High live birth rates after laparoscopic isthmocele repair in infertility: a systematic review and meta-analysis

Abstract

Background: Cesarean sections are becoming more common worldwide. One of the long-term complications of cesarean section is a cesarean scar defect or isthmocele. The presence of isthmocele is associated with infertility. Objectives: This systematic review and meta-analysis examined the effect of laparoscopic isthmocele repair on the reproductive outcomes of patients with and without infertility. Search strategy: We searched MEDLINE, EMBASE, and the Cochrane CENTRAL databases in April 2024. Selection criteria: The study included cohort studies, case-control studies, and case series reporting reproductive outcomes after laparoscopic isthmocele repair among women with or without diagnosed infertility. Data collection and analysis: The meta-analysis examined rates of live birth, pregnancy, and miscarriage. Main results: The search identified 866 records and 17 articles were included. Clinical pregnancy rates after isthmocele resection were 62% (95% confidence interval (CI) 54-69%) in women with infertility, compared to 33% (95% CI: 16-57%) in women without infertility and 36% in women with unknown fertility status (36%, 95% CI: 21–55%). Live birth rates were 72% (95% CI: 54–85%) among those with infertility, 78% (95% CI: 46–94%) among those without infertility, and 61% (95% CI: 42–77%) with unknown fertility status. Women with and without infertility had low miscarriage rates of 10% (95% CI: 6–16%) and 7% (95% CI: 3–18%), respectively. The prevalence of co-existing endometriosis was 29% (95% CI: 22–37%). The statistical heterogeneity of the studies ranged from 0 to 86%. Conclusions: Laparoscopic isthmocele repair has demonstrated the potential to improve reproductive outcomes, specifically in cases where infertility is linked to isthmocele-related factors, such as challenges during embryo transfer or impaired implantation. However, further well-designed multicenter trials must confirm these findings and provide stronger evidence. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier (CRD42024548864).