Impact of ileal pouch-anal anastomosis on female fertility: meta-analysis and systematic review

Purpose The aim of this review is to determine the effect of ileal pouch-anal anastomosis (IPAA) on female fertility in ulcerative colitis (UC) and familial adenomatous polyposis (FAP), the mechanisms of this effect, strategies for prevention and management of infertility post-IPAA. Methods This paper is a systematic literature review of all articles investigating IPAA and fertility from 1966 onwards that were found searching the Medline and Embase databases. Meta-analysis was performed on relevant studies. Results Seventeen relevant studies were identified. Six studies were excluded (duplicate data, one; predominantly not IPAA patients, one; no control group, four). The control groups of the remaining 11 studies were too varied for comparison, and so the meta-analysis was limited to six studies that provided data on infertility both pre- and post-IPAA. Five of these involved predominantly UC patients and one FAP. Average infertility rates were 20% pre-IPAA and 63% post-IPAA. The relative risk of infertility after IPAA is 3.91 ([2.06, 7.44] 95% CI). The possibility of publication bias suggests that the risk may be lower. Any increased risk is probably due to tubal dysfunction secondary to adhesions. Various methods have been proposed to reduce pelvic adhesions, but there is no evidence they have any effect in preventing infertility. Infertility treatment post-IPAA is associated with good success rates. Conclusions Infertility is increased after IPAA in female patients in both UC and FAP. Both these disease processes affect patients during their reproductive years. This evidence emphasizes the need for careful consideration of fertility in the choice and timing of surgery.