Secondary Infertility After C-Section: Fertility Case Study #1

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This is the first in an ongoing series showcasing real-world patient journeys and clinical outcomes to illustrate the impact of restorative reproductive medicine in practice.

Abstract 

Uterine perforation is a rare but serious complication associated with intrauterine procedures. The most common procedures causing uterine perforation include dilation and curettage (D&C), hysteroscopy, and intrauterine device (IUD) insertion. Those who have a weakened myometrial wall through cesarean section have an increased risk. Even when resolved, uterine perforations can contribute to infertility by causing intrauterine scarring or adhesions. In rare cases, they may result in incarceration, prolapse, or damage to the fallopian tubes. In those cases, future pregnancies hold the risk of placenta previa, ectopic pregnancy, or abnormal placental attachment. This report presents a case of fallopian tube destruction secondary to uterine perforation, which was managed via laparoscopic surgery and ultimately resolved natural fertility and spontaneous conception on the first try.

Introduction 

A uterine perforation involves accidental penetration of the uterine wall which can lead to injury of surrounding organs. The organs mostly affected include the omentum, intestines, abdominal and pelvic viscera, urinary bladder, bowel. Involvement of the fallopian tubes is uncommon but can have significant reproductive consequences, including infertility and impaired conception. Fallopian tube complications may occur when a perforation allows the tube to become entrapped, prolapsed into the uterine cavity, or physically damaged by surgical instruments. Destruction or severe trauma to the fallopian tube can disrupt its anatomical integrity and function, impairing oocyte transport and increasing the risk of infertility or ectopic pregnancy. Definite diagnosis can be made on rare occasions when abdominal contents are found in the cervix or instruments can reach beyond the cavity during intrauterine procedures. 

Case

A 33-year-old G3P2012 with a history of two cesarean deliveries presented for a second opinion regarding possible retained products of conception. Her recent medical history was notable for a missed abortion at 8 weeks and 5 days managed with dilation and curettage (D&C) at an outside facility. The procedure was complicated by a uterine perforation, which resulted in injury to the fallopian tube.

During the procedure, there was an anterior wall perforation of the uterus despite ultrasound guidance. Perforation was identified by surgeon noticing abnormal yellow tissue on instruments that he thought was the omentum. The surgeon believed that perforation occurred due to the degree of retroversion of the uterus. Surgery was transitioned into a diagnostic laparoscopy. Specimen labeled “products of conception and omentum” were sent to the lab. Post-operation, the surgeon stated, “her left fallopian tube and ovary was adhesed to the anterior abdominal wall, but looked otherwise healthy.” Patient received Cytotec medical management to expel remaining tissue that was left in uterus. At her follow-up appointment, patient was informed that “a small segment of fallopian tube was seen on pathology specimen” including fimbriated end. Subsequent ultrasound demonstrated “a gestational sac and fetal pole.” 

She presented to us for a second opinion and underwent a selective hysterosalpingogram with attempted tubal cannulation, diagnostic hysteroscopy with endometrial and endocervical cultures and biopsies, diagnostic laparoscopy with laser surgery for endometriosis, lysis of adhesions, chromopertubation, left tuboplasty and fibrioplasy, and isthmocele repair. 

During attempted hysteroscopy, there was concern for perforation through isthmocele.  At this time, there was suspected false passage, so it was temporarily stopped.  

Attention was turned to the patient’s abdomen as laparoscopy began. Adhesiolysis was performed. Left fimbriae were not visible until dissection into anterior/left abdominal wall. Left fimbriae were healthy and luscious after extensive dissection and reconstruction of the tube. Raw edges were repaired and fibrioplasy was performed and tucked back into anatomical position. 

Right fallopian tube adhesions were taken down from the right adnexa to the bowel and from the right tube to the uterus. The right tube was blunted 3cm from isthmus with no distal tube or fimbriae found. 

Isthmocele was visualized on inspection. Repair was performed via gentle dissection of 1-2mm of myometrium leading into the endocervical canal. Chromopertubation was tempted without spilling from the left tube before and after isthmocele repair. 

After the discontinuation of the robotic platform, a catheter was advanced to the left tubal ostia, and dye was injected into the left fallopian tube while intratubal pressures were measured. Tubal cannulation was attempted with three passes of a floppy guidewire. The pressures did not go down and no spill was noted. 

Selective HSG under hysteroscopic guidance was unsuccessful. 

Patient conceived 3 months later using timed intercourse during her fertile window. Intrauterine embryo with normal embryonic cardiac rate confirmed on ultrasound. 

Discussion

Dilation and curettage (D&C) is a diagnostic and therapeutic surgical procedure with an overall complication rate of approximately 0.7%.1 Uterine perforation is a risk of performing the procedure, but the risk varies based on the precenting patient. In the case presented above, the patient is premenopausal and was only 0.3% at risk for uterine rupture. Postmenopausal women have a 2.6% risk of uterine perforation.2 It is important to note that uterine perforation is diagnosed through pathology reports from tissue found during the procedure and imaging. Therefore, if the surgeon does not send abnormal finding tissue to pathology, the uterine perforation will go undocumented.3 Also, if the surgeon does not order the diagnostic imaging such an ultrasound with high-resolution transvaginal probes to detect signs such as bowel loops in the uterine cavity, abnormal positioning of fallopian tubes, or extrauterine fluid, findings will never be documented.4

Risk factors for uterine perforation during D&C include difficult access to endometrial cavity or weakened myometrial walls. Myometrial walls can be thinned from previous surgeries such as the two cesarean deliveries this patient had previously.2

The most common location of uterine perforation are the anterior and posterior midline surfaces. Due to their vascularity, many uterine perforations may go asymptomatic and undetected. The most severe location is lateral. Lateral perforations are more likely to lead to bowel injury and require immediate surgical intervention.2 

Fallopian tube destruction refers to significant damage or compromise of the fallopian tube’s structural integrity, often resulting from trauma such as uterine perforation during intrauterine procedures. This damage can impair or completely obstruct the tube’s ability to transport gametes or embryos, contributing to infertility. Inflammatory responses to such injury may further exacerbate fertility issues by promoting adhesion formation and scarring within the reproductive tract. According to researchers at Columbia University, tubal factor infertility accounts for approximately 25–30% of all infertility cases.⁵

For example, a 2024 case report described a 40-year-old woman with abnormal uterine bleeding and secondary infertility. She was found to have uterine adhesions and a perforation with the right fallopian tube incarcerated into the uterine wall. Surgical intervention involved bilateral salpingectomy and uterine wall repair, aiming to restore uterine integrity and address fertility concerns.6

These cases underscore the importance of prompt recognition and management of uterine perforation and associated fallopian tube complications to preserve fertility. Surgical interventions, such as laparoscopy, can be utilized to correct anatomical abnormalities and improve reproductive outcomes.

Techniques such as laparoscopy and hysteroscopy enable the repair of damaged organs. Salpingoplasty may be performed to restore tubal function if the fimbriae portion remains intact. Postoperative assessments using hysterosalpingography or hysteroscopy are essential to confirm uterine healing, absence of synechiae, and tubal patency.7 While surgical success rates for tubal obstruction are high (>90%), spontaneous pregnancy rates post-repair remain lower at approximately 30-36% due to residual damage or scarring.⁵

Preventative measures include careful procedural techniques and consideration of patient risk factors such as advanced age, multiparity, or recent pregnancy. 

Conclusion

Uterine perforation is a rare complication of intrauterine procedures that can cause other structural abnormalities including fallopian tube prolapse, damage, or incarceration. Adhesiolysis of adhered fallopian tubes is an effective procedure in improving fertility and live birth rate. By restoring the fallopian tube to represent its natural structure as much as possible, fertility rates increase. Future research should focus on refining preventive strategies and improving surgical techniques to minimize complications. More research should also be conducted on the role adhesions, uterine perforation, and fallopian tube structure abnormality has on fertility. Additional research is needed on adhesion prevention. 

References

1. Dilation and Curettage (D&C) patient education fact sheet. Reproductivefacts.org. Published 2023. Accessed April 8, 2025. https://www.reproductivefacts.org/news-and-publications/fact-sheets-and-infographics/dilation-and-curettage-dc/

2. Kim M. Incarcerated Omentum With Tamponade Effect in the Uterine Perforation Scar After Dilation and Curettage: A Case Report. Journal of Medical Cases. 2014;5(4):204-207. doi: https://doi.org/10.14740/jmc.v5i4.1713

3. Zorilă GL, Căpitănescu RG, Drăgușin RC, et al. Uterine Perforation as a Complication of the Intrauterine Procedures Causing Omentum Incarceration: A Review. Diagnostics. 2023;13(2):331. doi: https://doi.org/10.3390/diagnostics13020331

4. Dudhe SS, Waghulkar S, Mishra GV, Parihar P, Nimodia D. A Rare Occurrence of Uterine Perforation Following the Dilation and Curettage for Missed Abortion. Cureus. Published online September 24, 2024. doi: https://doi.org/10.7759/cureus.70079

5. Tubal Factor Infertility (Fallopian Tube Obstruction) | ColumbiaDoctors - New York. ColumbiaDoctors. Published June 20, 2017. https://www.columbiadoctors.org/treatments-conditions/tubal-factor-infertility-fallopian-tube-obstruction

6. De Landtsheer-Pletsa N, Pening D, Moutard N, et al. Aberrant oviduct pathway following vacuum aspiration: A case report and literature review. Radiology Case Reports. 2024;19(12):6402-6405. doi: https://doi.org/10.1016/j.radcr.2024.09.031

7. Kondo W, Bruns RF, Nicola MC, Ribeiro R, Trippia CH, Zomer MT. Laparoscopic Treatment of Intrauterine Fallopian Tube Incarceration. Case Reports in Obstetrics and Gynecology. 2013;2013:1-3. doi: https://doi.org/10.1155/2013/205957