As a woman focused on holistic health and intent on taking the natural path as often as possible, you may be wondering if the D&C your doctor has just suggested is a good idea.
Specifically, you want to know if it’s necessary and whether it can impact your chances of getting pregnant down the line.
As usual, the devil is in the details, and the honest answer to both questions is: it depends.
Here’s the deal on D&C and fertility:
What is a D&C?
Dilation & Curettage, more commonly referred to as a D&C, is a procedure to remove tissue or masses from inside the uterus. While a D&C can be used to remove cervical or uterine polyps, placental tissue remaining after delivery, or a uterine tumor, D&C is also commonly performed to clear out tissue in the uterus following a miscarriage.
Do I need a D&C? Aren’t miscarriages natural?
This is a big question, and we are glad you asked. As with many medical procedures, the decision is personal and should be made with plenty of information on deck.
In some cases, a miscarriage does not require a D&C, and it's not only possible but encouraged to let the miscarriage pass on its own. However, a D&C is deemed medically necessary to clear the tissue and prevent infection or stop bleeding in some cases.
To know when a D&C might be right for you, let's consider the different types of miscarriages and available treatment options.
A complete miscarriage
This term is sometimes used to refer to a miscarriage that occurs early in the first trimester and clears on its own through bleeding. No treatment is usually necessary.
An incomplete miscarriage
This term refers to a miscarriage that starts to clear on its own but never entirely completes the process of clearing, with heavy bleeding, blood clots, and pelvic pain (sometimes accompanied by a fever) that isn’t letting up.
A missed miscarriage
This term refers to a miscarriage that occurs without any signs to the mother, as in without bleeding or pain. Often, these are the most heartbreaking losses because they are such a shock, discovered either on ultrasound or at a visit with a provider.
In 50% of cases, a complete miscarriage, the pregnancy tissue will clear away on its own via the release of blood out of the vagin*. In the case of an incomplete or missed miscarriage, there are three options available to women: expectant management, medication management, or surgical management, which is the D&C.
Expectant management
Expectant management is the wait-and-see method, and while it is less common than it used to be, it is still an option for women whose providers support it and feel the miscarriage will likely either continue to clear on its own or begin to clear. This natural process of clearing the miscarriage can typically last from several hours to several weeks. Still, if the process doesn't start in an appropriate amount of time as determined by your provider, it may be time to move on to medication or surgical management.
Also, this option is usually only available to low-risk women who do not currently have a uterine infection, are not at increased risk of severe bleeding, and don’t have a history of stillbirth, miscarriage, or extreme blood loss in past pregnancies.
Medication management
This is a common route for missed or incomplete miscarriages and involves the administration of medication, called misoprostol, to induce cramping and bleeding that clears the uterus of the miscarried tissue. This medication can take several hours to begin working and then several more hours to clear the tissue. Women can expect bleeding and blood clotting and mild to severe cramping during this process. Significant bleeding should subside after the first day, but it’s normal to have spotting over the next several weeks.
Surgical management/D&C
The D&C is the surgical route to clear a miscarriage. It's an option for women who have heavy and prolonged uterine bleeding, are at risk of, or are already displaying signs of an infection, were unsuccessful with the medication route, or those who want an immediate end to the miscarriage process.
It is painful because the D&C involves scraping (albeit gently) the uterine walls to clear tissue. Due to this, most doctors offer patients either general anesthesia, local anesthesia or pain medication for the procedure, which lasts about 15 minutes.
On the day of your procedure, a gynecologist will insert a speculum into your vagin* – just like for a pap test - and gently dilate the cervix open a small amount using special instruments. The curette is then inserted, and the contents of the uterus are removed, either by suction or manually.
Following the procedure, you’ll stay in the recovery room for several hours and need a ride home if you had anesthesia. While you may need a few days to recover and feel back to normal (including the cessation of cramping and spotting), many women can go back to work the next day.
Will a D&C affect my fertility?
This is the question we started this blog with, and this is the question we will answer.
A D&C can affect a woman’s fertility and make it harder for her to get pregnant down the line. However, this infertility outcome, which is called Asherman’s syndrome, is very rare, and only in its most severe form does it cause infertility. Most women have no adverse effects on their fertility or overall health following one or two uncomplicated D&Cs.
Asherman’s syndrome
This condition can occur in women who have had any type of pelvic infection or uterine surgery in the past, including a hysteroscopy, C-section, or D&C.
In the case of Asherman’s syndrome, scar tissue resulting from any of the above procedures can begin to grow on the uterus walls and bond or stick together, dividing the uterus into sections and decreasing the overall volume of the uterus.
The syndrome ranges from mild, where only small portions of the walls are fused together, to severe, where a large majority of the uterine walls are bonded. As a result, symptoms also range from mild to severe – from lighter periods, abdominal pain, lack of periods altogether, and infertility.
Infertility can result from two Asherman-caused symptoms: either a lack of menstruation or a uterus that cannot support embryo implantation because there are no suitable uterine surfaces on which to implant.
The most common treatment for the syndrome is surgery, which is typically very successful and can restore natural fertility by clearing and healing the uterus.
What about other forms of reproductive or prenatal issues resulting from D&C?
Asherman’s syndrome aside, it should be noted that the science on whether a D&C affects fertility and pregnancy – from miscarriage to cervical incompetence to preterm birth – is mixed. The bottom line is that the evidence to support the idea that a D&C causes a significant risk to fertility is limited, except for Asherman's syndrome, which is rare.
Should I get a D&C?
This is a big decision and one that you and your healthcare provider should make. Again, it all depends on your situation, medical history, and how your uterus is coping with the miscarriage. If you do choose to go the D&C route, rest assured that the D&C will likely not play a role in your fertility in the future. In fact, properly clearing miscarriage-related tissue from the uterus is vital to achieving a future pregnancy.
To learn more about your fertility and treatment options, schedule a first consultation with Dr. Anne Davis at Pearl Mini-IVF in San Diego.
