Caesarean Scar Defect

Caesarean Scar Defect (CSD) is defined as the presence of a “niche” at the site of a Caesarean delivery scar site.

With the rising rate of caesarean section, prevalence of CSD is between 24% and 70% in a random population of women with at least one Caesarean delivery.

The issue arises when the defect becomes a pouch, or isthmocele in the lower uterine segment and accumulates fluid or blood. When old menstrual blood becomes trapped in the isthmocele and uterine cavity, it sets up an inflammatory response in the uterus impairing embryo implantation.

It is postulated that accumulated blood in the niche can ultimately degrade cervical mucus and sperm function, as well as inhibit sperm transport, a proposed mechanism of infertility.

What Medications are used

A British study has reported that 30 percent of women who had a C-section were not able to conceive another child. The National Institutes of Health (NIH) says Caesarean scars are clinically relevant or cause symptoms in 19-88% of C-section patients.

A retrospective case–control study including 310 IVF patients showed that a caesarean section scar can could decrease the chances of embryo implantation (24.01 vs. 34.67%) and reduce the pregnancy rate (40.28 vs. 54.22%)

The presence of a Caesarean scare “niche” is associated with future potential fertility problems including an increased likelihood of needing a C-section in a subsequent pregnancy, ectopic pregnancy in the scar, miscarriage, potential uterine rupture in a future pregnancy, and secondary infertility.

CDS may be asymptomatic or present with range of symptoms: pelvic pain, abnormal bleeding, vaginal discharge, painful periods and infertility.

Women having a difficulty falling pregnant following a previous C-section should seek medical consultation to evaluate the possibility of CSD being the cause.

Diagnosis of CSD can be made with the following:

  • Ultrasound
  • Saline infusion sonohysterography
  • Magnetic resonance imaging (MRI)
  • 3-D ultrasonography

Benefits and Risks

To promote fertility and decrease symptoms, the defect must be repaired. Laparoscopic repair of the defect is recommended for women who desire future fertility. A major benefit of laparoscopic repair is about 75% of patients become pregnant following niche repair. It is recommended to wait at least 3 months before attempting conception.

There are two successful techniques described for laparoscopic repair of CSD : one without processing scar resection and other with processing scare resection. Pregnancy outcome is similar irrespective of the approach.