Journal of Infertility and Reproductive Biology

Published date: Sep 20 2025

Journal Title: Journal of Infertility and Reproductive Biology

Issue title: Journal of Infertility and Reproductive Biology: Volume 13, Issue 3

Pages: 129 - 143

DOI: 10.18502/jirb.v13i3.19528

Mohanad Suhail Najmmohanadsuhail@uoanbar.edu.iqDepartment of Human Anatomy, College of Medicine, University of Anbar, Anbar

Hengameh DortajDortajH@mums.ac.irDepartment of Anatomy and Cell Biology, School of Medicine, Mashhad University of Medical Science, Mashhad

Isthmocele, also known as a uterine niche or cesarean scar defect, is a 1 to 2 mm defect in the anterior myometrium that appears as a hypoechoic triangle at the location of the lower segment caesarean section scar. The term is derived from the Greek words “isthmo” (uterine isthmus) and “cele” (cavity or pouch). The number of cases of isthmoceles varies significantly in the medical literature, with approximately 30% of afflicted women exhibiting symptoms. The Delphi consensus classified the disorder as Caesarean Scar Disorder (CSD), characterized as a uterine niche with at least one major symptom (postmenstrual spotting, discomfort during uterine bleeding, technical problems after embryo transfer) or two secondary symptoms (unexplained infertility and intrauterine fluid). Isthmocele is a serious iatrogenic condition of caesarean birth that might have long-term consequences for reproductive health. The pathophysiological pathways connecting isthmocele and infertility are diverse, comprising mechanical impediment, chronic inflammation, intrauterine fluid buildup, and disturbance of normal uterine contractility and receptivity. Diagnostic advances, such as upgraded ultrasonography methods and standardized criteria, have facilitated the identification and characterization of many abnormalities. Therapeutic options are evolving, with less invasive surgical procedures exhibiting excellent success in treating problems and restoring fertility. However, considerable knowledge gaps persist, and further research is needed to better understand the best surgical method for different defect shapes and long-term obstetric outcomes following surgical repair. The growing global caesarean rate ensures that isthmoceles will remain a major clinical problem in reproductive medicine.

Keywords: isthmocele, anatomical defects, fertility implications

[1] Rupa R, Kushvaha S, Venkatesh K. Uterine isthmocele—a frequently overlooked complication of cesarean sections. Indian J Radiol Imaging. 2021;31(03):601-604.

[2] Tulandi T, Cohen A. Emerging manifestations of cesarean scar defect in reproductive-aged women. J Minim Invasive Gynecol. 2016;23(6):893-902.

[3] Gubbini G, Casadio P, Marra E. Resectoscopic correction of the “isthmocele” in women with postmenstrual abnormal uterine bleeding and secondary infertility. J Minim Invasive Gynecol. 2008;15(2):172-175.

[4] Tsuji S, Nobuta Y, Hanada T, Takebayashi A, Inatomi A, Takahashi A, et al. Prevalence, definition, and etiology of cesarean scar defect and treatment of cesarean scar disorder: A narrative review. Reprod Med Biol. 2023;22(1):e12532.

[5] Vidal A, Geiger J, Vinayahalingam V, Pape J, Gulz M, Karrer T, et al. High live birth rates after laparoscopic isthmocele repair in infertility: a systematic review and meta-analysis. Front Endocrinol (Lausanne). 2025;16:1507482.

[6] Morris H. Surgical pathology of the lower uterine segment caesarean section scar: is the scar a source of clinical symptoms? Int J Gynecol Pathol. 1995;14(1):16-20.

[7] Angolile CM, Max BL, Mushemba J, Mashauri HL. Global increased cesarean section rates and public health implications: A call to action. Health Sci Rep. 2023;6(5):e1274.

[8] Betran AP, Ye J, Moller A-B, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021;6(6):e005671.

[9] Fakhr MS, Mozafari M, Rezvanfar K, Amini Z, Amiri K, Hosseini RS, et al. Investigating the risk factors for isthmocele development after cesarean delivery. AJOG Glob Rep. 2024;4(2):100299.

[10] Baldini GM, Lot D, Malvasi A, Di Nanni D, Laganà AS, Angelucci C, et al. Isthmocele and infertility. J Clin Med. 2024;13(8):2192.

[11] Stout A, Dicks-Ilori L, Elghobashy A. Isthmocele: A Case Report and Review of an Increasingly Common Gynecological Hurdle. Cureus. 2024;16(10)1-19.

[12] Wu Z, Liu S, Huang F, Ke Y. The Diagnosis and Treatment of Caesarean Scar Defect: Progress and Controversies. Clin Exp Obstet Gynecol. 2023;50(6):116-121.

[13] Kjellberg U, van Rooijen M, Bremme K, Hellgren M. Factor V Leiden mutation and pregnancy-related complications. Am J Obstet Gynecol. 2010;203(5):469-468.

[14] Goland S, Elkayam U. Pregnancy and Marfan syndrome. Ann Cardiothorac Surg. 2017;6(6):642-500.

[15] Gupta T, Singal K, Gupta N, Kohli S, Kanyal M. Comparative Study of USG and MRI in Evaluation of Isthmocele. J Obstet Gynaecol India. 2021;71(3):292-296.

[16] Haylen BT. The retroverted uterus: ignored to date but core to prolapse. Int Urogynecol J. 2006;17(6):555-558.

[17] Fiaschetti V, Massaccesi M, Fornari M, Nezzo M, Da Ros V, Sorrenti G, et al. Isthmocele in a retroflexed uterus: a report of an unrecognized case. Clin Exp Obstet Gynecol. 2015;42(5):705-707.

[18] Lerman OZ, Galiano RD, Armour M, Levine JP, Gurtner GC. Cellular dysfunction in the diabetic fibroblast: impairment in migration, vascular endothelial growth factor production, and response to hypoxia. Am J Pathol. 2003;162(1):303-312.

[19] Gornet ME, Abhari S, Christianson MS. Isthmocele endometriosis: When two is definitely not better than one. Fertil Steril. 2022;117(6):1337-1338.

[20] Florio P, Filippeschi M, Moncini I, Marra E, Franchini M, Gubbini G. Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility. Curr Opin Obstet Gynecol. 2012;24(3):180-186.

[21] van der Voet L, Bij de Vaate A, Veersema S, Brölmann H, Huirne J. Long-term complications of caesarean section. The niche in the scar: a prospective cohort study on niche prevalence and its relation to abnormal uterine bleeding. BJOG. 2014;121(2):236-244.

[22] 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(2):230-239.

[23] Marotta M-L, Donnez J, Squifflet J, Jadoul P, Darii N, Donnez O. Laparoscopic repair of postcesarean section uterine scar defects diagnosed in nonpregnant women. J Minim Invasive Gynecol. 2013;20(3):386-391.

[24] Donnez O, Jadoul P, Squifflet J, Donnez J. Laparoscopic repair of wide and deep uterine scar dehiscence after cesarean section. Fertil Steril. 2008;89(4):974-980.

[25] Raimondo G, Grifone G, Raimondo D, Seracchioli R, Scambia G, Masciullo V. Hysteroscopic treatment of symptomatic cesarean-induced isthmocele: a prospective study. J Minim Invasive Gynecol. 2015;22(2):297-301.

[26] Li C, Guo Y, Liu Y, Cheng J, Zhang W. Hysteroscopic and laparoscopic management of uterine defects on previous cesarean delivery scars. J Perinat Med. 2014;42(3):363-370.

[27] Zhou J, Yao M, Wang H, Tan W, Chen P, Wang X. Vaginal repair of cesarean section scar diverticula that resulted in improved postoperative menstruation. J Minim Invasive Gynecol. 2016;23(6):969-978.

[28] Api M, Boza A, Gorgen H, Api O. Should cesarean scar defect be treated laparoscopically? A case report and review of the literature. J Minim Invasive Gynecol. 2015;22(7):1145-1152.

[29] Chen Y, Chang Y, Yao S. Transvaginal management of cesarean scar section diverticulum: a novel surgical treatment. Med Sci Monit. 2014;20:1395.

[30] Zhang Y. A comparative study of transvaginal repair and laparoscopic repair in the management of patients with previous cesarean scar defect. J Minim Invasive Gynecol. 2016;23(4):535-341.

[31] Vitale SG, Ludwin A, Vilos GA, Török P, Tesarik J, Vitagliano A, et al. 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(1):33-52.

[32] Klein Meuleman SJ, Post B, Vissers J, de Leeuw RA, Post Uiterweer ED, Huirne JA. Presence of intrauterine fluid in women with a large niche is not associated with a difference in endometrial thickness. Fertil Steril. 2023;119(2):322-325.

[33] Ahamed FM, Solkar S, Stevikova M, Moya BP. Link between cesarean section scar defect and secondary infertility: Case reports and review. JBRA Assist Reprod. 2023;27(1):134-141.

[34] Harjee R, Khinda J, Bedaiwy MA. Reproductive outcomes following surgical management for isthmoceles: a systematic review. J Minim Invasive Gynecol. 2021;28(7):1291-1302.

[35] Zhang H, Huang J, Wu X, Fan H, Li H, Gao T. Clinical classification and treatment of cesarean scar pregnancy. J Obstet Gynaecol Res. 2017;43(4):653-661.

[36] Jordans I, De Leeuw R, Stegwee S, Amso N, Barri-Soldevila P, Van Den Bosch T, et al. Sonographic examination of uterine niche in non-pregnant women: a modified Delphi procedure. Ultrasound Obstet Gynecol. 2019;53(1):107-115.

[37] Baldini D, Beck R, Negro F, De Viti D. Assisted reproductive technologies and metabolic syndrome complications: medico-legal reappraisal. Clin Ter. 2019;170(5):364-367.

[38] Chen Y-Y, Tsai C-C, Kung F-T, Lan K-C, Ou Y-C. Association between hysteroscopic findings of previous cesarean delivery scar defects and abnormal uterine bleeding. Taiwan J Obstet Gynecol. 2019;58(4):541-544.

[39] Donnez O. Cesarean scar defects: management of an iatrogenic pathology whose prevalence has dramatically increased. Fertil Steril. 2020;113(4):704-716.

[40] Huang C-C, Chiu S-C, Pan C-M, Huang C-C, Chang CY-Y, Chao S-C, et al. New efficient method for hysteroscopic isthmoplasty: four simple steps lead to a significant improvement in bleeding status. J Clin Med. 2022;11(21):1-19.

[41] Karampelas S, Engels S, Birbarah C, Nisolle M. Laparoscopic approach for a cesarean scar pregnancy. Fertil Steril. 2022;117(5):1099-1101.

[42] Krentel H, Lauterbach L-K, Mavrogiannis G, De Wilde RL. Laparoscopic Fluorescence Guided Detection of Uterine Niche—The Next Step in Surgical Diagnosis and Treatment. J Clin Med. 2022;11(9):2657- 2600.

[43] Iwashita T, Uemura S, Tezuka R, Senju A, Iwata S, Ohashi Y, et al. Endoscopic ultrasound-guided rendezvous techniques for difficult biliary cannulation: Technical review. Dig Endosc. 2025;37(1):68- 76.

[44] Katsimperis S, Tzelves L, Feretzakis G, Bellos T, Tsikopoulos I, Kostakopoulos N, et al. Innovations in Robot-Assisted Surgery for Genitourinary Cancers: Emerging Technologies and Clinical Applications. Appl Sci. 2025;15(11):6118-1002.

[45] Shutak M, Ostrovska K, Makarchuk O, Ostrovska O. P-748 Reproductive impact of isthmocele. Hum Reprod. 2025;40(Supplement_1):deaf097.1053.

[46] Ioannou D, Tempest HG. The genetic basis of male and female infertility. Syst Biol Reprod Med. 2025;71(1):143-169.

[47] Yan L, Li Q, Fu K, Zhou X, Zhang K. Progress in the application of artificial intelligence in ultrasoundassisted medical diagnosis. Bioengineering. 2025;12(3):288-279.

[48] Dokras A, Somigliana E, Donnez O, Humphries LA, Shah DK, Christianson MS, et al. Isthmocele—fix it or observe, an ongoing dilemma. Fertil Steril. 2025;123(6):981-988.

[49] Harjee R, Devji J, Barrett-Chan EK, Khinda J, Bedaiwy MA. Surgical management of caesarean scar disorder using different techniques: a scoping review and case series. Middle East Fertil Soc J. 2024;29(1):25.