This was a large, retrospective cohort study using a U.S. hospital database of deliveries from 2016–2020. Researchers compared women who conceived with assisted reproductive technology (ART, including IVF) and other infertility treatments to those who conceived spontaneously. The sample included hundreds of thousands of deliveries (over 200,000 after infertility treatment) and examined how often peripartum hysterectomy (removal of the uterus at or right after delivery) occurred. Primary outcomes were the rate of peripartum hysterectomy and associated risk factors, including type of treatment and multiple gestations.
Peripartum hysterectomy was rare overall but occurred significantly more often in pregnancies conceived with infertility treatments than in spontaneous conceptions. IVF pregnancies, especially those using frozen embryos and those resulting in twins or higher-order multiples, had the highest relative risks. Underlying conditions commonly seen in infertility (prior cesarean delivery, placenta previa/accreta spectrum, fibroids, and abnormal placentation) were strongly associated with the need for hysterectomy. The analysis suggests that part of the higher risk is related to these coexisting conditions, not just the treatment itself, but an independent association with infertility treatment remained even after adjustment.
The study used administrative and hospital billing data, which rely on accurate coding and lack detailed clinical information (e.g., precise infertility diagnoses, stimulation protocols, embryo quality, and transfer details). It is observational, so it can show associations but cannot prove that infertility treatments themselves directly cause the increased hysterectomy risk. Important confounders—such as severity of endometriosis, adenomyosis, fibroid size and location, and lifestyle factors—were not fully captured. The findings reflect U.S. hospital practice patterns over specific years, which may not generalize to all countries, centers, or to patients with different access to restorative care. Residual confounding by indication (sicker or more complex patients being more likely to receive ART) likely remains.
Clinically, the study reinforces that ART pregnancies, particularly IVF and frozen transfers, should be treated as higher risk for severe delivery complications, including hemorrhage requiring hysterectomy. Because this is an observational database study, it cannot fully separate the impact of the underlying infertility diagnosis, prior uterine surgery, and placenta disorders from the procedures themselves. The findings are broadly consistent with prior work linking ART with higher rates of placenta previa/accreta, cesarean delivery, and postpartum hemorrhage, but this paper extends that link to hysterectomy. Methodologically, large sample size and adjustment for many confounders strengthen the results, though coding accuracy, residual confounding, and lack of detailed cycle-level data limit firm causal conclusions.
Patients using or considering IVF or other infertility treatments should be counseled that, while still uncommon, the chance of needing an emergency hysterectomy at delivery is higher than in spontaneous pregnancies. Restorative approaches that focus on diagnosing and treating root causes of infertility (e.g., hormonal imbalances, endometriosis, fibroids, inflammation, metabolic issues) may reduce the need for high-intensity interventions and some of the conditions linked to hysterectomy risk. Single-embryo transfer and avoiding intentional high-order multiples align with this study’s suggestion that twins or more raise risk substantially. Preconception optimization of uterine health, careful monitoring for placenta location and invasion during pregnancy, and planned delivery in a hospital prepared for major hemorrhage are key safety strategies.
This study looked at many births and found that women who became pregnant using fertility treatments, especially IVF, were more likely to need an emergency hysterectomy (removal of the uterus) around the time of delivery than women who conceived naturally. This outcome was still rare, but the difference between groups was large enough to pay attention to, especially with twins or more. Part of the increased risk seems related to reasons people needed fertility treatment in the first place, such as prior cesarean sections, uterine scars, fibroids, and placenta problems, which can all lead to heavy bleeding. For someone on a fertility journey, this highlights the value of a root-cause approach: carefully evaluating hormones, ovulation, uterine structure, inflammation, and metabolic health before pregnancy, and planning pregnancy and delivery with a team that understands your individual risk factors and monitors you closely.
For clinicians, this study underscores the importance of stratifying hemorrhage and peripartum hysterectomy risk in ART-conceived pregnancies, especially IVF with frozen embryo transfer and multiple gestations. Attention to modifiable contributors—elective single-embryo transfer, minimizing unnecessary repeat cesareans, aggressive management of fibroids or adenomyosis where appropriate, and preconception optimization of endometrial environment—fits both the data and a restorative framework. Integrate early and serial assessment of placental position and suspected PAS in ART pregnancies, particularly in women with prior uterine surgery; consider targeted imaging (detailed ultrasound, MRI when indicated) and planned delivery in higher-level centers if PAS risk is elevated. From a restorative standpoint, comprehensive evaluation of biomarkers and contributors (cycle charting, mid-luteal progesterone and estradiol, thyroid panel, prolactin, insulin resistance markers, inflammatory markers, vitamin D, and thorough assessment for endometriosis and uterine pathology) may reduce the need for escalated ART or improve outcomes when ART is needed. Use this evidence in shared decision-making, balancing success rates, maternal risks, and alternatives, while clearly communicating absolute versus relative risk to patients.
Educational insights, not a diagnosis or individualized treatment advice. Discuss findings with your own clinician. Visit Reproductive Health Insights to explore fertility resources.