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

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.