Defects are ‘currently underdiagnosed and may consequently be left untreated at a staggering rate’, says one of a number of experts calling for more information to be provided to women.
A little-known complication of caesarean sections is causing infertility in a small minority of women worldwide. Experts say the evidence is now strong enough that women should be routinely warned of the risk if they have the procedure, or are considering it.
“Knowledge is power,” said Dr Farr Nezhat, a pioneering obstetric and gynaecological surgeon in New York City. “I definitely think women should know, and I don’t believe you are going to scare anybody.”
The condition is commonly called caesarean scar defect, niche, pouch, or isthmocele and is a small pocket that forms on the scar on the inside of the uterus. The defects are very common – between about 20% and 80% of women will develop one – and in most women they cause no problems.
But sometimes the defect will act as a reservoir, retaining menstrual blood from each cycle and remaining constantly inflamed. For a small group of women – we don’t know how many – this fluid can damage sperm and interfere with embryo implantation, leaving them infertile or struggling to get pregnant.
Further, about one third of women who have a defect will have symptoms of abnormal bleeding and spotting between periods, ongoing pain, very painful periods or pain during sex. Those who are left infertile don’t always have these symptoms.
The symptoms can very often be resolved, and fertility restored, with a relatively simple surgery. There have been about 1,200 such surgeries reported in the literature since 2003.
That first reported surgery was lead by prominent surgeon Dr Camran Nezhat, an expert in endometriosis and minimally-invasive surgery. Based in Northern California, he estimates he’s performed about 50 such repairs since.
Camran Nezhat – brother of Farr, quoted above – recently wrote in an academic paper that because of the continued lack of awareness, defects are “currently underdiagnosed and may consequently be left untreated at a staggering rate”.
Wellington fertility specialist Dr Simon McDowell, who spoke on behalf of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, said: “I do think this is a cause of infertility, I do, and I think it’s one that is probably unrecognised in many situations.” In New Zealand most GPs were not aware of the condition and even some fertility specialists were not giving it the consideration it deserved, he said.
“I think the College position is that women should be informed, absolutely.”
McDowell predicted the College would develop formal guidelines for diagnosis and treatment of problematic defects in the next few years. (The Ministry of Health holds no data on the condition but says such guidelines would be used to inform important resources such as the pamphlets given to women after caesarean sections). McDowell emphasised that defects do not usually cause problems and the very small risk of infertility should not deter a woman from having a caesarean section if she needed one.
Women who have unexplained bleeding or pain, or those struggling to conceive after a caesarean section, should seek help from a specialist. “And don’t assume that you’re going to have problems getting pregnant because you had a caesarean section – but a well-trained fertility specialist will consider that as a possible cause.”
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