Fertility and mode of delivery after ileal pouch‐anal anastomosis for ulcerative colitis: A population‐based study

BACKGROUND AND AIMS: Fertility and mode of delivery are major concerns for women with ulcerative colitis (UC) undergoing ileal pouch-anal anastomosis (IPAA). Although infertility after IPAA has been attributed to pelvic adhesions, the impact of minimally invasive approaches remains uncertain. Similarly, evidence guiding Caesarean section (CS) versus vaginal delivery is limited. METHODS: We conducted a retrospective, population-based study using Ontario health administrative databases (1994-2022). Female UC patients aged 18-45 years undergoing IPAA were matched by birth year, parity and rural residence to UC controls (without surgery) and non-UC controls. Primary outcome was live birth after IPAA. Subgroup analyses included nulliparous patients and laparoscopic versus open IPAA. Among patients with live births, delivery modes were compared. RESULTS: We included 1,094 eligible women with IPAA (median age 32). After IPAA, 13.8% had ≥1 live birth, significantly lower than UC controls (27.2%; RR 0.53, 95% CI 0.46-0.60) and non-UC controls (22.5%; RR 0.53, 95% CI 0.47-0.59). Among nulliparous women, live birth rates remained significantly reduced (18.5% vs. 32.7% in UC controls; RR 0.66, 95% CI 0.57-0.77). Laparoscopic IPAA did not significantly increase live birth rates (13% vs. 10%, RR 1.41, 95% CI 0.75-2.65), though the number of births per patient was higher. CS rates were substantially elevated in women who delivered after IPAA versus controls. CONCLUSIONS: In this population-based study, IPAA for UC was associated with significantly reduced live birth rates compared with both controls. Laparoscopic IPAA did not eliminate fertility disadvantage, though higher birth numbers suggest possible benefit. CS rates were markedly higher after IPAA.