Post-Caesarean section niche-related impaired fertility: hypothetical mechanisms

Jolijn Vissers, Wouter Hehenkamp, Cornelis Bavo Lambalk, Judith Anna Huirne, Jolijn Vissers, Wouter Hehenkamp, Cornelis Bavo Lambalk, Judith Anna Huirne

Abstract

Caesarean section can result in an indentation of the myometrium at the site of the Caesarean scar, called a niche. Niches can cause symptoms of abnormal uterine blood loss, dysmenorrhoea, chronic pelvic pain and dyspareunia and are possibly related to subfertility. Various other explanations for the cause of subfertility after Caesarean section have been proposed in the literature, such as uterine pathology, intra-abdominal adhesions and women's reproductive choices. Not all niches cause symptoms and the relation with subfertility and a niche in the uterine scar still needs further study since direct evidence is lacking so far. Based on the limited available evidence, and in combination with observations made during sonographic hysteroscopic evaluations and laparoscopic niche repair, we propose and discuss three hypothetical mechanisms: (i) the environment for sperm penetration and implantation may be detrimental; (ii) there could be a physical barrier to embryo transfer and implantation; and (iii) psychogenic factors may reduce the likelihood of pregnancy. Several innovative surgical treatments have been developed and are being implemented for niche-related problems. Promising results are reported, but more evidence is needed before further implementation in daily practice. The additional value of niche resections should be compared to expectant management or fertility therapies, such as ART, in randomized controlled trials. Therefore, our suggested hypotheses should, for the time being, not be used for justification of any specific procedures outside clinical trials.

Keywords: Caesarean section; Istmocele; Niche; assited reproductive technique; fertility.

© The Author(s) 2020. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Figures

Figure 1
Figure 1
Intrauterine fluid accumulation in the uterus and the niche. (a) Image of niche using transvaginal ultrasound in mid-sagittal plane with high fluid accumulation in the uterus and the large niche. (b) Schematic figure of an embryo that is separated from the endometrium on a film of fluid. The intracavitary fluid in relation with the accumulation of fluid in the niche may impact embryo implantation.
Figure 2
Figure 2
Accumulation of fluid/blood in the niche. (a) Image of niche using transvaginal ultrasound in mid-sagittal plane with intrauterine fluid accumulation in the large niche. (b and c) Macroscopic image of a uterus with a niche, removed by laparoscopy because of abnormal uterine bleeding and dysmenorrhoea. Clear accumulation of mucus and blood in the niche can be recognized.
Figure 3
Figure 3
Mucus accumulation appears from the niche in the sagittal plane (a) and communicating nabothian cysts with the niche in the transversal plane in 2D ultrasound (b) and 3D ultrasound (c).
Figure 4
Figure 4
Image of a complex niche with various branches. (a) Schematic diagram of a niche with various branches and (b) schematic diagram of hysteroscopic entrance of the cervix.
Figure 5
Figure 5
A large niche before (a) and after (b) laparoscopic niche repair. The position of the uterus changed from retroverted (a) to anteverted (b).

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