Fertility and pregnancy outcomes after a uterine niche resection in women with and without infertility: a systematic review and meta-analysis

Verberkt, C.; Meuleman, Saskia.J.M. Klein; Ket, Hans; Wely, Madelon van; Bouwsma, Esther V.A.; Huirne, Judith A F

doi:10.1016/j.xfnr.2022.05.003

Cited by 6 publications

(11 citation statements)

References 42 publications

(128 reference statements)

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“…Although surgical management of CSDi has been investigated in an RCT for the amelioration of abnormal uterine bleeding, 20 data for treating other niche-related symptoms is very scarce. 21 Currently 1 RCT 22 has been registered that compares the effect of a laparoscopic niche resection vs expectant management in infertile women with a large niche, and an RCT 23 that evaluates the effect of a laparoscopic niche resection compared with hormonal treatment in women with niche-related spotting complaints is underway as well. With respect to hysteroscopic niche resection, 1 study evaluated the effect on clinical pregnancy rate in 61 secondary infertile patients and showed superiority of the hysteroscopic niche resection compared with expectant management.…”

Section: Discussionmentioning

confidence: 99%

Definition and Criteria for Diagnosing Cesarean Scar Disorder

et al. 2023

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ImportanceApproximately 60% of women develop a uterine niche after a cesarean delivery (CD). A niche is associated with various gynecological symptoms including abnormal uterine bleeding, pain, and infertility, but there is little consensus in the literature on the distinction between the sonographic finding of a niche and the constellation of associated symptoms.ObjectiveTo achieve consensus on defining the clinical condition that constitutes a symptomatic uterine niche and agree upon diagnostic criteria and uniform nomenclature for this condition.Design, Setting, and ParticipantsA consensus based modified electronic Delphi (eDelphi) study, with a predefined Rate of Agreement (RoA) of 70% or higher. Experts were selected according to their expertise with niche-related consultations, publications, and participation in expert groups and received online questionnaires between November 2021 and May 2022.Main Outcomes and MeasuresDefinition, nomenclature, symptoms, conditions to exclude, and diagnostic criteria of an illness caused by a symptomatic uterine niche.ResultsIn total, 31 of the 60 invited experts (51.7%) participated, of whom the majority worked in university-affiliated hospitals (28 of 31 [90.3%]), specialized in benign gynecology (20 of 31 [64.5%]), and worked in Europe (24 of 31 [77.4%]). Three rounds were required to achieve consensus on all items. All participants underlined the relevance of a new term for a condition caused by a symptomatic niche and its differentiation from a sonographic finding only. Experts agreed to name this condition cesarean scar disorder, defined as a uterine niche in combination with at least 1 primary or 2 secondary symptoms (RoA, 77.8%). Defined primary symptoms were postmenstrual spotting, pain during uterine bleeding, technical issues with catheter insertion during embryo transfer, and secondary unexplained infertility combined with intrauterine fluid. Secondary symptoms were dyspareunia, abnormal vaginal discharge, chronic pelvic pain, avoiding sexual intercourse, odor associated with abnormal blood loss, secondary unexplained infertility, secondary infertility despite assisted reproductive technology, negative self-image, and discomfort during participation in leisure activities. Consensus was also achieved on certain criteria that should be met and conditions that should be excluded before making the diagnosis.Conclusions and RelevanceIn this modified Delphi study, a panel of 31 international niche experts reached consensus for the constellation of symptoms secondary to a uterine niche and named it cesarean scar disorder.

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Section: Discussionmentioning

confidence: 99%

Definition and Criteria for Diagnosing Cesarean Scar Disorder

et al. 2023

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“…The most robust RCT included in both reviews demonstrated a pregnancy rate of 75% for those treated by hysteroscopy, compared with 32% for those managed expectantly [48]. The cumulative pregnancy rates across all surgical interventions in each review were 65 and 67%, respectively [11 ▪▪ ,12 ▪▪ ]. Surgical CSD repair may, thus, be appropriate for treating isolated secondary infertility, particularly through hysteroscopy when the RMT is adequate.…”

Section: Treatmentmentioning

confidence: 98%

“…This is felt to be secondary to inflammation, fibrosis, and necrosis within the defect itself [5 ▪ ]. The presence of a CSD is also associated with secondary infertility, possibly because of the impact of this inflammatory response from menstrual blood and scarring within the defect on cervical mucous quality, sperm transport, and sperm quality [11 ▪▪ ,12 ▪▪ ]. This inflammatory milieu is also postulated to affect embryo implantation, similar to a hydrosalpinx [4].…”

Section: Clinical Signs and Symptomsmentioning

confidence: 99%

“…There continues to be debate surrounding the impact of CSD repair on fertility outcomes, though a systematic review suggests that the balance may be tipping in favor of surgical intervention [11 ▪▪ ]. Conversely, another systematic review and meta-analysis concluded that evidence is insufficient for recommendation of CSD repair to treat secondary infertility [12 ▪▪ ]. The most robust RCT included in both reviews demonstrated a pregnancy rate of 75% for those treated by hysteroscopy, compared with 32% for those managed expectantly [48].…”

Section: Treatmentmentioning

confidence: 99%

“…In fact, in their systematic review, Verberkt et al [12 ▪▪ ] identified recurrent CSPs in 1% of pregnancies even after surgical repair. Signs of uterine dehiscence or rupture were noted in 3% of deliveries following hysteroscopic repair and none following other repair methods, raising further question regarding the utility of this treatment in prevention of these outcomes [12 ▪▪ ,49]. The incidence of CSP and uterine rupture in expectantly managed CSDi is lacking.…”

Section: Treatmentmentioning

confidence: 99%

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The presentation and management of cesarean scar defects: an updated review on an evolving diagnosis

McGrattan

Kobylianskii

Thiel

et al. 2023

Current Opinion in Obstetrics &Amp; Gynecology

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Purpose of review The purpose of this review is to provide a clinically relevant synthesis of the current literature on cesarean scar defects, focusing on their epidemiology and clinical presentation, diagnosis, treatment, and prevention. Recent findings Cesarean scar defects (CSDs) are an emerging area of gynecologic research, with an influx of higher quality cohorts, randomized controlled trials, and systematic reviews published within the last decade. Recent developments of importance include the European Niche Taskforce consensus on the measurement and diagnosis of CSDs, the proposal of clinical criteria for Cesarean scar disorder (CSDi), as well as the publication of several systematic reviews, which provide enhanced support for clinical decision-making in treatment strategies. Areas for continued research include risks factors for CSDs and preventive strategies, as well as their role in obstetrical complications. Summary CSDs are a common sonographic finding. While those incidentally identified in an asymptomatic population require no treatment, CSDs can cause significant burden in the form of abnormal uterine bleeding, pelvic pain, and infertility. Their role in obstetrical complications has yet to be fully elucidated. Given the high incidence of cesarean sections, many – if not all – providers of uterine care will encounter their sequalae. As such, continued awareness amongst all providers regarding their evaluation and management is key. Video Abstract http://links.lww.com/COOG/A91

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Evaluation of Association Between Adenomyosis and Cesarean Scar Defect

Shakki Katouli,

Zebardast,

Tavoli

et al. 2023

J of Ultrasound Medicine

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PurposeThis study aims to investigate and compare quantitative factors of the cesarean scar defect (CSD) in symptomatic patients with and without uterine adenomyosis.MethodThis study was conducted as a case–control study. Patients who met the inclusion criteria were divided into two groups: with adenomyosis (case) and without adenomyosis (control). The demographic data, medical history, and sonohysterography findings were extracted from the patient's documents and archived images.ResultDuring 2 years, 310 symptomatic women with a history of previous cesarean section underwent sonohysterography. Among them, 204 patients met the inclusion criteria. The most common chief complaints were post‐menstrual bleeding (34.3%) and prolonged bleeding (27%). Cesarean scar depth and width significantly differed between these two groups, and patients with underlying adenomyosis had significantly larger defects (P‐value of .009 and .005, respectively). Mean RMT/AMT ratio was 31.83% in the case group and 42.88% in the control group. In our study, RMT/AMT ratios were significantly lower in the case group (P‐value of .001). In addition, we performed analysis on a subgroup of patients with one prior cesarean section. Similar results were achieved with a lower RMT/AMT ratio in case group (mean of 31.20% in case group and 46.47% in control group; P‐value of .000).ConclusionOur study showed a strong association between the presence of adenomyosis and larger clinically more significant CSDs. To establish a causative relationship, we suggest a prospective cohort study to follow up the patients and compare the evolution of CSD in patients with and without adenomyosis.

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Fertility and pregnancy outcomes after a uterine niche resection in women with and without infertility: a systematic review and meta-analysis

Cited by 6 publications

References 42 publications

Definition and Criteria for Diagnosing Cesarean Scar Disorder

Definition and Criteria for Diagnosing Cesarean Scar Disorder

The presentation and management of cesarean scar defects: an updated review on an evolving diagnosis

Evaluation of Association Between Adenomyosis and Cesarean Scar Defect

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