Repair of C-Section Scars Causing Secondary Infertility

C-section scars & secondary infertility at a glance

  • Women who have delivered by C-section can have scarring that causes infertility, as well as pain and abnormal bleeding.
  • This results when scar tissue does not heal properly and forms a pouch in the lower part of the uterine lining that fills with fluid and delays normal menstrual bleeding.
  • The inability to become pregnant again after already delivering a child is known as secondary infertility, which an estimated 3 million U.S. women experience.
  • Many women delay or do not seek treatment for secondary infertility.
  • Women who have C-section scars and experience secondary infertility should consult a reproductive specialist.
  • Laparoscopic surgery can correct the problem and cure infertility in about 75 percent of patients.

What is cesarean section scarring & secondary infertility?

The Centers for Disease Control and Prevention’s (CDC’s) latest figures report that 32.2 percent of all U.S. births are by cesarean section (C-section). While C-section has significantly reduced the infant and maternal death rates from childbirth, saving many lives, there are some associated problems with future fertility after a C-section.

These potential problems include an increased likelihood of needing a C-section in a subsequent pregnancy, potential rupture of the womb in a future pregnancy, and secondary infertility. Secondary infertility is the inability to become pregnant again after already having delivered one child. A British study has reported that 30 percent of women who had a C-section were not able to conceive another child.

Secondary infertility following a C-section is caused by improper healing of scar tissue in the uterus following the surgical incision in the uterine wall to allow birth. What can result is a defect that can become a fluid-filled pouch, or isthmocele, which forms in the lower uterine segment and causes an accumulation of blood. When old menstrual blood becomes trapped in the isthmocele and within the uterine cavity, it sets up an inflammatory response in the uterus that then impairs embryo implantation.

Symptoms of C-section scar tissue

The National Institutes of Health says that C-section scars that are clinically relevant or cause symptoms happens in 19-88 percent of C-section patients. Symptoms of such scarring include:

  • Pelvic pain
  • Abnormal bleeding
  • Vaginal discharge
  • Painful periods
  • Infertility
  • Difficulty with gynecologic procedures such as IUD insertion and uterine evacuation
  • Ectopic pregnancy in the C-section scar.

Women having a difficult time becoming pregnant following a C-section should seek medical consultation to evaluate the possibility of uterine scarring being the cause. It can often be corrected, yet women needlessly overlook this option.

That’s because many women and couples experiencing secondary infertility don’t talk about it. They are often surprised that they are having difficulty becoming pregnant again. OB/GYNs are becoming more proactive in following up on their C-section patients regarding fertility issues, and other complications, that may follow the surgery.

Diagnosis and treatment of C-section scars

We generally evaluate women having difficulty becoming pregnant after a C-section birth with diagnostic tests. These tests are best performed after a woman’s menstruation because the blood has likely collected in the pouch, rendering it more visible.

Transvaginal ultrasound involves an ultrasound probe inserted through the vagina to examine the uterus. The sound waves reflect off the uterine structure providing a computer image of the uterus, which can reveal scar tissue. Usually the uterine scar defect can be easily seen with the transvaginal ultrasound.

A saline infusion sonohysterography, or hysterosonography, may also be used for diagnosis and is more accurate in defining the degree or severity of the defect. The physician injects a saline solution into the uterus in conjunction with the vaginal ultrasound. The saline fills the uterine cavity and the C-section scar defect, providing a better delineation of the depth and width of the defect. The physician might also use an MRI, hysteroscopy (a tube with camera inserted in the uterus through the vagina providing a view) and 3-D ultrasonography (sound waves directed at angles produce a 3-D image).

Once the diagnosis confirms the presence of the abnormal uterine pouch, the patient and reproductive surgeon have options to correct the problem. Sometimes hormonal therapy can be tried, but it is generally not as effective as surgical treatments.

Surgical correction

Laparoscopic excision is recommended for women wishing to conceive again. It is a minimally invasive surgery to remove the C-section scar defects through the use of a laparoscope. The surgeon makes small incisions in the patient’s abdomen and inserts the laparoscope, a thin tube with a lighted camera that provides a video view. Special instruments are inserted through small incisions. The C-section scar tissue is cut away and the uterine muscle is sewn back together. With the new incisions and repair, the defect is markedly reduced or closed.

A major benefit of laparoscopic excision is that about 75 percent of patients do recover their fertility and become pregnant. Laparoscopic excision also restores the integrity of the affected uterine muscle tissue, thereby reducing the chance of uterine rupture during a subsequent pregnancy. General benefits of laparoscopic surgery include less scarring, bleeding and pain, shorter time in surgery, faster recovery and less risk of complications.

A hysteroscopic treatment involves placing an instrument with a camera through the cervix where the defect is visualized from the endocervical canal. Using an energy source, the tissue within the defect is cauterized, destroying the endometrial tissue in the defect that is the source of the trapped blood. Another option is to have a hysteroscopic endometrial ablation in which all the uterine lining tissue is destroyed, scarring the uterine cavity. This alleviates symptoms but requires follow-up for continued effectiveness. This technique reduces menstrual bleeding but endometrial ablation should only be considered if future pregnancy is not desired.

Risks of these surgeries are low but li any surgery include blood loss, infection, complications, damage to tissue, reaction to anesthesia and pain.