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Sima YT, Magnus MC, Kvalvik LG, Morken NH, Klungsøyr K, Skjærven R, Sørbye LM. The relationship between cesarean delivery and fecundability: a population-based cohort study. Am J Obstet Gynecol 2024; 230:667.e1-667.e21. [PMID: 37863159 DOI: 10.1016/j.ajog.2023.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 10/09/2023] [Accepted: 10/15/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Previous studies have found that women who undergo cesarean delivery have fewer pregnancies. Cesarean delivery is also more common among women with lower fecundability. The potential role of cesarean delivery in reduced fecundability is not known. OBJECTIVE This study aimed to assess the bidirectional relationship between cesarean delivery and fecundability. STUDY DESIGN This was a prospective cohort study based on data from the Norwegian Mother, Father, and Child Cohort study linked with the Medical Birth Registry of Norway. We estimated the fecundability ratio (per cycle probability of pregnancy) and relative risk of infertility (time to pregnancy ≥12 months) by mode of delivery in the previous delivery among 42,379 women. For the reverse association, we estimated the relative risk of having a cesarean delivery by fecundability (the number of cycles women needed to conceive) among 74,024 women. RESULTS The proportion of women with infertility was 7.3% (2707/37,226) among women with a previous vaginal delivery and 9.9% (508/5153) among women with a previous cesarean delivery, yielding an adjusted relative risk of 1.21 (95% confidence interval, 1.10-1.33). Women with a previous cesarean delivery also had a lower fecundability ratio (0.90; 95% confidence interval, 0.88-0.93) than women with a previous vaginal delivery. When assessing the reverse association between fecundability and cesarean delivery, we found that women who did not conceive within 12 or more cycles had a higher risk for cesarean delivery (adjusted relative risk, 1.57; 95% confidence interval, 1.48-1.66) than women who conceived within the first 2 cycles. The associations remained after controlling for sociodemographic and clinical risk factors and were observed across parity groups. CONCLUSION Among women with more than 1 child, those who had a previous cesarean delivery subsequently had a lower fecundability ratio and an increased infertility risk than those who had a vaginal delivery. However, women who needed a longer time to conceive were also more prone to be delivered by cesarean delivery, indicating a bidirectional relationship between cesarean delivery and fecundability. This could suggest a common underlying explanatory mechanism and that the surgical procedure itself may not or only partly directly influence fecundability.
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Affiliation(s)
- Yeneabeba Tilahun Sima
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
| | | | - Liv Grimstvedt Kvalvik
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Nils-Halvdan Morken
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Kari Klungsøyr
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Division of Mental and Physical Health, Norwegian Institute of Public Health, Bergen, Norway
| | - Rolv Skjærven
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway; Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Linn Marie Sørbye
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway; Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway; Norwegian Research Centre for Women's Health, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Rottenstreich M, Glick I, Srebnik N, Tsafrir A, Grisaru-Granovsky S, Sela HY. The association between primary cesarean delivery in primipara and subsequent mode of conception, a retrospective study. J Matern Fetal Neonatal Med 2021; 35:9031-9037. [PMID: 34872439 DOI: 10.1080/14767058.2021.2012651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To examine the association between primary cesarean delivery and the mode of conception in the subsequent delivery among women without a history of infertility. METHODS A retrospective study. Women with the first two consecutive deliveries in our medical center were included. Excluded were women who conceived following fertility treatments or were older than 35 years at their first delivery. RESULTS Twenty-three thousand four hundred and twenty-seven women were included in the study. Of those, 2215 (9.5%) underwent cesarean delivery in their first delivery, while 21,212 (90.5%) delivered vaginally. Univariate analysis revealed that women with primary cesarean delivery compared to women how delivered vaginally had higher rates of fertility treatments at the subsequent delivery (2.5 vs. 0.8%; p < .01). Those who had fertility treatments were significantly older during both the first and second deliveries, had higher rates of diabetic disorders of pregnancy (pregestational and gestational) at both the first and second deliveries, obesity and morbid obesity at the second delivery, and higher incidence of repeat cesarean delivery. Multivariate analysis revealed that the only factor that correlated significantly with the use of fertility treatments at the second delivery was maternal age at second delivery [aOR 1.2 (1.1-1.3), p < .01]. CONCLUSION Among women without a history of infertility, cesarean delivery in the first delivery is not independently associated with fertility treatments in the subsequent delivery.
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Affiliation(s)
- Misgav Rottenstreich
- Department of Obstetrics & Gynecology, Faculty of Medicine, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel
| | - Itamar Glick
- Department of Obstetrics & Gynecology, Faculty of Medicine, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Naama Srebnik
- Department of Obstetrics & Gynecology, Faculty of Medicine, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Avi Tsafrir
- Department of Obstetrics & Gynecology, Faculty of Medicine, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics & Gynecology, Faculty of Medicine, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hen Y Sela
- Department of Obstetrics & Gynecology, Faculty of Medicine, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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Bane S, Carmichael SL, Snowden JM, Liu C, Lyndon A, Wall-Wieler E. The impact of Severe Maternal Morbidity on probability of subsequent birth in a population-based study of women in California from 1997-2017. Ann Epidemiol 2021; 64:8-14. [PMID: 34418536 PMCID: PMC8629841 DOI: 10.1016/j.annepidem.2021.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 06/25/2021] [Accepted: 08/11/2021] [Indexed: 11/19/2022]
Abstract
IMPORTANCE Complications during pregnancy and birth can impact whether an individual has more children. Individuals experiencing SMM are at a higher risk of general and reproductive health issues after pregnancy, which could reduce the probability of a subsequent birth. OBJECTIVE To examine whether experiencing SMM during an individual's first birth affects their probability of having an additional birth, and whether this effect varies by maternal factors. METHODS This retrospective cohort study US linked vital records and maternal discharges from 1997 to 2017 to identify all California births. The exposure, Severe Maternal Morbidity (SMM) was identified using a Centers for Disease Control and Prevention index. Individuals whose first birth was a singleton live birth were followed until their second birth or December 31, 2017, whichever came first. Hazard ratios for having a subsequent birth were estimated using Cox proportional hazard regression models. This association was assessed overall and stratified by maternal factors of a priori interest: age, race/ethnicity, and payer. RESULTS Of the 3,916,413 individuals in our study, 51,872 (1.3%) experienced SMM at first birth. Compared to those who do not experience SMM, individuals who had SMM had a lower hazard, or instantaneous rate, of subsequent birth (adjusted HR 0.83, 95% CI: 0.82, 0.84); this association was observed in all levels of stratification (for example, adjusted HR range for known race/ethnicity: 0.78, 95% CI: 0.76, 0.80 for non-Hispanic White to 0.90, 95% CI: 0.88, 0.92 for Hispanic) and all indicators of SMM (0.24, 95% CI: 0.17, 0.35 for cardiac arrest/ventricular fibrillation to 0.84, 95% CI: 0.80, 0.87 for eclampsia). CONCLUSION AND RELEVANCE Our findings suggest that individuals who experience SMM at the time of their first birth are less likely to have a subsequent birth as compared to those who do not experience SMM at the time of their first birth. While the reasons for these findings are unclear, they could inform reproductive life planning discussions for individuals experiencing SMM. Future directions include studies exploring the reasons for not having a subsequent birth.
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Affiliation(s)
- Shalmali Bane
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA 94306
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA 94306
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford CA, USA 94306
| | - Jonathan M Snowden
- School of Public Health, Oregon Health & Science University-Portland State University, Portland OR, USA 97239
- Department of Obstetrics and Gynecology Oregon Health & Science University, Portland OR, USA 97239
| | - Can Liu
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA 94306
| | - Audrey Lyndon
- Rory Meyers College of Nursing, New York University, NY, USA 10010
| | - Elizabeth Wall-Wieler
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada MB R3T 2N2
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The Influence of Cesarean Delivery on Ovarian Reserve: a Prospective Cohort Study. Reprod Sci 2021; 29:639-645. [PMID: 34472035 DOI: 10.1007/s43032-021-00730-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/26/2021] [Indexed: 11/27/2022]
Abstract
To assess the association between cesarean delivery and ovarian reserve, as compared to vaginal delivery. A prospective case control study conducted at a single tertiary medical center between June 2018 and June 2019. Study population included women with singleton pregnancy that underwent first cesarean delivery that were compared to women undergoing normal vaginal delivery. Women with low ovarian reserve, endometriosis, previous pelvic surgery, chronic maternal disease, and active labor were excluded. Ovarian reserve was estimated by Anti-Mullerian hormone (AMH) levels that was determined twice for each participant: up to a week before and 3 months after delivery. Primary outcome was defined as the delta in AMH levels. Data were analyzed by non-parametric tests. During the study period, 135 women were enrolled, of them 63 (47%) underwent cesarean delivery and 72 (53%) had vaginal delivery. Women in the cesarean delivery group were older (34 (31-38) vs. 32 (29-35); p = 0.001); nevertheless, AMH levels measured before delivery were comparable between the two groups (0.92 (0.51-1.79) vs. 0.95 (0.51-1.79) pg/mL; p = 0.42). AMH levels measured after delivery were more than doubled in the study and control groups (2.15 (1.24-3.05) vs. 2.62 (1.05-5.09); p = 0.50), and delta AMH levels were also found comparable (1.25 (0.61-2.22) vs. 1.59 (0.63-3.41), respectively; p = 0.43). Linear regression analysis including age, mode of delivery, gestational age at delivery, and delta hemoglobin levels revealed that only maternal age was significantly associated with delta in AMH levels (B = - 0.09, p = 0.04). Cesarean delivery does not decrease ovarian reserve as estimated by AMH.
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Kjerulff KH, Paul IM, Weisman CS, Hillemeier MM, Wang M, Legro RS, Repke JT. Association Between Mode of First Delivery and Subsequent Fecundity and Fertility. JAMA Netw Open 2020; 3:e203076. [PMID: 32310282 PMCID: PMC7171551 DOI: 10.1001/jamanetworkopen.2020.3076] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE More than 20% of births globally are by cesarean delivery, including more than 30% in the US. Prior studies have reported lower rates of childbearing after cesarean delivery, but it is not clear if this is due to maternal choice or lower conception rates. OBJECTIVE To investigate the association between mode of first delivery and subsequent conceptions and live births. DESIGN, SETTING, AND PARTICIPANTS The First Baby Study was a multicenter prospective cohort study of women aged 18 to 35 years with singleton pregnancies, enrolled and interviewed before first childbirth, who delivered in Pennsylvania from 2009 to 2011 and were followed up for 36 months after delivery (until April 2014). Data analysis for this study took place between May and July 2019 and in January 2020. EXPOSURES Mode of first delivery (cesarean or vaginal). MAIN OUTCOMES AND MEASURES Rates of subsequent conceptions and live births. Discrete-time Cox proportional hazard regression models were used to compare the rate of subsequent conception (vaginal vs cesarean) among those who completed the 36-month survey, accounting for reported months of unprotected intercourse during the follow-up period and adjusting for relevant covariates. A log binomial regression was used to compare the age-adjusted rate of subsequent live birth (vaginal vs cesarean) among those who completed the 36-month survey. RESULTS The study population consisted of 2423 women who were retained to the 36-month survey (mean [SD] age at baseline was 27.2 [4.4] years and 712 [29.4%] delivered by cesarean). There were 2046 women who had unprotected intercourse during the follow-up period, 2021 of whom provided data on months of unprotected intercourse. Cesarean delivery was associated with lower rates of conception after unprotected intercourse during the follow-up period (413 of 599 [68.9%]) compared with vaginal delivery (1090 of 1422 [76.7%]) (adjusted hazard ratio, 0.85; 95% CI, 0.74-0.96). Cesarean delivery was also associated with reduced likelihood of a subsequent live birth (305 women [42.8%]) compared with vaginal delivery (857 women [50.1%]), with an age-adjusted risk ratio of 0.83 (95% CI, 0.75-0.92). CONCLUSIONS AND RELEVANCE In the 3 years following first childbirth, women who delivered their first child by cesarean had lower rates of conception after unprotected intercourse, and fewer of these women had a second child than those who delivered vaginally.
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Affiliation(s)
- Kristen H. Kjerulff
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Ian M. Paul
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | - Carol S. Weisman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - Marianne M. Hillemeier
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Health Policy and Administration, Penn State College of Health & Human Development, University Park, Pennsylvania
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Richard S. Legro
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
| | - John T. Repke
- Department of Obstetrics and Gynecology, Penn State College of Medicine, Hershey, Pennsylvania
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