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

Angela Vidal ^1* James Geiger ² Vithusha Vinayahalingam ³ Janna Pape ¹ Marietta Gulz ⁴ Tanya Karrer ⁵ Michael David Mueller ⁴ Michael Von Wolff ¹

• ¹ Division of Gynecological Endocrinology and Reproductive Medicine, Women's University Hospital, Inselspital Bern, University of Bern, Switzerland, Bern, Switzerland
• ² Division of Reproductive Endocrinology and Infertility, University Hospital Basel, Basel, Switzerland., Basel, Switzerland
• ³ Department of Gynecology and Obstetrics, Hospital Wolhusen, Switzerland., Switzerland, Lucerne, Switzerland
• ⁴ Department of Gynecology and Obstetrics, Bern University Hospital, University of Bern, 3010 Bern, Switzerland, Bern, Switzerland
• ⁵ Medical Library, University Library of Bern, University of Bern, Switzerland, Bern, Switzerland

Background: Cesarean sections are becoming more common worldwide. One of the longterm 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.The meta-analysis examined rates of live birth, pregnancy, and miscarriage.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%.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.