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Keywords:

  • Absence of conception;
  • caesarean section;
  • future pregnancy;
  • infertility;
  • population-based study

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References

Background  Women who deliver by caesarean section have been shown to be less likely to have a subsequent pregnancy. It is not clear whether this is due to a direct effect of the procedure on future fertility or due to deliberate avoidance of a future pregnancy.

Objective  To investigate whether absence of conception following caesarean section is voluntary or involuntary.

Design  Follow up of a population-based retrospective cohort.

Setting  Grampian region, Scotland.

Population  Women who had no further viable pregnancies within 5 years of an initial delivery.

Methods  Cases included women who delivered their first child by caesarean section between 1980 and 1995 but had no further viable pregnancies by December 2000. Controls included women who delivered their first child during the same period, by means of either spontaneous vaginal delivery (SVD) or instrumental vaginal delivery (IVD), and who had no further viable pregnancies by December 2000. Eligible women were identified from the Aberdeen Maternity and Neonatal Databank (AMND) and sent postal questionnaires to determine the extent to which not conceiving after first delivery was voluntary and the reasons for avoiding further pregnancies. Characteristics of the different mode of delivery groups were compared using univariate techniques.

Main outcome measures  Extent to which absence of conception following an initial delivery by caesarean section is voluntary.

Results  Questionnaires were returned by 3204 (60%) of 5300 women identified from the AMND. Of these, 1675 women had not conceived at all during the follow-up period (median duration = 13 years). Absence of conception was voluntary in 488 (69%; 95% CI 66–73%) women following caesarean section, 340 (71%; 95% CI 67–76%) following SVD and 354 (72%; 95% CI 68–76%) following IVD. Few women considered seeking fertility treatment (caesarean section = 72 [10%], SVD = 50 [11%], IVD = 39 [8%]). Of the women who decided to delay or avoid a further pregnancy, fewer women who delivered by SVD reported that the birth experience influenced their decision (caesarean section = 163 [32%], SVD = 67 [18%], IVD = 136 [35%]; P < 0.001).

Conclusions  Irrespective of mode of delivery, not conceiving following the birth of the first child is mainly voluntary. The experience of the previous birth is one of several factors affecting women's decisions to avoid a subsequent pregnancy.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References

Rising rates of caesarean section have led to concerns about its long-term effects1 including fewer subsequent conceptions. Initial delivery by caesarean section has been shown to lead to infertility (absence of pregnancy, despite a year or more of unprotected intercourse)2–6 and prolonged time to next conception.7,8 In 2004, an association was shown between caesarean section at full dilatation of the cervix and subsequent infertility at 3 years.8 The causes of reduced fertility following caesarean section remain largely unexplored and the relative contribution of involuntary and voluntary factors unknown. Caesarean section can potentially cause pelvic adhesions, infection or placental bed disruption.2,9,10 However, there is evidence to suggest that uncomplicated caesarean section is not associated with uterine or tubal pathology11,12 and its association with infertility may be due to pre-existing problems.7

It has been argued that absence of conception following caesarean section could be mainly voluntary and possibly linked with the delivery experience.4,5,13,14 A small study in Aberdeen,15 suggested that over 80% of women voluntarily avoided a subsequent pregnancy after an initial caesarean section. The authors highlighted the need for long-term follow up of large cohorts to explore the reasons for this.

Since 1951, the Aberdeen Maternity and Neonatal Databank (AMND)16 has prospectively collected data on all obstetric events in a relatively stable population in northeast Scotland. A previous study showed that women who delivered their first baby by caesarean section were less likely to have a subsequent pregnancy.6 In the current study, we explored the reasons for the absence of conceptions in this group. Using the AMND, we investigated whether the lack of a subsequent pregnancy in these women was mainly voluntary due to a deliberate decision not to get pregnant or involuntary, i.e. failure to conceive despite attempts to do so. In women who chose not to attempt another pregnancy, we also explored the reasons for avoidance of a subsequent pregnancy including the impact of the delivery experience on women's decision. As controls, we included women who had no recorded viable pregnancies within 5 years of an initial spontaneous vaginal delivery (SVD) or instrumental vaginal delivery (IVD).

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References

The AMND was used to identify women in Grampian who had a singleton live birth by caesarean section, IVD or SVD in their first viable pregnancy during the period 1980–1995 but had no subsequent viable pregnancy recorded within the next 5 years (to the end of 2000). This initial cohort thus included women who had no subsequent pregnancies as well as those who had failed pregnancies (such as miscarriages or ectopics). Women with miscarriages and termination of pregnancies prior to their initial delivery were included, as these events were unlikely to compromise future fertility.17 Women who had multiple pregnancies or stillbirths were excluded as these events could have more substantial effects on future fertility than the actual mode of delivery.

Ethical approval was obtained from the Grampian Research Ethics Committee. We used a mixed method approach (questionnaire and interview), but only the quantitative data are reported here. Postal questionnaires were sent to all eligible Grampian women who had undergone either caesarean section or IVD, and to a random sample of Aberdeen women who had SVD at the same hospital. A reminder was sent to non-responders after 2 weeks. Questionnaires were modelled on a previous version15 and included demographic details, aspects of the index birth (vaginal or caesarean) and decisions about future childbearing. It was piloted on 20 women prior to the study. Questionnaires targeting those who had caesarean section were sent out in 2002, while those intended for women who had SVD or IVD were sent approximately 12 months later (2003). The two questionnaires differed slightly in terms of queries regarding the circumstances of the delivery and analgesia or anaesthesia used, reflecting the need to address differences between abdominal and vaginal delivery.

As the focus of this study was to explore the reasons why women did not conceive after their initial delivery, this study presents responses from women who had no further pregnancies following their index delivery (1Figure 1). In these women, the absence of pregnancy after a minimum of 5 years was categorised as ‘voluntary’ or ‘involuntary’ on the basis of their responses to a number of questions about deliberate attempts to become pregnant and contraceptive use. Not conceiving was considered to be voluntary in women who had not tried for a pregnancy and used contraception. In those who had tried for pregnancy at any point in time since their first childbirth, not conceiving was considered to be involuntary, although some of them may have used contraception intermittently. The reason for the absence of pregnancy was classified as uncertain in the following cases: (1) women who indicated that they were not in a relationship and (2) women who had not used contraception but also not tried to become pregnant. Where relevant, women were asked about their reasons for avoiding another pregnancy.

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Figure 1. Flow of participants.*Women discussed in this study.

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Data analysis

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References

Data were entered and analysed using SPSS for windows version 11.5. (SPSS Inc., Chicago, IL, USA) Descriptive techniques were used to characterise the study population. To explore associations between variables and mode of delivery, chi-square test was applied to categorical variables, and analysis of variance and independent t test or Kruskal–Wallis test was applied to normally and non-normally distributed continuous variables, respectively. The association between mode of delivery and reason for not conceiving was adjusted for the effect of confounding factors using multiple logistic regression. Participants in whom the reason was uncertain were excluded from this analysis.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References

Characteristics of women and experience of birth

Overall, 3204 (60%) women returned the questionnaires, with 1251 (75%), 1035 (52%) and 918 (56%) women responding in the caesarean section, SVD and IVD groups, respectively (P < 0.001) (Figure 1). Responders were similar to non-responders in terms of mean (SD) age (40.6 [6.64] versus 39.3 [6.73] years), residence in a deprived area (as suggested by post code; 175 [5%] versus 196 [9%]) and median (interquartile range [IQR]) weeks of gestation at first delivery (40 [39, 41] versus 40 [39, 41]). Ineligible women (those who delivered elsewhere within 5 years) were excluded (n= 314), and responses from those who had (1) conceived but subsequently had a failed pregnancy (miscarriage or ectopic pregnancy) within 5 years (n= 160) or (2) had a pregnancy 5 years after the index delivery (n= 1055) were not considered within this study. Thus, 705 (caesarean section), 476 (SVD) and 494 (IVD) women confirmed that they had no pregnancies since their first delivery. Subsequent analysis on the reasons for not conceiving is restricted to these women (n= 1675). The median duration of follow up for the entire cohort was 13 years (IQR 10–17 years). As 1Table 1 shows, these women differed in terms of age at delivery, presence of a partner at follow up, partners’ occupation and length of follow up. Although statistically significant, the clinical relevance of these differences is uncertain as this could reflect the relatively large sample size. Time to conception of the index pregnancy was shortest in women delivering by SVD. Labour was shortest in women who had SVD and longest in women who had caesarean section. Mode of delivery was associated with women's rating of the birth experience. Women who had IVD rated the experience worst, followed by women who had caesarean section and then by women who had SVD (P < 0.001).

Table 1.  Characteristics of women who did not conceive after initial delivery
 Caesarean section (n= 705)SVD (n= 476)IVD (n= 494)P value
  • *

    Excluding 129 women who had elective caesarean section. Missing values: caesarean section = 97, SVD = 51, IVD = 55.

  • **

    Missing values: caesarean section = 129, SVD = 23, IVD = 44.

  • ***

    Type of caesarean section unknown for 30 women.

Age at index delivery in years, mean (SD) 29.9 (5.91)27.1 (5.66)28.6 (5.45)<0.001
Duration of follow up in years, median (IQR) 12 (9, 16)13 (10, 18)14 (10, 19)<0.001
Had a partner at follow up, n (%) 474 (67)349 (73)370 (75)0.009
Partner's occupation at follow up, n (%)0.002
 Registrar General's category I or II 161 (23)128 (27)151 (31) 
 Registrar General's category III 238 (34)134 (28)136 (28) 
 Registrar General's category IV or V 72 (10)37 (8)44 (9) 
 Other 18 (3)2 (0)8 (2) 
 Missing or not applicable 216 (31)175 (37)155 (31) 
Length of index labour in hours, median (IQR)* 17 (10, 24)10 (6, 15)16 (11, 24)<0.001
Number of months trying to conceive index pregnancy, median (IQR)** 3 (1, 2)2 (0, 6.5)3 (0, 12)<0.001
Found aspects of index birth particularly distressing, n (%) 295 (42)170 (36)312 (63)<0.001
Rating of index birth experience, n (%)<0.001
 Very good 211 (30)148 (31)42 (9) 
 Good 222 (31)185 (39)128 (26) 
 Average 142 (20)99 (21)171 (35) 
 Poor 57 (8)27 (6)84 (17) 
 Very poor 60 (9)12 (3)67 (14) 
 Missing 13 (2)5 (1)2 (0) 
For caesarean section group***Elective caesarean section (n= 129)Emergency caesarean section (n= 546)P value 
 Found aspects of index birth particularly distressing, n (%)40 (31)247 (45)0.003 
 Rating of index birth experience, n (%)0.003 
  Very good52 (40)146 (27) 
  Good45 (35)167 (31) 
  Average20 (16)120 (22) 
  Poor4 (3%)51 (9%) 
  Very poor7 (5)50 (9) 
  Missing1 (1)12 (2) 

Caesarean section

The majority of caesarean sections (546/705 or 77%) were performed as emergency procedures (Table 1). Despite finding delivery less distressing compared with those who had an emergency procedure (40 [31%] versus 247 [45%]), women who had elective caesarean section were more likely to avoid or delay another pregnancy (107 [83%] versus 379 [69%]) (2Table 2). Following elective caesarean section, absence of conception was voluntary in 103 (80%) women, compared with 366 (67%) women who had emergency caesarean section (Table 2).

Table 2.  Reasons for not conceiving following initial delivery
 Caesarean section (n= 705)SVD (n= 476)IVD (n= 494)P value
  • *

    Type of caesarean section unknown for 30 women.

Reason for absence of conception, n (%)0.793
 Voluntary 488 (69)340 (71)354 (72) 
 Involuntary 110 (16)67 (14)65 (13) 
 Uncertain 107 (15)69 (15)75 (15) 
Decided to forgo/delay further children, n (%)<0.001
 Yes 504 (71)370 (78)392 (79) 
 No 157 (22)70 (15)65 (13) 
 Do not know 40 (6)34 (7)28 (6) 
 Missing 4 (1)2 (0)9 (2) 
Tried to become pregnant since index delivery, n (%) 106 (15)68 (14)69 (14)0.812
Used contraception (yes or yes except when trying for pregnancy), n (%) 502 (71)337 (71)326 (66)0.121
Considered seeking or sought fertility advice after failing to become pregnant again, n (%)<0.001
 Yes 72 (10)50 (11)39 (8) 
 No 98 (14)29 (6)30 (6) 
 Not applicable 521 (74)394 (83)418 (85) 
 Missing 14 (2)3 (1)7 (1) 
Women who delivered by caesarean section*Elective caesarean section (n= 129)Emergency caesarean section (n= 546)P value 
Reason for absence of conception, n (%)0.003 
 Voluntary103 (80)366 (67) 
 Involuntary8 (6)98 (18) 
 Uncertain18 (14)82 (15) 
Decided to forgo/delay further children, n (%)0.009 
 Yes107 (83)379 (69) 
 No16 (12)132 (24) 
 Do not know6 (5)32 (6) 
 Missing0 (0)3 (1) 

Voluntary versus involuntary absence of conception

Following their index delivery, 370 (78%) women who had SVD, 392 (79%) women who had IVD and 504 (71%) who had caesarean section had made the decision to forgo or delay further children (Table 2). Absence of conceptions was mainly voluntary in all the three delivery groups (SVD = 340 [71%], IVD = 354 [72%] and caesarean section = 488 [69%]) (Table 2), with little difference across the groups (P= 0.8).

Excluding women with an uncertain reason for not conceiving and taking SVD as the reference category, the odds ratios for failure to conceive, despite trying to do so (95% CI), were 0.93 (95% CI 0.64–1.35) for women who delivered by IVD and 1.14 (95% CI 0.82–1.60) for women who delivered by caesarean section. Adjustment for characteristics of the women (i.e. age at index delivery, duration of follow up, partners’ occupation and time to initial conception leading to live birth) did not materially affect the estimates.

Reason for voluntary infertility

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References

The reasons for deciding to delay or forgo further children were multiple and varied between the three delivery groups (3Table 3). More women following caesarean section and IVD (193 [38%] and 133 [35%]) expressed their unwillingness to experience childbirth again, compared with 59 (16%) women who delivered by SVD (Table 3). The experience of birth directly influenced the decision to prevent another pregnancy in about one-third of women following IVD and caesarean section but in less than one-fifth after SVD (Table 3). Table 3 highlights specific aspects of the birth experience that affected women's decision to avoid another pregnancy. The experience of labour and the birth itself were particularly relevant in women who delivered vaginally, while the recovery period was a significant factor in women who had caesarean section.

Table 3.  Reasons for deciding to forgo/delay further children
 Caesarean section (n= 504)SVD (n= 370)IVD (n= 392)P value
  • *

    Women could choose more than one reason.

Unwilling to experience pregnancy/childbirth again, n (%)*193 (38)59 (16)133 (35)<0.001
Money, n (%)*141 (28)111 (31)109 (29)0.650
Relationship with partner, n (%)*129 (26)123 (34)99 (26)0.012
Age, n (%)*152 (30)81 (23)87 (23)0.013
Lifestyle, n (%)*78 (16)81 (23)74 (20)0.030
Career, n (%)*52 (10)69 (19)57 (15)0.001
Relationship with child, n (%)*63 (13)33 (9)11 (3)<0.001
Other, n (%)*108 (21)113 (31)114 (30)0.001
Influenced by birth experience, n (%)<0.001
 Yes163 (32)67 (18)136 (35) 
 No324 (64)292 (79)238 (61) 
 Do not know14 (3)3 (1)11 (3) 
 Missing3 (1)8 (2)7 (2) 
Aspects of birth experience influential in decision to delay/forgo further children, n (%)Caesarean section (n= 162)SVD (n= 67)IVD (n= 136)P value
Experience of labour*76 (47)49 (73)107 (79)<0.001
The birth itself*71 (44)35 (52)102 (75)<0.001
Recovery period in hospital and at home*109 (67)25 (37)71 (52)<0.001
Own feelings about the birth*60 (37)18 (27)43 (32)0.295
Initial bonding with child*53 (33)14 (21)21 (15)0.002
Other*26 (16)9 (13)8 (6)0.023

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References

Principal findings

In women with one previous child, subsequent absence of conception is mainly voluntary. This occurs irrespective of the type of previous delivery and is sensitive to a number of social and personal factors. The childbirth experience was worse for women with emergency abdominal and vaginal operative deliveries, and influenced the decision to avoid future pregnancies in about one-third of them. In comparison with women delivering vaginally, women who delivered by caesarean section were no more likely to either try unsuccessfully for a second pregnancy or seek advice for infertility.

Strengths and weaknesses

This is the first large population-based study, with an adequate period of follow up, to focus on the reasons for absence of conception after an initial caesarean section. In doing so, it provides the answer to the question raised in a recently published study,6 which showed that women delivering by caesarean section were less likely to have another pregnancy. The sample size, as well as the duration of follow up (median 12–14 years), exceeds those in the previous studies.5,7,8 The majority of women contacted were living with a partner, thus making their response more relevant. This study does not seek to explore the association between caesarean section and subsequent pregnancy failure as this has been addressed in a previous study.6 Nor does it analyse the link between caesarean section and subsequent stillbirth that needs a much larger sample size than the present cohort provides.

As a retrospective study, the data are not free from recall bias. The presence of changing circumstances in women's lives made it difficult to accurately categorise the absence of conceptions as voluntary or involuntary in all cases. Although the issue was explored using a number of questions, it was difficult to capture the entire spectrum of women's perceptions over a period of time using a questionnaire. The prolonged interval between the index delivery and the follow up meant that the response rate was slightly lower than in previous studies where women were contacted within 2–3 years of their delivery.5,8 Questionnaires were sent in two phases: phase 1 included all women who had caesarean section and phase 2 included all women who had IVDs and a random sample of women who had SVD. This may, in part, explain the differential response rate obtained.

Meaning of the study

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References

Characteristics of women

Results of this study are directly relevant to women who had no further pregnancies after their first delivery. The higher response rate from women who delivered by caesarean section may be linked to the more invasive nature of the operation and unanswered questions in the women's minds. Clinical profiles of women delivering by different means were dissimilar; those who had caesarean section were older and had spent longer trying to conceive in their first pregnancy.

Birth experience

The experience of childbirth was worst in women who had unplanned operative deliveries (IVD or emergency caesarean section), while women who had SVD or elective caesarean section were more positive. This is consistent with previous findings.5 Most caesarean section procedures were performed as emergencies, as would be expected in a population of primigravida, many of whom had long and difficult labours.

Reasons for absence of conception

Lack of conception was a consequence of voluntary avoidance of pregnancy in the majority of women irrespective of the mode of first delivery. This is a conservative estimate in that women who had ever tried for pregnancy but who may have used contraception at other times were classified as failure to conceive due to involuntary causes. This may explain why only around 10% of women in any of the delivery groups considered seeking fertility advice. In contrast to previous works,5,8 this study shows that failure to conceive, despite trying to do so, was no higher after IVD or caesarean section in comparison with SVD.

There was no association between mode of delivery and the proportion of women who either used contraception or actively tried for a second pregnancy. The long follow up meant that women's circumstances and intentions changed over time. For example, an initial decision to delay or forgo another pregnancy could have been overturned by circumstances. This could be followed by age-related decline in fertility when women finally decided to try for a pregnancy. In view of this, questionnaire responses were categorised to allow an overall judgement of whether pregnancy had been actively avoided or not, but there were a number of cases where this distinction could not be made. It is more difficult to be confident about the prevalence of involuntary infertility in this cohort, as deliberate avoidance of pregnancy could have obscured any latent pathological infertility. Time to initial conception was high in those who delivered by caesarean section, but unlike previous reports, it was no greater than women who had IVD.7,18 The cause-and-effect relationship between caesarean section and infertility is known to be unclear7 as women with infertility face a higher risk of caesarean section.12,18–21

Reasons for voluntary avoidance of pregnancy

The reasons for avoiding pregnancy after the index birth varied in the three groups. It is probable that some of these could have changed over time. Relevant social and financial factors included lifestyle, age and lack of a partner. As suggested previously,5,8 the experience of labour and delivery was important, affecting the decision to delay or avoid another pregnancy in one-third of women who had operative deliveries (IVD and caesarean section). Obstetric experience was also not always predictive of subsequent fertility. Lower satisfaction rates associated with IVD (in comparison with caesarean section) and emergency caesarean section (in comparison with elective caesarean section) did not appear to correspond with increased voluntary avoidance of conception. During the time period (1980–1995) over which women in this study had their first delivery, elective caesarean section was rare in primigravidae without coexistent medical complications. These women were older than those who had emergency caesarean section. This may explain both the choice of elective abdominal delivery and the women's decision to stop after one child. The aspect of childbirth most likely to discourage future pregnancy was the experience of labour in women who delivered by IVD and the postoperative recovery period in women who had a caesarean birth. As these women experienced similar lengths of labour, the significant increase in subsequent problems with recovery and bonding following caesarean section may be relevant when choosing mode of delivery.

Areas for further research

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References

In this study, it was difficult to determine the relative contribution of voluntary and involuntary factors to absence of conception, by means of a questionnaire survey. A qualitative approach would go further towards unravelling the complex reasons behind women's decisions to avoid a future pregnancy.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References

Absence of conception following an initial delivery either by the abdominal or by the vaginal route is usually voluntary and the result of choice. Although associated with the experience of the initial delivery, the decision to avoid a subsequent pregnancy is affected by a number of other socio-economic factors. Delivery by caesarean section does not increase the proportion of women who try unsuccessfully for a second pregnancy.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References

We wish to acknowledge Linda Murdoch for extracting data from AMND, and Val Angus for facilitating the mailing of questionnaires from the Department of Public Health. We thank all the participants. This study was funded by the Chief Scientist Office of the Scottish Executive Health Department and The Wellcome Trust.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Data analysis
  6. Results
  7. Reason for voluntary infertility
  8. Discussion
  9. Meaning of the study
  10. Areas for further research
  11. Conclusion
  12. Acknowledgements
  13. Conflict of interest
  14. References