Reproductive intentions and pregnancy outcomes following bilateral and unilateral uterine artery ligation: A retrospective pilot cohort study

OBJECTIVE: This study evaluates and compares the long-term effects of unilateral and bilateral uterine artery ligation (UAL) for postpartum hemorrhage (PPH) on fertility, pregnancy intentions, and obstetric outcomes. METHODS: This retrospective pilot cohort study included 229 women (58 unilateral UAL patients, 26 bilateral UAL patients, and 145 controls) undergoing cesarean delivery (between March 2018 and October 2024). Data from electronic records and structured telephone interviews were analyzed using multivariable logistic regression. RESULTS: Secondary infertility rates did not differ significantly (5 five events across 229 patients: control 2.8%, unilateral 1.7%, bilateral 0.0%; P > 0.999), confirming preserved biological reproductive capacity. However, pregnancy intentions were significantly lower in UAL groups compared to controls (22.6% vs 55.2%; P < 0.001). In multivariable models, UAL remained an independent predictor of reduced pregnancy desire (unilateral adjusted odds ratio [aOR] 0.12, 95% CI 0.05-0.32; bilateral aOR 0.15, 95% CI 0.05-0.47). Regarding neonatal outcomes, the unilateral group showed an exploratory signal of shorter fetal length (P = 0.043) and higher fetal growth restriction/small for gestational age (18.2%, 2/11) compared to controls. No significant differences were found in preterm birth, low birth weight, or placenta accreta spectrum (PAS), with zero PAS cases observed. CONCLUSION: UAL is biologically safe for fertility preservation; however, the traumatic PPH experience and subsequent intervention might pose a significant behavioral barrier to future reproduction. The exploratory finding of altered fetal growth after unilateral UAL suggests that these patients might benefit from enhanced antenatal surveillance.