PURPOSE: After restorative proctocolectomy (RPC) with ileal pouch-anal anastomosis (IPAA), fertility rates decline, and cesarean section (CS) has been the preferred mode of delivery. We aimed to assess the current trends and outcomes of pregnancy and delivery in patients who underwent RPC with IPAA. METHODS: This retrospective cohort study included 386 patients who underwent RPC with IPAA for UC between 2007 and 2023. Clinical data were collected through a chart review. Surgical techniques were mainly one- or modified two-stage RPC with stapled IPAA. The fallopian tube traction technique was applied to prevent adhesions. Fertility rates and delivery outcomes were also examined. RESULTS: Among 83 females of < 40 years of age, 18 attempted pregnancy after surgery. Natural conception was achieved in 14 cases (78%), and 2 cases were conceived through in vitro fertilization, resulting in a total of 16 pregnancies (89%). Among the 15 births, 11 (73%) were vaginal deliveries (VD), and 4 (27%) were CS. The reasons for CS included breech presentation (2 cases), prior CS (1 case), and a history of rectovaginal fistula (1 case). One VD case required episiotomy and the other experienced a perineal tear. However, there were no significant differences in postpartum defecation between the VD and CS groups. CONCLUSION: Fertility after RPC with IPAA appears to have improved compared to previous reports, possibly due to the prevention of fallopian tube adhesions. After a stapled IPAA, VD is a feasible option, and CS is not universally required solely because of the history of IPAA.