Karthik Raj: Caesarean Scar Defect and Secondary Infertility
Karthik Raj, Clinical Embryologist at The Boon IVF and Fertility, shared on LinkedIn:
“A caesarean scar defect (CSD), also known as an isthmocele or uterine niche, is a pouch- like indentation in the myometrium at the site of a previous caesarean section. Although frequently overlooked during routine evaluation, this defect may have important implications for women experiencing secondary infertility.
The proposed mechanisms include retention of menstrual blood within the niche, impaired drainage of uterine secretions, chronic local inflammation, altered endometrial function and intrauterine fluid accumulation. These changes may interfere with sperm transport, embryo implantation and the uterine environment required for early pregnancy.
In IVF, persistent intracavitary fluid associated with a caesarean scar defect deserves particular attention, as fluid within the endometrial cavity around embryo transfer may compromise implantation. However, the presence of a niche does not automatically establish the cause of infertility, and many women with caesarean scar defects remain asymptomatic and conceive spontaneously.
Diagnosis may involve transvaginal ultrasonography, saline infusion sonohysterography or hysteroscopy, with MRI considered in selected cases. Management should be individualised according to symptoms, residual myometrial thickness, fertility goals and the presence of associated intracavitary fluid. Surgical options may include hysteroscopic niche resection or laparoscopic repair in appropriately selected patients.
In secondary infertility, the previous caesarean section should not be viewed only as obstetric history. The scar itself may be an important part of the uterine evaluation.”
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