REPRODUCTIVE DYSFUNCTION AFTER CESAREAN SECTION: THE ROLE OF ISTHMOCELE, DIAGNOSIS, AND TREATMENT

Cesarean section is a life-saving mode of delivery; however, the increasing number of procedures is accompanied by a rise in long-term complications that may impair menstrual and reproductive function. One of the most clinically significant consequences is a uterine scar defect—an isthmocele. This review summarizes evidence on the prevalence, mechanisms of formation, clinical manifestations, diagnosis, and treatment of isthmocele in women of reproductive age. A scar defect may promote retention of menstrual blood, chronic inflammation, and bacterial colonization of the uterine cavity, impair sperm transport, and reduce endometrial receptivity. Clinically, isthmocele may present with postmenstrual spotting, dysmenorrhea, chronic pelvic pain, and secondary infertility. Transvaginal ultrasonography is the primary first-line diagnostic modality; saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging are used to further characterize the defect and plan surgery. Management is determined by symptom severity, niche depth, residual myometrial thickness, and reproductive plans. Hysteroscopic correction is appropriate for small defects with adequate myometrial thickness, whereas deep niches require reconstructive metroplasty. Early diagnosis and an individualized, organ-preserving approach can reduce clinical symptoms and increase the likelihood of a subsequent pregnancy.