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Chen H, Yao M, Gao Z, Yang X, Wang Y, Wang X. Outcomes of vaginal repair and vaginal repair combined with GnRHa administration in the treatment of cesarean section scar defects: A randomized clinical trial. J Minim Invasive Gynecol 2024:S1553-4650(24)00234-6. [PMID: 38810836 DOI: 10.1016/j.jmig.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Abstract
STUDY OBJECTIVE To prospectively investigate whether the application of vaginal repair (VR) of cesarean section scar defect (CSD) combined with a gonadotropin-releasing hormone agonist (GnRHa) achieve better clinical outcomes than VR alone. DESIGN A randomized clinical trial. SETTING University hospital. PATIENTS A total of 124 women with CSD were undergoing expectant management from December 2016 to September 2021. 61 were randomised to VR+ GnRHa and 63 to VR alone. INTERVENTION Vaginal repair combined with GnRHa and vaginal repair alone. MEASURES AND MAIN RESULTS The primary outcome was the duration of menstruation and thickness of the remaining muscular layer (TRM) at 6 months after surgery. Secondary outcomes included the length, width and depth of the CSD; operation time; estimated blood loss; hospitalization time; and operative complications. Women were treated with either VR (n = 63) or VR + GnRHa (n = 61). Menstruation and TRM in patients pre. vs. post comparisons either with VR or VR + GnRHa are significant improved (P < .05). Significant differences in menstruation duration and TRM occurred in patients treated with VR + GnRHa compared with those treated with VR (P < .05). Moreover, the rate of CSD after surgery in the VR group was significantly higher than that in the VR + GnRHa group (P = .033), and CSD patients in the VR + GnRHa group achieved better therapeutic effects than those in the VR group (P = .017). Patients who received VR + GnRHa had a shorter menstruation duration and a greater increment of TRM postoperatively than did patients treated with VR alone (P = .021; P = .002, respectively). CONCLUSION VR + GnRHa therapy has a greater potential to improve scar healing and reduce the number of menstruation days than VR alone for symptomatic women with CSD. PRéCIS: Vaginal Repair Combined with GnRHa Creates Better Therapeutic Effects of CSD. TRIAL REGISTRATION Date of registration: October 13, 2016, Date of initial participant enrollment: December 20, 2016, Clinical trial identification number: NCT02932761, URL of the registration site: ClinicalTrials.gov, Figshare DOI: 10.6084/m9.figshare.24117114 LINK TO THE CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/study/NCT02932761.
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Affiliation(s)
- Huihui Chen
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Min Yao
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Zhenyan Gao
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Xiaoqian Yang
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 201204, China
| | - Yizhi Wang
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China; Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, 201204, China
| | - Xipeng Wang
- Department of Obstetrics and Gynecology, Xin Hua Hospital affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China.
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Candiani M, Dolci C, Schimberni M, Bartiromo L, Villanacci R, Grisafi G, Tandoi I, Salvatore S, Ferrari SM. Reproductive outcomes after vaginal repair of isthmocele: A preliminary study and systematic review of the literature. Eur J Obstet Gynecol Reprod Biol 2024; 296:163-169. [PMID: 38447278 DOI: 10.1016/j.ejogrb.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/06/2024] [Accepted: 02/11/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE Although vaginal repair of isthmocele is an effective and safe surgical option, data on reproductive and obstetrical outcomes are lacking. The aim of this study is to evaluate reproductive outcomes of women undergone vaginal repair of isthmocele. We also systematically reviewed the existent literature to offer a general view of available data. STUDY DESIGN Retrospective analysis of a database prospectively collected between January 2018 and January 2022 at San Raffaele Hospital, Milan, Italy. We included secondary infertile women with ultrasound documented isthmocele who undergone vaginal repair. Post-surgical clinical, reproductive and obstetric outcomes were recorded. An advanced systematic search of the literature up to January 2023 was conducted. RESULTS 17 women were included. The mean age of the included patients was 37.2 ± 2.7 years. The median of previous caesarian sections was 1 (1-2). One intra-operative complication (5.9 %) was reported (bladder injury, repaired at the time of surgery). At follow up, bleeding was successfully treated in 8 women (8/10; 80 %). Pregnancy was obtained in 7 women (7/17; 41.2 %): the conception was spontaneous in 4 women (4/7; 57.1 %) and trough assisted reproductive technology in 3 patients (3/7; 42.9 %). The mean time from surgery to pregnancy was 10.8 (±6.7) months. One spontaneous abortion was reported (1/7; 14.3 %), while live birth was achieved in 6 pregnancies (6/7; 85.7 %). All deliveries were by caesarian section at a median gestational age of 37.5 (36-38.25) weeks. No obstetrical complications were reported. At the time of caesarean section, no defects on the lower segment were retrieved. Regarding the systematic research, among the 21 studies screened, only 4 articles were included in the review. Pregnancy rate was around 60-70 % with very few obstetrical complications (0.01 %) such as abnormal placentation or preterm birth. CONCLUSIONS Vaginal repair of isthmocele is a minimally invasive, safe and effective surgical approach in terms of postsurgical residual myometrium tichness. Systematic review to date has found low-quality evidences on the impact of vaginal surgery in the management of secondary infertility and obstetrics outcomes in women with isthmocele.
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Affiliation(s)
- Massimo Candiani
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Carolina Dolci
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy.
| | - Matteo Schimberni
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Ludovica Bartiromo
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Roberta Villanacci
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Giorgia Grisafi
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Iacopo Tandoi
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Stefano Salvatore
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Stefano Maria Ferrari
- Gynecology/Obstetrics Unit, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy
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Wang L, Zhao C, Zhang Q. Impact of cesarean scar defect on reproductive outcomes after assisted reproductive technology. Zhejiang Da Xue Xue Bao Yi Xue Ban 2024:1-8. [PMID: 38562032 DOI: 10.3724/zdxbyxb-2023-0539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
In last twenty years, the cesarean section rate has been rising in China, leading to an increased prevalence of cesarean scar defect (CSD) and secondary infertility. CSD decreases receptivity of endometrium, induces adenomyosis and endometriosis, disrupts uterine micro-environment, causes difficulty of embryo transplant operation and further pregnancy complications. For women undergoing assisted reproductive technology (ART), CSD significantly reduces embryo implantation rate, clinical pregnancy rate and live birth rate. CSD can be effectively treated by hysteroscopic surgery, laparoscopic surgery and transvaginal surgery to increase the pregnancy rate. This article reviews the research progress on the impact of CSD on the reproductive outcomes of ART, the potential factors and related treatment, to provide reference for CSD management in ART patients.
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Affiliation(s)
- Ling Wang
- Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou 310007, China.
| | - Chenhan Zhao
- The First Clinical College of Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Qin Zhang
- Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou 310007, China.
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Higuchi N, Sako Y, Shiota K, Hirata T. Cervical Stenosis After Hysteroscopic Surgery for Cesarean Scar Disorder. Cureus 2024; 16:e56922. [PMID: 38665709 PMCID: PMC11043053 DOI: 10.7759/cureus.56922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Cesarean scar disorder (CSDi) is a newly recognized cause of secondary infertility. Laparoscopic or hysteroscopic surgery is generally chosen for the surgical treatment of CSDi, depending on the residual myometrial thickness of the cesarean scar. Previously, hysteroscopic transcervical resection for CSDi (TCR-CSDi) has been reported to be a safe procedure, with no cases of postoperative cervical stenosis. Herein, we report a novel case of cervical stenosis after circumferential hysteroscopic TCR-CSDi of an extensive CSDi lesion. Notably, although no cervical stenosis was observed upon postoperative hysteroscopy one month postoperatively, cervical stenosis developed four months after the surgery; therefore, it is important to avoid circumferential resection and cauterization in patients with CSDi, even when abnormal blood vessels are present. Additionally, it is advisable to check for delayed cervical stenosis at least three weeks before embryo transfer in patients who have undergone TCR-CSDi.
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Affiliation(s)
- Naofumi Higuchi
- Department of Obstetrics and Gynecology, St. Luke's International Hospital, Tokyo, JPN
| | - Yusuke Sako
- Department of Obstetrics and Gynecology, St. Luke's International Hospital, Tokyo, JPN
| | - Kyoko Shiota
- Department of Obstetrics and Gynecology, St. Luke's International Hospital, Tokyo, JPN
| | - Tetsuya Hirata
- Department of Obstetrics and Gynecology, St. Luke's International Hospital, Tokyo, JPN
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Fatehnejad M, Hadizadeh A, Tayebi A, Ayati A, Marjani N, Gheshlaghi P, Asgari Z, Hosseini R. Assessment of the clinical outcomes and complications of hysteroscopic and laparoscopic approaches in the treatment of symptomatic isthmocele: An observational study. Int J Gynaecol Obstet 2023; 163:965-971. [PMID: 37350282 DOI: 10.1002/ijgo.14926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/23/2023] [Accepted: 05/28/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVES To investigate the outcomes of patients undergoing laparoscopic or hysteroscopic approaches for isthmoplasty. METHODS A total of 99 isthmocele patients with an average age of 38.45 ± 4.72 years were included in the 2 years of this retrospective cohort study. Forty-five underwent laparoscopic and 54 underwent hysteroscopic isthmocele excision and myometrial repair. RESULTS Pain scores were significantly higher in the hysteroscopy group before the procedure, but there were no significant pain score differences after the surgery. In 1 year of follow up, dysmenorrhea and dyspareunia were higher among hysteroscopy patients. Furthermore, hysteroscopy significantly improved postmenstrual spotting after surgery better than laparoscopy, but in the follow up, there was no significant difference between the two groups in this regard (mean rank for hysteroscopy vs. laparoscopy: 32.30 vs. 37.48, U = 418, P = 0.29). CONCLUSION In patients with a history of infertility, ectopic pregnancy, lower gravidity, lower parity, and a lower number of cesarean sections, laparoscopic isthmoplasty is preferred over the hysteroscopic approach. Both methods have similar effects on midcycle vaginal bleeding, duration of postmenstrual spotting, and pain. However, a higher rate of dyspareunia and dysmenorrhea could be associated with hysteroscopy.
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Affiliation(s)
- Mina Fatehnejad
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Hadizadeh
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Tayebi
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Aryan Ayati
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Narjes Marjani
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Parand Gheshlaghi
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Asgari
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reihaneh Hosseini
- Department of Laparoscopic Surgery, Arash Women Hospital, Tehran University of Medical Sciences, Tehran, Iran
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6
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Al-Ghotani B, Martini N, Alabdallah E, Alawad I, Hussien K. A large post-caesarean Niche (Isthmocele) with amenorrhea, a symptom that was not reported in the medical literature: A rare case report. Int J Surg Case Rep 2023; 109:108528. [PMID: 37499350 PMCID: PMC10413087 DOI: 10.1016/j.ijscr.2023.108528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/02/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Isthmocele is identified as an iatrogenic defect in the myometrium of the anterior uterine wall at the site of a previous cesarean scar due to defective tissue healing. Patients may have varied symptoms including abnormal uterine bleeding (AUB) and pelvic pain. Herein, we report a rare case of a large isthmocele that manifested with secondary amenorrhea; which was not reported in the medical literature previously. CASE PRESENTATION A 30-year-old Syrian woman, G5P5, came to our clinic with a complaint of secondary amenorrhea that began two years ago. She was treated symptomatically with progesterone with no response. She has had five cesarean sections. Ultrasonography findings suggested a large uterine niche. Trans-Abdominal niche repair was the obtained technique, depending on the drainage of the isthmocele, excising the fibrotic tissue from the edges and re-approximating them. On follow-up, menstruation returned to normal. CLINICAL DISCUSSION Isthmocele can be, radiologically, defined as a hypoechoic or anechoic, triangular area at the scar site. Its pathophysiology is still unknown. Although, an isthmocele can be diagnosed using a variety of imaging techniques like ultrasonography (US), magnetic resonance imaging (MRI), sonohysterography, and hysteroscopy; transvaginal ultrasound (TVUS) is the first method described for assessing it. The goal of isthmocele treatment is to alleviate symptoms. CONCLUSION We recommend that health awareness campaigns alert people to the need to see a specialist doctor in the context of a serious complaint. For the uterine niche, many risk factors can be avoided to reduce its probability.
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Affiliation(s)
- Basel Al-Ghotani
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic.
| | - Nafiza Martini
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Ebaa Alabdallah
- Damascus University, Faculty of Medicine, Damascus, Syrian Arab Republic; Stemosis for Scientific Research, Damascus, Syrian Arab Republic
| | - Ieman Alawad
- Stemosis for Scientific Research, Damascus, Syrian Arab Republic; Alassad Medical Complex, Hama, Syrian Arab Republic
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7
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Donnez O. Cesarean scar disorder: Management and repair. Best Pract Res Clin Obstet Gynaecol 2023; 90:102398. [PMID: 37598564 DOI: 10.1016/j.bpobgyn.2023.102398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/14/2023] [Accepted: 07/27/2023] [Indexed: 08/22/2023]
Abstract
Cesarean scar disorder (CSD) is an entity recently defined as uterine niche with at least one primary or 2 secondary symptoms. CSDs can be visualized by hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging, but diagnosis should be performed by exams able to measure the residual myometrial thickness (RMT). Although there is a limited number of studies evaluating fertility and reproductive outcomes after different types of surgery, the following consideration should be kept in mind. Asymptomatic women should not be operated with the hope of improving obstetrical outcomes. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be offered according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and RMT measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique in case of RMT <3 mm. In this instance, repair is essential and can only be achieved by a laparoscopic or vaginal approach. The benefit of laparoscopic approach seems to persist after subsequent CS. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made.
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Affiliation(s)
- Olivier Donnez
- Complex Endometriosis Center (CEC), Polyclinique Urbain V (Elsan Group), Avignon, France.
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8
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Yao W, Chen Y, Yao H, Yao Q, Wang L, Wang M, Yue J. Uterine niche is associated with adverse in vitro fertilization and intracytoplasmic sperm injection outcomes: a retrospective cohort study. Fertil Steril 2023; 119:433-441. [PMID: 36493872 DOI: 10.1016/j.fertnstert.2022.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To investigate the relationship between uterine niche and reproductive outcomes of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). DESIGN A retrospective cohort study. SETTING A reproductive medicine center. PATIENT(S) A total of 2,449 women with cesarean section history who underwent 2,874 IVF/ICSI cycles between January 2015 and December 2019. INTERVENTION(S) A defect deeper than 2 mm visible under three-dimensional transvaginal sonography or hysteroscopy was defined as uterine niche. The IVF/ICSI outcomes of the first embryo transfer were obtained by telephone interview 1 year after embryo transfer regardless of fresh embryos or frozen-thawed embryos. Generalized estimating equations, logistic regression analyses, and propensity score matching were applied to clarify the relationship between uterine niche and IVF/ICSI outcomes. MAIN OUTCOME MEASURE(S) Primary outcome was live birth rate. Secondary outcomes were positive human chorionic gonadotropin test results, clinical pregnancy rate, implantation rate, miscarriage rate, and ectopic pregnancy rate. RESULTS After excluding 48 cycles for uterine malformation; 18 cycles for chromosome abnormality; 281 cycles for no available embryo or no embryo transfer; 5 cycles for oocyte donation; and 7 cycles for loss of follow-up, we finally included 2,231 women with 2,515 cycles in our study. Compared with women without niche, women with niche had reduced live birth rate (18.99% vs. 31.51%, : 0.51, 95% CI: 0.34-0.77), positive human chorionic gonadotropin test rate (34.08% vs. 46.40%, adjusted odds ratio [aOR]: 0.61, 95% confidence interval [CI]: 0.43-0.87), clinical pregnancy rate (29.05% vs. 42.25%, aOR: 0.57, 95% CI: 0.39-0.82) and implantation rate (25.87% vs. 36.95%, aOR: 0.53, 95% CI: 0.38-0.76). In all the sensitivity analyses, the niche group had a 7.28% to 18.22% increase in miscarriage rate even not all of them were statistically significant. CONCLUSION(S) Uterine niche may have a detrimental effect on subsequent fertility of women with cesarean section history undergoing IVF/ICSI treatment. Practitioners should be noted that women with uterine niches may be associated with adverse IVF/ICSI outcomes.
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Affiliation(s)
- Wen Yao
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Ying Chen
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Haixia Yao
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Qingyun Yao
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Lan Wang
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Meng Wang
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jing Yue
- Reproductive Medicine Center, Tongji Hospital, Tongji Medicine College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
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He C, Xia W, Yan L, Wang Y, Tian Y, Mol BW, Zhang J, Huirne J. Fertility outcomes after hysteroscopic niche resection compared with expectant management in women with a niche in the uterine cesarean scar. Eur J Obstet Gynecol Reprod Biol 2023; 284:136-142. [PMID: 36989689 DOI: 10.1016/j.ejogrb.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 03/01/2023] [Accepted: 03/10/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE To determine whether hysteroscopic niche resection (HNR) and expectant management are suitable in women with fertility desire and a niche with a residual myometrium thickness (RMT) ≥ 2.5 mm. STUDY DESIGN This retrospective cohort study was conducted at International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China between September 2016 and December 2021. We reported the fertility outcomes between women (with fertility desire and a niche with RMT ≥ 2.5 mm) who received HNR or expectant management. RESULTS We studied 166 women, of whom 72 accepted HNR and 94 accepted expectant management. The HNR group included more symptomatic women, in terms of postmenstrual spotting or infertility. No differences were found regarding niche measures before treatment. The live birth rate was comparable in both groups (HNR versus expectant management as 55.5% versus 45.7%, risk ratio = 1.48, 95% Cl 0.80-2.75, p = 0.21). The pregnancy rate was higher in HNR group than that in expectant management group (n = 72.2% versus n = 56.4%, risk ratio = 2.01, 95% CI 1.04-3.88, p = 0.04). In a subgroup of women with infertility before entry in the study, HNR resulted in a significant higher live birth rate (p = 0.04) and pregnancy rate (p = 0.01). CONCLUSION In women with infertility with a symptomatic niche with RMT ≥ 2.5 mm, HNR may be superior to expectant management. This retrospective cohort biased selection against a randomized study, our results still need to be validated in the future with larger clinical multicenter randomized controlled trials.
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Affiliation(s)
- Chuqing He
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Wei Xia
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Li Yan
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Yang Wang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Yuan Tian
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Ben W Mol
- Department of Obstetrics and Gynecology, Monash University, 246 Clayton Road, Clayton 3168, Victoria, Australia; Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - Jian Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.
| | - Jaf Huirne
- Department of Obstetrics and Gynecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centre, Location AMC and VUmc, Amsterdam, The Netherlands
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10
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Tandukar A, Aryal R, Khaniya B, Maskey S, Ojha N, Chataut D. Pregnancy in an isthmocele: A rare case from Nepal. Clin Case Rep 2023; 11:e6875. [PMID: 36694651 PMCID: PMC9842908 DOI: 10.1002/ccr3.6875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/09/2022] [Accepted: 01/03/2023] [Indexed: 01/18/2023] Open
Abstract
An infrequent form of ectopic pregnancy, pregnancy in an isthmocele can be hazardous due to hemorrhage or uterine rupture. With no clear guidelines for the management of this condition, surgery is the preferred option.
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Affiliation(s)
- Alina Tandukar
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Roshan Aryal
- Maharajgunj Medical CampusInstitute of MedicineKathmanduNepal
| | - Bishal Khaniya
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Suvana Maskey
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Neebha Ojha
- Department of Obstetrics and GynecologyTribhuvan University Teaching HospitalKathmanduNepal
| | - Dinesh Chataut
- Department of Radiology and ImagingTribhuvan University Teaching HospitalKathmanduNepal
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Casadio P, Raffone A, Alletto A, Filipponi F, Raimondo D, Arena A, La Rosa M, Virgilio A, Franceschini C, Gubbini G, Franchini M, Paradisi R, Lenzi J, Travaglino A, Mollo A, Carugno J, Seracchioli R. Postoperative morphologic changes of the isthmocele and clinical impact in patients treated by channel-like (360°) hysteroscopic technique. Int J Gynaecol Obstet 2023; 160:326-333. [PMID: 35929843 PMCID: PMC10086996 DOI: 10.1002/ijgo.14387] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/06/2022] [Accepted: 07/28/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To evaluate the changes in (1) residual myometrial thickness (RMT), (2) cesarean scar defect (CSD) size, and (3) clinical symptoms, before and after channel-like (360°) hysteroscopic resection for the treatment of CSD. METHODS A single-center, observational, prospective, cohort study was carried out enrolling all symptomatic patients of childbearing age, diagnosed with CSD and routinely scheduled for channel-like (360°) hysteroscopic resection from July 2020 to July 2021 at the Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Univeristaria di Bologna. University of Bologna, Italy. The primary outcome was the difference in mean RMT before and after the procedure. Secondary outcomes were the differences before and 4 months after the surgery in: (1) CSD size measured by transvaginal ultrasound, (2) visual analog scale (VAS) scores for the symptoms, and (3) abnormal uterine bleeding (AUB) rate. Lastly, patients' satisfaction was assessed by the global impression of improvement (PGI-I) score. RESULTS We found a significant difference before and after the procedure in: (1) mean RMT (+2.0 mm; P < 0.001); mean size of the CSD (base: +1.6 mm; height: -2.5 mm; transverse diameter: -3.2 mm; volume: -263.7 mm3 ; P < 0.001); (2) mean VAS score for dyspareunia (-5.84; P < 0.001), dysmenorrhea (-8.94; P < 0.001), pelvic pain (-2.94; P < 0.001); (3) AUB rate (91% vs. 3%; P < 0.001). Lastly, the mean PGI-I score ± SD was 1.7 ± 0.9. CONCLUSION Channel-like (360°) hysteroscopic resection for the treatment of patients with symptomatic CSD may lead to an increase in RMT, decrease in CSD, and improvement of symptoms after the procedure, with high patient satisfaction.
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Affiliation(s)
- Paolo Casadio
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Raffone
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Alletto
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesco Filipponi
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Diego Raimondo
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Alessandro Arena
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mariangela La Rosa
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Agnese Virgilio
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Camilla Franceschini
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giampietro Gubbini
- Department of Gynecology, Madre Fortunata Toniolo Clinic, Bologna, Italy
| | - Mario Franchini
- Department of Obstetrics and Gynecology, Tuscany Health Agency, Florence, Italy
| | - Roberto Paradisi
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Jacopo Lenzi
- Section of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Antonio Travaglino
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Mollo
- Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry "Schola Medica Salernitana", University of Salerno, Baronissi, Italy
| | - Josè Carugno
- Obstetrics, Gynecology and Reproductive Science Department, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Renato Seracchioli
- Division of Gynaecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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12
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Tsuji S, Nobuta Y, Hanada T, Takebayashi A, Inatomi A, Takahashi A, Amano T, Murakami T. Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review. Reprod Med Biol 2023; 22:e12532. [PMID: 37577060 PMCID: PMC10412910 DOI: 10.1002/rmb2.12532] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/05/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023] Open
Abstract
Background Cesarean scar defects (CSD) are caused by cesarean sections and cause various symptoms. Although there has been no previous consensus on the name of this condition for a long time, it has been named cesarean scar disorder (CSDi). Methods This review summarizes the definition, prevalence, and etiology of CSD, as well as the pathophysiology and treatment of CSDi. We focused on surgical therapy and examined the effects and procedures of laparoscopy, hysteroscopy, and transvaginal surgery. Main findings The definition of CSD was proposed as an anechoic lesion with a depth of at least 2 mm because of the varied prevalence, owing to the lack of consensus. CSD incidence depends on the number of times, procedure, and situation of cesarean sections. Histopathological findings in CSD are fibrosis and adenomyosis, and chronic inflammation in the uterine and pelvic cavities decreases fertility in women with CSDi. Although the surgical procedures are not standardized, laparoscopic, hysteroscopic, and transvaginal surgeries are effective. Conclusion The cause and pathology of CSDi are becoming clear. However, there is variability in the prevalence and treatment strategies. Therefore, it is necessary to conduct further studies using the same definitions.
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Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Yuri Nobuta
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Tetsuro Hanada
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Aike Takebayashi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Ayako Inatomi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Akimasa Takahashi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Tsukuru Amano
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
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13
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Wei L, Xu C, Zhao Y, Zhang C. Higher Prevalence of Chronic Endometritis in Women with Cesarean Scar Defect: A Retrospective Study Using Propensity Score Matching. J Pers Med 2022; 13:jpm13010039. [PMID: 36675699 PMCID: PMC9863930 DOI: 10.3390/jpm13010039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
(1) Background: A cesarean scar defect may cause localized inflammation of the endometrial tissue, and various researchers believe that the presence of a cesarean scar defect is associated with chronic endometritis. However, there is no report on the possible association between cesarean scar defects and chronic endometritis thus far. This study aimed to assess the role of having a cesarean scar defect in a person's susceptibility to chronic endometritis. (2) Methods: This retrospective propensity-score-matched study comprised 1411 patients with chronic endometritis that were admitted to Henan Provincial People's Hospital in China from 2020 to 2022. Based on whether a cesarean scar defect was present or not, all cases were assigned to the cesarean scar defect group or the control group. (3) Results: Of the 1411 patients, 331 patients with a cesarean scar defect were matched to 170 controls. All unbalanced covariates between groups were balanced after matching. Before matching, the prevalence of chronic endometritis in the cesarean scar defect group and in the control group was 28.8% and 19.6%, respectively. After correcting for all confounding factors, a logistic regression analysis showed that cesarean scar defect occurrence may increase the risk of chronic endometritis (odds ratio (OR), 1.766; 95% confidence interval (CI), 1.217-2.563; p = 0.003). After matching, the prevalence of chronic endometritis was 28.8% in the cesarean scar defect group and 20.5% in the control group. Thus, even after correcting for all confounding factors, the logistic regression analysis still showed that a cesarean scar defect remained an independent risk factor for chronic endometritis prevalence (OR, 1.571; 95% CI, 1.021-2.418; p = 0.040). The findings were consistent throughout the sensitivity analyses. (4) Conclusions: The present results suggest that the onset of a cesarean scar defect may increase the risk of chronic endometritis.
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Affiliation(s)
- Longlong Wei
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
- Department of Reproductive Medicine Center, Henan Provincial People’s Hospital, Zhengzhou 450003, China
| | - Chunyu Xu
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
- Department of Reproductive Medicine Center, Henan Provincial People’s Hospital, Zhengzhou 450003, China
| | - Yan Zhao
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
| | - Cuilian Zhang
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
- Department of Reproductive Medicine Center, Henan Provincial People’s Hospital, Zhengzhou 450003, China
- Correspondence:
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14
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Bandry KW, Abou-Taleb H, Seifeldein GS, Taha MG, Qenawy OK. Prediction of the relationship of cesarean section scar niche and postmenstrual spotting: is there any relation? THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2022. [DOI: 10.1186/s43055-022-00699-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Postmenstrual spotting has recently been related to a discontinuation of the myometrium at the site of a previous cesarean section called "CS scar niche". There was no consensus regarding the gold standard method for the assessment of the niche. Recently, Magnetic resonance imaging (MRI) has shown promise in the evaluation of the niche. Our study aims to assess the role of MRI in the evaluation of the CS scar niche characters and its association with post-menstrual spotting.
Results
A total of 65 patients with CS niche were prospectively included in this study and subdivided into two groups, according to presence or absence of postmenstrual spotting (Group A; 34 patients with postmenstrual spotting and Group B; 31 patients without spotting). All patients were examined using a 1.5 T MRI unit. CS scar niche volume was significantly higher among women with post-menstrual spotting (0.57 ± 0.07 vs. 0.07 ± 0.05 (cm3); P < 0.001). Also, women with post-menstrual spotting have significantly higher scar length (9.38 ± 3.06 vs. 5.02 ± 2.10 (mm); P < 0.001), scar depth (6.95 ± 3.16 vs. 3.23 ± 0.99 (mm); P < 0.001), scar width (15.78 ± 3.94 vs. 9.87 ± 1.84 (mm); P < 0.001) in comparison to those without post-menstrual spotting.
Scar depth (> 7.4 mm) had 81% sensitivity and 97% specificity for prediction of post-menstrual spotting with overall accuracy was 88.7%. While scar width (> 12.8 mm) had 71% sensitivity and 97% specificity for prediction of post-menstrual spotting with overall accuracy was 83.3%. Scar volume (> 0.15 cm3) had 97% sensitivity and 100% specificity for prediction of post-menstrual spotting with overall accuracy was 98.4%.
Conclusion
MRI measures (CS scar volume, depth, and width) are predictors for postmenstrual spotting in patients with CS scar niche, and scar volume is the most powerful predictor.
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15
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Mutlu AE. Assessment of in vitro fertilization outcomes after hysteroscopic isthmoplasty in recurrent implantation failure. J Obstet Gynaecol Res 2022; 48:1829-1835. [PMID: 35623894 DOI: 10.1111/jog.15317] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/28/2022] [Accepted: 05/18/2022] [Indexed: 11/29/2022]
Abstract
AIM The aim of this study was to assess the in vitro fertilization (IVF) treatments outcomes of women with recurrent implantation failure (RIF) after hysteroscopic isthmoplasty for isthmocele. METHODS This retrospective, observational study included 61 patients with RIF and isthmocele who presented to IVF Unit of Hüma Obstetrics and Gynecology Hospital between January, 2018 and December, 2020. Thirty-one patient who underwent hysteroscopic isthmoplasty-before IVF procedure-were included. Remaining 30 patients underwent IVF without hysteroscopic isthmoplasty were included as controls. The fertility outcome were compared between groups. RESULTS After 3 months, spontaneous pregnancy was achieved in 18.4% (7/38) of patients with isthmocele who underwent hysteroscopic isthmoplasty. In the isthmoplasty group, implantation rate, clinical pregnancy rate, biochemical pregnancy rate, and the miscarriage rate were 41.9% (13/31), 35.5% (11/31), 6.5% (2/31), and 9.7% (3/31), respectively. The live birth rate after in vitro fertilization was 25.8% (8/31) in the isthmoplasty group and 3.3% (1/30) in the control group (p < 0.05). There were no significant differences in the IVF outcomes such as the biochemical pregnancy rate and miscarriage rate between the isthmoplasty and control groups. CONCLUSION This study demonstrated that hysteroscopic isthmoplasty improves pregnancy and live birth rates for women with a history of RIF and isthmocele. Reproductive results of the IVF cycles after hysteroscopic correction of isthmocele were comparable to those of the patients without any uterine abnormalities and those with diagnosis of unexplained infertility.
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Affiliation(s)
- Ahmet Emin Mutlu
- Department of Obstetrics and Gynecology, Hüma Obstetrics and Gynecology Hospital, IVF Center, Kayseri, Turkey
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16
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Gencer FK, Dincgez B, Yuksel S. Levonorgestrel-Releasing Intrauterine Device Use Can Be a Treatment Option in Symptomatic Patients with Isthmocele. Reprod Sci 2022; 29:2977-2982. [PMID: 35610461 DOI: 10.1007/s43032-022-00976-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022]
Abstract
Levonorgestrel-releasing intrauterine devices have been used for contraception and treatment of heavy menstrual bleeding. There is only limited data about the effect of this on isthmocele. Here, we aimed to evaluate the effect of levonorgestrel-releasing intrauterine devices in a larger study population with a longer follow-up as compared to the literature on symptomatic patients with isthmocele. A total of 29 patients with symptomatic isthmocele and inserted levonorgestrel-releasing device were included in this prospective study. All patients were included at January 2020 and followed for 18 months. Sociodemographic findings, laboratory parameters, premenstrual spotting, postmenstrual spotting, menorrhagia, dysmenorrhea, and pelvic pain related to isthmocele were recorded. In sonography, width, length, area of isthmocele, and residual myometrial thickness were determined. The frequency of symptoms during follow-up was compared between visits and also compared between groups according to residual myometrial thickness. Premenstrual spotting and pelvic pain were significantly reduced at 6th months (48.3 to 10.3%, p = 0.007 and 34.5 to 10.3%, p = 0.039, respectively) and no significant change was detected until the end of follow-up period. Postmenstrual spotting reduced at 6th months (96.6 to 34.5%, p < 0.001) and also significant change was detected between 6 and 12th months (34.5% vs 13.8%, p = 0.031). Menorrhagia and dysmenorrhea disappeared at 12th months. No association was found between residual myometrial thickness and the frequency of symptoms for each follow-up. Levonorgestrel-releasing intrauterine devices are useful and reliable therapeutic tools for symptomatic isthmocele patients who do not desire fertility, regardless of residual myometrial thickness.
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Affiliation(s)
- Fatma Ketenci Gencer
- Department of Obstetrics and Gynecology, Istanbul Gaziosmanpasa Training and Research Hospital, University of Health Sciences, Hizirefendi Street, Gaziosmanpasa, 34255, Istanbul, Turkey.
| | - Burcu Dincgez
- Department of Obstetrics and Gynecology, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Semra Yuksel
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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17
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Hosseini E, Aghajanpour S, Zameni N, Hafezi M. Isthmocele—a neglected cause of secondary infertility and implantation failure: A case report. Clin Case Rep 2022; 10:e05853. [PMID: 35600035 PMCID: PMC9107921 DOI: 10.1002/ccr3.5853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/18/2022] [Accepted: 04/27/2022] [Indexed: 12/02/2022] Open
Abstract
Isthmocele is myometrial scar tissue that develops after cesarean section delivery. In this case, other more prevalent pathologies delayed isthmocele diagnosis as the main cause of the patient's symptoms. Considering isthmocele is a fluid‐filled pouch‐like defect associated with infection caused by stagnant menstrual blood, its immunological aspects lead to implantation failure.
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Affiliation(s)
- Elham Hosseini
- Department of Obstetrics and Gynecology Mousavi Hospital School of Medicine Zanjan University of Medical Sciences Zanjan Iran
| | - Samaneh Aghajanpour
- Department of Endocrinology and Female Infertility Reproductive Biomedicine Research Center Royan Institute for Reproductive Biomedicine ACECR Tehran Iran
| | - Nadia Zameni
- School of Medicine Shahid Beheshti University of Medical Sciences Tehran Iran
| | - Maryam Hafezi
- Department of Endocrinology and Female Infertility Reproductive Biomedicine Research Center Royan Institute for Reproductive Biomedicine ACECR Tehran Iran
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18
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Mc Gowan S, Goumalatsou C, Kent A. Fantastic niches and where to find them: the current diagnosis and management of uterine niche. Facts Views Vis Obgyn 2022; 14:37-47. [PMID: 35373546 PMCID: PMC9612856 DOI: 10.52054/fvvo.14.1.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background Caesarean section (CS) scar niche is a well recognised complication of caesarean delivery and is defined as an indentation at the site of the CS scar with a depth of at least 2mm. Objectives To review systematically the medical literature regarding the current diagnosis and management of uterine niche Materials and methods We carried out a systematic review using MeSH terms ‘niche’ OR ‘sacculation’ OR ‘caesarean scar defect’ OR ‘caesarean section scar’ OR ‘uterine defect’ OR ‘isthmocele.’ Articles included were peer-reviewed and in English language. Main outcome measures Prevalence, symptoms, diagnosis, pathophysiology and management of uterine niche. Results CS scar niche is common and, in a subgroup, produces a range of symptoms including post-menstrual bleeding, dyspareunia and subfertility. It may be linked to use of locked sutures during CS closure. Niche repair can be achieved laparoscopically or hysteroscopically and appears to improve symptoms, although solid conclusions regarding fertility outcomes cannot be drawn. Conclusions CS scar niche is associated with a range of symptoms. Repair may aid subfertile patients and those with post-menstrual spotting. The presence of a niche is probably irrelevant in the absence of symptoms. What is new? LNG-IUS and surgical repair appear to improve symptoms in those with a niche.
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19
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Vrijdaghs V, Dewilde K, Froyman W, Van den Bosch T. Hysteroscopic management of caesarean scar defects. J OBSTET GYNAECOL 2022; 42:816-822. [PMID: 35014923 DOI: 10.1080/01443615.2021.2003310] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
A caesarean section may lead to a defect of the myometrium at the site of the uterine scar. The association with abnormal uterine bleeding or impaired fertility has been demonstrated. Hysteroscopic remodelling reportedly reduces the symptoms. To review the available literature reporting on hysteroscopic treatment of these defects in symptomatic women with abnormal uterine bleeding or impaired fertility. A systematic search of PubMed and Cochrane databases has been performed until January 2021, including 27 articles. Hysteroscopic remodelling relieved symptoms of abnormal uterine bleeding in 60-100% and 25-100% of women with impaired fertility conceived within the follow up period. No major complications were reported. Hysteroscopic remodelling seems a treatment option in the management of symptomatic caesarean scar defects. Long-term follow-up and larger studies are needed to evaluate the effect on abnormal uterine bleeding as well as on reproductive outcomes.
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Affiliation(s)
- V Vrijdaghs
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - K Dewilde
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - W Froyman
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - T Van den Bosch
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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20
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Nobuta Y, Tsuji S, Kitazawa J, Hanada T, Nakamura A, Zen R, Amano T, Murakami T. Decreased Fertility in Women with Cesarean Scar Syndrome Is Associated with Chronic Inflammation in the Uterine Cavity. TOHOKU J EXP MED 2022; 258:237-242. [DOI: 10.1620/tjem.2022.j082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yuri Nobuta
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Jun Kitazawa
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Tetsuro Hanada
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Akiko Nakamura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Rika Zen
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Tsukuru Amano
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science
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21
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Nguyen AD, Nguyen HTT, Duong GTT, Phan TTH, Do DT, Tran DA, Nguyen TK, Nguyen TB, Ville Y. Improvement of symptoms after hysteroscopic isthmoplasty in women with abnormal uterine bleeding and expected pregnancy: A prospective study. J Gynecol Obstet Hum Reprod 2022; 51:102326. [DOI: 10.1016/j.jogoh.2022.102326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/11/2022] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
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22
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de Luget CD, Becchis E, Fernandez H, Donnez O, Quarello E. Can uterine niche be prevented? J Gynecol Obstet Hum Reprod 2021; 51:102299. [PMID: 34958983 DOI: 10.1016/j.jogoh.2021.102299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/12/2021] [Accepted: 12/20/2021] [Indexed: 12/31/2022]
Abstract
Uterine niche is a potential significant consequence of Caesarean section and is diagnosed by ultrasound. The timing of Caesarean section (during pre, early or advanced labour), location of the incision (distance from the internal os), techniques for opening and closing the uterine cavity, and bladder flap have been frequently mentioned in the literature, however, these factors continue to be a source of disagreement with respect to whether they increase the risk of uterine niche or protect against this complication. In this review, we outline and discuss the possible risk factors that may be responsible for this entity. The main factor upon which obstetricians can act is the rate of first Caesarean section, which can and should be reduced. Moreover, a rather high incision at a distance from the internal os, and a sparing use of bladder detachment should be always kept in mind as well.
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Affiliation(s)
- Claire Delage de Luget
- Service de Gynécologie-Obstétrique-AMP, Hôpital Saint Joseph, 26 Bd de Louvain, 13285 Marseille Cedex, France
| | - Elise Becchis
- Service de Gynécologie-Obstétrique-AMP, Hôpital Saint Joseph, 26 Bd de Louvain, 13285 Marseille Cedex, France
| | - Hervé Fernandez
- Service de gynécologie et obstétrique, Hôpital de Bicêtre, AP-HP, Le Kremlin Bicêtre, France, Université Paris-Saclay
| | - Olivier Donnez
- Institut du sein et de Chirurgie gynécologique d'Avignon (ICA), Polyclinique Urbain V (Groupe Elsan), Avignon, France
| | - Edwin Quarello
- Service de Gynécologie-Obstétrique-AMP, Hôpital Saint Joseph, 26 Bd de Louvain, 13285 Marseille Cedex, France.; Centre Image2, 6 rue Rocca, 13008 Marseille, France..
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Higuchi A, Tsuji S, Nobuta Y, Nakamura A, Katsura D, Amano T, Kimura F, Tanimura S, Murakami T. Histopathological evaluation of cesarean scar defect in women with cesarean scar syndrome. Reprod Med Biol 2021; 21:e12431. [PMID: 35386374 PMCID: PMC8967299 DOI: 10.1002/rmb2.12431] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/06/2021] [Accepted: 11/25/2021] [Indexed: 11/11/2022] Open
Abstract
Purpose To explore the histopathological findings of cesarean scar defect (CSD) and the immunological component in women with cesarean scar syndrome (CSS). Methods This retrospective study was conducted in a university hospital and a public hospital. A total of 63 patients with secondary infertility due to CSS who underwent laparoscopic resection of the CSD lesion were enrolled (CSS group), and 21 patients who underwent hysterectomy with a history of cesarean section were enrolled as control (non‐CSS group). We compared the differences in histopathological findings of CSD lesions by hematoxylin and eosin staining and immunohistochemistry for CD3, CD20, CD56, CD68, CD138, myeloperoxidase, and tryptase between the two groups. Results The frequency of presence of endometrium on the CSD surface was significantly lower (p = 0.0023) and that of adenomyosis was significantly higher (p = 0.0195) in the CSS group than in the non‐CSS group. The number of CD3‐, CD20‐, CD68‐, and tryptase‐positive cells was significantly lower in the CSS group than in the non‐CSS group; however, the number of CD138‐positive cells was significantly higher in the CSS group (p = 0.0042). Conclusions This study suggested that the absence of endometrium, presence of adenomyosis, and chronic inflammation in CSD contributes to secondary infertility due to CSS.
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Affiliation(s)
- Asuka Higuchi
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Shunichiro Tsuji
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Yuri Nobuta
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Akiko Nakamura
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Daisuke Katsura
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Tsukuru Amano
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Fuminori Kimura
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
| | - Satoshi Tanimura
- Department of Obstetrics and Gynecology Toyama Central Prefectural Hospital Toyama Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology Shiga University of Medical Science Otsu Shiga Japan
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Karampelas S, Salem Wehbe G, de Landsheere L, Badr DA, Tebache L, Nisolle M. Laparoscopic Isthmocele Repair: Efficacy and Benefits before and after Subsequent Cesarean Section. J Clin Med 2021; 10:jcm10245785. [PMID: 34945080 PMCID: PMC8708618 DOI: 10.3390/jcm10245785] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/03/2021] [Accepted: 12/08/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate the effect of laparoscopic isthmocele repair on isthmocele-related symptoms and/or fertility-related problems. The residual myometrial thickness before and after subsequent cesarean section was also evaluated. DESIGN Retrospective, case series. SETTING Public university hospital. POPULATION Women with isthmocele (residual myometrium < 5 mm) complaining of abnormal uterine bleeding, chronic pelvic pain or secondary infertility not otherwise specified. METHODS Women's complaints and the residual myometrium were assessed pre-operatively and at three to six months post-operatively. In patients who conceived after surgery, the latter was measured at least six months after delivery by cesarean section. MAIN OUTCOME MEASURES Resolution of the main symptom three to six months after surgery and persistence of laparoscopic repair benefits after subsequent cesarean section were considered as primary outcome measures. RESULTS Overall, 31 women underwent laparoscopic isthmocele repair. The success rates of the surgery as improvement of abnormal uterine bleeding, chronic pelvic pain and secondary infertility were 71.4% (10 of 14), 83.3% (10 of 12) and 83.3% (10 of 12), respectively. Mean residual myometrial thickness increased significantly from 1.77 mm pre-operatively to 6.67 mm, three to six months post-operatively. Mean myometrial thickness in patients who underwent subsequent cesarean section (N = 7) was 4.49 mm. In this sub-group, there was no significant difference between the mean myometrial thickness measured after the laparoscopic isthmocele repair and that measured after the subsequent cesarean section. None of these patients reported recurrence of their symptoms after delivery. CONCLUSION Our findings suggest that the laparoscopic isthmocele excision and repair is an appropriate approach for the treatment of isthmocele-related symptoms when done by skilled laparoscopic surgeons. The benefit of this new surgical approach seems to persist even after a subsequent cesarean section. Further investigations and prospective studies are required to confirm this finding.
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Affiliation(s)
- Stavros Karampelas
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium; (G.S.W.); (D.A.B.)
- Correspondence:
| | - Georges Salem Wehbe
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium; (G.S.W.); (D.A.B.)
| | - Laurent de Landsheere
- Department of Obstetrics and Gynecology, CHR de La Citadelle, University of Liège, 4000 Liège, Belgium; (L.d.L.); (L.T.); (M.N.)
| | - Dominique A. Badr
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, 1020 Brussels, Belgium; (G.S.W.); (D.A.B.)
| | - Linda Tebache
- Department of Obstetrics and Gynecology, CHR de La Citadelle, University of Liège, 4000 Liège, Belgium; (L.d.L.); (L.T.); (M.N.)
| | - Michelle Nisolle
- Department of Obstetrics and Gynecology, CHR de La Citadelle, University of Liège, 4000 Liège, Belgium; (L.d.L.); (L.T.); (M.N.)
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Zhang Q, Lei L, Zhang A, Zou L, Xu D. Comparative effectiveness of laparoscopic versus hysteroscopic approach in patients with previous cesarean scar defect: a retrospective cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1529. [PMID: 34790735 PMCID: PMC8576701 DOI: 10.21037/atm-21-4339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022]
Abstract
Background The aim of this study was to evaluate the clinical effectiveness and obstetric outcomes of laparoscopic and hysteroscopic surgery in patients with previous cesarean scar defect (PCSD). Methods A retrospective cohort analysis was performed on women who underwent laparoscopic or hysteroscopic surgery for PCSD from 2016 to 2019 at the Third Xiangya Hospital of Central South University. Among these participants, 13 underwent laparoscopic surgery and 33 received hysteroscopic surgery. Results Significant differences were displayed in the operative times (156.9±42.3 vs. 40.7±38.9 min, P<0.05), intra-operative blood loss (80.0±61.0 vs. 17.9±51.2 mL, P<0.05), hospital stay (7.1±1.6 vs. 4.1±2.1 days, P<0.05), postoperative hospital stay (4.3±0.8 vs. 1.5±1.1 days, P<0.05), and hospitalization expenses (22,240.3±249.9 vs. 9,547.1±4,747.2 yuan, P<0.05) between the laparoscopic surgery and hysteroscopic group. No significant difference was observed in the incidence of clinical efficacy between the laparoscopic and hysteroscopic surgery group. A total of 2 of the 4 patients in the laparoscopic surgery group, and 9 of 11 patients in the hysteroscopic surgery group delivered successfully. All 2 participants in the laparoscopic surgery group and 2 participants in the hysteroscopic surgery group were diagnosed with placenta previa. No uterine rupture was reported in our study. Conclusions Both laparoscopic and hysteroscopic surgery are safe and effective treatments for PCSD patients, and hysteroscopic surgery is more efficient for PCSD patients.
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Affiliation(s)
- Qi Zhang
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Lei Lei
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China.,Medical Center of Hysteroscopy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Aiqian Zhang
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Lingxiao Zou
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Dabao Xu
- Department of Obstetrics and Gynecology, Third Xiangya Hospital, Central South University, Changsha, China
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Caesarean section defects may affect pregnancy outcomes after in vitro fertilization-embryo transfer: a retrospective study. BMC Pregnancy Childbirth 2021; 21:487. [PMID: 34229640 PMCID: PMC8261987 DOI: 10.1186/s12884-021-03955-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/31/2021] [Indexed: 11/10/2022] Open
Abstract
Background Caesarean section rates are rising worldwide. One adverse effect of caesarean section reported in some studies is an increased risk of subfertility. Only a few studies have assessed the relationship between the previous mode of delivery and in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET) reproductive outcomes. In this study, we primarily investigated the impact of a history of caesarean section with or without defects on IVF/ICSI-ET outcomes compared to a vaginal delivery history. Methods This retrospective study included 834 women who had a IVF or ICSI treatment at our centre between 2015 and 2019 with a delivery history. In total, 401 women with a previous vaginal delivery (VD) were assigned to the VD group, and 433 women with a history of delivery by caesarean section were included, among whom 359 had a caesarean scar (CS) without a defect and were assigned to the CS group and 74 had a caesarean section defect (CSD) and were assigned to the CSD group. Baseline characteristics of the three groups were compared and analysed. Binary logistic regression analyses were performed to explore the association between clinical outcomes and different delivery modes. Results There were no significant differences in the live birth rate, biochemical pregnancy rate, clinical pregnancy rate, mean implantation rate or abnormal pregnancy rate between the CS and VD groups However, the live birth rate and mean implantation rate in the CSD group were significantly lower than those in the VD group (21.6 vs 36.4%, adjusted OR 0.50 [0.27–0.9]; 0.25 ± 0.39 vs 0.35 ± 0.41, adjusted OR 0.90 [0.81–0.99]). Among women aged ≤ 35 years, the subgroup analyses showed that the live birth rate, biochemical pregnancy rate, clinical pregnancy rate, and mean implantation rate in the CSD group were all significantly lower than those in the VD group (21.4 vs 45.8%, adjusted OR 0.35[0.15 ~ 0.85]; 38.1 vs 59.8%, adjusted OR 0.52[0.24–0.82]; 31.0 vs 55.6%, adjusted OR 0.43[0.19–0.92]; 0.27 ± 0.43 vs 0.43 ± 0.43, adjusted OR 0.85[0.43 ± 0.43]). For women older than 35 years, there was no statistically significant difference in any pregnancy outcome among the three groups. Conclusions This study suggested that the existence of a CS without a defect does not decrease the live birth rate after IVF or ICSI compared with a previous VD. However, the presence of a CSD in women, especially young women (age ≤ 35 years), significantly impaired the chances of subsequent pregnancy.
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Pelvic Abscess after Cesarean Section Treated with Laparoscopic Drainage. Case Rep Obstet Gynecol 2021; 2021:8868608. [PMID: 34221524 PMCID: PMC8213458 DOI: 10.1155/2021/8868608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 05/26/2021] [Indexed: 11/17/2022] Open
Abstract
Cesarean section (CS), the rate of which is increasing worldwide, may be associated with complications. Although pelvic abscess after CS is rare, it is difficult to treat. We herein report two cases of pelvic abscess treated laparoscopically after CS. The abscesses of the patients were located in the pouch of Douglas and the uterine scar after CS, respectively. Several days after CS, the patients presented with lower abdominal pain and fever. Laparoscopic drainage was performed because imaging revealed a pelvic abscess that was not amenable to drainage through interventional radiology. The patients recovered from infection and were discharged four days after drainage.
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Harjee R, Khinda J, Bedaiwy MA. Reproductive Outcomes Following Surgical Management for Isthmoceles: A Systematic Review. J Minim Invasive Gynecol 2021; 28:1291-1302.e2. [PMID: 33839308 DOI: 10.1016/j.jmig.2021.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/11/2021] [Accepted: 03/28/2021] [Indexed: 10/21/2022]
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 isthmocele-associated 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.
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Affiliation(s)
- Rahana Harjee
- Department of Obstetrics & Gynaecology (Dr. Harjee); Faculty of Medicine (Mr. Khinda); Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynaecology (Dr. Bedaiwy), University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaskaran Khinda
- Department of Obstetrics & Gynaecology (Dr. Harjee); Faculty of Medicine (Mr. Khinda); Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynaecology (Dr. Bedaiwy), University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohamed A Bedaiwy
- Department of Obstetrics & Gynaecology (Dr. Harjee); Faculty of Medicine (Mr. Khinda); Division of Reproductive Endocrinology & Infertility, Department of Obstetrics & Gynaecology (Dr. Bedaiwy), University of British Columbia, Vancouver, British Columbia, Canada.
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Karakuş R, Karakuş SS, Güler B, Ünver G, Özkaya E. Myometrial thickness overlying cesarean scar pregnancy is significantly associated with isthmocele formation in the third month of the postoperative period. Turk J Obstet Gynecol 2021; 18:37-43. [PMID: 33715331 PMCID: PMC7962161 DOI: 10.4274/tjod.galenos.2021.65288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: To determine some associated factors for isthmocele formation 3 months after the treatment of cesarean scar pregnancy (CSP). Materials and Methods: This is a prospective consecutive case series of CSP managed by fertility preservation modalities at a single tertiary care center from May 2016 to March 2019 (n=95). Patients with a diagnosis of CSP were identified and followed prospectively to collect data on the patients’ demographics; detailed medical, surgical, and social history; symptoms; imaging and laboratory parameters at the time of CSP diagnosis and during treatment; treatment modalities, myometrial thickness; and outcomes in terms of isthmocele formation. Results: Mean myometrial thickness overlying scar pregnancy was significantly lower in the group with isthmocele formation, and the mean gestational age of scar pregnancy was also significantly lower in the group with isthmocele formation following treatment of scar pregnancy (p<0.05). Multivariate regression analysis was conducted to determine associations between certain variables and isthmocele development, which revealed that the gestational age of scar pregnancy and myometrial thickness were significantly associated with isthmocele formation. Conclusion: Myometrial thickness and gestational age of scar pregnancy were significantly associated with isthmocele formation 3 months after treatment.
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Affiliation(s)
- Resul Karakuş
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Sultan Seren Karakuş
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Burak Güler
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Gökhan Ünver
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Enis Özkaya
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
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Tsuji S, Takahashi A, Higuchi A, Yamanaka A, Amano T, Kimura F, Seko-Nitta A, Murakami T. Pregnancy outcomes after hysteroscopic surgery in women with cesarean scar syndrome. PLoS One 2020; 15:e0243421. [PMID: 33270754 PMCID: PMC7714235 DOI: 10.1371/journal.pone.0243421] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/03/2020] [Indexed: 11/18/2022] Open
Abstract
Cesarean scar defect often causes postmenstrual abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, and infertility, which are collectively known as cesarean scar syndrome (CSS). Several studies have reported that hysteroscopic surgery can restore fertility in women with CSS. The study aimed to identify factors that influence subsequent pregnancy following hysteroscopic surgery. Therefore, we studied 38 women with secondary infertility due to CSS who underwent hysteroscopic surgery at Shiga University of Medical Hospital between July 2014 and July 2019. Our hysteroscopic procedure included inferior edge resection and superficial cauterization of the cesarean scar defect under laparoscopic guidance. Patients were followed up for 3 to 40 months after surgery. Surgery was successful in all cases and no complications were observed. Twenty-seven patients (71%) became pregnant (pregnant group), while 11 (29%) did not (non-pregnant group). Baseline characteristics of age, body mass index, gravidity, parity, previous cesarean section, presence of endometriosis, retroflex uterus, and preoperative residual myometrial thickness were not significantly different between the groups. However, the median residual myometrium thickness was significantly higher after surgery than before surgery in the pregnant group (1.9 [1.1-3.6] vs 4.9 [3.4-6.6] mm, P<0.0001), whereas this difference was not significant in the non-pregnant group. Of those who became pregnant, 85% conceived within 2 years of surgery. Although three pregnancies resulted in abortion and one is ongoing at the time of writing, 23 pregnancies resulted in healthy babies at 35-38 gestational weeks by scheduled cesarean sections with no obstetrical complications due to hysteroscopic surgery. The average birth weight was 3,076 g. Our findings support that hysteroscopic surgery is a safe and effective treatment for secondary infertility due to CSS. The thickness of the residual myometrium may be a key factor that influences subsequent pregnancy in women with CSS.
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Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
- * E-mail:
| | - Akimasa Takahashi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Asuka Higuchi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Akiyoshi Yamanaka
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Tsukuru Amano
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Fuminori Kimura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Ayumi Seko-Nitta
- Department of Radiology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu City, Shiga, Japan
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Donnez O. Cesarean scar defects: management of an iatrogenic pathology whose prevalence has dramatically increased. Fertil Steril 2020; 113:704-716. [PMID: 32228874 DOI: 10.1016/j.fertnstert.2020.01.037] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 01/17/2020] [Accepted: 01/29/2020] [Indexed: 02/01/2023]
Abstract
Around 20% of pregnant women undergo cesarean section (CS), and in most regions of the world CS rates continue to grow. There is still no clear definition of what is considered a normal physiologic aspect of a CS scar and what is abnormal. Cesarean scar defects (CSDs) should be suspected in women presenting with spotting, dysmenorrhea, pelvic pain, or infertility and a history of CS. CSDs can be visualized with the use of hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be contemplated according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and residual myometrium thickness (RMT) measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique if the RMT is <3 mm, in which case repair is essential and can be achieved by only laparoscopic or vaginal approach. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made. Because prevention is better than cure, risk factors should be identified early to ensure appropriate management.
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Affiliation(s)
- Olivier Donnez
- Institut du Sein et de Chirurgie Gynécologique d'Avignon, Polyclinique Urbain V (Elsan Group), Avignon, France; and Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.
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Antoine C, Young BK. Cesarean section one hundred years 1920-2020: the Good, the Bad and the Ugly. J Perinat Med 2020; 49:5-16. [PMID: 32887190 DOI: 10.1515/jpm-2020-0305] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/10/2020] [Indexed: 12/15/2022]
Abstract
In present-day obstetrics, cesarean delivery occurs in one in three women in the United States, and in up to four of five women in some regions of the world. The history of cesarean section extends well over four centuries. Up until the end of the nineteenth century, the operation was avoided because of its high mortality rate. In 1926, the Munro Kerr low transverse uterine incision was introduced and became the standard method for the next 50 years. Since the 1970's, newer surgical techniques gradually became the most commonly used method today because of intraoperative and postpartum benefits. Concurrently, despite attempts to encourage vaginal birth after previous cesareans, the cesarean delivery rate increased steadily from 5 to 30-32% over the last 10 years, with a parallel increase in costs as well as short- and long-term maternal, neonatal and childhood complications. Attempts to reduce the rate of cesarean deliveries have been largely unsuccessful because of the perceived safety of the operation, short-term postpartum benefits, the legal climate and maternal request in the absence of indications. In the United States, as the cesarean delivery rate has increased, maternal mortality and morbidity have also risen steadily over the last three decades, disproportionately impacting black women as compared to other races. Extensive data on the prenatal diagnosis and management of cesarean-related abnormal placentation have improved outcomes of affected women. Fewer data are available however for the improvement of outcomes of cesarean-related gynecological conditions. In this review, the authors address the challenges and opportunities to research, educate and change health effects associated with cesarean delivery for all women.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Bruce K Young
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
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Dou Y, Zeng D, Zou Z, Wan Y, Xu D, Xiao S. Hysteroscopic treatment of cesarean scar defect. Arch Gynecol Obstet 2020; 302:1215-1220. [PMID: 32803393 DOI: 10.1007/s00404-020-05739-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate the effect of hysteroscopic surgery on the outcomes of obstetrics and gynecology among patients with cesarean section diverticulum. METHODS Ninety-nine infertile patients with cesarean section diverticulum received hysteroscopic treatment and were retrospectively analyzed. Patients were followed for 1 year. RESULTS The study included ninety-nine symptomatic patients with cesarean section diverticulum. After surgery, the menstrual periods of patients were improved from 11.15 ± 4.44 to 7.69 ± 2.85 days. Forty-seven (47/99) women became pregnant after surgery. The number of patients who became pregnant with an anteflexion uterus after hysteroscopic surgery is 32 (32/57), and the number of women who became pregnant with a retroflexion uterus is 15 (15/42). CONCLUSION Hysteroscopic surgery could improve the PCSD-associated prolonged menstrual bleeding, and satisfactory obstetrical outcomes could be achieved by the surgery treatment in women with cesarean defect.
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Affiliation(s)
- Yingyu Dou
- Department of Gynecology and Obstetrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Da Zeng
- Department of Gynecology and Obstetrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Zi'ang Zou
- Department of Gynecology and Obstetrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Yajun Wan
- Department of Gynecology and Obstetrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Dabao Xu
- Department of Gynecology and Obstetrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Songshu Xiao
- Department of Gynecology and Obstetrics, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
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Does the time interval between the diagnosis to hysteroscopic evacuation of retained products of conception affect reproductive outcome? Arch Gynecol Obstet 2020; 302:1523-1528. [PMID: 32785781 DOI: 10.1007/s00404-020-05711-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 07/25/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Retained products of conception (RPOC) refer to the presence of placental and/or fetal tissue in the uterus following delivery, miscarriage, or termination of pregnancy. The presence of such tissue might lead to complications, which might be the culprit of secondary infertility. Although some studies have considered the management of symptomatic RPOC, there are no data regarding the management of asymptomatic, incidentally diagnosed RPOC, nor the optimal time for surgical intervention required to prevent adverse reproductive outcomes. OBJECTIVE This study aimed to examine whether the time interval between the pregnancy termination to surgical evacuation of RPOC influences the reproductive outcome in asymptomatic women. DESIGN This is a retrospective cohort study, which includes women who were admitted for an elective procedure in the gynecology day-care clinic due to suspected RPOC. The diagnosis was made during patients' routine examination following either delivery or miscarriage between the years 2010 and 2018. SETTING Records of women who were admitted to the day-care gynecology department during the years 2010-2018 for hysteroscopic removal of RPOC. PATIENTS The patients were divided into three groups, according to the time from desired pregnancy to conception following the procedure (> 6; 3-6 and < 3 months). Data regarding obstetric history prior to the procedure was retrieved from patients' clinical files, while data concerning reproductive outcome following the procedure was obtained by telephone questionnaires. INTERVENTION Data regarding obstetric history prior to the procedure was retrieved from patients' clinical files, while data concerning reproductive outcome following the procedure was obtained by telephone questionnaires. MEASUREMENTS 75 patients whose reproductive outcome could be analyzed were included in the study. The time interval between the end of pregnancy and surgical intervention was analyzed as a continuous variable and was compared between the three groups, together with parameters such as age and obstetric history. RESULTS There were no significant differences between the groups. CONCLUSIONS The main finding of the present study is that the time interval between the end of pregnancy and surgical evacuation of the asymptomatic, incidentally diagnosed RPOC, has no significant implication on patients' reproductive outcomes.
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Casadio P, Gubbini G, Franchini M, Morra C, Talamo MR, Magnarelli G, Paradisi R, Florio P, Seracchioli R. Comparison of Hysteroscopic Cesarean Scar Defect Repair with 26 Fr Resectoscope and 16 Fr Mini-resectoscope: A Prospective Pilot Study. J Minim Invasive Gynecol 2020; 28:314-319. [PMID: 32512208 DOI: 10.1016/j.jmig.2020.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 05/30/2020] [Accepted: 06/02/2020] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVE Several studies have been published on hysteroscopic treatment of cesarean scar defect using the 26 Fr resectoscope. This study compared the effects of the 26 Fr resectoscope with those of the 16 Fr mini-resectoscope in terms of efficacy, safety profile, and peri- and postoperative complications. DESIGN A prospective cohort study. SETTING Tertiary care university hospital (S. Orsola-Malpighi, Bologna, Italy). PATIENTS Three hundred and nine women having symptoms and with a cesarean scar defect diagnosis were divided into 2 groups according to a temporal criterion: from March 2012 to March 2015, 155 consecutive women (control group) underwent isthmoplasty with the 26 Fr resectoscope (Karl Storz, Tuttlingen, Germany), whereas from April 2015 to March 2018, 154 consecutive women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope (Gubbini system, Tontarra Medizintechnik, Tuttlingen, Germany). INTERVENTIONS One hundred and fifty-five women (control group) underwent isthmoplasty with the 26 Fr resectoscope, and 154 women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope. The so-called "channel-like" 360° endocervical resection technique was applied. MEASUREMENTS AND MAIN RESULTS The isthmoplasty time with the 2 resectoscopes, excluding cervical dilatation, was similar (p = .25), whereas the overall surgical time was shorter in the case of the mini-resectoscope. The use of the 16 Fr mini-resectoscope was significantly associated with a reduced volume of distension medium used (p <.001) and a lower fluid absorption (p <.001). A significant increase (p = .01) in postoperative complications in the control group (9/155; 5.8%) compared with the study group (1/154; 0.7%) was also found. No significant reduction in discharge time was observed between the 2 groups (p = .13). Patient satisfaction immediately after surgery was significantly higher (p <.001) in the study group than in the control group. CONCLUSION Isthmoplasty with a 16 Fr mini-resectoscope seems to be as effective as isthmoplasty with a 26 Fr resectoscope in reducing postmenstrual abnormal uterine bleeding and suprapubic pelvic pain. It is associated with a significant reduction in overall surgical time owing to the non-necessity of performing cervical dilatation. The 16 Fr mini-resectoscope facilitates surgery in small anatomical spaces such as the cervical canal and reduces the complication rate linked to blind maneuvers not respecting the uterine anatomy.
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Affiliation(s)
- Paolo Casadio
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli)
| | - Giampietro Gubbini
- Department of Gynecology, Madre Fortunata Toniolo Clinic, Bologna (Dr. Gubbini)
| | - Mario Franchini
- Department of Obstetrics and Gynecology, Tuscany Health Agency, Florence (Dr. Franchini)
| | - Ciro Morra
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli).
| | - Maria Rita Talamo
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli)
| | - Giulia Magnarelli
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli)
| | - Roberto Paradisi
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli)
| | - Pasquale Florio
- Department of Obstetrics and Gynecology, S. Jacopo Hospital, Pistoia (Dr. Florio), Italy
| | - Renato Seracchioli
- Gynecology and Human Reproduction Physiopathology Unit, S. Orsola Hospital, University of Bologna (Drs. Casadio, Morra, Talamo, Magnarelli, Paradisi, and Seracchioli)
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Gurbuz AS, Gode F, Ozcimen N. Non-Invasive Isthmocele Treatment: A New Therapeutic Option During Assisted Reproductive Technology Cycles? J Clin Med Res 2020; 12:307-314. [PMID: 32489506 PMCID: PMC7239582 DOI: 10.14740/jocmr4140] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/17/2020] [Indexed: 12/26/2022] Open
Abstract
Background The objective of the study was to evaluate a new medical treatment strategy for infertile patients with isthmocele. Methods This was a retrospective evaluation of the records of infertile patients with symptomatic isthmocele who received non-invasive isthmocele treatment (NIIT) before in vitro fertilization (IVF) treatment cycles. Isthmocele volumes were measured before and after NIIT. The IVF results and isthmocele-related complaints were also analyzed. The patients were treated with a depot gonadotropin-releasing hormone agonist for 3 months before frozen-thawed embryo transfer cycles. Results The mean isthmocele volume was 471.06 ± 182.81 mm3 (range: 289.43 - 765.4 mm3) in fresh cycles, but was reduced to 47.94 ± 29.48 mm3 (range: 18.70 - 105.6 mm3) in frozen-thawed cycles (P < 0.05). Intrauterine fluid was observed in two patients during fresh cycles, but was absent after NIIT during frozen-thawed cycles. There was no brown bloody discharge on the tip of the embryo transfer catheter in any case after NIIT. Two patients became pregnant and underwent term cesarean delivery (25%). Conclusions NIIT can serve as an alternative pretreatment option for patients with isthmocele during IVF cycles.
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Affiliation(s)
- Ali Sami Gurbuz
- Department of Obstetrics and Gynaecology, KTO Karatay University Medical Faculty, Konya, Turkey.,Novafertil IVF Center, Konya, Turkey
| | - Funda Gode
- Department of Obstetrics and Gynecology, Bahcesehir University Medical Faculty, Istanbul, Turkey
| | - Necati Ozcimen
- Department of Obstetrics and Gynaecology, KTO Karatay University Medical Faculty, Konya, Turkey
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Vitale SG, Ludwin A, Vilos GA, Török P, Tesarik J, Vitagliano A, Lasmar RB, Chiofalo B. From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis. Arch Gynecol Obstet 2020; 301:33-52. [PMID: 31989288 DOI: 10.1007/s00404-020-05438-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 01/13/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications. METHODS PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology. RESULTS We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%). CONCLUSIONS We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5 mm) and when hysteroscopic treatment is inconclusive.
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Affiliation(s)
- Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy.
| | - Artur Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland.,Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - George Angelos Vilos
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Péter Török
- Faculty of Medicine, Institute of Obstetrics and Gynaecology, University of Debrecen, Debrecen, Hungary
| | | | - Amerigo Vitagliano
- Unit of Gynecology and Obstetrics, Department of Women and Children's Health, University of Padua, Padua, Italy
| | - Ricardo Bassil Lasmar
- Department of Surgery and Specialities, Federal Fluminense University, Niterói, Brazil
| | - Benito Chiofalo
- Gynecologic Oncology Unit, Department of Experimental Clinical Oncology, IRCCS Regina Elena National Cancer Institute, Rome, Italy
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Wang Y, Zhu Q, Lin F, Xie L, Li J, Wang X. Development and internal validation of a Nomogram for preoperative prediction of surgical treatment effect on cesarean section diverticulum. BMC Womens Health 2019; 19:136. [PMID: 31711470 PMCID: PMC6849201 DOI: 10.1186/s12905-019-0817-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/23/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The aim of this study was to develop and validate an individualized score based on preoperative parameters to predict patient outcomes after vaginal repair of cesarean section diverticulum. METHODS This is a retrospective cohort study (Canadian Task Force classification II-2). Patients were enrolled between Jun 11, 2012, to May 27, 2016. Multivariable logistic regression analyses were used to construct the predictive model. Then, we generated a nomogram to assess the individualized risk of poor prognosis after operation. This prediction model included information from 167 eligible patients diagnosed with cesarean section diverticulum who underwent vaginal repair. Class-A healing group was defined as CSD patients who had menstruation duration of no more than 7 days and a thickness of the remaining muscular layer of no less than 5.8 mm after vaginal repair according to conferences. Others were included in the non-class-A healing group. A final nomogram was computed using a multivariable logistic regression model. RESULTS The factors contained in the individualized prediction nomogram included the depth/ the thickness of the remaining muscular layer ratio, number of menstruation days before surgery, White blood cell and fibrinogen. This model demonstrated adequate discrimination and calibration (C-index = 0.718). There was a significant difference in the number of postmenstrual spotting days (12.98 ± 3.86 VS 14.46 ± 2.86, P = 0.022) and depth/ the thickness of the remaining muscular layer ratio (2.81 ± 1.54 VS 4.00 ± 3.09, P = 0.001) between two groups. Decision curve analysis showed that this nomogram was clinically useful. CONCLUSIONS This cesarean section diverticulum score can predict the outcomes of cesarean section diverticulum and can be useful for counseling patients who are making treatment decisions.
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Affiliation(s)
- Yizhi Wang
- Department of Gynecology & Obstetrics, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092 China
| | - Qinyi Zhu
- Shanghai first maternity and infant health institute, Shanghai, China
| | - Feikai Lin
- Department of Gynecology & Obstetrics, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Xie
- Clinical Statistics Center, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jiarui Li
- Department of Gynecology & Obstetrics, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092 China
| | - Xipeng Wang
- Department of Gynecology & Obstetrics, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, 1665 Kong Jiang Road, Shanghai, 200092 China
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Kremer TG, Ghiorzi IB, Dibi RP. Isthmocele: an overview of diagnosis and treatment. ACTA ACUST UNITED AC 2019; 65:714-721. [PMID: 31166450 DOI: 10.1590/1806-9282.65.5.714] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/31/2018] [Indexed: 11/21/2022]
Abstract
An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.
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Affiliation(s)
- Thaysa Guglieri Kremer
- Department of Medicine at the Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brasil
| | - Isadora Bueloni Ghiorzi
- Department of Medicine at the Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brasil
| | - Raquel Papandreus Dibi
- Department of Gynecology and Obstetrics at the Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, RS, Brasil
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Vegas Carrillo de Albornoz A, López Carrasco I, Montero Pastor N, Martín Blanco C, Miró Matos M, Alonso Pacheco L, Moratalla Bartolomé E. Outcomes after Hysteroscopic Treatment of Symptomatic Isthmoceles in Patients with Abnormal Uterine Bleeding and Pelvic Pain: A Prospective Case Series. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2019; 13:108-112. [PMID: 31037920 PMCID: PMC6500081 DOI: 10.22074/ijfs.2019.5704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/27/2018] [Indexed: 11/22/2022]
Abstract
Background Isthmoceles are described as complications associated with caesarean section (CS). Only symptomatic
isthmoceles should be treated. The main symptoms are abnormal uterine bleeding (AUB) in the absence of any other
causes, pelvic pain and secondary infertility. There are several techniques described for the correction of isthmoceles.
Isthmoplasty can be performed by hysteroscopy, laparoscopy or vaginal surgery. The aim of this study was to assess
the effectiveness of hysteroscopic surgical treatment of isthmoceles in women with associated symptoms such as
pelvic pain and AUB. Materials and Methods A prospective case series study was performed; this study included all women with AUB,
pelvic pain and ultrasonographic (US) diagnosis of isthmocele, who had undergone hysteroscopic correction between
June 2014 and December 2017 in our Hospital. Results Thirty eight women underwent surgical hysteroscopy for correction of symptomatic isthmoceles. All patients
presented AUB, 42.1% experienced pelvic pain and 28.9% had secondary infertility. US evaluation of isthmoceles
was performed using 2D ultrasound. The residual myometrial thickness (RMT) above the isthmocele was measured in
women who expected future pregnancy; if it was <2.5 mm the patient was not included in the study because the cor-
rection was performed laparoscopically. Follow-up was performed one and two months after the surgery. In all cases,
pelvic pain was resolved one month after the surgery. AUB disappeared within the first month in 87.5% of patients
and in the second month in 96.8% of subjects; however, one patient needed further surgery to alleviate her symptoms.
Secondary infertility was assessed one year after surgical isthmoplasty. Seven women completed the first year of fol-
low up, and three of them (42.8%) reported pregnancy after treatment between six and eight months after the surgery. Conclusion Hysteroscopic correction of symptomatic isthmoceles may constitute a safe and effective technique for
patients who present AUB and pelvic pain.
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Affiliation(s)
| | - Irene López Carrasco
- Department of Obstetrics and Gynecology, University Hospital HM Montepríncipe, Madrid, Spain. Electronic Address:
| | - Nerea Montero Pastor
- Department of Obstetrics and Gynecology, University Hospital HM Montepríncipe, Madrid, Spain
| | - Carmen Martín Blanco
- Department of Obstetrics and Gynecology, University Hospital HM Montepríncipe, Madrid, Spain
| | - María Miró Matos
- Department of Obstetrics and Gynecology, University Hospital HM Montepríncipe, Madrid, Spain
| | - Luis Alonso Pacheco
- Department of Gynaecological Endoscopy, Gutenberg Center, Xanit International Hospital, Malaga, Spain
| | - Enrique Moratalla Bartolomé
- Department of Obstetrics and Gynecology, University Hospital HM Montepríncipe, Madrid, Spain.,Department of Obstetrics and Gynecology, University Hospital Ramón y Cajal, Madrid, Spain
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López Rivero LP, Jaimes M, Camargo F, López-Bayghen E. Successful treatment with hysteroscopy for infertility due to isthmocele and hydrometra secondary to cesarean section: A case report. World J Clin Cases 2019; 7:753-758. [PMID: 30968040 PMCID: PMC6448083 DOI: 10.12998/wjcc.v7.i6.753] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/04/2019] [Accepted: 02/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND An isthmocele is a scar defect in the uterine wall due to a cesarean section. Its prevalence is unknown, but it has been associated with secondary infertility. Here, we present a case where the patient suffered from an isthmocele that was associated with persistent hydrometra, which developed during in vitro fertilization.
CASE SUMMARY The patient underwent hysteroscopic surgery, which successfully resolved the isthmocele as well as the hydrometra. Afterward, two high-quality, euploid embryos, determined by morphological assessment and pre-implantation genetic diagnostic testing, were transferred. This resulted in uterine pregnancy, as determined byserum β-human chorionic gonadotropin levels on day 14 (180 mU/mL) and ultrasound-confirmed presence of a gestational sac with a positive embryocardia at week 6. The pregnancy reached 36 wk without any complications, and the product was born in good health. We report a successful isthmocele treatment in a patient with secondary infertility, in which the isthmocele was the cause of persistent hydrometra.
CONCLUSION Hydrometra caused by secondary cesarean is an infertility factor, which can be corrected by hysteroscopy plus ablation of the isthmocele.
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Affiliation(s)
| | - Miguel Jaimes
- Instituto de Infertilidad y Genética México SC, Ingenes México City 05320, México
| | - Felipe Camargo
- Instituto de Infertilidad y Genética México SC, Ingenes México City 05320, México
| | - Esther López-Bayghen
- Departamento de Toxicología, Centro de Investigación de Estudios, México City 07360, México
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Prevalence of Infertility Among Patients With Isthmocele and Fertility Outcome After Isthmocele Surgical Treatment: A Retrospective Study. Ochsner J 2019; 19:204-209. [PMID: 31528130 DOI: 10.31486/toj.18.0048] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: An isthmocele is a diverticulum on the anterior wall of the uterine isthmus at the site of a cesarean delivery scar. We evaluated the prevalence of infertility among patients with isthmocele, the resolution of symptoms, and infertility outcomes after hysteroscopic isthmoplasty. Methods: We conducted a retrospective study of 35 consecutive patients with symptomatic isthmocele between 2010 and 2015 at Hospital Piero Palagi in Florence, Italy. Patients with symptomatic isthmocele had postmenstrual abnormal uterine bleeding, sovrapubic pain, and infertility. Results: The study population was divided into Group A - Fertile Patients (n=19) and Group B - Infertile Patients (n=16) according to the prevalence of infertility after the diagnosis of isthmocele. Group B was subdivided into Group B1 (became pregnant, n=9) and B2 (did not become pregnant, n=7) according to infertility resolution after isthmocele treatment. We found statistically significant differences between Groups A and B regarding the number of cesarean sections (P=0.0205), the grade of isthmocele (P=0.0421), and body mass index (P=0.0001). In the subgroup analysis, we found statistically significant differences between Groups B1 and B2 for age (P=0.0151), grade of isthmocele (P=0.0361), and cervical dilatation (P=0.0293). Conclusion: We identified a subgroup of patients at higher risk of being infertile after the diagnosis of isthmocele and a subgroup of patients who could benefit the most in terms of fertility after minimally invasive hysteroscopic surgery.
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Iannone P, Nencini G, Bonaccorsi G, Martinello R, Pontrelli G, Scioscia M, Nappi L, Greco P, Scutiero G. Isthmocele: From Risk Factors to Management. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2019; 41:44-52. [PMID: 30646424 PMCID: PMC10416161 DOI: 10.1055/s-0038-1676109] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 10/10/2018] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE The aim of the present study was to perform a comprehensive review of the literature to provide a complete and clear picture of isthmocele-a hypoechoic area within the myometrium at the site of the uterine scar of a previous cesarean section-by exploring in depth every aspect of this condition. METHODS A comprehensive review of the literature was performed to identify the most relevant studies about this topic. RESULTS Every aspect of isthmocele has been studied and described: pathophysiology, clinical symptoms, classification, and diagnosis. Its treatment, both medical and surgical, has also been reported according to the actual literature data. CONCLUSION Cesarean section is the most common surgical procedure performed worldwide, and one of the consequences of this technique is isthmocele. A single and systematic classification of isthmocele is needed to improve its diagnosis and management. Further studies should be performed to better understand its pathogenesis.
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Affiliation(s)
- Piergiorgio Iannone
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Giulia Nencini
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Gloria Bonaccorsi
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Ruby Martinello
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Giovanni Pontrelli
- Section of Obstetrics and Gynaecology, Policlinico di Abano Terme, Abano Terme, Padova, Italy
| | - Marco Scioscia
- Section of Obstetrics and Gynaecology, Policlinico di Abano Terme, Abano Terme, Padova, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Pantaleo Greco
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
| | - Gennaro Scutiero
- Section of Obstetrics and Gynecology, Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliero-Universitaria S. Anna, Università di Ferrara, Cona, Ferrara, Italy
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Abdou AM, Ammar IMM. Role of hysteroscopic repair of cesarean scar defect in women with secondary infertility. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2018. [DOI: 10.1016/j.mefs.2018.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Lv B, Xie X, Liu C, Lin Y. Laparoscopic combined with hysteroscopic repair or operative hysteroscopy in the treatment of symptomatic cesarean-induced diverticulum. Med Sci (Paris) 2018; 34 Focus issue F1:47-51. [PMID: 30403175 DOI: 10.1051/medsci/201834f109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The postmenstrual bleeding with cesarean-induced diverticulum is a bothersome symptom and can be confused with other abnormal-uterine bleeding disease. The aim of the present study was to evaluate the efficacy and safety of laparoscopic combined with hysteroscopic repair vs operative hysteroscopy in treatment of symptomatic cesarean-induced diverticulum. METHODS Eighty-two women with cesarean-induced diverticulum who underwent either laparoscopic combined with hysteroscopic repair or operative hysteroscopy between January 2012 and September 2015 were retrospectively included in the study. We evaluated the menstrual duration before and after the surgery, the width, length and depth of the niche, operating time, blood loss, complications, and postoperative pregnancy status. RESULTS 62.2% (51/82) patients started to have postmenstrual bleeding immediately when they gained regular menstruation after their cesarean section. The laparoscopic group has longer operative time and greater blood loss (p<0.001). Both groups have a significant improvement in their menstruation duration ( p< 0.001). The patients in the laparoscopic repair group had a greater improvement in bringing the uterine bleeding into normal menstruation duration (P=0.046) and the same in pregnancy rate (P=0.505). The interval between operation and pregnancy in laparoscopic combined with hysteroscopic group was much longer than the hysteroscopic group (27 vs 10 months, p<0.001). CONCLUSION the laparoscopic repair exhibited a better efficiency in bringing the uterine bleeding into normal menstruation duration and in improving the pregnancy rate However, there was not a clear absolute advantage for one of the two type of surgeries. Thus, patients with post-cesarean section diverticulum (PCSD) should choose with caution the type of surgery, considering the residual myometrial thickness (RMT), the age, the desire for further fertility and ovarian reserve capacity.
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Affiliation(s)
- Bingqing Lv
- Department of Gynecology and Obstetrics, Fujian Province Maternity and Children's Hospital, affiliated hospital of Fujian Medical University, No.18 Anshan Road, Gulou District Fuzhou City, Fujian Province 350001, PR China
| | - Xi Xie
- Department of Gynecology and Obstetrics, Fujian Province Maternity and Children's Hospital, affiliated hospital of Fujian Medical University, No.18 Anshan Road, Gulou District Fuzhou City, Fujian Province 350001, PR China
| | - Chaobin Liu
- Department of Gynecology and Obstetrics, Fujian Province Maternity and Children's Hospital, affiliated hospital of Fujian Medical University, No.18 Anshan Road, Gulou District Fuzhou City, Fujian Province 350001, PR China
| | - Yuan Lin
- Department of Gynecology and Obstetrics, Fujian Province Maternity and Children's Hospital, affiliated hospital of Fujian Medical University, No.18 Anshan Road, Gulou District Fuzhou City, Fujian Province 350001, PR China
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Isthmocele, challenging but not a rare entity; Its expected incidence might be more than reported. JOURNAL OF SURGERY AND MEDICINE 2018. [DOI: 10.28982/josam.424328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Park IY, Kim MR, Lee HN, Gen Y, Kim MJ. Risk factors for Korean women to develop an isthmocele after a cesarean section. BMC Pregnancy Childbirth 2018; 18:162. [PMID: 29764452 PMCID: PMC5952596 DOI: 10.1186/s12884-018-1821-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 05/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The increase in number of cesarean section (CS) operations has resulted in an increase in cases of isthmocele development. The objective of this study is to determine the risk factors for isthmocele development after CS. METHODS Isthmocele measurements were taken for 404 women with a history of at least one low transverse CS. The following potential risk factors were investigated: patient's age at CS, cause of CS, weeks of gestation at CS, premature rupture of membrane (PROM), phase of labor, type suture (single/double layer), operation time, uterine flexion (anteversion/retroversion), and blood transfusion during operation. A transvaginal ultrasound was carried out to examine the isthmocele in the uterus after CS, including the shape of the isthmocele, residual myometrial thickness, depth and width of isthmocele, cervical thickness, location of the isthmocele, and clinical characteristics. RESULTS In our study population, the isthmocele had a prevalence of 73.8%. Most isthmocele had a triangular (65.4%) or semicircular shape (10.4%). The presence of an isthmocele was significantly associated with repeat CS, premature rupture of membrane (PROM), short operation time, and extent of cervix dilatation at CS. The risk of isthmocele was low in women who had placenta previa totalis (PPT), twin, a long operation time, or a transfusion during the operation. CONCLUSIONS In our study, isthmocele development was significantly associated with repeat CS, PROM, a short operation time, and the extent of cervix dilatation at CS. Therefore, PROM prevention and a more careful uterine closure are needed to reduce the risk of developing an isthmocele after CS.
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Affiliation(s)
- I Y Park
- Department of Obstetrics and Gynecology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - M R Kim
- Department of Obstetrics and Gynecology, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - H N Lee
- Department of Obstetrics and Gynecology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, Bucheon, Gyeonggi-do, 14647, Republic of Korea
| | - Y Gen
- Department of Obstetrics and Gynecology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, Bucheon, Gyeonggi-do, 14647, Republic of Korea
| | - M J Kim
- Department of Obstetrics and Gynecology, College of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, 327 Sosa-ro, Bucheon, Gyeonggi-do, 14647, Republic of Korea.
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Pomorski M, Fuchs T, Rosner-Tenerowicz A, Zimmer M. Sonographic evaluation of surgical repair of uterine cesarean scar defects. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:455-460. [PMID: 28186617 DOI: 10.1002/jcu.22449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/23/2016] [Accepted: 12/26/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND The aim of the study was to assess the clinical outcomes of surgical repair of uterine cesarean scar defects with sonography (US). METHODS Seven nonpregnant women with history of cesarean section and a large uterine scar defect were enrolled. The surgical repair was performed by minilaparotomy. The US assessment of the uterine scar was performed using a standardized approach at baseline, then at a first visit 2-3 days following the surgical intervention (V1) and at a follow-up visit 3 months later (V2). Residual myometrial thickness (RMT), width, and depth of the scar defect were measured. RESULTS The mean RMT increased significantly from 1.9 mm at baseline to 8.8 mm at V1 and 8.0 mm at V2. No intraoperative complications were observed. Postmenstrual spotting and abdominal pain reported preoperatively resolved after the operation. CONCLUSIONS A surgical repair procedure for an incompletely healed uterine cesarean scar is effective in increasing RMT thickness, decreasing the depth of the scar, and reducing symptoms related to the cesarean section scar defect. Further studies on post-repair pregnancy outcomes are required to evaluate whether the procedure affects the rate of cesarean scar pregnancy, morbidly adherent placenta, and/or uterine scar dehiscence and rupture. The repair of a cesarean scar defect is recommended only for symptomatic women. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:455-460, 2017.
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Affiliation(s)
- Michal Pomorski
- 2nd Department of Gynecology and Obstetrics, Wroclaw Medical University, Ul. Borowska 213, 50-556, Wroclaw, Poland
| | - Tomasz Fuchs
- 2nd Department of Gynecology and Obstetrics, Wroclaw Medical University, Ul. Borowska 213, 50-556, Wroclaw, Poland
| | - Anna Rosner-Tenerowicz
- 2nd Department of Gynecology and Obstetrics, Wroclaw Medical University, Ul. Borowska 213, 50-556, Wroclaw, Poland
| | - Mariusz Zimmer
- 2nd Department of Gynecology and Obstetrics, Wroclaw Medical University, Ul. Borowska 213, 50-556, Wroclaw, Poland
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Tsuji S, Kimura F, Yamanaka A, Hanada T, Hirata K, Takebayashi A, Takashima A, Seko-Nitta A, Murakami T. Impact of hysteroscopic surgery for isthmocele associated with cesarean scar syndrome. J Obstet Gynaecol Res 2017; 44:43-48. [PMID: 28892298 DOI: 10.1111/jog.13464] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 06/18/2017] [Accepted: 07/09/2017] [Indexed: 12/01/2022]
Abstract
AIM Cesarean scar syndrome (CSS) is characterized by increased risk of postmenstrual abnormal uterine bleeding, dysmenorrhea, and infertility, due to a post-cesarean scar defect known as an isthmocele. This study aimed to assess the impact of hysteroscopic surgery on isthmocele associated with CSS. METHODS Eighteen patients with CSS were enrolled. Surgical methods included resection of the inferior edge and superficial cauterization of the isthmocele via hysteroscopic surgery. We evaluated the residual myometrial thickness and isthmocele volume using magnetic resonance imaging, before and after hysteroscopic surgery. RESULTS All patients underwent surgery without any complications. The residual myometrium was thicker after hysteroscopic surgery (median: 2.1 mm and 4.2 mm, before and after surgery, respectively; P = 0.0001). Isthmocele volume was significantly reduced after hysteroscopic surgery (median: 494.9 mm3 and 282.8 mm3 , before and after surgery, respectively; P = 0.0016). CONCLUSION This study demonstrated that hysteroscopic surgery is effective in increasing the residual myometrial thickness and reducing the size of isthmocele.
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Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu City, Shiga, Japan
| | - Fuminori Kimura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu City, Shiga, Japan
| | - Akiyoshi Yamanaka
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu City, Shiga, Japan
| | - Tetsuro Hanada
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu City, Shiga, Japan
| | - Kimiko Hirata
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu City, Shiga, Japan
| | - Akie Takebayashi
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu City, Shiga, Japan
| | - Akiko Takashima
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu City, Shiga, Japan
| | - Ayumi Seko-Nitta
- Department of Radiology, Shiga University of Medical Science, Otsu City, Shiga, Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu City, Shiga, Japan
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Abacjew-Chmylko A, Wydra DG, Olszewska H. Hysteroscopy in the treatment of uterine cesarean section scar diverticulum: A systematic review. Adv Med Sci 2017; 62:230-239. [PMID: 28500899 DOI: 10.1016/j.advms.2017.01.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 10/12/2016] [Accepted: 01/24/2017] [Indexed: 10/19/2022]
Abstract
The aim of this paper is to review and to analyze the results of previous studies dealing with hysteroscopic treatment of postcesarean scar defects. A systematic review of publications indexed in MEDLINE/PubMed database identified a total of 11 studies dealing with resectoscopic treatment of postcesarean scar defect. The review was conducted in line with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines and the PRISMA statement. In only few studies, patients were qualified for hysteroscopic surgery based on the measurement of the defect depth and thickness of residual myometrium above the pouch. Two principal techniques were used for the hysteroscopic treatment: resection of one edge of the scar diverticulum, and resection of the inferior and superior edges of the defect. Additionally, most authors performed electrocauterization of the niche bottom. Resectoscopic treatment turned out to be highly effective in the case of women with AUB. No complications of the hysteroscopic procedure have been reported. Methodological value of the reviewed studies was relatively low due to non-unified selection/verification criteria and incomplete, non-systematic postoperative assessment. In conclusion, hysteroscopic treatment seems to be a promising option in the management of postcesarean scar defects, but still further research is needed on the problem in question.
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