Does Caesarean section cause infertility?

Maureen Porter1,3, Siladitya Bhattacharya1, Edwin van Teijlingen2 and Allan Templeton1

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


    Abstract
 Top
 Abstract
 Introduction
 Infertility following CS
 Voluntary infertility following...
 Future studies
 References
 
The global rise in the rate of Caesarean sections (CS) during the last 20 years has coincided with an increase in the number of couples seeking help for infertility. There have been attempts to examine the link between these two conditions, and available data confirm an association between CS and infertility. The relationship is complex, however, involving more than a simple patho-physiological association. There may be a voluntary component to the causal relationship between CS and infertility, which is best explored using qualitative methods. We argue that CS does cause infertility, but the mechanism could be social/psychological rather than pathological.

Key words: Caesarean section/decision making/secondary infertility


    Introduction
 Top
 Abstract
 Introduction
 Infertility following CS
 Voluntary infertility following...
 Future studies
 References
 
Caesarean section (CS) rates have risen rapidly throughout the developed world during the last 20 years, and now stand at approximately one birth in five (Thomas, 2001Go). Many factors have contributed to this rise, including maternal choice, increased maternal age and more liberal use of the procedure for women with previous CS, breech and multiple pregnancy (Leitch and Walker, 1998Go). Concerns have been expressed about the financial costs of the operation (Soliman and Burrows, 1993Go; Potter et al., 2001Go) and the consequences for the women involved. Whilst recent reviews have questioned some conventionally held beliefs about the potential benefits of CS to mother and baby (Goer, 2001Go; Bewley and Cockburn, 2002Go), the evidence is contradictory and could as easily be used to make a case for increasing the CS rate.

One of the issues causing widespread concern is the effect of CS on future fertility. Hemminki et al. (1985)Go 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)Go 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)Go found that 50% of women having a CS did not return with another pregnancy. Jolly et al. (1999)Go 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)Go 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., 1991Go; Leiblum et al., 1998Go) and the stigma of having ‘only’ one child (Mueller and Yoder, 1999Go). 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, 1999Go). 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.


    Infertility following CS
 Top
 Abstract
 Introduction
 Infertility following CS
 Voluntary infertility following...
 Future studies
 References
 
There is no evidence that the incidence of infertility has increased over the last few decades, but the availability of diagnostic and treatment facilities has probably resulted in more couples coming forward for treatment (Anderson and Irvine, 1993Go). Estimates of the prevalence of primary and secondary infertility vary greatly. Page (1989)Go calculated on the basis of a pilot study that 20–35% of couples took more than a year to conceive. Templeton et al. (1990)Go found that 9% of women experienced a period of primary infertility, 5% had secondary infertility and infertility remained an unresolved problem in 7%. Greenhall and Vessey (1990)Go, reviewing both pre-existing and new data, concluded that 24% of women experience a period of infertility at some time in their lives, 13% when trying to conceive a first child and 17% a subsequent child. They suggest that only 3% are involuntarily childless, although 6% of women do not have as many children as they would like. Thonneau et al. (1991)Go found that 14.1% of women in France consulted a doctor about infertility problems.

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)Go attributed subfertility following CS to medical causes. Murphy et al. (2002)Go 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, 1996Go; Irion et al., 1998Go). Women are at risk of haemorrhage, infection, ileus, Mendelson’s syndrome, intestinal obstruction, bladder injury and hysterectomy (Amu et al., 1998Go). Yet, evidence in support of a patho-physiological explanation for impaired fertility following CS remains inconclusive. Wolf et al. (1990)Go and Bider et al. (1998)Go established that uncomplicated CS was not associated with uterine or tubal infertility, but Hurry et al. (1984)Go found a link between pelvic abscess following CS and subsequent infertility. Nielsen and Hokegard (1984)Go 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)Go linking previous CS with placenta praevia, placenta accreta and antepartum haemorrhage have been confirmed by others (Ananth et al., 1997Go; Lydon-Rochelle, 2001Go).

Although an elective CS is safer than an emergency procedure (Hall, 2001Go), and more acceptable to women (Mould et al., 1996Go; Graham et al., 1999Go), both carry psychological risks. After examining obstetric records, Leitch and Walker (1998)Go 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., 1998Go). Many women report feeling angry, disappointed or upset (Reader and Savage, 1983Go; Garel et al., 1987Go), having more marital adjustment problems (Mutryn, 1993Go), and more problems bonding with their babies and establishing breastfeeding (Rowe-Murray and Fisher, 2001Go) after a CS. Although early studies suggested that women are more likely to suffer from postnatal depression after a CS (Boyce and Todd, 1992Go; Edwards et al., 1994Go), later studies refute this (Johnstone et al., 2001Go; Chaaya et al., 2002Go).

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., 2002Go). The literature suggests that women who have a period of primary infertility are more likely to deliver by CS (Bhalla et al., 1992Go; Bider et al., 1998Go; Pandian et al., 2001Go). This could be because they are older or more closely monitored. Sheiner et al. (2001)Go 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)Go 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.


    Voluntary infertility following CS
 Top
 Abstract
 Introduction
 Infertility following CS
 Voluntary infertility following...
 Future studies
 References
 
Relatively few studies have examined the influence of women’s previous experiences and decision-making on reproductive outcome following CS, but there is some evidence of an effect. An early German study of 269 women reported that those with CS had fewer children and were more often afraid of further deliveries (de Gregorio, 1988Go). In a small study in Aberdeen, Still et al. (1993)Go found that 86% of those who had no further children five or more years after a primary CS did so voluntarily, and often for reasons connected with the CS. Hillan (1992)Go, in a comparative study of 50 women having babies vaginally and 50 by CS, found that the latter were more likely to say that they wanted no more or fewer children compared with those who had had a normal birth. Jolly et al. (1999)Go found that 5 years after delivery, 26% of those who had delivered by CS, 25% of those who had had an instrumental delivery and 10% of those with a vaginal delivery were still frightened by the idea of another birth. As women having a primary CS are more likely to undergo CS in subsequent pregnancies (Nielsen and Hokegard, 1984Go; Davies et al., 1996Go), fear may be an important factor. Gottvall (2002)Go reported that women who had a negative experience of their first birth, including CS, had fewer subsequent children and a longer interval until their next child. Gamble (2001)Go showed that despite having negative views of their first CS, women requested another because of fears relating to current or previous obstetric complications.

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, 1996Go; Miller and Pasta, 1996Go) and adjustment to the disrupted life-course that childlessness or infertility may bring (Abbey et al., 1994Go; Ulrich and Weatherall, 2000Go). 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, 1995Go). Mueller and Yoder (1999)Go 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)Go 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, 1993Go), 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, 1982Go), 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, 1981Go).


    Future studies
 Top
 Abstract
 Introduction
 Infertility following CS
 Voluntary infertility following...
 Future studies
 References
 
Existing epidemiological studies have confirmed an association between CS and infertility. What are needed now are qualitative studies to determine the role and nature of the CS experience for reproductive decisions, including voluntary infertility. The need for qualitative research in itself and to complement quantitative studies in women has been acknowledged (Grant, 2001Go). Rather than testing preconceived hypotheses, qualitative studies use rich data derived from interviews, observation, focus groups and documentary analysis to examine events from the point of view of the participants, and to generate theoretically based hypotheses from the data collected (Pope and Campbell, 2001Go). Similar techniques have helped researchers understand that decisions about child number, and in particular childlessness, are of an on-going nature, negotiated and highly context dependent (Jones and Hunter, 1996Go; Gillespie, 1999Go; Altucher, 2001Go). The reliability of qualitative studies is difficult to establish, but checklists for improving rigour or ‘technological fixes’ exist (Giacomini and Cook, 2000Go; Mays and Pope, 2000Go). These include rigorous sampling, triangulation of data sources, researcher reflexivity and deviant case analysis.

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 women’s 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.


    References
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 Introduction
 Infertility following CS
 Voluntary infertility following...
 Future studies
 References
 
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Submitted on January 13, 2003; resubmitted on May 1, 2003; accepted on June 18, 2003.





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