A 35 year-old lady was referred to CARE for further investigation of secondary infertility after 3 failed IVF- embryo transfers.
Three years prior, she had conceived naturally without difficulty and had her daughter by emergency C-section delivery for failure to progress and fetal distress.
After one year of trying unsuccessfully for a second pregnancy, she consulted a fertility specialist. Through IVF, she was able to produce 3 good-quality embryos. Sadly, all failed to implant after transfer.
She was subsequently referred to CARE on the basis of ultrasound discovery of C-section defect. Upon questioning, she related that she was also experiencing post-menstrual dark brown vaginal discharge and pain with intercourse. Both were de-novo symptoms which she only noticed after the C-section delivery.
Following detailed ultrasound assessment showing a moderately large C-section defect, she underwent hysteroscopy and laparoscopic repair of C-section.
Four months after the surgery, she conceived naturally and went on to deliver another daughter at term by elective C-section.
What is a C-section defect?
This is a defect in the muscle layer on the anterior wall of the uterine isthmus that has the appearance of a a pouch over a previous c-section scar.
How common is C-section defect?
The prevalence of C-section defect is not known, but may be quite common than realised. It has been reported amongst women after 1 or more previous C-Section in:
•24% to 70% upon transvaginal ultrasound examination
•56% to 84% on sonohysterogram (SHG)
•20% to 84% in women with postmenstrual spotting
What are the potential clinical implications of C-section?
While most women who have had C-section delivery may not encounter any problem, the following are potential clinical symptoms or problems which may be associated with C-section defect:
- Abnormal uterine bleeding: post-menstrual spotting
- Pain: pelvic pain, period pain, painful sex
- C-section scar-related abnormal implantation: CSD pregnancy, placenta previa, accreta, percreta, scar rupture.
- Secondary infertility and failed IVF: blood inside the CSD could affect the cervical mucus and sperm quality, obstruct sperm transport and impair embryo implantation
Although the causal relationship between C-Section defects and related symptoms has not been established, treatment has been reported to be successful in the resolution of symptoms.
How can C-section defect be corrected?
There are a number of ways of correcting a C-section defect:
- Laparoscopic surgery
- Hysteroscopic surgery
- Vaginal surgery
What is the best method to correct a C-section defect?
A systemic review of the above-mentioned methods concluded that laparoscopic surgery was superior in reducing abnormal uterine bleeding and scar depth than the other surgical interventions.
In the largest prospective study reported in the literature to date, laparoscopic surgery was found to improve the main presenting symptom in 80% , resolved intra-uterine fluid in 87% of women, and significantly increased residual myometrium.
- Yunan He et al. Four Surgical Strategies for the Treatment of Cesarean Scar Defect: A Systematic Review and Network Meta-analysis. Journal of Minimally Invasive Gynecology 2019.
- Vervoort AJMW et al. The effect of laparoscopic resection of large niches in the uterine caesarean scar on symptoms, ultrasound findings and quality of life: a prospective cohort study. BJOG 2017.
- Murat Api et al. Should Cesarean Scar Defect Be Treated Laparoscopically? A Case Report and Review of the Literature. Journal of Minimally Invasive Gynecology 2015.