Association Between Appendicectomy in Females and Subsequent Pregnancy Rate: A Cohort Study.

Literature Review Article

Association Between Appendicectomy in Females and Subsequent Pregnancy Rate: A Cohort Study. Wei, L, MacDonald, T, Shimi, S. Fertil Steril 2012; 98(2): 401-405. 

Review
John Parry, M.D.
 

The purpose of this retrospective cohort study was to determine whether appendectomy decreases fecundability. The authors looked at 76, 426 patients under the age of 45 that underwent appendectomy between 1986 and 2009 and compared them with 152, 852 control patients from the same interval. Two age and practice matched controls were selected for each case. Exclusions were for age <12 years, <30 days of follow-up, reaching the age of 53, sterilization, hysterectomy, and death. The authors did not continue to follow patients after the first pregnancy. In the follow up period, 39.3% of appendectomy patients and 28.3% of controls conceived. These results do not seem to be biased secondary to PID rates in the controls (1.1% appendectomy patients, 0.4% controls) or other comborbidities, although appendectomy patients were more likely to have a history of previous pregnancy (23.9% vs 17.5%). The authors speculate that previous parity coupled with greater utilization of oral contraceptives in the appendectomy group may reflect that patients that have had previous appendectomies were relatively more sexually active. They also acknowledge that both laparoscopic and open appendectomies were included (the latter being potentially more adhesiogenic) which could bias the study away from the null; however, this could potentially have been counterbalanced by looking at all appendectomies which would bias the study towards the null, instead of focusing on appendectomies performed for appendicitis, ruptured appendicitis, and/or peritonitis.

 

Comments
Daniel B. Williams, M.D.
 

This is a retrospective cohort study using a large database (General Practice Research Database) in the UK.   Female patients between the ages of 12 and 45 were compared with age-matched controls from the same database.   The study endpoints were the first pregnancy or if they reached the age of 53 years, had sterilization of hysterectomy or died, or at the end of follow-up (10.5 years).   (ICD)-9 codes were used to determine outcome and covariates.  The authors found that significantly more patients conceived 39.3% in the appendectomy cohort compared to the comparator group (39.3% vs. 28.3%).   

The authors concluded that a prior history of appendectomy does not impair fertility.  

This study suffers from significant limitations inherent in any large database: namely, an inability to adequately control for confounding variables as well as relying (ICD) – 9 codes for accurate diagnosis.   In particular, this study did not examine patients with appendicitis, ruptured appendix, or peritonitis secondary to appendicitis, all of which could be presumed to increase the risk for adhesive disease and possibly infertility.   While it is reasonable to assume that elective appendectomy may not result in impaired fertility, the actual increase in pregnancy following appendectomy found in this study is probably not clinically relevant.  

 

 

The above review and commentary on this article were written by SRS members. Publication of these summaries does not reflect endorsement of any particular procedure or treatment. Views expressed in these summaries do not necessarily reflect the views of SRS or ASRM.

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