Published online Oct 19, 2026. doi: 10.5498/wjp.121996
Revised: June 15, 2026
Accepted: August 10, 2026
Published online: October 19, 2026
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Cesarean scar defect (CSD) is a common complication of the uterine cesarean section that leads to secondary infertility. Women experiencing CSD-associated infertility have a dual psychologic burden: Fertility-related distress compounded by guilt and anxiety stemming from past surgical decisions. However, the prevalence of clinically significant depression and anxiety in this population, compared with that in the general population, and their independent effect on assisted reproductive technology (ART) outcomes, have not been comprehensi
To analyze the psychological morbidity profile of women with CSD-associated infertility and to determine independent predictors for failure of ART through multivariate regression analysis.
A retrospective cohort study was conducted at the General Hospital of the 73rd Group Army of the People’s Liberation Army (January 2016 to December 2024), enrolling 100 women with CSD confirmed by ultrasound or hysteroscopy and concurrent infertility who underwent assisted reproduction (ART). Baseline psychological status was assessed using the Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), Fertility Quality of Life scale (FertiQoL) and Spousal Support Scale. CSD severity was defined according to residual myometrial thickness (RMT): Mild (≥ 3.5 mm), moderate (2.5-3.4 mm), or severe (< 2.5 mm). ART outcome data, including clinical pregnancy, live birth, and miscarriage, were collected. The type of the nursing intervention (routine vs comprehensive psychological nursing) was included as a covariable in the analyses. Independent prognostic factors for clinical pregnancy failure were identified by univariate and multivariate binary logistic regression. Subgroup ana
At baseline, 74% of participants had clinically significant anxiety (SAS score ≥ 50) and 68% had depression (SDS score ≥ 53); 56% had co-morbid anxiety and depression, a rate nearly doubled that observed in general infertile populations. There was a significant difference in psychological scores between pregnant and non-pregnant patients (SAS score: 54.2 ± 9.6 vs 62.7 ± 10.3, P < 0.001; SDS score: 52.1 ± 9.1 vs 61.4 ± 10.0, P < 0.001). CSD severity was a very strong stratifier of both psychological burden and ART outcomes: Clinical pregnancy rates were 74.3%, 54.1% and 17.9% for mild, moderate, and severe CSD, respectively (P < 0.001). Multivariate logistic regression identified six independent prognostic factors for ART failure: SAS score [adjusted odds ratio (aOR) per one-point increase = 0.949, 95% confidence interval (CI): 0.913-0.987, P = 0.009], FertiQoL score (aOR = 1.060, P = 0.008), RMT (aOR = 1.629, P = 0.002), CSD severity (mild vs severe: aOR = 5.167, P = 0.005), co-morbid anxiety and depression (aOR = 0.306, P = 0.029), and spousal support score (aOR = 1.044, P = 0.040). The model had good discriminatory power (area under the curve = 0.821). Nursing intervention type was significantly associated with the outcome in univariate analysis (odds ratio = 2.732), but this association did not remain independently significant after full covariate adjustment.
Depression and anxiety are common among CSD-associated infertility women and are independent prognosticators for ART failure, alongside CSD severity and fertility-related quality of life. These findings support the integration of systematic psychological screening, CSD severity–based risk stratification, and spouse-involved supportive care as essential components of ART management in this population.
Core Tip: This retrospective cohort study is the first to systematically characterize the psychological burden of cesarean scar defect (CSD)-associated infertility and quantify its independent prognostic contribution to assisted reproductive technology (ART) outcomes. Among the 100 women included, clinically significant anxiety and depression were detected in 74% and 68%, respectively—rates that nearly double those reported in general infertile populations. Multivariate logistic regression identified six independent prognostic factors for ART failure: Anxiety score, fertility-related quality of life, residual myometrial thickness, CSD severity, co-morbid anxiety and depression, and spousal support. These findings support routine psychological screening and CSD-severity-based risk stratification as essential components of ART management.