title: Threefold increased risk of infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis.
abstract: BACKGROUND
  Increased infertility in women has been reported after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis but reported infertility rates vary substantially.
  
  
  OBJECTIVE
  (1) To perform a systematic review and meta-analysis of the relative risk of infertility post-IPAA compared with medical management; (2) to estimate the rate of infertility post-IPAA; and (3) to identify modifiable risk factors which contribute to infertility.
  
  
  METHODS
  Medline, EMBASE, Current Contents, meeting abstracts, and bibliographies were searched independently by two investigators. The titles and abstracts of 189 potentially relevant studies were reviewed; eight met the criteria and all data were extracted independently. Consensus was achieved on each data point, and fixed effects meta-analyses, a funnel plot, and sensitivity analyses were performed.
  
  
  RESULTS
  The initial meta-analysis of eight studies had significant heterogeneity (p = 0.004) due to one study with very high preoperative infertility (38%). When this study was omitted, the relative risk of infertility after IPAA was 3.17 (2.41-4.18), with non-significant heterogeneity. The weighted average infertility rate in medically treated ulcerative colitis was 15% for all seven studies, and the weighted average infertility rate was 48% after IPAA (50% if all eight studies are included). We were unable to identify any procedural factors that consistently affected the risk of infertility.
  
  
  CONCLUSIONS
  IPAA increases the risk of infertility in women with ulcerative colitis by approximately threefold. Infertility, defined as achieving pregnancy in 12 months of attempting conception, increased from 15% to 48% in women post-IPAA for ulcerative colitis. This provides a basis for counselling patients considering colectomy with IPAA. Further studies of modifiable risk factors are needed.
authors.affiliation: Division of Gastroenterology, University of Michigan, 6520 MSRB I, Box 0682, 1150 West Medical Center Drive, Ann Arbor, MI 48109, USA.
authors.forename: A
authors.initials: A
authors.lastname: Waljee
authors.forename: J
authors.initials: J
authors.lastname: Waljee
authors.forename: A M
authors.initials: AM
authors.lastname: Morris
authors.forename: P D R
authors.initials: PD
authors.lastname: Higgins
mesh_terms: D003093:Colitis, Ulcerative / Q000601:surgery*; D039021:Colonic Pouches / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007247:Infertility, Female / Q000453:epidemiology / Q000209:etiology*; D016737:Proctocolectomy, Restorative / Q000009:adverse effects*; D018570:Risk Assessment; D012307:Risk Factors