Isthmocele and fertility disorders: analysis of risk factors for infertility

Abstract

The increasing rate of cesarean section (CS) is accompanied by a corresponding rise in its complications. Among the long-term outcomes of CS, particularly after repeat procedures, the development of isthmocele (niche) is one of the most challenging and is associated with a broad spectrum of obstetric and gynecological manifestations, including secondary infertility. Objective. To investigate the prevalence and prognostic significance of various factors contributing to infertility in patients with isthmocele. Patients and methods. This study included 34 women aged 22–44 years (mean age: 28.7 ± 4.1 years) with secondary infertility and a history of CS. All patients were diagnosed with a cesarean scar defect (isthmocele). The diagnosis was made during hospitalization based on the findings of transvaginal ultrasound and magnetic resonance imaging and subsequently confirmed by hysteroscopy. Isthmocele severity was classified as moderate in 12 (35.3%) patients, severe in 16 (47.1%), and very severe in 6 (17.6%). Results. Infertility was associated with fluid accumulation within the niche in 58.8% of women. All of these patients exhibited evidence of uterine microbiota dysbiosis of varying severity. Gynecological manifestations were observed in 52.9% of the cohort, with dysmenorrhea being the most prevalent condition. Concomitant uterine microbiota dysbiosis was present in 88.9% of symptomatic patients. Conclusion. Uterine microbiota dysbiosis appears to be a major factor contributing to infertility in patients with a cesarean scar defect. Abnormal endometrial microbiome may impair sperm transport and trophoblast implantation. These findings should be taken into consideration when planning surgical correction of isthmocele. Key words: isthmocele, niche, infertility, microbiome, dysbiosis