1 Department of Obstetrics and Gynaecology, and 2 Department of Public Health, Aberdeen University, Foresterhill, Aberdeen AB25 2ZD, UK
3 To whom correspondence should be addressed. e-mail: m.a.porter{at}abdn.ac.uk
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Abstract |
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Key words: Caesarean section/decision making/secondary infertility
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Introduction |
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One of the issues causing widespread concern is the effect of CS on future fertility. Hemminki et al. (1985) examined Scandinavian data from the early 1980s and concluded that those who have their first baby by CS tend to have fewer children. Hall et al. (1989)
reported that only 47% of those delivering by CS went on to have a subsequent pregnancy over a 5-year period, compared with 57% of those having an instrumental delivery and 62% of those with a spontaneous vaginal delivery. More recent studies confirm the trend. Leitch and Walker (1998)
found that 50% of women having a CS did not return with another pregnancy. Jolly et al. (1999)
showed that 42% of women who delivered by CS had no further children after 5 years compared with 29% of those with a spontaneous vaginal delivery; of those who had further children, the CS group had fewest. Murphy et al. (2002)
also demonstrated an association between CS and prolonged time to conception, 14.4% of those having a CS taking more than a year to conceive again compared with 8.5% of those not having a CS.
At a time of decreasing population growth and increasing rates of CS, infertility following CS is clearly a cause for concern. For couples it may involve the mental and physical distress known to be associated with infertility (Andrews et al., 1991; Leiblum et al., 1998
) and the stigma of having only one child (Mueller and Yoder, 1999
). For governments and other health service providers there is the short-term cost of infertility treatment and the long-term economic effects of having fewer young people to support an ageing population (Hall, 1999
). Epidemiological studies appear to suggest a link between CS and subsequent infertility. What has been less widely studied is the nature of the link. As yet it is unclear whether reproductive potential is compromised by the effect of pelvic surgery, or whether women are deliberately limiting their fertility following CS.
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Infertility following CS |
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A number of authors have speculated about the mechanism by which CS can lead to infertility. After examining official statistics of the prevalence of ectopic pregnancies, miscarriages and placental complications in subsequent births, Hemminki et al. (1985) attributed subfertility following CS to medical causes. Murphy et al. (2002)
suggest that women who had their first child by CS may take longer to conceive because of pelvic adhesions, infection or placental bed disruption. It is known that CS carries an increased maternal risk in comparison with vaginal delivery (Jones and Hunter, 1996
; Irion et al., 1998
). Women are at risk of haemorrhage, infection, ileus, Mendelsons syndrome, intestinal obstruction, bladder injury and hysterectomy (Amu et al., 1998
). Yet, evidence in support of a patho-physiological explanation for impaired fertility following CS remains inconclusive. Wolf et al. (1990)
and Bider et al. (1998)
established that uncomplicated CS was not associated with uterine or tubal infertility, but Hurry et al. (1984)
found a link between pelvic abscess following CS and subsequent infertility. Nielsen and Hokegard (1984)
reported that the incidence of spontaneous abortion, extra-uterine pregnancy and legal abortion was no higher in CS patients than in the general population. The results of a subsequent study by Nielsen et al. (1989)
linking previous CS with placenta praevia, placenta accreta and antepartum haemorrhage have been confirmed by others (Ananth et al., 1997
; Lydon-Rochelle, 2001
).
Although an elective CS is safer than an emergency procedure (Hall, 2001), and more acceptable to women (Mould et al., 1996
; Graham et al., 1999
), both carry psychological risks. After examining obstetric records, Leitch and Walker (1998)
concluded that unknown aspects of the CS could have discouraged women from having further children. The decision to undergo a CS can bring a feeling of fear as well as relief (Ryding et al., 1998
). Many women report feeling angry, disappointed or upset (Reader and Savage, 1983
; Garel et al., 1987
), having more marital adjustment problems (Mutryn, 1993
), and more problems bonding with their babies and establishing breastfeeding (Rowe-Murray and Fisher, 2001
) after a CS. Although early studies suggested that women are more likely to suffer from postnatal depression after a CS (Boyce and Todd, 1992
; Edwards et al., 1994
), later studies refute this (Johnstone et al., 2001
; Chaaya et al., 2002
).
Thus, it would appear that the relationship between CS and infertility is far from straightforward. A potential confounder is the possibility of pre-existing subfertility in this group of women (Murphy et al., 2002). The literature suggests that women who have a period of primary infertility are more likely to deliver by CS (Bhalla et al., 1992
; Bider et al., 1998
; Pandian et al., 2001
). This could be because they are older or more closely monitored. Sheiner et al. (2001)
showed that a combination of older age and infertility treatment increased the risk of CS to 71.4%. This they attributed to increased anxiety surrounding the management of such pregnancies. LaSala and Berkeley (1987)
found a small excess of infertility following CS even after controlling for pre-existing infertility, but were unable to attribute it directly to the CS. They speculate that surgery may be the crucial factor, which pushes some less fertile women into the infertile zone.
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Voluntary infertility following CS |
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The decision to forego a further pregnancy after a CS is clearly a major one, with consequences for the couple, their families and society. Yet, it has not been the explicit subject of medical or sociological research. Pertinent sociological studies have examined gender differences in decision-making about child numbers (Bimbi, 1996; Miller and Pasta, 1996
) and adjustment to the disrupted life-course that childlessness or infertility may bring (Abbey et al., 1994
; Ulrich and Weatherall, 2000
). Studies that examine stigma are more common, and these suggest that parents of only children feel just as stigmatized as do the childless (Whiteford and Gonzalez, 1995
). Mueller and Yoder (1999)
studied 15 voluntarily childless, 15 one-child and 15 mothers of four or more children and found that all felt stigmatized because of their non-normative choices; one-child mothers were regarded as selfish and their child as lonely or pitiable. Letherby (1999)
found that others regarded infertile women as pitiable or desperate, and that they continued to feel inferior after achieving motherhood through infertility treatment.
In addition to the stigma attached to the decision to have only one child, CS has become so commonplace, and its major surgical aspects so trivialized (Mutryn, 1993), that it may be difficult for mothers to admit to being discouraged by some aspect of the CS experience. The prospect of a further operative delivery or a possibly daunting sounding trial of scar may deter women, as may the maternal illness, or premature or sick baby that often accompany emergency CS. On the other hand, a traumatic birth may cause women to delay a further pregnancy to a point where age-related factors contribute to genuine involuntary infertility. Conjugal relationships may also suffer as a result of the CS (Lipson, 1982
), leading to ambivalence or indecision about further children. The role played by partners, in response to the traumatic birth of their child, is also unknown at present, but it is likely that fathers will have strong views on whether their partners should undergo further life-threatening pregnancies or surgery (Affonso and Domino, 1981
).
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Future studies |
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While large epidemiological studies remain the mainstay of proving associations between clinical conditions, there are many factors that cannot be addressed by such studies alone. The issue of infertility following CS warrants a combined approach; a quantitative study to establish the extent of infertility and possible reasons for it, and a qualitative, in-depth study to obtain verbatim accounts of womens fertility-related decision-making and behaviour. Only by this approach will it be possible to disassemble the complex relationship between CS and infertility, and to investigate the extent to which infertility following CS is voluntary. If this proves to be the case, there is a responsibility to bring this to the attention of women trying to make an informed choice about mode of delivery.
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References |
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Affonso, D. and Domino, G. (1981) A perspective on fathers: a question of facts and fallacies. In Affonso, D. (ed.) Impact of Cesarean Births. Davis & Co., Philadelphia, PA, pp. 85111.
Altucher, K.A. (2001) Changing lives, changing plans: work, fertility intentions and voluntary childlessness. Diss. Abstr. Int., 61, 3784-A.
Amu, O., Rajendran, S. and Bolaji, I.I. (1998) Should doctors perform an elective caesarean section on request? Maternal choice alone should not determine method of delivery. BMJ, 317, 463465.[ISI][Medline]
Ananth, C., Smulian, J. and Vintzileos, A. (1997) The association of placenta previa with history of cesarean delivery and abortion: a metaanalysis. Am. J. Obstet. Gynecol., 177, 10711078.[ISI][Medline]
Anderson, K. and Irvine, D. (1993) Referral and investigation of infertility in Aberdeen. Br. J. Obstet. Gynecol., 100, 293.
Andrews, F., Abbey, A. and Halman, L. (1991) Stress from infertility, marriage factors, and subjective well-being of wives and husbands. J. Health Soc. Behav., 32, 238253.[ISI][Medline]
Bewley, S. and Cockburn, J. (2002) The unfacts of request caesarean section. Br. J. Obstet. Gynecol., 109, 597605.
Bhalla, A.K., Sarala, G. and Dhaliwal, L. (1992) Pregnancy following infertility. Aust. N. Z. J. Obstet. Gynecol., 32, 249251.[ISI][Medline]
Bider, D., Blankstein, J. and Tur-Kaspa, I. (1998) Fertility in anovulatory patients after primary cesarean section. J. Reprod. Med., 43, 869871.[ISI][Medline]
Bimbi, F. (1996) Gender differences in the choice of having children. Inchiesta, 26, 1522.
Boyce, P.M. and Todd, A.L. (1992) Increased risk of postnatal depression after emergency caesarean section. Med. J. Aust., 157, 172174.[ISI][Medline]
Chaaya, M., Campbell, O.M., El Kak, F., Shaar, D., Harb, H. and Kaddour, A. (2002) Postpartum depression: prevalence and determinants in Lebanon. Arch. Women Ment. Health, 5, 6572.[CrossRef][Medline]
Davies, G.A., Hahn, P.M. and McGrath, M.M. (1996) Vaginal birth after cesarean. Physicians perceptions and practice. J. Reprod. Med., 41, 515520.[ISI][Medline]
deGregorio, G., Hillemanns, H., Quaas, L. and Mentzel, J. (1988) Late morbidity following cesarean section a neglected factor. Geburtshilfe Frauenheilkd., 48, 1619.[ISI][Medline]
Edwards, D.R., Porter, S.A. and Stein, G.S. (1994) A pilot study of postnatal depression following caesarean section using two retrospective self-rating instruments. J. Psychosom. Res., 38, 111117.[CrossRef][ISI][Medline]
Gamble, J.A.R. (2001) Womens preference for a Cesarean section: incidence and associated factors. Birth, 28, 101110.[CrossRef][ISI][Medline]
Garel, M., Lelong, M. and Kaminski, M. (1987) Psychological consequences of caesarean section in primiparas. J. Psychosom. Obstet. Gynecol., 6, 197209.[ISI]
Giacomini, M.K. and Cook, D.J. (2000) Users guides to the medical literature: XXIII. Qualitative research in health care A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA, 284, 357362.
Gillespie, R. (1999) Voluntary childlessness in the United Kingdom. Reprod. Health Matters, 7, 4353.
Goer, H.B. (2001) The case against elective Cesarean section. J. Perinat. Neonatal Nurs., 15, 2338.[ISI][Medline]
Gottvall, K. and Waldenstrom, U. (2002) Does a traumatic birth experience have an impact on future reproduction? Int. J. Obstet. Gynecol., 109, 254260.
Graham, W.J., Hundley, V., McCheyne, A.L., Hall, M.H., Gurney, E. and Milne, J. (1999) An investigation of womens involvement in the decision to deliver by caesarean section. Br. J. Obstet. Gynecol., 106, 213220.[ISI][Medline]
Grant, J.M. (2001) Qualitative and quantitative research in womens health. Br. J. Obstet. Gynecol., 108, 231232.
Greenhall, E. and Vessey, M. (1990) The prevalence of subfertility: a review of the current confusion and a report of two new studies. Fertil. Steril., 54, 978983.[ISI][Medline]
Hall, D.M. (1999) Children in an ageing society. BMJ, 319, 13561358.
Hall, M.H. (2001) Caesarean section. In Lewis, G. (ed.) Why Mothers Die: Fifth Report of the Confidential Enquiry into Maternal Deaths in the United Kingdom. RCOG Press, London, UK, pp. 317322.
Hall, M.H., Campbell, D.M., Fraser, C. and Lemon, J. (1989) Mode of delivery and future fertility. Br. J. Obstet. Gynecol., 96, 12971303.[ISI][Medline]
Hemminki, E., Hoffman, H.J., Graubard, B.I., Mosher, W.D. and Fetterly, K. (1985) Cesarean section and subsequent fertility: results from the 1982 National Survey of Family Growth. Fertil. Steril., 43, 520528.[ISI][Medline]
Hillan, E. (1992) Research and audit: womens views of caesarean section. In Roberts, H. (ed.) Womens Health Matters. Routledge, London, UK, pp. 157175.
Hurry, D.J., Larsen, B. and Charles, D. (1984) Effects of postcesarean section febrile morbidity on subsequent fertility. Obstet. Gynecol., 64, 256260.[Abstract]
Irion, O., Hirsbrunner, A.P. and Morabia, A. (1998) Planned vaginal delivery versus elective caesarean section: a study of 705 singleton term breech presentations. Br. J. Obstet. Gynecol., 105, 710717.[ISI][Medline]
Johnstone, S.J., Boyce, P.M., Hickey, A.R., Morris-Yates, A.D. and Harris, M.G. (2001) Obstetric risk factors for postnatal depression in urban and rural community samples. Aust. N. Z. J. Psychiatry, 35, 6974.[CrossRef][ISI][Medline]
Jolly, J., Walker, J. and Bhabra, K. (1999) Subsequent obstetric performance related to primary mode of delivery. Br. J. Obstet. Gynecol., 106, 227232.[ISI][Medline]
Jones, S. and Hunter, M. (1996) The influence of context and discourse on infertility experience. J. Reprod. Infant Psychol., 14, 93111.
LaSala, A.P. and Berkeley, A.S. (1987) Primary cesarean section and subsequent fertility. Am. J. Obstet. Gynecol., 157, 379383.[ISI][Medline]
Leiblum, S.R., Aviv, A. and Hamer, R. (1998) Life after infertility treatment: a long-term investigation of marital and sexual function. Hum. Reprod., 13, 35693574.[Abstract]
Leitch, C. and Walker, J. (1998) The rise in caesarean section rate; the same indications but a lower threshold. Br. J. Obstet. Gynecol., 105, 621626.[ISI][Medline]
Letherby, G. (1999) Other than mother and mothers as others: the experience of motherhood and non-motherhood in relation to infertility and involuntary childlessness. Womens Stud. Int. Forum, 22, 359372.[CrossRef][ISI]
Lipson, J. (1982) Effects of a support group on the emotional impact of cesarean childbirth. Prev. Hum. Serv., 1, 1729.[Medline]
Lydon-Rochelle, M. (2001) First-birth cesarean and placental abruption or previa at second birth. Obstet. Gynecol., 97, 765769.
Mays, N. and Pope, C. (2000) Qualitative research in health care. Assessing quality in qualitative research. BMJ, 320, 5052.
Miller, W. and Pasta, D. (1996) Couple disagreement: effects on the formation and implementation of fertility decisions. Pers. Relatsh., 3, 307336.[Medline]
Mould, T., Chong, S., Spencer, J. and Gallivan, S. (1996) Womens involvement with the decision preceding their caesarean section and their degree of satisfaction. Br. J. Obstet. Gynecol., 103, 10741077.[ISI][Medline]
Mueller, K. and Yoder, J. (1999) Stigmatization of non-normative family size status. Sex Roles, 41, 901919.[CrossRef][ISI]
Murphy, D.J., Stirrat, G.M., Heron, J. and the ALSPAC Study Team (2002) The relationship between caesarean section and subfertility in a population-based sample of 14 541 pregnancies. Hum. Reprod., 17, 19141917.
Mutryn, C. (1993) Psychosocial impact of Cesarean section on the family: a literature review. Soc. Sci. Med., 37, 12711281.[CrossRef][ISI][Medline]
Nielsen, T.F. and Hokegard, K.H. (1984) The course of subsequent pregnancies after previous cesarean section. Acta Obstet. Gynecol. Scand., 63, 1316.[ISI][Medline]
Nielsen, T.F., Hagberg, H. and Ljungblad, U. (1989) Placenta previa and antepartum hemorrhage after previous cesarean section. Gynecol. Obstet. Invest., 27, 8890.[ISI][Medline]
Page, H. (1989) Estimation of the prevalence and incidence of infertility in a population: a pilot study. Fertil. Steril., 51, 571577.[ISI][Medline]
Pandian, S., Bhattacharya, S. and Templeton, A. (2001) A review of unexplained infertility and obstetric outcome: a 10 year review. Hum. Reprod., 16, 25932597.
Pope, C. and Campbell, R. (2001) Qualitative research in obstetrics and gynaecology. Br. J. Obstet. Gynecol., 108, 233237.[CrossRef][ISI]
Potter, J., Berquo, E., Perpetuo, I., Leal, O., Hopkins, K., Souza, M. and Formiga, M. (2001) Unwanted caesarean sections among public and private patients in Brazil: prospective study. BMJ, 323, 11551156.
Reader, F. and Savage, W. (1983) Coping with Caesarean and Other Difficult Births. Macdonald Publishers, Edinburgh, UK.
Rowe-Murray, H.J. and Fisher, J.R. (2001) Operative intervention in delivery is associated with compromised early motherinfant interaction. BJOG, 108, 10681075.[Medline]
Ryding, E.L., Wijma, K. and Wijma, B. (1998) Experiences of emergency cesarean section: A phenomenological study of 53 women. Birth, 25, 246251.[CrossRef][ISI][Medline]
Sheiner, E., Shoham-Vardi, I., Hershkovitz, R., Katz, M. and Mazor, M. (2001) Infertility treatment is an independent risk factor for cesarean section among nulliparous women aged 40 and above. Am. J. Obstet. Gynecol., 185, 888892.[CrossRef][ISI][Medline]
Soliman, S.R. and Burrows, R.F. (1993) Cesarean section: analysis of the experience before and after the National Consensus Conference on Aspects of Cesarean Birth. CMAJ, 148, 13151320.[Abstract]
Still, L., Campbell, D., Hall, M. and Kenyon, N. (1993) Relative infertility after caesarean section: voluntary or involuntary. Br. J. Obstet. Gynecol., 100, 293294.
Templeton, A., Fraser, C. and Thompson, B. (1990) The epidemiology of infertility in Aberdeen. BMJ, 301, 148152.[ISI][Medline]
Thomas, J., Paranjothy, S. and Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Unit (2001) National Sentinel Caesarean Section Audit Report. RCOG Press, London, UK.
Thonneau, P., Marchand, S., Tallec, A., Ferial, M.L., Ducot, B., Lansac, J., Lopes, P., Tabaste, J.M. and Spira, A. (1991) Incidence and main causes of infertility in a resident population (1,850,000) of three French regions (19881989). Hum. Reprod., 6, 811816.[Abstract]
Ulrich, M. and Weatherall, A. (2000) Motherhood and infertility: viewing motherhood through the lens of infertility. Fem. Psychol., 10, 323336.[ISI]
Whiteford, L.M. and Gonzalez, L. (1995) Stigma: the hidden burden of infertility. Soc. Sci. Med., 40, 2736.[CrossRef][Medline]
Wolf, M.E., Daling, J.R. and Voigt, L.F. (1990) Prior cesarean delivery in women with secondary tubal infertility. Am. J. Public Health, 80, 13821383.[Abstract]
Submitted on January 13, 2003; resubmitted on May 1, 2003; accepted on June 18, 2003.