clinical examination is often unsatisfactory, with 30-65% of ovarian tumours being unnoticed and mostly overlooked by most doctors.  Ultrasound studies of ovarian cysts will however confirm the presence or absence of cysts in nearly all cases. Combined with a pelvic exam, this will lead to diagnosing close to 100% of all cysts.

Vaginal ultrasonography is the most widely performed and accurate procedure for prediction of the benign nature of a cyst.

How do Gynecologists conduct the evaluation?

1. Gynecologists first take a detailed medical history of the patient and perform a physical examination.  During the physical examination the gynecologist will perform a pelvic exam.

2. In a pelvic exam the gynecologist will place an instrument called a speculum into the vagina and will examine the vaginal walls and the cervix. The gynecologist may take samples of vaginal discharge or perform a Pap smear (removing cells from the cervix with a small brush). Samples are sent to a laboratory for microscopical examination.

3. The gynecologist will then do a bimanual exam by inserting two fingers into the vagina and placing the other hand on the abdomen to examine the size and shape of the uterus and ovaries.  The ovaries may feel larger than normal and this exam may make the patient have discomfort.  If cysts are felt, the gynecologist will suggest additional laboratory and diagnostic tests.

4. Laboratory tests mostly include;

a)        a complete blood count (CBC) and a WBC to perceive any infection and internal bleeding,

b)a pregnancy test to identify uterine pregnancy or ectopic pregnancy.

5. Diagnostic tests include an ultrasound, Doppler studies, Vaginal ultrasonography, and if needed, an x-ray and laparoscopy.

6. An ultrasound test mostly able to shows size, numbers and what the cysts are made of.  If the patient having the cyst is consisted of solid materials or a combination of fluid and solid materials, the gynecologist may suggest an x-ray to find whether it is a benign cyst or a malignant tumor.

7. Gynecologists may recommend later an additional diagnostic test that is laparoscopy if he suspects endometriosis having the cyst enlarged much without fluid.

8. Laparoscopic procedure involves the placing of a laparoscope (a narrow tube with a fiberoptic light at one end) into the lower abdomen.  This is done via a small incision just below the navel to detect the ovaries.  Next if the gynecologist feels the necessity, he may drain the fluid from the cyst, or he can remove the cyst entirely.

Would cysts be discovered during a tubal reversal surgery?

Yes – if you have cysts on either ovary during your tubal reversal surgery, Dr. Morice can remove the cysts at no additional charge.

Why is the diagnosis important?

The search for a diagnosis to explain ovarian cysts should be done with complete awareness of all of the possibilities.  Ovarian cysts can result from a devastating process such as ovarian cancer, or may be simply normal, enlarged follicles in a young patient who is ovulating. The reason for the cyst(s) must be determined in order to provide appropriate medical care.

Do cysts cause problems?

Most ovarian cysts are small and do not cause problems, especially if a woman is in its natural reproductive age. However, larger cysts may cause problems even if they are simply reproductive (physiological) cysts.  Pain and swelling with bloating in the abdomen are the first signs.  A simple pelvic exam can provide information about the size of the cyst(s) and their location. An ultrasound exam can determine the exact size and the relative likelihood of the cyst being a normal, reproductive cysts versus a potential cancer.

Some tests to help the diagnosis include:

1. Radiographic tests including ultrasound, CAT scan, and MRI.
2. Clinical pelvic examination
3. Laboratory tests including CA-125 serum concentrations.  In almost 70% of women who have benign ovarian cysts, the concentration is within average limits.  For malignant cyst(s), there were higher concentrations of serum CA-125 identified.  Unfortunately, 30-65% of ovarian tumors cannot be identified by serum CA-125 concentrations.
4. Vaginal ultrasonography is considered the most accurate modality for diagnosis. In most cases, the prediction of a benign versus a malignant cyst is possible.
5. Ovarian cytology is a very reliable way to know the state of ovaries.  Fluid can be withdrawn from the ovary and sent for special tests.
6. Ovarian pathology – this is the definitive method of determining if the ovary is benign or malignant, but of course this requires a biopsy or removal of the ovary.

Polycystic ovaries are one of the concerns for patients after tubal reversal. Even after a tubal reversal surgery, some patients will have problems with ovarian cysts that cause them to have difficulty in getting pregnant. Some women may not succeed in becoming pregnant after tubal reversal surgery because they do not ovulate regularly. This can be due to cystic ovaries. After tubal reversal surgery, close monitoring is needed to evaluate the fertility of women who have difficulty getting pregnant.