Fertility outcomes following obstetric fistula repair: a prospective cohort study

Obstetric fistula (OF) is a birth injury that causes leakage of urine, stool, or both that occurs most frequently in low-income countries. Surgical repair of OF is possible, but there is little data on the reproductive outcomes of women in the years following OF repair. This study describes the fertility outcomes and family planning practices in a population of women in the years following OF repair. Women who had an OF repair in the past 1–4 years were recruited and enrolled to complete a home-based survey of demographic and reproductive health data since their repair. Of the 297 women enrolled with a prior OF repair, 148 were determined to be fertile and included in this analysis. Thirty-one pregnancies since fistula repair were reported among 30 women, with the majority ending with cesarean delivery. Most women who had no menses at the time of repair had resumption of menses at the time of the follow-up survey. Few sexually active women reported pain with sex, and many women accessed effective methods of contraception. In this long-term follow-up study of women after OF repair, many women were able to achieve a pregnancy with a live birth, have normal menses, be sexually active, and access contraception. These achievements will further assist a population of women whose reintegration and restoration of dignity is closely tied to their ability to achieve their reproductive goals.

Obstetric fistula (OF), which includes both vesicovaginal fistula and rectovaginal fistula, is one of the most debilitating and devastating causes of maternal morbidity in low-income countries. Often the consequence of prolonged and obstructed labor that results in a stillbirth, OF leads to a constant leakage of urine (in a vesicovaginal fistula or VVF), feces (in a rectovaginal fistula or RVF), or both (a combined VVF/RVF), which then often leads to divorce and social isolation [1]. Though surgical repair is possible for many women, the social and reproductive consequences of OF may persist. A full recovery after fistula repair should involve more than simply regaining continence. As Dr. Coetze recognized in his treatment of fistula patients 50 years ago, “For a 100% cure of a patient with vesicovaginal fistula, the following conditions must be fully satisfied: 1) the patient should have compete continence; 2) no stress incontinence should be present; 3) dyspareunia should not occur; 4) traumatic amenorrhea should not occur; and 5) the patient should be able to bear children” [2].

Though not the primary goal of fistula repair, for many women, a return of reproductive capacity is essential to successful reintegration into their communities after surgery [3]. In a recent qualitative study of women 1–2 years after OF repair, 45% of these women desired to have additional children [4]. Reported pregnancy rates in women with a repaired OF range between 10 and 20% [4‐7], but this data is limited to small studies that did not evaluate the childbearing potential of the women interviewed. To promote optimal healing and prevent fistula recurrence, women are typically counseled to wait at least 12 months after fistula repair to conceive and then have an scheduled cesarean delivery for all future pregnancies [8]. However, it is unknown how many women are able to adhere to this advice or the outcomes of women who do not adhere. Understanding the fertility outcomes of women who have undergone an OF repair is important in counseling women who are undergoing OF repair and addressing needs after repair.

Amenorrhea may impact the fertility of women after fistula repair since amenorrheic women are unlikely to be ovulating. In women presenting for fistula repair, 20–40% of women have unexplained amenorrhea [6, 7, 9, 10]. Some studies suggest that a subset of these women may resume menses after repair, but data on how frequently this occurs is limited [6, 7]. Additionally, vaginal stenosis is a common sequela of OF [11]. This may not improve after fistula repair and could potentially worsen, impacting sexual function and the ability of a couple to have vaginal intercourse and attempt to conceive [1]. Hormone markers have been shown to predict fertility and amenorrhea [12, 13] and may be useful predictors in women undergoing obstetric fistula repair. Antimüllerian hormone (AMH) has been shown to be a particularly useful predictor because it measures ovarian reserve and unlike other hormones, is not affected by the menstrual cycle.

Finally, though many women desire to become pregnant after OF repair, others may wish to delay or limit their childbearing. In a recent qualitative study, 10% of women who underwent OF repair did not desire future fertility and were interested in accessing long-term and permanent methods of family planning [4]. Therefore, our study objective was to evaluate this population’s long-term fertility desires, outcomes, and family planning practices, so that we can better assist them in achieving their reproductive goals.

In our cohort of 148 women with reproductive potential and prior OF repair, over one-fifth conceived and nearly one-third still desired a pregnancy. Many of these pregnancies resulted in a live birth, and few of the women who became pregnant reported incontinence after delivery. Most women with amenorrhea at the time of repair resumed menses, and few women reported dyspareunia. Approximately half of women not attempting to conceive were using family planning, with implant as the most common method utilized.

A recent review of 11 studies (including one from our study population [4]) found that 212 (17.4%) of 1218 women followed after OF repair became pregnant, with a range of 2.5–40% [17]. Our proportion of 20.2% is well within this range. Possible causes for infertility include ovulatory disorders [7], cervical or uterine scarring [18], vaginal stenosis [11], and not having a sexual partner [1]. However, we are unable to comment on the frequencies of these conditions for the women in this study due to the design of the study using a survey with a non-medical staff person in a survey instead of a clinical exam.

Compared to reports of OF patients in other settings, women in our study who became pregnant after repair had a slightly lower proportion of stillbirth. The previously-mentioned review found that 7.6% of pregnancies ended in stillbirth, whereas our proportion was 4.5%, which is still slightly higher than the 3.4% reported among all pregnancies in Malawi [17, 19]. However, 16.1% of our pregnancies resulted in spontaneous abortion, which is higher than the 5.4% calculated from the review and the 4.7% reported overall in Malawi [20]. In another smaller study of women with and without OF repair in Malawi, of the 10 pregnancies since OF repair, only one resulted in a live birth, and this woman had a recurrence of her fistula [21]. The three largest published series of pregnancies after OF repair reported perinatal mortality proportions of 17–37%; our perinatal mortality of 9.1% was lower than these other studies [21‐23].

The differences found in obstetric outcomes between our study and other studies may be related to the differences in population and study design. Unlike other studies, which were retrospective, often without a denominator, and with short follow-up periods, our study was prospective, and we were able to follow-up all eligible women within 8 districts of Malawi up to 4 years after OF repair. Therefore, our study design minimized non-respondent bias, whereas other studies may have oversampled women with either positive or negative reproductive outcomes, depending on the medical behavior patterns in their populations. However, we excluded women who had died since their OF repair since they could not be interviewed. Since we did not know the cause of death for the four women who had died, we were unable to calculate a proportion for maternal death after OF repair.

Only four of 22 women in our study reported urinary incontinence after delivery, and two already had urinary incontinence prior to delivery. Our maximum proportion of 9.1% for fistula recurrence is slightly higher than the 5.0% reported in the review [17] but lower than the 12–33% women reported in other studies [6, 22, 23]. In one of these studies, fistula recurrence was associated with delivery outside the hospital where the repair took place, at home, or after 2 or more days of obstructed labor [22]. In a study of Ethiopian fistula patients, only 59% of women recalled advice to deliver in a hospital after OF repair [5]. Women in our study population received intensive instructions on the recommendation for cesarean delivery with any pregnancies after repair and hence may not be representative of a typical sample of fistula patients. In Malawi, there is no charge for a scheduled cesarean delivery at government hospitals. However, a recent case study from Malawi demonstrated that even when women present to the hospital prior to labor, delay of clinical care can result in perinatal death and fistula recurrence [24].

Amenorrhea is commonly reported in women presenting for OF repair at rates of 22–44% [6, 7, 9]. Possible causes include pituitary gland ischemia from postpartum hemorrhage following obstructed labor (Sheehan’s syndrome) [7], functional hypothalamic amenorrhea from anorexia or depression, or intrauterine scarring (Asherman’s syndrome), but it is often unexplained [18]. A recent analysis that evaluated the causes of amenorrhea among OF patients at the time of repair using FSH, estradiol, and AMH testing and pelvic ultrasound found that 42% were unexplained, 27% were likely from breastfeeding, 12% were from polycystic ovarian syndrome (PCOS), 9% were from use of the depot medroxyprogesterone acetate injectable, 6% were from hypergonadotropic hypogonadism, and 3% were from hypogonadotropic hypogonadism [10].

However, two studies from Nigeria have demonstrated that some women who are amenorrheic at the time of their fistula repair later have return of menses. In both studies, 41% of women resumed menses, within 6–24 months of repair [6, 7]. In our study, we demonstrated that 78% of those who were amenorrheic at the time of repair resumed menses within 1–4 years of fistula repair surgery. Interestingly, one of the women who was determined to have hypergonadotrophic hypogonadism reported resumption of menses. One case study of an adolescent with this condition and galactosemia details a spontaneous resumption of regular menstrual cycles four years after diagnosis with normalization of FSH and LH [25]; otherwise, reports of this condition spontaneously reversing are rare.

We do not have hormonal data on all women, but no difference in the proportion of women reporting a pregnancy or return of menses was seen in comparisons using AMH at the time of fistula repair. However, our sample size was limited. It is possible that AMH is not predictive of these outcomes in the OF population, or we were not able to detect this difference because of the small sample size.

Finally, we found that 51 (34.4%) of our 148 women were currently using a method of family planning. This proportion is lower than the 46.0% for current use of contraception among sexually active women in Malawi and is likely secondary to the fact that 48 (33.3%) of the women in our population were actively trying to conceive [25]. In addition, 28 (18.9%) of our women were using the implant, which is more than double the 9.0% reported among all women in Malawi, whereas only 7 women (4.7%) were using the injectable, compared to 22.5% among all Malawian women [25]. This is likely due to the fact that we trained two of our nurses in implant insertion in November 2013, and this made them more comfortable to counsel women about implants and to provide them at their follow-up visits. In addition, our nurses provide daily morning educational sessions for our patients in the pre-operative and post-operative wards, which includes family planning methods as one of the topics. We recommend that other fistula centers use a similar approach to ensure that they are meeting the needs of women who do not want any future pregnancies or want to delay them.

This study presents reproductive data on one of the largest cohorts of OF patients followed up 1–4 years after fistula repair. By tracing women in their homes, we were able to gather information on women who had not completed any prior clinical follow-up. This led to decreased potential bias arising from follow-up losses. Additionally, we are able to compare reproductive outcomes to reproductive history, physical examination, and hormone marker findings at the time of repair, which has not previously been documented.

However, it is important to note that we relied on participant self-report for pregnancy, menstrual, sexual, and family planning data, which could be prone to error and/or social desirability bias. We did not have access to medical records to verify pregnancy or family planning outcomes due to the geographic distribution of the women’s homes and health care facilities. Additionally, we only recruited and enrolled women living within a predetermined distance of the Fistula Care Centre, which may have created selection bias. Results may not be generalizable to fistula patients in other parts of the world with different access to reproductive services.

In this long-term follow-up study of women after OF repair, many women were able to achieve a pregnancy with a live birth, have normal menses, resume sexual function, and access contraception. We recommended that other fistula surgeons also ensure that their patients are provided with the comprehensive one-on-one educational counseling that emphasizes the need to wait 1 year before attempting to conceive and to receive appropriate antenatal and delivery care at a hospital for any future pregnancies to minimize fistula recurrence and poor obstetric outcomes. In addition, we recommend that other fistula centers train their staff in all methods of family planning, so that they are comfortable with counseling patients about all options prior to discharge and with providing these methods on site as needed. Further efforts by organizations that care for women with OF should focus on assisting women with achieving their reproductive goals after OF repair, whether that be pregnancy or prevention of unwanted pregnancy. These efforts will greatly assist a population of women for whom reintegration and restoration of dignity is closely tied to their ability to achieve their reproductive goals.