Surgical Management of Cesarean Scar Defect in Restoring Fertility
Cesarean scar defect, niche, or isthmocele is commonly detected as an incidental finding on transvaginal ultrasound as a wedge-shaped anechoic area. The presence of a uterine scar defect is usually asymptomatic or relates to postmenstrual spotting and dark red or brown discharge, pelvic pain or infertility. Surgical repair or isthmoplasty is associated with an improvement in uterine bleeding in 59% to 100% of cases and a pregnancy rate of 77.8% to 100%. Therefore, treatment of isthmocele should be offered to women with symptoms or if it is causing infertility. Hysteroscopic isthmoplasty appears to be the most popular and less invasive treatment. However, in the absence of randomized trials, the efficacy of different surgical approaches remains to be evaluated.
KeywordsCesarean scar defect Isthmocele Hysteroscopic resection Laparoscopic excision Vaginal repair Postmenstrual spotting Pelvic pain Infertility
- 3.Bij de Vaate AJ, van der Voet LF, Naji O, Witmer M, Veersema S, Brölmann HA, Bourne T, Huirne JA. Prevalence, potential risk factors for development and symptoms related to the presence of uterine niches following cesarean section: systematic review. Ultrasound Obstet Gynecol. 2014;43(4):372–82.CrossRefGoogle Scholar
- 25.Di Spiezio SA, Saccone G, McCurdy R, Bujold E, Bifulco G, Berghella V. Risk of cesarean scar defect in single- versus double-layer uterine closure: a systematic review and meta-analysis of randomized controlled trials. Ultrasound Obstet Gynecol. 2017; doi: 10.1002/uog.17401. [Epub ahead of print]
- 27.Kaelin Agten A, Cali G, Monteagudo A, Oviedo J, Ramos J, Timor-Tritsch I. The clinical outcome of cesarean scar pregnancies implanted “on the scar” versus “in the niche”. Am J Obstet Gynecol. 2017; doi: 10.1016/j.ajog.2017.01.019. [Epub ahead of print]
- 29.Baranov A, Salvesen KÅ, Vikhareva O. Assessment of cesarean hysterotomy scar before pregnancy and at 11–14 weeks of gestation: a prospective cohort study. Ultrasound Obstet Gynecol. 2016; doi: 10.1002/uog.16220. [Epub ahead of print].
- 33.Tsuji S, Murakami T, Kimura F, Tanimura S, Kudo M, Shozu M, Narahara H, Sugino N. Management of secondary infertility following cesarean section: report from the subcommittee of the reproductive endocrinology committee of the Japan society of obstetrics and gynecology. J Obstet Gynaecol Res. 2015;41(9):1305–12.CrossRefPubMedGoogle Scholar