Combined Hysteroscopic and Vaginal Repair of Cesarean Scar Defect (Isthmocele): A Case Series from a Tertiary Infertility Center

Rakshita, Sandeep, Shalini Lohan, Shashank Sanagoudar and Vipin Chandra

Department of Reproductive Medicine, Indira IVF Hospital Limited, Vashi, India Department of Reproductive Medicine, Indira IVF Hospital Limited, Udaipur, India Department of Clinical and Lab Operations, Indira IVF Hospital Limited, Udaipur, India

^*Correspondance to: Shashank Sanagoudar 

 PDF  Full Text Case Report | Open Access

Abstract:

Background: Isthmocele, also known as a cesarean scar defect, is an increasingly recognized complication of cesarean delivery that may manifest as abnormal uterine bleeding (AUB), chronic pelvic pain, postmenstrual spotting, and secondary infertility. Although various surgical approaches have been described, the optimal management strategy remains controversial. Objective: To evaluate the clinical presentation, diagnostic characteristics, surgical outcomes, and fertility outcomes of women undergoing surgical repair of isthmocele at a tertiary infertility center. Methods: This retrospective cross-sectional case series was conducted at Indira IVF Hospital, Hisar, Haryana, between 2021 and 2024. Women aged >21 years with a previous cesarean section and diagnosed with isthmocele were evaluated. Patients with residual myometrial thickness (RMT) <3 mm and persistent symptoms or infertility were considered for surgical repair. Preoperative assessment included transvaginal sonography (TVS) to evaluate defect dimensions, cervical length, scar position, uterine mobility, and sliding sign. Fourteen patients underwent combined hysteroscopic and vaginal repair, while two underwent laparoscopic repair. Postoperative outcomes included symptom relief, change in RMT, complications, and fertility outcomes. Results: Among 72 women with previous cesarean delivery, 30 (41.7%) were diagnosed with isthmocele and 16 underwent surgical correction. Fourteen patients underwent vaginal repair and two underwent laparoscopic repair. Successful anatomical correction was achieved in all cases and confirmed hysteroscopically. Symptomatic improvement was observed in 15 of 16 patients (93.8%). One patient continued to experience vaginal discharge with persistent fluid in the uterine cavity on follow-up imaging. Surgical complications included one postoperative scar-site hematoma and one bladder injury during laparoscopic repair, both managed successfully. During follow-up, 7 of 16 women (43.8%) conceived; five achieved live births, one experienced a first-trimester miscarriage, and one pregnancy was ongoing at the time of analysis. A significant increase in postoperative myometrial thickness and overall patient satisfaction were observed. Conclusion: Isthmocele should be considered in women with secondary infertility, abnormal uterine bleeding, or pelvic pain following cesarean section. Combined hysteroscopic and vaginal repair is a safe and effective treatment option in carefully selected patients, providing excellent symptom relief, restoration of myometrial thickness, and favorable reproductive outcomes. Larger prospective studies with longer follow-up are needed to establish standardized diagnostic criteria and optimal management strategies.

Keywords:

Isthmocele; Cesarean scar defect; Secondary infertility; Vaginal repair; Hysteroscopy; Residual myometrial thickness

Cite the Article:

Rakshita, Sandeep, Lohan S, Sanagoudar S, Chandra V. Combined Hysteroscopic and Vaginal Repair of Cesarean Scar Defect (Isthmocele): A Case Series from a Tertiary Infertility Center. Ann Clin Case Rep. 2026; 11: 2853..