Investigating the Association Between Cesarean Section, Endometriosis, Infertility, and Elevated CA-125 Levels

Hanan J. Kadhim, Sahar Mohammad Zaki, Mohsin H. Shekh Mohammed, Hamdia M Ahmed, Edrees Mohammad Ameen
In: The Medical Journal of Tikrit University · 2026 · vol. 32(1) , pp. 98–113 · doi:10.25130/mjotu.32.1.11 · W7165909876
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This study found a significant association between cesarean sections and endometriosis, infertility, and elevated CA-125 levels, suggesting cesarean sections increase the risk of iatrogenic endometriosis which may contribute to secondary infertility.

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This cross-sectional study investigated the link between prior cesarean sections and the development of endometriosis, secondary infertility, and elevated CA-125 levels in women presenting with related symptoms. The researchers analyzed data from patients in the Kurdistan region who underwent diagnostic assessments including laparoscopy and histopathology to confirm diagnoses. Results indicated a highly significant association between cesarean delivery, iatrogenic endometriosis, and subsequent infertility, alongside abnormal CA-125 marker levels. However, the authors noted that while observational evidence supports this connection, a direct causal link remains unproven and requires further robust research. This paper is centrally about endometriosis — specifically examining how cesarean section may contribute to the development of iatrogenic endometriosis and associated secondary infertility.

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Abstract

Background: The emergence of endometriosis-related symptoms following cesarean section that accompanied by secondary infertility, has drawn the attention of clinicians. This study aimed to investigate the association between Cesarean section and the development of endometriosis, as well as its subsequent impact on infertility and the presence of elevated CA-125 levels. Methods: A cross-sectional study was conducted on women attending an obstetrics and gynecology department in the Kurdistan region (Erbil, Sulaymaniyah, Duhok, Halabja) between February 2023 and August 2025, using convenience sampling. Participants presented with symptoms suggestive of primary or iatrogenic endometriosis and were assessed through history, examination, and investigations, including imaging, laparoscopy, and histopathology. Serum CA-125 levels supported the diagnosis and follow-up, and the data were analyzed using SPSS with both descriptive and inferential statistics.Most of the study sample aged between 18 and 45 years old. Twelve complaints were recorded by the sample, with the three highest rates: infertility (75.12%), dysmenorrhea (31%), and menorrhagia (23.5%). Result: There was a highly significant association between endometriosis and cesarean section, infertility, and abnormal CA-125 marker level. Also, there was a highly significant association between infertility (high rate of secondary infertility) and undergoing cesarean section previously (p=<0.001). Cesarean section is associated with an increased risk of iatrogenic endometriosis. This form of endometriosis may contribute to the development of secondary infertility in affected individuals. While observational studies support this association, the evidence remains inconclusive regarding a direct causal link. Therefore, further research employing robust methodological designs is essential to clarify the relationship and guide clinical practice.
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Background

The emergence of endometriosis-related symptoms following cesarean section that accompanied by secondary infertility, has drawn the attention of clinicians. This study aimed to investigate the association between Cesarean section and the development of endometriosis, as well as its subsequent impact on infertility and the presence of elevated CA-125 levels.

Methods

A cross-sectional study was conducted on women attending an obstetrics and gynecology department in the Kurdistan region (Erbil, Sulaymaniyah, Duhok, Halabja) between February 2023 and August 2025, using convenience sampling. Participants presented with symptoms suggestive of primary or iatrogenic endometriosis and were assessed through history, examination, and investigations, including imaging, laparoscopy, and histopathology. Serum CA-125 levels supported the diagnosis and follow-up, and the data were analyzed using SPSS with both descriptive and inferential statistics. Most of the study sample aged between 18 and 45 years old. Twelve complaints were recorded by the sample, with the three highest rates: infertility (75.12%), dysmenorrhea (31%), and menorrhagia (23.5%).

Result

There was a highly significant association between endometriosis and cesarean section, infertility, and abnormal CA-125 marker level. Also, there was a highly significant association between infertility (high rate of secondary infertility) and undergoing cesarean section previously (p=<0.001). Cesarean section is associated with an increased risk of iatrogenic endometriosis. This form of endometriosis may contribute to the development of secondary infertility in affected individuals. While observational studies support this association, the evidence remains inconclusive regarding a direct causal link. Therefore, further research employing robust methodological designs is essential to clarify the relationship and guide clinical practice.

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