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Introduction After incomplete healing of the uterine cesarean section scar, a niche can be observed; 24% of the women develop large niches with a residual myometrial thickness <3 mm. In these cases a laparoscopic resection is possible. The effect of this new treatment on fertility outcome is not known yet. This paper describes reproductive outcomes 2 years after a laparoscopic niche resection and compares women with or without secondary infertility at baseline. Material and methods A prospective cohort study was performed, with consecutive inclusion of women between 2011 and 2019. Women with a niche in the uterine cesarean scar, with a residual myometrial thickness of <3 mm and with a desire to become pregnant, were scheduled to undergo a laparoscopic niche resection because of one or more of the following problems (1) postmenstrual spotting; (2) midcycle intrauterine fluid accumulation diagnosed during the fertility workup or (3) difficulties with a previous embryo transfer and preferring a surgical therapy. The study is registered in the ISRCTN register (ref. no. ISRCTN02271575) on April 23, 2013. Results There were 133 (62%) women included with a desire to become pregnant, 88 with secondary infertility. In all, 83 had an ongoing pregnancy at the 2‐year follow‐up. The ongoing pregnancy rate in patients with previous fertility problems was 60.2% compared with 66.7% in patients without infertility (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.32–1.7). The OR for live births was 0.57 (95% CI 0.02–1.2). Overall, 8.3% of the pregnancies resulted in miscarriages by the 2‐year follow‐up. Conclusions The reproductive outcomes in women with and without previous fertility problems undergoing resection of a large niche are very promising and quite comparable in both groups. These results suggest, but do not prove, a beneficial effect of this therapy for these indications. The results support the design of future randomized controlled trials to evaluate the effect of niche resection vs expectant management to assess its additional value in women with or without fertility problems who desire pregnancy. Our results show positive reproductive outcomes and improved postmenstrual spotting with few complications and lend support for carrying out randomized controlled trials for fertility reasons only.

Introduction A symptomatic uterine niche is a long‐term complication after a cesarean section (CS). A group of international niche experts reached consensus on a standardized definition of a disorder caused by a symptomatic niche, named cesarean scar disorder (CSDi). However, the prevalence of this disorder is unclear. The aim of this study was to assess the prevalence of CSDi in patients 3 years after a first CS. Material and Methods A secondary analysis was performed on the 3‐year follow‐up results of the 2Close study. The 2Close study was a multicenter randomized controlled trial that evaluated single‐ versus double‐layer uterine closure at CS in 32 hospitals in the Netherlands and included 2292 patients (registered in Dutch trial register: [NTR5480]). Patients, aged ≥18 years, undergoing a first CS were included. Three months after their CS, transvaginal ultrasonography was performed to evaluate the uterine scar for the presence of a niche. Three years after their CS, a digital questionnaire was sent to evaluate the primary and secondary symptoms of CSDi. For this secondary analysis, patients were excluded if they were pregnant, breastfeeding, or using hormonal contraception. The primary outcome of the study was the prevalence of CSDi. Results Of the 1648 participants who completed the 3‐year questionnaire, patients were excluded due to pregnancy or breastfeeding (n = 305), use of hormonal contraception (n = 509), missing ultrasound evaluations (n = 76), and incomplete responses (n = 88). Of the 670 patients included in this analysis, 543 (81.0%) had a uterine niche visible on ultrasound and 127 (19.0%) were without a niche. The prevalence of CSDi at 3 years following a first CS was 42.5% (285/670). Most reported symptoms were chronic pelvic pain (35.0%), postmenstrual spotting (32.8%), and abnormal vaginal discharge (23.2%). Conclusions Our study found a high prevalence of CSDi 3 years following their first CS. Symptoms were self‐reported and the exclusion criteria of pregnancy, breastfeeding, or hormonal contraception use could have introduced selection bias. Therefore, this percentage could be an overestimation of the actual prevalence. However, this high prevalence should be included in counseling patients with a scheduled CS. Three years following a first caesarean section 42.5% of all patients develop Caesarean Scar Disorder. Most reported symptoms within the Caesarean Scar Disorder are chronic pelvic pain, postmenstrual spotting and abnormal vaginal discharge. The long‐term consequences of a Caesarean Section on patients’ health should be structurally investigated.

Purpose To compare the anatomical changes of the uterine niche in women before and after hysteroscopic niche resection (HNR) and to investigate the correlation between these changes and the improvement in postoperative spotting symptoms by thin-slice MRI. Methods This prospective observational study enrolled women with symptomatic uterine niches between June 2019 and February 2024. All participants underwent thin-slice magnetic resonance imaging (MRI) before and after HNR. We assessed the effective rate of postoperative spotting at the 6-month follow-up (effective treatment was defined as a reduction of at least 50% in spotting days relative to baseline during the 6-month follow-up period) and the pre- and post-HNR anatomical indicators. Results A total of 108 women were included in the study. Six months after HNR, 70.4% (76/108) of women experienced at least a 50% reduction in spotting days from baseline. Residual myometrial thickness (RMT) significantly increased by 1.9 ± 2.2 mm ( p  < 0.01). The volume of niche significantly decreased, with a median reduction rate of 38.5% (IQR 8.5–88.2%) ( p  < 0.01). Based on the ROC curve, a cut-off value of 50 mm 2 for volume was identified as an optimal threshold for subclassifying large niches and small niches, according to treatment efficacy. The reduction in niche volume was more pronounced in the small niche group compared to the large niche group, with median reduction rates of 51.9% (IQR 13.5–100.0%) and 12.4% (IQR −15.4–43.9%), respectively ( p  < 0.01). There is an interesting finding that most cases in the anatomical failure group (those with an enlarged niche) had a preoperative volume of ≥ 50 mm 2 (19.2%, p  < 0.01). Furthermore, the effective treatment group exhibited a more significant increase in RMT and a greater reduction in niche volume after HNR compared to the ineffective group. Multivariate logistic regression analysis indicated that small niches [OR 16.85 (3.36–84.47), p  < 0.01] and greater reductions in niche volume [OR 1.14 (1.07–1.21), p  < 0.01] were associated with effective treatment. Conclusion HNR is a promising approach for managing postmenstrual spotting, especially in treating small uterine niches (volume < 50 mm 2 ). After HNR, RMT increases, and niche size decreases slightly.

Cesarean scar-related abnormal uterine bleeding (AUB) is commonly associated with niche formation and is characterized by prolonged menstruation and postmenstrual spotting, which may significantly affect quality of life. Evidence comparing nonsurgical treatment options remains limited. This study aimed to evaluate and compare the effectiveness of tranexamic acid, combined oral contraceptive pills (OCP), their combination, and the levonorgestrel-releasing intrauterine system (LNG-IUS) in improving bleeding patterns among women with cesarean scar-related AUB. This prospective, randomized, non-blinded comparative study was conducted at the Department of Obstetrics and Gynaecology, Saudi German Hospital, Madinah, Saudi Arabia, between March 2019 and October 2022. Participants were allocated into four groups: tranexamic acid (Group A), combined OCP (Group B), tranexamic acid plus combined OCP (Group C), and LNG-IUS (Group D). Changes in menstrual duration and postmenstrual spotting days were recorded using menstrual diaries at 3, 6, 9, and 12 months. All interventions were associated with significant reductions in menstrual duration and postmenstrual spotting compared with baseline (P < 0.001 for all groups). The combination therapy group demonstrated greater improvement in both outcomes at all follow-up points compared with the other treatment groups (P < 0.001). Combined tranexamic acid and OCP therapy was associated with greater reduction in menstrual duration and postmenstrual spotting compared with single-modality treatments and LNG-IUS in women with cesarean scar-related AUB. These findings suggest that combination therapy may be a useful nonsurgical option, particularly in selected patients; however, further studies are warranted to confirm long-term effectiveness.

Background The cesarean scar defect (CSD), or niche, is one of the emerging complications after cesarean section (CS), potentially leading to symptoms such as abnormal uterine bleeding, pelvic pain and secondary infertility. Objectives To determine the prevalence of CSD among women attending the outpatient clinic at Women's Health Hospital, Assiut university, Egypt, and to identify the possible CSD-related symptoms and risk factors for CSD formation. Methods This cross-sectional observational study included 234 women with a history of CS performed more than one year before recruitment, between June 2022 and December 2023. Participants underwent 2D transvaginal ultrasound to detect CSD, defined as an indentation of [greater than or equal to] 2 mm depth at the CS scar site. Data collected encompassed demographic, obstetric, and variable symptoms and analyzed using univariate analysis and multiple logistic regression. Results A cross-sectional analysis revealed that 49.15% of participants (n = 115/234) have CSD. Stratified analysis of associated symptoms indicated a significantly higher incidence of postmenstrual spotting (73.9% vs. 26.1%, p < 0.001), dysmenorrhea (p = 0.007), and dyspareunia (p = 0.006) in women diagnosed with CSD compared to those without CSD. Furthermore, the median number of previous cesarean deliveries was significantly elevated in the CSD group (median 3 vs. 2, p = 0.004). Multivariate logistic regression modeling identified some independent risk factors for CSD, including the number of previous cesarean deliveries (Odds Ratio [OR] = 2.8, 95% Confidence Interval [CI] = 1.7-4.5, p < 0.001) and emergency CS (OR = 3.2, 95% CI = 1.8-5.8, p < 0.001). Conclusion CSD is prevalent in nearly half of women with previous CS. It is significantly associated with symptoms such as postmenstrual spotting, dysmenorrhea, and dyspareunia. Key risk factors include multiple previous CS, and emergency cesarean deliveries. 2D TVUS is the first diagnostic tool used for detection and assessment of women with CSD.

We demonstrate an effective reduction in postmenstrual spotting after our novel hysteroscopic isthmoplasty. This study included 66 patients with isthmocele-related postmenstrual spotting confirmed by sonography and diagnostic hysteroscopy between 2000 and 2017. Our new interventions included the following four steps: (1) make a resection gradient of the distal edge of the isthmocele from the ape of the isthmocele down to the cervical outer orifice; (2) resect the distal and proximal niches of the isthmocele; (3) electrocauterize the distal and proximal sides (not only the niche bottom) of the small cave on the scar side of the isthmocele; (4) manage the isthmocele until it is largely connected to the cavity. In our results, all patients underwent extensive hysteroscopic repair of newly hysteroscopic isthmoplasty without any intra- or postoperative complications. After final hysteroscopic repair modification, prolonged menstrual spotting was significantly decreased in 98.2% (53/54) of the patients, and the total number of bleeding days per menstrual cycle significantly decreased from a mean of 15.38 ± 3.3 days to 6.4 ± 1.9 days postoperatively (p < 0.001). Our four-step hysteroscopic technique successfully resolved prolonged menstrual spotting in over 90% of the patients, exceeding the resolution rates of 60–85% achieved with other hysteroscopic techniques used to treat symptomatic isthmocele. No patients experience recurrence after long-term follow up. Four simple steps led to a significant improvement in bleeding status.

Background Double-layer compared to single-layer closure of the uterus after a caesarean section (CS) leads to a thicker myometrial layer at the site of the CS scar, also called residual myometrium thickness (RMT). It possibly decreases the development of a niche, which is an interruption of the myometrium at the site of the uterine scar. Thin RMT and a niche are associated with gynaecological symptoms, obstetric complications in a subsequent pregnancy and delivery and possibly with subfertility. Methods Women undergoing a first CS regardless of the gestational age will be asked to participate in this multicentre, double blinded randomised controlled trial (RCT). They will be randomised to single-layer closure or double-layer closure of the uterine incision. Single-layer closure (control group) is performed with a continuous running, unlocked suture, with or without endometrial saving technique. Double-layer closure (intervention group) is performed with the first layer in a continuous unlocked suture including the endometrial layer and the second layer is also continuous unlocked and imbricates the first. The primary outcome is the reported number of days with postmenstrual spotting during one menstrual cycle nine months after CS. Secondary outcomes include surgical data, ultrasound evaluation at three months, menstrual pattern, dysmenorrhea, quality of life, and sexual function at nine months. Structured transvaginal ultrasound (TVUS) evaluation is performed to assess the uterine scar and if necessary saline infusion sonohysterography (SIS) or gel instillation sonohysterography (GIS) will be added to the examination. Women and ultrasound examiners will be blinded for allocation. Reproductive outcomes at three years follow-up including fertility, mode of delivery and complications in subsequent deliveries will be studied as well. Analyses will be performed by intention to treat. 2290 women have to be randomised to show a reduction of 15% in the mean number of spotting days. Additionally, a cost-effectiveness analysis will be performed from a societal perspective. Discussion This RCT will provide insight in the outcomes of single- compared to double-layer closure technique after CS, including postmenstrual spotting and subfertility in relation to niche development measured by ultrasound. Trial registration Dutch Trial Register ( NTR5480 ). Registered 29 October 2015.

Purpose Caesarean delivery (c-section) scar dehiscences may cause bleeding abnormalities, e.g. postmenstrual spotting, dysmenorrhea and abdominal pain, secondary sterility and at worst peripartum uterine rupture. The purpose of this study was firstly to identify the correlation of women’s complaints after c-section with scar-related clinical symptoms. Secondly, the effects of corrective surgery on preoperatively existing complaints were analysed and assessed in the patient population of our clinic. Methods We present data of a retrospective study of 13 premenopausal, non-pregnant women with symptomatic c-section scars. In 9 out of 13 patients, a microsurgical uterus reconstruction was performed by mini-laparotomy. The postoperative changes of scar-associated symptoms were assessed by a questionnaire as earliest as 4 months after surgery ( N  = 5). Results The c-section scar was visualised by transvaginal sonography in 12 out of 13 women by a typical U- or V-shaped hypoechoic or anechoic fluid accumulation in the region of former uterotomy and in all 13 patients by hysteroscopy. Bleeding disorders were often accompanied by dysmenorrhea/abdominal pain (38.5 %, N  = 5) and secondary sterility (46.2 %, N  = 6). Blood residues in the scar pouch and bleeding disorders/postmenstrual spotting were found in 30.8 % of patients ( N  = 4) and combined with secondary sterility in 38.5 % of patients ( N  = 5). Reconstructive surgeries resulted in discontinuation of bleeding disorders in all women and a pregnancy in three out of five patients (60 %) with secondary sterility. Conclusion Clinical symptoms, e.g. “bleeding disorders” like postmenstrual spotting, “pain/dysmenorrhea” and “secondary sterility” could be specific indicators for the diagnosis of uterine dehiscence after c-section. Scar dehiscences can be diagnosed by obtaining the patients medical history and asking for typical symptoms followed by vaginal sonography and diagnostic hysteroscopy. If a c-section scar defect is confirmed, microsurgical uterus reconstruction can stop postmenstrual spotting, reduce abdominal pain/dysmenorrhea and improve fertility.

Background/Objectives: To assess the effectiveness of the levonorgestrel-releasing intrauterine device (LNG-IUD) compared to hysteroscopic resection for managing women with symptomatic cesarean scar defects (CSDs). Methods: This systematic review and meta-analysis followed PRISMA guidelines. A comprehensive search of four electronic databases was conducted to identify studies comparing LNG-IUD with hysteroscopic management for symptomatic CSDs. Studies reporting outcomes of bleeding and spotting days and effectiveness rates were included. Quality assessment was performed using the ROBINS-I and RoB-2 tools. Results: Three studies involving 344 patients met the inclusion criteria. At 6 months, LNG-IUD use significantly reduced total bleeding days (MD −4.13; 95% CI: −5.17 to −3.09; p < 0.00001) and spotting days (MD 1.90; 95% CI: 0.43 to 3.37; p = 0.01) compared to hysteroscopic treatment. By 12 months, LNG-IUD demonstrated superior effectiveness (OR 3.46; 95% CI: 1.53 to 7.80; p = 0.003), with fewer total bleeding days (MD −5.69; 95% CI: −6.55 to −4.83; p < 0.00001) and spotting days (MD 3.09; 95% CI: 1.49 to 4.69; p = 0.0002). Approximately 50% of LNG-IUD users experienced amenorrhea within 1 year. Conclusions: LNG-IUD offers a minimally invasive and effective alternative to hysteroscopic resection for women with symptomatic CSD and no desire for future pregnancies. Its role should be considered in clinical practice, but further research is needed to validate these findings and define its long-term benefits and limitations.

Postmenstrual spotting has recently been related to a discontinuation of the myometrium at the site of a previous cesarean section called \"CS scar niche\". There was no consensus regarding the gold standard method for the assessment of the niche. Recently, Magnetic resonance imaging (MRI) has shown promise in the evaluation of the niche. Our study aims to assess the role of MRI in the evaluation of the CS scar niche characters and its association with post-menstrual spotting. A total of 65 patients with CS niche were prospectively included in this study and subdivided into two groups, according to presence or absence of postmenstrual spotting (Group A; 34 patients with postmenstrual spotting and Group B; 31 patients without spotting). All patients were examined using a 1.5 T MRI unit. CS scar niche volume was significantly higher among women with post-menstrual spotting (0.57 ± 0.07 vs. 0.07 ± 0.05 (cm.sup.3); P < 0.001). Also, women with post-menstrual spotting have significantly higher scar length (9.38 ± 3.06 vs. 5.02 ± 2.10 (mm); P < 0.001), scar depth (6.95 ± 3.16 vs. 3.23 ± 0.99 (mm); P < 0.001), scar width (15.78 ± 3.94 vs. 9.87 ± 1.84 (mm); P 7.4 mm) had 81% sensitivity and 97% specificity for prediction of post-menstrual spotting with overall accuracy was 88.7%. While scar width (> 12.8 mm) had 71% sensitivity and 97% specificity for prediction of post-menstrual spotting with overall accuracy was 83.3%. Scar volume (> 0.15 cm.sup.3) had 97% sensitivity and 100% specificity for prediction of post-menstrual spotting with overall accuracy was 98.4%. MRI measures (CS scar volume, depth, and width) are predictors for postmenstrual spotting in patients with CS scar niche, and scar volume is the most powerful predictor.