Reproductive Outcomes Following Surgical Management for Isthmoceles: A Systematic Review

Abstract

Objective: To evaluate the efficacy of surgical management for isthmoceles in patients presenting with secondary infertility. Data Sources: A systematic search was performed in MEDLINE, EMBASE, and Cochrane Library databases from inception to May 2020. The search was limited to studies published in English. Methods of Study Selection: After the removal of duplicates, 3380 articles were screened for inclusion independently by 2 authors. These 2 authors assessed for studies which focused on women of reproductive age with a diagnosed isthmocele and secondary infertility who underwent any surgical intervention for defect repair with at least 1 of the goals being fertility restoration. Tabulation, Integration, and Results: A total of 13 studies, comprising of 1 randomized controlled trial, 6 prospective case series, and 6 retrospective case series describing 234 patients who underwent surgical management for an isthmocele and secondary infertility were included. The methodologic quality of the included studies was assessed independently by both reviewers. Next, the data extraction was performed independently and then compared to ensure no discrepancies. A total of 188 patients were treated by hysteroscopy, 36 by laparoscopy, 7 by laparotomy, and 3 through a vaginal approach. In total, 153 of the 234 patients (65.4%) achieved pregnancy across all studies within their respective study periods. Pregnancy rates in the randomized controlled trial were 21 of 28 (75%) for those treated by hysteroscopy compared with 9 of 28 (32%) for those untreated. Among the studies reporting pregnancy outcomes, 101 of 116 (87.1%) pregnancies resulted in a live birth. The incidence of adverse events was 2%, including the risk of reoperation. Conclusion:The results of this systematic review suggest that the surgical treatment of an isthmocele, particularly through hysteroscopy, in patients with residual myometrial thickness of at least 2.5 mm, may be effective in treating isthmoceleassociated secondary infertility with a relatively low complication rate. Further high-quality studies are needed because of the small sample sizes and observational nature of most available data.

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

“…Second, Harjee et al ( 44) published a systematic review on reproductive outcomes after surgical management for uterine niches. The investigators concluded that the surgical treatment of niches, particular through hysteroscopy in patients with a residual myometrium of at least 2.5 mm, may be effective in treating niche-associated infertility (44).…”

“…Our systematic review differs from both publications on a number of points. Compared with Harjee et al (44), we included 7 additional articles published in the last year about women with infertility with a niche (n ¼ 418 women). Second, we also included 237 women without infertility.…”

Regarding “Reproductive Outcomes Following Surgical Management for Isthmoceles: A Systematic Review”

“…We have read with great interest the systematic review written by Harjee et al about reproductive outcomes following surgical management for isthmoceles (1). We embrace the awareness for longterm effects of caesarean sections, in particular with respect to the potential detrimental effect of isthmoceles on reproductive outcomes (2).…”

A Histopathologic Approach to Uterine Niche: What to Expect and to Report in Hysteroscopy-Resected Isthmocele Specimens

“…3 A deeper and larger fluid-filled triangular pouch at the isthmus is an isthmocele. 4 The prevalence and risk factors of isthmoceles are variable depending on detection methods and study populations. 2,5,6 Hysteroscopy allows diagnostic and minimally invasive surgical therapeutic approaches to isthmoceles.…”