National Perinatal Epidemiology Centre, Department of Obstetrics and Gynaecology, 5th Floor, Cork University Maternity Hospital, Wilton, Cork, Ireland.
BMC Pregnancy Childbirth. 2013 Aug 27;13:165. doi: 10.1186/1471-2393-13-165.
Caesarean delivery has increased worldwide, however, the effects on fertility are largely unknown. This systematic review aims to compare subsequent sub-fertility (time to next pregnancy or birth) among women with a Caesarean delivery to women with a vaginal delivery.
Systematic review of the literature including seven databases: CINAHL; the Cochrane Library; Embase; Medline; PubMed; SCOPUS and Web of Knowledge (1945 - October 2012), using detailed search-strategies and reference list cross-checking. Cohort, case-control and cross-sectional studies were included. Two assessors reviewed titles, abstracts, and full articles using standardised data abstraction forms and assessed study quality.
11 articles were eligible for inclusion in the systematic review, of these five articles which adjusted for confounders were combined in a meta-analysis, totalling 750,407 women using fixed-effect models. Previous Caesarean delivery was associated with an increased risk of sub-fertility [pooled odds ratio (OR) 0.90; 95% CI 0.86, 0.93]. Subgroup analyses by parity [primiparous women: OR 0.91; 95% CI 0.87, 0.96; not limited to primiparous women: OR 0.81; 95% CI 0.73, 0.90]; by publication date (pre-2000: OR 0.80, 95% CI 0.68, 0.94; post-2000: OR 0.90, 95% CI 0.86, 0.94); by length of follow-up (<10 years: OR 0.81, 95% CI 0.73, 0.90; >10 years: OR 0.91, 95% CI 0.87, 0.96); by indication for mode of delivery (specified: 0.92, 95% CI 0.88, 0.97; not specified: OR 0.81, 95% CI 0.73, 0.90); by cohort size (<35,000: OR 0.79, 95% CI 0.67, 0.92; >35,000: OR 0.90, 95% CI 0.87, 0.95), by definition of sub-fertility used divided into (birth interval [BI]: OR 0.89, 95% CI 0.84, 0.94; inter-pregnancy interval [IPI]: OR 0.91, 95% CI 0.85, 0.97; and categorical measures: OR 0.81, 95% CI 0.73, 0.90); continuous measures: OR 0.91, 95% CI 0.87, 0.96) were performed. Results of the six studies not included in the meta-analysis (which did not adjust for confounders) are presented individually.
The meta-analysis shows an increased waiting time to next pregnancy and risk of sub-fertility among women with a previous Caesarean delivery. However, included studies are limited by poor epidemiological methods such as variations in the definition of time to next pregnancy, lack of confounding adjustment, or details of the indication for Caesarean delivery. Further research of a more robust methodological quality to better explore any underlying causes of sub-fertility and maternal intent to delay childbearing is warranted.
剖宫产术在全球范围内有所增加，但对生育能力的影响尚不清楚。本系统评价旨在比较剖宫产后妇女与阴道分娩后妇女的继发性不孕（下一次妊娠或分娩的时间）。
系统检索了七个数据库的文献，包括 CINAHL；Cochrane 图书馆；Embase；Medline；PubMed；SCOPUS 和 Web of Knowledge（1945 年至 2012 年 10 月），使用详细的检索策略和参考文献交叉核对。纳入队列研究、病例对照研究和横断面研究。两名评估员使用标准数据提取表评估标题、摘要和全文，并评估研究质量。
11 篇文章符合系统评价的纳入标准，其中 5 篇文章经过混杂因素调整后进行了荟萃分析，共有 750407 名女性使用固定效应模型。既往剖宫产与继发性不孕风险增加相关[汇总比值比（OR）0.90；95%置信区间（CI）0.86，0.93]。亚组分析显示，初产妇[OR 0.91；95% CI 0.87，0.96；非初产妇：OR 0.81；95% CI 0.73，0.90]；按发表日期（2000 年前：OR 0.80；95% CI 0.68，0.94；2000 年后：OR 0.90；95% CI 0.86，0.94）；按随访时间长短（<10 年：OR 0.81；95% CI 0.73，0.90；>10 年：OR 0.91；95% CI 0.87，0.96）；按分娩方式的适应证（明确：OR 0.92；95% CI 0.88，0.97；未明确：OR 0.81；95% CI 0.73，0.90）；按队列规模（<35000 人：OR 0.79；95% CI 0.67，0.92；>35000 人：OR 0.90；95% CI 0.87，0.95）；按所用的继发性不孕定义（生育间隔[BI]：OR 0.89；95% CI 0.84，0.94；妊娠间隔[IPI]：OR 0.91；95% CI 0.85，0.97；和分类测量：OR 0.81；95% CI 0.73，0.90）；连续测量：OR 0.91；95% CI 0.87，0.96）。未纳入荟萃分析的六篇研究的结果（未调整混杂因素）单独呈现。
荟萃分析显示，既往剖宫产的妇女等待下一次妊娠的时间延长，继发性不孕的风险增加。然而，纳入的研究受到较差的流行病学方法的限制，例如下一次妊娠时间的定义变化、缺乏混杂因素调整或剖宫产适应证的详细信息。需要进一步进行方法学质量更高的研究，以更好地探索继发性不孕和产妇延迟生育意愿的潜在原因。
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