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The presence and dimensions of the isthmocele were assessed via transvaginal ultrasonography using Delphi consensus criteria. Morphometric and obstetric data were analyzed using descriptive statistics, correlation analysis, and binary logistic regression.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Isthmocele was identified in 71.6% of participants, with prevalence rising from 42.9% after the first cesarean to 100% after the fourth. The isthmocele group had significantly higher gravidity, parity, and cesarean numbers (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Niche depth, length, and the depth\/AMT ratio were significantly elevated, while RMT was reduced (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). The number of cesareans showed a strong negative correlation with RMT (\n                      <jats:italic>r<\/jats:italic>\n                      \u2009=\u2009\u20130.499,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001) and a strong positive correlation with the depth\/RMT ratio (\n                      <jats:italic>r<\/jats:italic>\n                      \u2009=\u20090.615,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Multivariate analysis identified having three or more cesareans as an independent predictor of isthmocele (OR\u2009=\u200915.6; 95% CI 3.27\u201374.4;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). Niche length had the highest diagnostic accuracy for symptomatic isthmocele (AUC 0.700; 95% CI 0.589\u20130.796; cutoff 5\u00a0mm).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Repeated cesarean deliveries significantly increase both the risk and severity of isthmocele. In women with four cesareans, isthmocele was detected in 100% of cases. A niche length of\u2009\u2265\u20095\u00a0mm proved to be the most reliable morphometric marker in identifying symptomatic cases.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Implications for clinical practice<\/jats:title>\n                    <jats:p>These findings emphasize the importance of routine transvaginal ultrasound screening post-cesarean\u2014especially in women with multiple cesarean sections\u2014and the incorporation of morphometric assessment (including RMT and depth\/RMT ratio) into clinical decision-making.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00404-025-08238-6","type":"journal-article","created":{"date-parts":[[2025,11,8]],"date-time":"2025-11-08T06:52:36Z","timestamp":1762584756000},"page":"2321-2332","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Isthmocele risk in repeated cesarean: the diagnostic and clinical role of morphometric parameters"],"prefix":"10.1007","volume":"312","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-7741-3681","authenticated-orcid":false,"given":"G\u00fclhan","family":"\u00d6z\u00fcm","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3033-985X","authenticated-orcid":false,"given":"Hakan","family":"G\u00fcraslan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5444-9116","authenticated-orcid":false,"given":"Levent","family":"Deniz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-5842-9996","authenticated-orcid":false,"given":"Tu\u011fba","family":"Demirta\u015f","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,11,8]]},"reference":[{"issue":"6","key":"8238_CR1","doi-asserted-by":"publisher","first-page":"440","DOI":"10.1007\/s13224-020-01370-0","volume":"70","author":"V Kulshrestha","year":"2020","unstructured":"Kulshrestha V, Agarwal N, Kachhawa G (2020) Post-caesarean niche (isthmocele) in uterine scar: an update. 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