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.