Q: I am a 32 years old woman who had two c-sections and then developed an incisional hernia. My husband and I would like to conceive a third child but hernia is extremely painful. My doctor advised me to undergo surgery. He told me that hernia would not harm the child, but it may become larger and more painful. Will hernia affect my conception?

A:This is a difficult question. There is nothing in the books that answers this, and one has to comment on the basis of one's own experience and judgment. I would be wary of advising you to conceive while you actually have the hernia. Your doctor is quite right: all that may happen is that the hernia may get larger and more painful. On the other hand hernias are known to have complications. Is complication more likely during pregnancy? I don't know, but the complications certainly cannot be less likely. Other doctors may disagree, but if my wife had an incisional hernia I would get that repaired first thing, then consider other issues. My own guess is that you are looking at a 10% chance of complications, with a possibly serious outcome: it's probably not worth the risk. Getting pregnant in the presence of the hernia is a very unattractive option. On the other hand, the uterus tends to go into the hernia sac, with grave possible complications. Apparently this complication is common enough, though I haven't seen a case. What happens if you become pregnant after the hernia is repaired? Assuming that you wait long enough (three to five years) after surgery and that healing is complete, the wound should remain intact during the pregnancy. The abdomen certainly will not burst, but you may develop considerable pain. I tried looking through the literature. There is very little literature on this subject, though the problem cannot be rare.

Many experts favour delaying repair till childbirth is complete. There is one formal paper on this topic, but the paper describes only one such case, so we cannot make any conclusions on that. If you get pregnant, you are looking at another caesarean (90% chance). An abdominal operation after mesh repair of hernia is quite a difficult procedure (I speak from experience!). So getting pregnant after the hernia repair is also a very unattractive option.

Not getting pregnant at all? It is a bad thing for a doctor to give this advice, but only you can say how unattractive this proposition is. On the other hand, there is at least one paper: "Abrahamson J, Gorman J. Pregnancy and ventral hernia repair. Hernia 2000;4:187–191." In this paper 27 patients underwent incisional hernia repairs. So what's my own final verdict, given that I have to choose between three very unhappy options? First, consider no more babies. Get the hernia repaired, and a tubal ligation done at the same sitting. Safest, most logical option, but may not be emotionally acceptable to you. Second, get the repair done and then plan your pregnancy. Both the pregnancy and the caesarean will be very difficult. However, the risks to you and the baby are fewer. Third, have your baby and then get the repair done (or done at the time of the caesarean section). This has risks, and I personally think that this is the worst option. You should print this out and consult another senior surgeon.