We need to avoid uterine surgery if possible

If we want to retain our fertility, that is. This is one of those subjects I feel SO strongly about, but I don't get the chance to jump onto my soapbox. Why? Because this is a VERY touchy subject. Surgical uterine intervention is often emotional. D&Cs and Cesarean Sections are often criticized, so women feel defensive at the mere mention of it. Although most of the D&Cs that I am aware of occurred after a miscarriage, which is a HORRIBLE time in the life of a woman. A time when a woman is in so much physical and emotional pain. She is very vulnerable. When a woman learns that she is carrying her dead baby the shock and horror defy description. Doctors are human too, and they see our pain, and they want to "save" us from it. They want to make it go away as quickly as possible. There is a problem with that. Asherman's Syndrome. This is where residual scar tissue within/around the uterus prevents subsequent pregnancies. I looked it up in Wikipedia.

The cavity of the uterus is lined by the endometrium. This lining is composed of two layers, the functional layer which is shed during menstruation and an underlying basal layer which is necessary for regenerating the functional layer. Trauma to the basal layer, typically after a dilation and curettage (D&C) performed after a miscarriage, or delivery, or for elective abortion can lead to the development of intrauterine scars resulting in adhesions which can obliterate the cavity to varying degrees. In the extreme, the whole cavity has been scarred and occluded. Even with relatively few scars, the endometrium may fail to respond to estrogens and rests. Often, patients experience secondary menstrual irregularities characterized by changes in flow and duration of bleeding (amenorrhea, hypomenorrhea, or oligomenorrhea) [1] and becomes infertile. Menstrual anomalies are often but not always correlated with severity: adhesions restricted to only the cervix or lower uterus may block menstruation. Pain during menstruation and ovulation are also sometimes experienced, and can be attributed to blockages.
Asherman's syndrome occurs most frequently after a D&C is performed on a recently pregnant uterus, following a missed or incomplete miscarriage, birth, or elective termination (abortion) to remove retained products of conception/placental remains. As the same procedure is used in all three situations, Asherman's can result in all of the above circumstances. It affects women of all races and ages as there is no underlying predisposition or genetic basis to its development. According to a study on 1900 patients with Asherman’s syndrome, over 90% of the cases occurred following pregnancy-related curettage [2]. It is estimated that up to 5% of D&Cs result in Asherman's. More conservative estimates put this rate at 1%. Asherman's results from 25% of D&Cs performed 1-4 weeks post-partum [3][4][5], 30.9% of D&Cs performed for missed miscarriages and 6.4% of D&Cs performed for incomplete miscarriages. [6] In the case of missed miscarriages, the time period between fetal demise and curettage increases the likelihood of adhesion formation to over 30.9% [2][7]The risk of Asherman's also increases with the number of procedures: one study estimated the risk to be 16% after one D&C and 32% after 3 or more D&Cs [8].
Depending on the degree of severity, Asherman's syndrome may result in infertility, repeated miscarriages, pain from trapped blood, and high risk pregnancies [9]. There is evidence that left untreated, the obstruction of menstrual flow resulting from scarring can lead to endometriosis[5].
Asherman's can also result from other pelvic surgeries including Cesarean sections[2], removal of fibroid tumours (myomectomy) and from other causes such as IUDs, pelvic irradiation, schistosomiasis[10] and genital tuberculosis[11]. Chronic endometritis from genital tuberculosis is a significant cause of severe IUA in the developing world, often resulting in total obliteration of the uterine cavity which is difficult to treat [12].
An artificial form of Asherman's syndrome can be surgically induced by endometrial ablation in women with excessive uterine bleeding, in lieu of hysterectomy.

My purpose in mentioning this is to educate. I pray that you are never faced with this. But if you find yourself in the situation of a miscarriage, PLEASE consider waiting to miscarry naturally. Of course there are times for surgical intervention. But remember. You never know *which* D&C will be your last.

Here is part of an article from TimesOnline.

Rebecca McAra went through £1,000 of tests over a 12-month period before discovering that she had Asherman’s, caused by a D&C carried out after a miscarriage. “I was so traumatized when I lost my baby that when I was offered a D&C I jumped at the chance, thinking it was the quickest and easiest option. I wish I had been told that a snap decision made in a hospital scanning room might irreparably compromise my fertility.

“I could have waited to see if the full miscarriage occurred naturally but was told this could take up to a month. I wasn’t informed about medication as an alternative to uterine surgery, nor about the risk of developing Asherman’s if I had a D&C.” Having undergone hystero-scopic surgery to remove uterine scar tissue, McAra is now trying to conceive again. Professor Ledger believes that hospitals should routinely warn women that there is a risk of developing Asherman’s if they opt for surgery. “The NHS is very hot on producing leaflets about anything and everything but few women are informed about Asherman’s.”

And Cesarean Sections can be a problem for future conception. Here is a quote from Web MD:

The study involved 283 women who completed questionnaires roughly three years after delivering their first child by cesarean section or vaginal delivery using forceps or vacuum pump. Three quarters of the women who said they wanted a second child achieved a pregnancy during that time. But the women who had vaginal deliveries were twice as likely to have conceived as those who had cesarean sections,

This is from Childbirth Connections:

# Future reproductive problems for mothers: A cesarean section in this pregnancy puts a woman at risk for future reproductive problems in comparison with a woman who has a vaginal birth. These problems may involve serious complications and medical emergencies. The likelihood of experiencing some of these conditions goes up sharply as the number of previous cesareans increases. These problems include:

* ectopic pregnancy: pregnancies that develop outside her uterus or within the scar
* reduced fertility, due to either less ability to become pregnant again or less desire to do so
* placenta previa: the placenta attaches near or over the opening to her cervix
* placenta accreta: the placenta grows through the lining of the uterus and into or through the muscle of the uterus
* placental abruption: the placenta detaches from the uterus before the baby is born
* rupture of the uterus: the uterine scar gives way during pregnancy or labor.