RPIPAA and Fertility

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The desire to have a child is one of the primary instincts of the woman. This may explain why many women, despite the sequelae of such a serious surgery, decide to have a child. As already seen, UC in itself does not seem to influence fertility [6]. Almost all studies present in the literature agree on ascribing the serious negative effect of RP-IPAA on fertility [40, 41, 43, 45]. However, these works contained important methodologic bias or included a small number of participants. Three recent publications stand out, being points of reference on this topic.

Johnson et al. [48] compared 153 patients who underwent RP-IPAA with 60 patients with UC but treated with medical therapy. In this study, we come to two essential conclusions:

1. Women who underwent surgery had an infertility rate significantly higher in comparison with women who did not undergo surgery (28.1% vs 13.3%).

2. Surgery is the key element to explaining this difference. If the infertility rate in women before surgery matched that of patients treated with medical therapy only (odds ratio 0.68, P=0.23), reduction of the fertility rate in the same study group of women evaluated before and after surgery is very high (odd ratio 0.021, P<0,0001). Moreover, through univariate data analysis, the authors attempted to identify which variables might influence the reduction in fertility. Surprisingly, only the increase of age seemed to have a statistically higher influence on fertility while the history of small-intestinal obstruction, the number of abdominal operations and postoperative pelvic sepsis (three events predisposing the development of adhesions) did not seem to have any influence.

The other two important studies come from the same Scandinavian group. In the first, the fertility rate of a cohort of patients who underwent RP-IPAA was compared with the expected number of births in the general population [49]. Also in this study, the fertility of patients with UC seemed to be slightly reduced in the preoperative stage but is halved after surgery. This reduction reaches the 35% if operated patients who underwent in vitro fertilisation are not included. In the second study, the fecundity rate of 290 women with UC who underwent surgery was compared with 661 healthy women, showing in this case also a reduction of fertility of 80%.

The implications of these studies are very important for preoperative counselling, which must explore the desire for maternity of women waiting to undergo RP-IPAA and, if the clinical situation allows, advise postponement of surgery until after pregnancy.

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