Significant Variation in Recommendation of Care for Women of Reproductive Age with Ulcerative Colitis Postileal Pouch–Anal Anastomosis

Abstract

Ileal pouch-anal anastomosis (IPAA) is the preferred surgical option for treatment refractory ulcerative colitis. Infertility risk post IPAA and sphincter injury concerns with vaginal delivery has led to a lack of consensus regarding timing and recommended mode of delivery (MOD) post-IPAA. To better understand these issues, we surveyed gastroenterologists (GI), colorectal surgeons (CRS), and obstetricians (OB) to assess practice variation in recommendations for delivery post IPAA. Clinical vignettes were developed to assess knowledge, attitudes, and beliefs surrounding (1) the impact of IPAA on fertility, (2) IPAA timing around pregnancy, (3) recommended MOD after IPAA and (4) which specialist should advise on MOD. These were emailed to providers using specialty society address lists. Univariate analyses tested differences among groups. A total of 244 GI, 158 CRS and 39 OBs responded to the survey. The majority of GI (67%) and CRS (60%) quoted fertility reduction of >20% post-IPAA versus 11% OB (p < 0.001). More GI than CRS (67 vs. 45%) recommended delaying IPAA until after pregnancy (p < 0.001), and this was more commonly suggested by CRS in practice <10 years (p = 0.01) and <45 years old (p = 0.003). Vaginal delivery was recommended post-IPAA in 43, 20 and 57% for GI, CRS and OB, respectively (p < 0.001). Only 28% CRS versus 59% OB thought OB should primarily advise on MOD (p < 0.001). There is significant intra- and inter-group variation in management of women post-IPAA. There is need for consensus among subspecialists involved in managing women with this complex condition.