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Adverse effects of C-section on fertility and on embryo transfer procedure

Adverse effects of C-section on fertility and on embryo transfer procedure. Mete Işıkoğlu GELECEK The Center For Human Reproduction ANTALYA-TURKEY. TJOD 2016 Antalya. Outline. Introduction What is already known Our results Conclusion.

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Adverse effects of C-section on fertility and on embryo transfer procedure

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  1. Adverse effects of C-section on fertility and on embryo transfer procedure Mete Işıkoğlu GELECEK The Center For Human Reproduction ANTALYA-TURKEY TJOD 2016 Antalya

  2. Outline • Introduction • What is already known • Our results • Conclusion

  3. The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990-2014 A Pilar, B Jianfeng, Y A Moller, J Zhang, M Gülmezoglu WHO 2014

  4. Cesareanratesbycountry OECD

  5. Cesareanrates in Turkey https://www.medikalakademi.com.tr/wp-content/uploads/2013/06/tjod-sezaryen-raporu-2013.pdf 1988: 5.7%

  6. RegionalvariationswithinTurkey

  7. Facility Legal aspect Staff Social Consent & Education Financial aspect https://www.medikalakademi.com.tr/wp-content/uploads/2013/06/tjod-sezaryen-raporu-2013.pdf

  8. Delivery costs

  9. PATIENTS: Myths • More women are asking for CS with no medical rationale? • Listening to Motherssurvey in 2005 in US: 1/ 1600with nomedical reason at her own request. • Changes in the population of childbearing women (older women with medical conditions, more multiple births) • CS rates are going up for all groups Sakala 2008 choicesinchildbirth.org

  10. PATIENTS: Facts • Low priority of enhancing women'sown abilities • Side effects of common labor interventions (labor induction, continuous electronic monitoring) • Refusal to offer the informed choice of vaginal birth (VBAC) • Casual attitudes about surgery and CS in particular • Limited awareness of harms Sakala 2008 choiceschildbirth.org

  11. Onequarter of the reportedthat they had experienced pressure from ahealth professional to have a cesarean There is a change in practicestandardsandprofessionalsareincreasingly willing to follow the cesareanpathunderallconditions. Sakala 2008 choiceschildbirth.org

  12. Adverseeffects of CS • Long term • adhesionformation • ongoing pelvic pain • bowel blockage • to be injuredduring future surgery • Infertility • ectopic pregnancy • placenta previa, placenta accreta, placental abruption, • uterine rupture

  13. CS-infertilityassociation • Tower 2000 • Oral 2007 • Eijsink 2008 • Evers 2014 • Hemminki E 1996 • Kjeruff 2013 • Gurol-Urganci 2013 • Collin 2006 • Smith 2006 • Tollanes 2007

  14. The impact of Caesarean section on subsequent pregnancies could be analysed in 10studies and on subsequent births in 16 studies. Patients with a CS history had a 9% lowersubsequent pregnancy rate [risk ratio (RR) 0.91,95%confidence interval (CI) (0.87, 0.95)] and11%lower birth rate [RR 0.89,95%CI (0.87, 0.92)],. Studies that controlled for maternal age or specifically analysed primary elective Caesareansection for breech delivery, and those that were least prone to bias according to the NOS reported smaller effects.

  15. Retrospective cohort study 52000 women Birth certificate records of first and subsequent deliveries 15% lower subsequent birth rate after Caesarean delivery

  16. 2013 Meta-analysis to reveal subsequent sub-fertility (time to next pregnancy or birth) (1945 - October 2012), 11 articles, 750,407 women Previous CS was associated with an increased risk of sub-fertility [pooled odds ratio (OR) 0.90; 95% CI 0.86,0.93]. Increased waiting time to next pregnancy 10% increased risk of subsequent sub-fertility Variations in the definition of time to next pregnancy, lack of confounding adjustment, or detailsof the indication for Caesarean delivery.

  17. No differences were observed between the Cesarean and vaginal groups with respect to infertility after theirmost recent delivery (7 versus6%, P ¼ 0.597), the interval between their first and second births (30.8 versus 30.6months, P ¼ 0.872), ormultiparity (75 versus 76%, P ¼ 0.650). A history ofCesarean delivery was not significantly associated withinfertility (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.64–1.26). Women who reported infertility prior to their first delivery were significantlymore likely to report infertility after each subsequent delivery (OR, 5.16; 95% CI, 3.60–7.39).

  18. The effect was smallest for elective Caesarean for breech, and not statistically significant in women<30 Larger effectswere observed after elective Caesarean for other indications and emergency Caesarean

  19. BJOG The natural fertility rate subsequent to delivery by CS was 17% lower than the natural fertility ratesubsequent to vaginal delivery (hazard ratio = 0.83, 95% CI 0.73–0.96, P < 0.01; controlling for age, parity, level of education,urban/rural residence and young age at first intercours

  20. Patient selection Bias Causal Social

  21. Confoundingfactors • advanced maternal age • family size • difficult or traumatic birth experience • infertility prior to first delivery

  22. Flow chart of review of clinical database and sample selection ALL INFERTILE WOMEN WITH DELIVERY IN HER HISTORY (# 87) #7 were excluded Group 1 (# 47): Womenwith a history of CS Group 2 (# 33): Women with a history of VD June 2008 and January 2016 GTB

  23. Primary outcome measures: • The association between the route of previous delivery and infertility • Difficult embryo transfer • Secondary outcome measures: • Clinical pregnancy rate • Implantation rate • Miscarriage rate

  24. Results • In order to compare the rate of CS among secondary infertile women at our clinic (59%) with the official CS rate in Turkey, we performed Z score analysis. • Calculated Z value was higher (2,55) than the statistically significant Z score level (1,96)

  25. Demographic data a Student-t test was used for the statistical analysis of the data

  26. Etiological reasons for infertility a Fisher’s exact test b Pearson Chi-square test

  27. Stimulation characteristics a Student-t test

  28. Laboratory variables a Student-t test b Pearson Chi-square test c Fisher’s exact test

  29. Clinical outcome variables a Pearson Chi-square test b Fisher’s exact test

  30. The implantation rates for CS and ND groups were 19,7% and 27,3% respectively. • Z score analysis showed a Z value of 0,77 which was not statistically significant.

  31. Strengths of thestudy • Direct measure of fertility • First data from more eastern region of the world. • First data on probable adverse effect of a prior caeseran on embryo transfer

  32. Conclusion • Preop counseling should have particular concern on future fertility • In case of CS history, mock transfer may be helpful • VD is better compared to CS (TJOD, FIGO, ACOG) • The long term problems of the CS abuse are starting to bother the new generation specialists

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