(* Consulting gynecologist/obstetrician, Hon. Endosopic Surgeon, Wadia hospital & Railway Hospital (Byculla), ** Consulting Gynecologist/Obstetrician, Vardann Hospital, *** Consulting Gynecologist/Obstetrician, **** Director, Velankar Hospital & Paranjpe Maternity Home, Mumbai, India.)
Isthmocele is a pouch-like defect on the anterior wall of the uterus at the isthmus. It appears as a fluid-filled pouch in the anterior uterine wall at the site of a previous cesarean section scar. The flow of blood during menstruation through the cervical region may be hampered by the presence of isthmocele. This is because the blood may accumulate in the pouch-like defect because of the presence of fibrotic tissue. This can also cause pelvic pain in the suprapubic area, infertility and abnormal post menstrual bleeding. The global incidence is somewhere between 6.2% and 36%, with an average rate of 21.1%. These symptoms, taken together, have been closely investigated and are called cesarean scar syndrome. Other complications of cesarean scar defect include complications occurring during subsequent pregnancy such as scar dehiscence, scar ectopic pregnancy, placenta previa and accreta. Complications can occur during gynecological procedures like uterine evacuation, hysteroscopy, or during intra uterine device insertion.
A 32 year old lady para 1 living1, married since 6 years with previous one cesarean section 4 years back presented with secondary infertility. She had irregular menses with intermenstrual bleeding. She had moderate to severe pain during menses which lasted for about 2 days only. About 7 to 10 days after menses, she had spotting and mild bleeding which again lasted for 2 to 3 days. General and systemic examination was normal. Per speculum and per vaginal examination showed normal findings. All routine blood investigations, hormonal assays, baseline follicular study and husband’s semen analysis were within normal limits. A transvaginal ultrasonography was done which was suggestive of a normal sized uterus with a diverticulum in the anterior wall of the uterine isthmus, at the site of her previous cesarean scar tissue (figure 1).
Figure 1. Ultrasonography picture of the defect
A diagnostic hystero-laparoscopy was done. An isthmocele was identified on hysteroscopy and also bilateral pathological tubal blockage was encountered during chromo-pertubation and cannulation. Hence, she underwent laparoscopic repair of ishtmocoele following which an IVF was planned.
Laparoscopic repair was done in the following manner. Bladder dissection was done by separating the uterovesical fold. Hysteroscopy was done concomitantly and transillumination seen laparoscopically. Scar was demarcated and excised by harmonic scalpel under guidance of transilluminesence. Intermittent suturing with barb sutures was performed in the first layer. Second layer suturing with same material to imbricate the first layer was done (figures 2 to 6).
Figure 2. Defect seen after separation of bladder fold.
Figure 3. Defect seen after transillumination.
Figure 4. After resection of the scar.
Figure 5. Suturing with barbed suture.
Figure 6. Final picture after completion of suturing.
Post operatively she was put on oral contraceptive pills for 6 months. This was followed by an IVF cycle and she conceived successfully with an intrauterine gestation. Thus an infertility was managed with planned scar defect repair and IVF since the tubes were blocked and also to prevent implantation at scar site.
"Isthmocele” is defined as the presence of a diverticulum on the anterior uterine wall at the isthmus at the site of a previous cesarean scar. It represents a possible consequence of one or more cesarean deliveries. The presence of fibrotic tissue below the previous cesarean delivery scar (PCDS) defect may impair the drainage of menstrual flow through the cervix, acting like a valve and producing blood accumulation in the pouch, which in turn leads to secondary postmenstrual spotting. This results in the stasis of the menstrual blood after menstruation in the cervix and may affect the mucus quality and sperm quality, obstruct sperm transport through the cervical canal leading to secondary infertility. Isthmocele can also cause abnormal uterine bleeding due to the stasis of blood and abnormal accumulation of blood in the pouch-like areas. This results in inter- menstrual bleeding and pelvic pain. Also the retained blood and debris can interfere with sperm transport and embryo implantation.
There are as such no studies relating to IVF and isthmocele, but there may be problems during the embryo transfer like – the deposition of the scar fluid or old blood on the catheter which is used for embryo transfer. Also, as there may be fluid present in the isthmocele, the effect of ovarian stimulation on this fluid and its release into the endometrial cavity has not been studied. And furthermore, the isthmocele scar fluid and old blood itself can cause difficulty in embryo implantation. This may be similar to patients with endometrial fluid with tubal factor infertility and hydrosalpinx.
It can be diagnosed on hysteroscopy and can be successfully treated by laparoscopic or resectoscopic repair. Menstrual suppression can also improve symptoms. In laparoscopy, different methods are described to locate the isthmocele. Klemm and colleagues had suggested to do a transvaginal ultrasonography under laparoscopic vision if the scar cannot be easily seen after bladder dissection. In our case we have used transillumination from inside the uterus which showed clear demarcation of the isthmocele.
It is suggested that every patient of previous scar pregnancy with complaints of pelvic pain or infertility, or abnormal bleeding should be evaluated with transvaginal ultrasound, saline infused sonohysterogram, hysterosalpingogram, hysteroscopy, or magnetic resonance imaging and isthmocele should be considered. An isthmocele may not only result in above symptoms but it can also be a site for implantation of pregnancy leading to scar ectopic pregnancy. These women may develop complications like scar rupture either spontaneous or during evacuation of the uterine cavity. We also encourage gynecologists to include previous cesarean delivery scar as a differential diagnosis of those with bleeding disorders and previous cesarean delivery, because it is easy to identify and correct. Further prospective controlled trials would be necessary to evaluate the effectiveness of the surgical treatment in those with unknown infertility in order to confirm its effect in restoring fertility.
- Nezhat CM, Grace L, Soliemannjad R, Razavi GM, Nezhat A. Cesarean Scar Defect: What Is It And How Should It Be Treated? Obg Management 2016; 28(4): 32-53.
- 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.
- Perez-Medina T, Sancho-Sauco J, Rios M, Pereira A, Argila N, Cabezas E et al. Hysteroscopy In Pregnancy-Related Conditions: Descriptive Analysis In 273 Patients. J Minim Invasive Gynecol. 2014;21(3):417–25.
- Fabres C, Aviles G, De La Jara C, Escalona J, Munoz Jf, Mackenna A et al. The Cesarean Delivery Scar Pouch: Clinical Implications And Diagnostic Correlation Between Transvaginal Sonography And Hysteroscopy. J Ultrasound Med. 2003;22(7):695–700
- Thurmond AS, Harvey WJ, Smith SA. Cesarean Section Scar As A Cause Of Abnormal Vaginal Bleeding: Diagnosis By Sonohysterography. J Ultrasound Med. 1999;18(1):13–6.
- Bij De Vaate AJ, Van Der Voet LF, Naji O, Witmer M, Veersema S, Brolmann HA et al. Prevalence, Potential Risk Factors For Development And Symptoms Related To The Presence Of Uterine Niches Following Cesarean Section: Systematic Review. Ultrasound Obstet Gynecol. 2014;43(4):372–82.
- Akman MA, Erden HF, Bahceci M. Endometrial Fluid Visualized Through Ultrasonography During Ovarian Stimulation In Ivf Cycles Impairs The Outcome In Tubal Factor, But Not PCOS Patients. Human Reproduction. 2005;20(4):906–9.
- Armstrong V, Hansen WF, Van Voorhis BJ, Syrop CH. Detection Of Cesarean Scars By Transvaginal Ultrasound. Obstet Gynecol. 2003; 101(1): 61-65.
- Klemm P, Koehler C, Mangler M, Schneider U, Schneider A. Laparoscopic And Vaginal Repair Of Uterine Scar Dehiscence Following Cesarean Section As Detected By Ultrasound. 2005; J Perinat Med 33(4): 324-331.
- 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):172-5.
Shah NH, Deshmukh M, Adsul SD, Paranjpe SH. Isthmocele - a cesarean scar defect managed hystero-laparoscopically. JPGO 2018. Volume 5 No.5. Available from:http://www.jpgo.org/2018/05/isthmocele-cesarean-scar-defect-managed.html