Reproductive outcomes following surgical management for isth
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Study aims to evaluate the efficacy of surgical management for isthmoceles in patients presenting with secondary infertility. A systematic search was performed in MEDLINE, EMBASE and Cochrane Library databases from inception to May 2020. The search was limited to studies published in English.

After the removal of duplicates, 3380 articles were screened for inclusion independently by two authors for studies. These two authors assessed for studies which focussed on reproductive aged women with a diagnosed isthmocele and secondary infertility who underwent any surgical intervention for defect repair with at least one of the goals being fertility restoration.

13 studies, comprised of 1 randomized controlled trial (RCT), 6 prospective case series and 6 retrospective case series describing 234 patients who underwent surgical management for an isthmocele and secondary infertility were included. The methodological quality of the included studies was assessed independently by both reviewers. Next, the data extraction was performed independently and then compared to ensure no discrepancies. 188 patients were treated by hysteroscopy, 36 by laparoscopy, 7 by laparotomy, and 3 through a vaginal approach. In total, 153 of the 234 patients (65.4%) achieved pregnancy across all studies within their respective study periods.. Pregnancy rates in the RCT were 21/28 (75%) for those treated via hysteroscopy compared to 9/28 (32%) for those untreated. Among studies reporting pregnancy outcomes, 101/116 (87.1%) pregnancies resulted in a live birth. The incidence of adverse events was 2%, including risk of reoperation.

The results of this systematic review suggest that surgical treatment of isthmocele, particularly via hysteroscopy in patients with residual myometrial thickness (RMT) of at least 2.5mm, may be effective in treating isthmocele-associated secondary infertility with a relatively low complication rate. Further high-quality studies are needed due to the small sample sizes and observational nature of most available data.

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