Subsequent fertility after cesarean scar pregnancy: a retrospective analysis

The relationship between CSP treatment and subsequent fertility and pregnancy outcomes has not been sufficiently evaluated to date. This may reflect the fact that most women who have experienced a CSP are fearful of recurrence, abandoning subsequent pregnancies despite the recurrence rate of CSP being relatively low [15, 16]. In our study sample, most women (74.9%) did not express the desire for a subsequent pregnancy after CSP treatment, with 54.9% (62/113) of women who initially intended a second pregnancy finally abandoning this goal due to concerns about recurrent CSP and its complications, such as PAS and uterine rupture.

Although women with a history of CSP are at risk of recurrent CSP and other serious maternal morbidities during the second pregnancy, those who retain reproductive function after CSP treatment can become pregnant again. In our study sample, the recurrence rate of CSP was 6.6% (5/76). Among the 51 women who intended to have a subsequent pregnancy, 31 (60.8%) achieved full-term pregnancy, with complications identified in two cases, namely PAS in two cases, with one case requiring hysterectomy during cesarean section due to massive bleeding. In a review of 73 women with CSP who retained their uterus after treatment, Sadeghi et al. [17] reported that 59 (81%) women became pregnant again, with CSP recurrence in 15 (25%) cases. In their follow-up fertility observation study of 189 CSP cases, Wang et al. [18] reported a recurrence rate of 15.6% among 32 women with a second pregnancy. In a recent single-center case series, eight women with a history of CSP had 10 repeat pregnancies, with CSP recurrence in four cases [19]. Nagi et al. [20] followed 21 women treated conservatively for CSP and reported a 5% recurrence rate of CSP during the second pregnancy. In their follow-up of 14 women treated conservatively for CSP, Seow et al. [21] reported that seven women achieved a subsequent pregnancy, four of which were intrauterine pregnancies delivered by cesarean section at 35–36 weeks of gestation. The other two pregnancies were complicated by PAS. One case was a triplet pregnancy, consisting of intrauterine twins and recurrent CSP, with cesarean section performed at 32 weeks of gestation with subsequent hysterectomy due to massive bleeding. The second case complicated by PAS was identified during cesarean section performed at 37 weeks of gestation. The remaining woman in the case series reported by Seow et al. became pregnant at 3 months after CSP treatment, which included curettage and cervical balloon compression; however, the patient sustained a spontaneous uterine rupture during pregnancy and died of hypovolemic shock with a stillbirth. Therefore, women who become pregnant again after CSP treatment should be informed of the risk for CSP recurrence and serious complications.

The lack of an optimal treatment strategy for CSP is partly due to the absence of sufficient evidence regarding the impact of different treatment options on subsequent fertility. A 5-year follow-up study of 10 women with a history of CSP attempting to become pregnant again, showed that six patients treated with UAE combined with dilatation and curettage succeeded in the birth of seven healthy babies [18]. A retrospective cohort study led by Chen et al. [22] reported a 23.7% rate of secondary infertility after high-intensity focused ultrasound or UAE combined with suction curettage under hysteroscopic guidance among 135 women with CSP. Another study reported that 79 women with CSP who received ultrasound-guided suction curettage tried to become pregnant again and 13 (16.5%) suffered from sterility [23]. A recent 2021 study reported a secondary infertility rate of 40% (16/40) in women treated with hysteroscopic therapy [24]. In our study sample, secondary infertility occurred in 8/51 (15.7%) women pursuing a pregnancy. Considering the CSP treatments received in these cases compared to CSP treatments for women who achieved a full-term pregnancy, a successful pregnancy rate of 68.8% and 88.9% was achieved among the 16 women treated with UAE combined with uterine aspiration and the 18 women treated with ultrasound-guided local lauromacrogol injection combined with uterine aspiration, respectively. Therefore, both of these CSP treatments may have a higher probability of successful subsequent pregnancy.

This study had some limitations. First, this was a retrospective observational study performed at a single center; therefore, the possibility of bias in CSP treatments, which would influence outcomes, cannot be denied. Second, as a high proportion of women in our study sample did not have a goal of pursuing a subsequent pregnancy after CSP treatment, our analysis of fertility and pregnancy outcomes is, in fact, based on a small sample (51 cases). Therefore, only a description of the association between CSP treatment and subsequent pregnancy and CSP recurrence was possible. Hence, further prospective studies with larger sample sizes are required for high-quality evidence regarding the effect of different CSP treatments on fertility and pregnancy outcomes.