Under normal circumstances, follicles grow, mature, and rise to the surface of the ovary, where they burst and release an egg to the fallopian tube. Pituitary hormones control this process. The remnants of the follicle then start to produce progesterone, which supports the lining of the uterus (endometrium) in case a fertilized egg finds it’s way into the uterine cavity. An increase in progesterone production will signal to the pituitary gland to stop stimulating the ovary for the development of eggs.

In polycystic ovaries, the follicles rise to just under the outer lining of the ovary, and are formed over and over because the pituitary has not been signaled to stop.  The ovaries become filled with these tiny cysts and can become enlarged.

These polycystic-appearing ovaries may be diagnosed based on their enlarged size.  Ovaries may get twice the normal size with small cysts present around the boundary and outside wall of the ovary.  These can be found in women who feel completely normal and have no symptoms, and also in women symptoms and significant endocrine disorders. Having polycystic-appearing ovaries do not necessarily mean that you have PCOS. PCOS requires that other criteria are met and includes other symptoms besides the presence of ovarian cysts.

PCOS increases your risk for metabolic and cardiovascular disease linked to insulin resistance, and endometrial cancer related to the prolonged exposure to persistant levels of Estrogen without Progesterone.

Risks of PCOS include:

• Increased glucose intolerance
• Type 2 diabetes
• Infertility; Polycystic ovarian syndrome is associated with anovulatory infertility
• High blood pressure
• An increased risk for endometrial cancer
• Abnormal periods and vaginal bleeding
• Increased risk of infertility
• Pregnancy-related complications

Although ultrasound is used to view the ovary as a diagnostic step in diagnosing the condition of polycystic ovaries, additional tests are required to diagnose PCOS. Since this condition is so common, many patients who undergo tubal ligation reversal will be affected by PCOS. A thorough evaluation by your primary gynecologist should rule out PCOS before you consider tubal reversal. Tubal reversal will not affect your PCOS condition, but in order to have success after a tubal ligation reversal, your risk of infertility from PCOS must be minimized.

To evaluate the risk of infertility from other causes beyond tubal disease, gynecologists will consider many additional tests. Having your tubal reversal performed by a skilled tubal reversal surgeon significantly improves your chance of getting pregnant. With an ideal tubal ligation reversal, your chance of achieving a pregnancy will be mostly affected by these other factors such as PCOS. Several medicines may be used after tubal reversal to cause increased ovarian stimulation for better follicle production to treat the underlying infertility caused by PCOS.

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.