Ask Dr. Marc........C-section scar and low AMH By Paula Hovell on July 29, 2013

This question and answer was originally published on the blog  by Katie: "Infertility Warrior, Mommy to two, wife of rock and roller, Child and Adolescent Psychotherapist , and Parenting Expert in Los Angeles, CA" 

Dear Dr. Marc

I am 30 years of age, had my first child naturally at the age of 26.  For that birth, I needed an emergency cesarean due to pre-eclampsia.  In seeking answers for our inability to fall pregnant after a year, it was found that I have fluid in my uterus from my c-sec scar and I also have a very low AMH for my age.  In determining this I have had a laparoscopy, and hysteroscopy.  We have done intrauterine insemination (IUI) once and two cycles of IVF.  My husband’s sperm has also been tested and is fine.  I have had very few eggs from each cycle, but have managed to have two day 5 blastocysts the first time and 3 blastocysts the second cycle.

Hi trying for number 2,

Your situation is quite interesting and somewhat unique.  First let’s talk about how a cesarian section is performed.  In most C-sections, a horizontal incision is made in the lower (closest to the vagina) part of the uterus.  Importantly, the scar on a woman’s abdomen has nothing to do with the type of scar which is made on the uterus.  Through this horizontal uterine incision, which is about 10 centimeters in diameter, the doctor can access the baby and placenta and remove them from the uterus.  Following delivery of the placenta, the uterine incision is normally repaired with at least 2 layers of stitches.   In the vast majority of cases, this repair is quite strong and has no significant impact on the structure or function of the uterus.  In fact, many women are able to have normal vaginal deliveries after having a C-section, this is called a VBAC (vaginal birth after caesarian).

In some circumstances however, the C-section repair is less than perfect and can affect future pregnancies.  It is important to know that this does not mean that your doctor made a mistake.  There are simply many factors that go into the healing of a C-section scar.  For you, it seems that these factors may have combined to cause there to be fluid in your uterus. 

The fluid may be due to a gland which healed within the scar and secrets mucus into the uterus.  Alternatively, there could be a channel which allows fluid to flow into the uterus from the outside.  Either way, the best step to further explore the scar is a hysteroscopy and laparoscopy.  If there is a structural abnormality responsible for the fluid, then it should be identifiable and treatable through hysteroscopy and laparoscopy. 

Moreover, some amount of fluid is normal in the uterus.  The uterus is full of glands and they produce mucus which is critical to the health of the uterine environment.  It is possible that you simply make more mucus than normal and that it has nothing to do with your C-section scar.    

This brings us to the other issue which is ovarian reserve.  We know that as we get older, each of our eggs is somewhat less likely to go on to become a baby.  The significance of age is different for each of us and unfortunately, some women experience decreased ovarian reserve earlier than others.  30 years of age is relatively young in the world of fertility, but some women do notice diminished ovarian reserve at 30.  I suspect that if you are not making many eggs per cycle, this is the case with you.  The good news is that although you do not make many eggs, the ones you do make seem to be of good quality.  Ultimately, this means that your prognosis good.

My advice to you is to have another doctor review the operative report form your surgery, if the C-section scar was visualized and appeared normal, then there is not much more that can be done surgically.  At that point I would focus on the next IVF cycle and making it as optimal as possible.  It would be reasonable to remove any extra mucus from the uterus prior to transferring embryos.  Alternatively, a frozen embryo transfer may be beneficial because the uterus tends to produce less mucus during a frozen cycle.

In conclusion, my feeling is that the mucus is less important than embryo quality and quantity.  Hopefully it is just a matter of getting the right embryo in place and then nature will take care of the rest!

Good Luck!

Dr. Marc         

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