O-054 Live Births following Laparoscopic Caesarean Scar Niche Repair in patients with Secondary Infertility: A Self-Controlled Case Series and Literature Review.
Authors: Deivanayagam M , Tsonis O , Kunde K , Kopeika Y 
Published: June 2023

Abstract

Study question
Does laparoscopic repair of caesarean scar niches as a treatment for secondary infertility improve live birth rates?

Summary answer
In our self-controlled case series, the laparoscopic repair of caesarean section niches in patients with secondary infertility has improved pregnancy and live birth rates.

What is known already
A niche is an iatrogenic myometrial defect due to abnormal tissue healing at a previous caesarean section scar site. Patients with a niche present with symptoms of vaginal discharge, abnormal uterine bleeding, chronic pelvic pain, dyspareunia and secondary infertility. As a niche is secondary to caesarean sections, rising caesarean section rates will lead to an increase in the rate of niche presentation and diagnosis.

Study design, size, duration
A retrospective review was performed of all women undergoing a hysteroscopy assisted laparoscopic niche repair between 2016 and 2023 at Guy’s and St Thomas’ Hospital in London. The primary outcome measure was live births. A literature review was performed to interrogate the currently available evidence on live birth rate following niche repair.
Ultrasound images of the niche prior to and post repair, as well as intra-operative laparoscopic and hysteroscopic images and videos, are also presented.

Participants/materials, setting, methods
The cases were identified from the Assisted Conception Unit database. Only women who presented with secondary infertility with a diagnosis and repair of a niche were reported.
Niche diagnosis was made in patients presenting with abnormal discharge, bleeding and fluid in the uterine cavity. Any incidental myometrial defect found on transvaginal ultrasound was also a diagnostic characteristic.

Main results and the role of chance
There are some reports in the literature on pregnancy outcome following niche repair. A scarcity of studies reporting specifically on live birth rates following repair, suggests this case series as unique.
Eleven patients underwent caesarean section niche repair by two surgeons at our unit. The mean age at repair of the patients was 36. All patients had two or more years of subfertility on presentation, with a proportion having several failed in-vitro fertilisation (IVF) cycles prior to repair.
The pregnancy rate, clinical pregnancy rate and live birth rate were 73% (8/11), 64% (7/11) and 45% (5/11) respectively. One patient had an early miscarriage at age 48 following repair and has not conceived again since. One patient underwent a second repair and is awaiting further investigations. Two patients have not yet conceived following repair, one of which had sickle cell disease, age factor and endometriosis.
Our findings suggest a positive correlation between surgical repair of the niche and live births. However, this could be due to a strict selection criteria in a small sample size. In the two patients that did not have live births following repair, other factors of subfertility such as age, male factor and comorbidities could also play a role.

Limitations, reasons for caution
The small sample size can lead to selection bias and impairs the external validity of our findings. The likelihood of random error is high. Lack of a control group prevents any comparisons. Furthermore, all repairs were performed by the two surgeons which introduces operator bias. Outcome assessors were not blinded.

Wider implications of the findings
Subfertility secondary to niches is likely to be a growing challenge as caesarean section rates continue to increase. Our study suggests that surgical repair may improve live birth rates. We present our findings to augment the current international data on live birth rates following niche repair.

Trial registration number
not applicable