Why You Should Avoid a Dilation and Curettage
It's not a political thing
I've been doing my research lately because I had a D&C almost a year and a half ago due to a stillbirth. I knew it would take a while to heal. My doctor had told me that my period would be back to normal in a few months, but a year and a half later it is just now starting again. My curiosity was piqued because I began reading more about miscarriages. I needed to feel comforted in hearing others' stories for one thing, but I kept hearing about complications after having a D&C. I want to share with you know just what I have found, and why you are risking your fertility by having this procedure done. Also, D&E's and aspiration also can have the same effect. These are things most doctors don't tell you, and yet the risk for infertility is so high. Read on as we touch on a sensitive subject.
*There are situations where a D&C is necessary. Please discuss your options with a qualified physician.
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What is a D&C?
According to American Pregnancy.org, D&C, also known as dilation and curettage, is a surgical procedure often performed after a first trimester miscarriage. Dilation means to open up the cervix; curettage means to remove the contents of the uterus. Curettage may be performed by scraping the uterine wall with a curette instrument or by a suction curettage (also called vacuum aspiration), using a vacuum-type instrument.
A D&C procedure may be done as an outpatient or inpatient procedure in a hospital or other type of surgical center. A sedative is usually given first to help you relax. Most often, general anesthesia is used, but IV anesthesia or paracervical anesthesia may also be used. You should be prepared to have someone drive you home after the procedure if general or IV anesthesia is used.
1) You may receive antibiotics intravenously or orally to help prevent infection.
2) The cervix is examined to evaluate if it is open or not. If the cervix is closed, dilators
(narrow instruments in varying sizes) will be inserted to open the cervix to allow the surgical instruments to pass through. A speculum will be placed to keep the cervix open.
3) The vacuum aspiration (also called suction curettage) procedure uses a plastic cannula (a flexible tube) attached to a suction device to remove the contents of the uterus. The use of a curette (sharp edged loop) to scrape the lining of the uterus may also be used, but is often not necessary.
4) The tissue removed during the procedure may be sent off to the pathology lab for testing.
5) Once the health care provider has seen that the uterus has firmed up and that the bleeding has stopped or is minimal, the speculum will be removed and you will be sent to recovery.
Resource: American Pregnancy.org
Looking back, I wish I had said more. I wish I had asked more questions. The night I started to miscarry I was in too much shock to speak up. I should have asked to be hospitalized or something. I had started bleeding, and so we went to the ER. They ran some tests and found a healthy heartbeat, so I was sent home to await an ultrasound. The only thing is I didn't make it to 10:30 the next morning. My baby was stillborn at home at 5 months. My husband took me to the ER with our little boy in my arms. The nurses cut the umbilical cord and the doctor tried to release the placenta by hand. I can't tell you how painful that was. I gripped the side of the bed so hard!! After 30 minutes of trying, they decided I needed to go to a different hospital. They were not set up for surgeries. I was sent by ambulance and a second doctor tried for 20 minutes to release the placenta by hand. I was informed I needed surgery. Was it necessary? I don't know. What if there was an alternative? We had no clue because alternatives were not discussed.
I do feel that surgery was the only option, and even though there are risks D&C's are necessary at times. They told us surgery would be about 20 minutes. It was over an hour before I was sent to recovery. I felt ok at first. I cannot remember what my blood count was, but my doctor said I lost a lot of blood. It ended up being over 50% of my blood volume, but given that I had been pregnant my blood volume was higher then normal. I did not need a transfusion at least. They wanted to send me home initially, but I got up to use the restroom and fainted, puking all over myself. I went to adjust my pillow at one point and the same thing happened. They decided I needed to stay overnight. I can remember reading the monitor and thinking 50/30 wow that's low blood pressure. At least, I'm the type of person who has normally low blood pressure anyway. I recovered enough to get up and walk.
By noon, I was released to go home with some heavy pain medication. I made it to the funeral home to make arrangements and then went home to crash in bed for the next few days. It really took a toll on my body. Over the last year an a half I have not had a period. I did not think too much about it, but I ran across a webpage regarding Asherman's and it concerned me. It made me upset to think that so many women are dealing with this and so many others are unaware of the risks. I continue to educate myself, and though I think we have decided not to get pregnant again, I am a little sad about the prospect of being infertile.
Know The Facts
"We believe women contemplating abortion would benefit from this knowledge and that providers of abortion procedures have an autonomy-based obligation to make women aware of the potential future reproductive harm. "
John M. Thorp, Jr., MD
The Debate Continues:
Would you terminate a pregnancy?
Asherman's Syndrome is also known as traumatic amenorrhea which basically means an absence of a menstrual cycle due to a traumatic event. In 1948, Asherman described the association of cervical stenosis and amenorrhea following instrumentation of the uterus in the puerperal period (Asherman 1948). Two years later he described the presence of intrauterine adhesions, which may prevent pregnancy. The occurrence of adhesions in the uterine cavity reportedly occurs in 40% of uteri following the secondary removal of placental tissue or a repeat curettage following missed abortion. The original article can be found here.
And just what does that mean? Findings have shown, that 40% of all dilation and curttage procedures resulted in intrautering adhesions 40% of the time. These adhesions are better known today as Asherman's Syndrome, named after the man who published these findings. Of these adhesions, up to 75% can be classified as moderate to severe (Westendorp, Ankum et al. 1998). The abstract to their medical research can be found here. Another study found that "Asherman's syndrome has been estimated to occur in about 25% of these procedures that are done one to four weeks following pregnancy (Buttram, et al., In J Fertil 1977;22:98-103) and as many as 30% of missed spontaneous abortions with the length of time between fetal demise and the D&C itself being directly correlated with the risk of adhesion formation (Adoni, et al., Int J Fertil 1982;27:117-18).
You can read more here.
What Did That Say?
Did that say 40%?
What are RPOC's? Retained products of conception and risks
An informative blog about Asherman's
- Asherman's and Placenta Accreta
What is Placenta Accreta
- National Institute of Health
More information about Asherman's
An abstract for research regarding Asherman's
Learn more about Asherman's
Asherman's In Detail
So What Is The Research Saying?
Breaking it all down to layman's terms, somewhere between 25-40% of all D&C procedures result in Asherman's Syndrome. Studies also show that Dilation and Evacuation (D&E) and Aspiration can also cause Asherman's at about the same rate. Ceseran Sections and STD's can cause Asherman's, but cases are rare. Of those that develop Asherman's, somewhere between 75% and 90% have fertility problems. Most studies cited that Asherman's caused infertility 90% of the time. The reason why Asherman's causes infertility is due to those adhesions, scar tissue, and connective tissues "sticking" together. These tissues can block the cervix causing severe pain.
The Breakdown In Numbers
According to the Center for Disease Control in the most recent data, 2006, there were 1,242,000 abortions in the U.S. For the sake of argument, we will assume that this number includes spontaneous and elective abortions since there is no indication as to which they are reporting. If this does not include spontaneous abortion, then the numbers are higher. So, let's start with their data.
1,242,000 women have abortions every year.
Of those, 40% will develop Asherman's Syndrome. That would be 496,800 women.
Of those 75% -90% experience infertility. That would be 372,600 women.
Of those approximately 40% either cannot conceive or miscarry after treatment for infertility.
That would be 148,800 women in the U.S. a year risk being completely infertile due to Asherman's even with treatment every year.
Treatment Options and Outcomes
According to Asherman's.org the most common treatment for Asherman's is by hysteroscopic surgery. In this procedure, a tiny camera is inserted into the womb and adhesions and scar tissue are removed. The outcomes of this surgery are not promising however. In a research article titled Reproductive outcome following hysteroscopic adhesiolysis in patients with infertility due to Asherman's syndrome in 2010 in the Archives of Gynecology and Obstetrics, "the overall conception rate was 40.4% after hysteroscopic adhesiolysis. The mean conception time after surgery was 12.8 months. There was no conception in patients who needed repeat adhesiolysis. The conception rate was higher (58%) in mild Asherman's syndrome compared to 30% conception rate in moderate and 33.3% conception rate in severe cases. From other articles I have read, 40% seems to be the general number.
Asherman's.org suggests that surgery is followed by estrogen therapy. Other procedures have been used to treat, such as laser therapy, but have not proven to be as effective as hysteroscopic surgery.