Scars that speak: my experience and evidence on uterine niche repair, fertility, and the hidden legacy of cesarean section — a systematic review in the Saudi context

Background Caesarean-section (CS) rates in Saudi Arabia are relatively high, and the downstream scars may form a uterine “niche” (caesarean-scar defect) linked to abnormal bleeding, pelvic discomfort, and impaired fertility. Objective To synthesise evidence on (1) the relationship between uterine niche and fertility and (2) the effect of niche repair on reproductive outcomes, with implications for the Saudi community. Methods A PRISMA-guided search of PubMed, Embase, Scopus and Cochrane Library (through September 2025) identified studies reporting fertility or obstetric outcomes in women with a niche and after surgical repair (hysteroscopic, laparoscopic or transvaginal). Data were extracted on pregnancy, live-birth, miscarriage, residual myometrial thickness (RMT), and complications. Quality was assessed with Newcastle–Ottawa and Cochrane RoB tools. Results Eighteen studies met inclusion criteria (1 RCT, 5 prospective cohorts, 12 retrospective series). Niche prevalence after CS ranged 24–70% by TVUS and 56–84% by sonohysterography. Niche presence was associated with delayed conception and lower implantation/live-birth rates in some IVF cohorts. Surgical repair improved symptoms and, in pooled analyses, increased spontaneous pregnancy (relative risk ≈ 2.4 vs. non-treated), though heterogeneity and bias limit certainty. Saudi-specific data remain scarce, but national statistics confirm high CS utilisation. Conclusions In the Saudi context, uterine niche is a meaningful, under-recognised driver of subfertility after CS. Repair appears promising for selected symptomatic infertile women, pending larger controlled trials with long-term follow-up.