As a tubal reversal specialist, I have been amazed at how many women are pressured into having a tubal ligation when their doctor discovers a uterine window.
I am often asked to review tubal ligation operative notes in which uterine windows were unexpectedly seen at the time of c-section.
Often the patient’s doctor will recommend a tubal ligation because a uterine window. A uterine window occurs when the uterine muscle is stretched so thin that you can see through it…just like a glass window. This usually means the uterine wall is weak… just barely able to contain the pregnancy.
The concern is that if the uterine wall is stretched thin now… then with the next pregnancy the uterine wall may rupture before the time of birth. This would be disastrous.
When doctors see a uterine window they will usually advise the patient to have a tubal ligation. Often this ‘counseling session’ happens at the wrong time…when the patient is on flat on her back, during a c-section, and after a long nine months of pregnancy. This is not the best time to have a discussion about a permanent procedure!
These women feel pressured into having an unplanned tubal ligation because of a newly diagnosed condition. Many feel victimized.
After the c-section is over, many of these women regret their sudden decision to having a tubal ligation. They usually feel like they were pressed into making a sudden decision to have a tubal ligation.
Many of the women who regret their decision will contact our office asking if they can have tubal reversal surgery and will the uterine window cause any future problems to pregnancy?
What is a uterine window?
Simply explained a uterine window is a weakness in the uterine muscle.
A uterine window can happen in any woman who has had uterine surgery but the most common reason is a previous c-section. Uterine windows are often discovered in the third trimester at the time of c-section. You cannot see a uterine window at the time of vaginal birth and uterine windows cannot be seen on ultrasound.
The uterine muscle is thick. In the non-pregnant state the uterine muscle can be as thick as 1 to 2 inches. During pregnancy the uterine muscle can be 1/4 to 1/2 inch thick around the time of birth. When a uterine window occurs the uterine muscle becomes as thin as Saran Wrap. It is so thin the baby can be seen through the thin uterine muscle. This is why it is called a ‘uterine window’.
It is commonly believed a uterine windows will cause uterine rupture in a future pregnancy. Unfortunately, this belief may not be true.
Many doctors believe the risk of uterine rupture is increased in future pregnancies when a uterine window is discovered and will often encourage women to have a tubal ligation to prevent the risk of future uterine rupture.
It is because of this belief that many women are counseled to have a tubal ligation.
Feeling the heat: Tubal reversals in patients with uterine windows
I was recently contacted by the doctor of one of my recent reversal patients. Her doctor was upset I performed a tubal reversal procedure.
The doctor, very politely, asked me if I had read the patient’s c-section operative note and if I had noted the diagnosis of a uterine window. I responded that I was aware of the diagnosis.
The doctor then proceeded, very politely, to ask me why I performed a tubal reversal and asked if I counseled the patient about the future risks of pregnancy because of the uterine window. I responded that I did but that it is our practice to let our patients decide what is best for their reproductive needs. This is why I call my practice A Personal Choice.
I then explained in my previous OB practice I had performed many c-sections and diagnosed uterine windows. I had performed repeat c-sections on many of these same women and most of them had normal findings and no uterine windows!
I told the doctor we mistakenly believe a uterine window is bad but my personal experience did not support this belief and, furthermore, there is no medical literature suggesting these beliefs are true.
The conversation ended abruptly and I could sense the doctors was upset and did not agree with me.
Research about uterine windows
A study about uterine windows was published in the Journal of Obstetrics and Gynecology. The authors studied 30 women with prior uterine dehiscence (uterine windows) and 14 women who had prior uterine rupture (torn uterine muscle). They recommended early, repeat c-section ( 1 to 4 weeks before their due dates) in these patients and no major complication occurred. Furthermore in these 44 women only 6% of these patients had asymptomatic uterine windows at the time of repeat c-section.
The conclusion of the study was women with prior uterine rupture or uterine windows can have excellent outcomes in future pregnancy if they are followed closely and have early delivery by repeat c-section.
To read a summary of the research findings visit: Pregnancy Outcomes in Patients With Prior Uterine Rupture or Dehiscence
This study made me feel better about my advice to patients seeking tubal reversal after having a uterine window.
Research on risks of uterine rupture
There has been extensive research on uterine ruptures. A uterine rupture can technically occur in any pregnant woman who is in labor at any time in pregnancy. Uterine rupture can occur as early as 20 weeks of pregnancy or as late as 42 weeks of pregnancy. Most cases of uterine rupture happen in women who are in labor after 38 weeks of pregnancy.
There is one main risk of uterine rupture: prior uterine surgery.
The most common uterine surgery in the Untied States is previous c-section delivery. Most uterine ruptures in the United States occur in women who have a history of a prior c-section who attempt a trial of labor (try to have a vaginal birth) after their c-sections. This is commonly referred to as vaginal birth after c-section or VBAC.
More information: Uterine rupture during trial of labor
If you have had a prior c-section and try to have a vaginal birth then you are at increased risk of uterine rupture when you go into labor. Overall the increased risk is low but the more c-sections you have then we believe there is an increased risk of uterine rupture. If you have had multiple c-sections the risk of uterine rupture with attempted vaginal delivery is likely less than 10%.
The current recommendations are if you have had one c-section then it may be reasonable to attempt a vaginal birth. If you have had two or more c-sections then the recommendations are that you have repeat c-sections for future pregnancies.
More information: Guidelines for vaginal birth after Cesarean Delivery
Other than the study quoted above there are no recommendations or guidelines for women who have been diagnosed with uterine windows. Uterine windows can only be truly diagnosed at the time of C-section. Uterine windows cannot be diagnosed accurately during a clinical exam or with ultrasound. To our knowledge, uterine windows only occur in women who have had prior c-sections. We also know uterine windows do not always predict uterine ruptures or bad outcomes in future pregnancies.
So uterine windows do not always equal a future uterine rupture and definite bad outcome.
Were you advised to have tubal ligation because of a uterine window?
If you underwent a tubal ligation because you were told you had a uterine window and were afraid of the future then you are not alone. If you want to become a mother again then you should know it is possible.
Our advice to you is don’t lose hope, find a supportive Ob/Gyn, and consider tubal ligation reversal or in-vitro fertilization (IVF).
Dr. Monteith specializes in tubal reversal and has taken care of many women who were counseled to have their tubes tied after their doctors diagnosed a uterine window at the time of c-section.
To see what Dr. Monteith’s patients have to say about their experience then we encourage you to watch this video.
To see more of Dr Monteith’s videos visit: Tubal reversal with Dr Monteith
Uterine window and uterine rupture: Is tubal reversal possible?
If you have had a uterine window or uterine rupture then future pregnancies are considered to be higher risk. This higher risk is manageable if the patient is well informed. Tubal ligation is not always required.
If you have been diagnosed with a uterine window and want a tubal reversal you can be reassured that if you are followed closely during future pregnancy then you have a good chance at having an excellent outcome.
For more information about tubal reversal surgery call (919) 977-5050 or visit our website to learn more about Dr Monteith: Tubal Reversal With A Personal Choice
