Investigating the impact of isthmocele and its surgical repair on fertility: results from a systematic review and meta-analysis

The aim of this systematic review was to quantify the impact of isthmocele and its treatment on fertility. The review was conducted according to the PRISMA guidelines, and the meta-analysis according to the MOOSE guidelines. The meta-analysis of data from 29 studies showed that 43% (rate 0.43, 95% CI 0.33–0.54; n = 2038) of women with a symptomatic isthmocele reported secondary infertility as a presenting symptom (quality of evidence [QOE)]: very low). In the IVF setting, women with an isthmocele were shown to have a lower live birth rate (LBR) than women with a previous Caesarean section without an isthmocele (odds ratio [OR] 0.57, 95% CI 0.49–0.66; n = 7719, eight studies) (QOE: high). Ten studies reported the LBR after isthmocele hysteroscopic repair in a cohort of infertile women (LBR 0.63, 95% CI 0.49–0.77; QOE: very low). Seven studies reported the LBR after isthmocele laparoscopic repair (LBR 0.51, 95% CI 0.40–0.63; QOE: very low). The combination of these findings suggests that isthmoceles play a role in the pathophysiology of infertility. Hysteroscopic and laparoscopic surgical repair emerged as promising options for the treatment of infertility in women with an isthmocele. To provide comprehensive counselling, these findings must be communicated to patients, together with the weaknesses of the underlying evidence.