Threefold increased risk of infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis

Abstract

Background: Increased infertility in women has been reported after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis but reported infertility rates vary substantially. Aims: (1) To perform a systematic review and meta-analysis of the relative risk of infertility post-IPAA compared with medical management; (2) to estimate the rate of infertility post-IPAA; and (3) to identify modifiable risk factors which contribute to infertility. Methods: Medline, EMBASE, Current Contents, meeting abstracts, and bibliographies were searched independently by two investigators. The titles and abstracts of 189 potentially relevant studies were reviewed; eight met the criteria and all data were extracted independently. Consensus was achieved on each data point, and fixed effects meta-analyses, a funnel plot, and sensitivity analyses were performed. Results: The initial meta-analysis of eight studies had significant heterogeneity (p = 0.004) due to one study with very high preoperative infertility (38%). When this study was omitted, the relative risk of infertility after IPAA was 3.17 (2.41-4.18), with non-significant heterogeneity. The weighted average infertility rate in medically treated ulcerative colitis was 15% for all seven studies, and the weighted average infertility rate was 48% after IPAA (50% if all eight studies are included). We were unable to identify any procedural factors that consistently affected the risk of infertility. Conclusions: IPAA increases the risk of infertility in women with ulcerative colitis by approximately threefold. Infertility, defined as achieving pregnancy in 12 months of attempting conception, increased from 15% to 48% in women post-IPAA for ulcerative colitis. This provides a basis for counselling patients considering colectomy with IPAA. Further studies of modifiable risk factors are needed.

Ulcerative Colitis Practice Guidelines in Adults: American College of Gastroenterology, Practice Parameters Committee

“…A meta-analysis of eight series found a threefold increase in infertility in women aft er IPAA, compared with women with UC treated medically (though there was no control for the extent of disease severity in patients treated medically) ( 325 ). Fecundity among women with UC before surgery is comparable to a control population of women without UC, but is only 20 % of fecundity rates of controls aft er IPAA ( 326 ).…”

Ulcerative colitis and pregnancy

“…In a meta-analysis on the effects of IPAA on infertility, fertility rates were recorded as 19.9% and 50.1% in UC subjects who received medical treatment and underwent IPAA, respectively. The results of this meta-analysis demonstrated that there is no exact response to the question of whether laparoscopic IPAA and rectal stump and subtotal colectomy with ileostomy increase the rates of infertility (12). In a study performed on 21 subjects to determine the effects of surgery on gynecological anatomy using hysterosalpingography (HSG), no abnormalities were determined in 14 subjects (67%).…”

Management of inflammatory bowel disease in pregnancy

“…For women who have not had previous pelvic surgery, their fertility is similar to age-matched peers in the general population [14]. Women who have undergone pelvic surgery have increased rates of infertility, particularly those who have had proctocolectomy with ileal pouch anal anastomosis (IPAA) [14][15][16]. A recent meta-analysis by Rajaratnam et al looking at female fertility in familial adenomatous polyposis patients post-IPAA found a 3.91-fold increased risk of infertility (95% CI: 2.06-7.44) [17].…”