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Reproductive outcomes following assisted reproductive technology after previous caesarean section: data from the
Angela Vidal1, Jérémy Levy2, Alexandra Kohl Schwartz3
1Division of Gynecological Endocrinology and Reproductive Medicine, Women's University Hospital, Inselspital Bern, University of Bern, Bern, Switzerland.
Introduction:
Caesarean section rates have risen worldwide, exceeding the rate of 10%-15% recommended by the WHO. This increase is driven by factors such as advanced maternal age, broader indications for caesarean section (CS), and increased use of assisted reproductive treatment (ART). Previous research, including meta-analyses, suggests that prior CS delivery (CSD) negatively affects the reproductive outcomes in ART, such as lower live birth rates (LBR) and potential subfertility, although the quality of the evidence is variable. Obstetric complications associated with CSD, for instance, uterine rupture and placental abnormalities, highlight the need for further investigation. This study therefore evaluates the impact of CSD on ART outcomes using a comprehensive national registry.
Materials And Methods:
This study includes a cohort of 3,266 women who underwent caesarean section delivery (n = 1,363) or vaginal delivery (VD) (n = 1,903) followed by ART therapy with fresh or frozen embryo transfer (ET) from 2014 to 2022. The outcomes of the first ET and of all ETs after CSD or VD were compared using univariate analyses. Mixed logit models were applied for the outcome of the first ET. For the cumulative outcome of all ETs, mixed Cox models were used. The primary outcome was clinical pregnancy rate (CPR), and the secondary outcomes were LBR. Pregnancy outcome parameters included early pregnancy complications such as vaginal bleeding and miscarriages.
Results:
The characteristics of the patients in both study groups were similar. Following the first embryo transfer, the clinical pregnancy rates were lower after CSD in univariate analysis (38.7% vs. 43.4%; p = 0.008) but not statistically significant after multivariable adjustment significant (odds ratio (OR) = 0.87, 95% CI: 0.76-1.01). In contrast, cumulative analyses across all embryo transfers demonstrated significantly lower cumulative clinical pregnancy and live birth rates after CSD (hazard ratio (HR) = 0.89, 95% CI: 0.82-0.97, p = 0.009 and HR 0.89, 95% CI: 0.81-0.97, p = 0.010, respectively). Miscarriage rates and pregnancy complications were not increased by CSD.
Conclusions:
A history of caesarean section was associated with lower clinical pregnancy rates across successive embryo transfers following ART. No significant association was observed after the first embryo transfer following multivariable adjustment, and miscarriage rates were not affected by the mode of the previous delivery. Further prospective studies, including imaging assessment of caesarean scar defects and isthmocele, are required to determine whether the observed association is related to caesarean section itself or to secondary scar pathology.
