Dilation and Curettage (D&C) | Fertilitywise (2024)

What is a dilation and curettage?

A dilation and curettage (D&C) is a surgical procedure that is used to remove tissue from the uterus. It involves dilation of the cervix, which allows for entry into the uterus. A small instrument, known as a curette, is inserted through the cervix into the uterus and is used to remove tissue such as the products of conception.i

Dilation and Curettage (D&C) | Fertilitywise (1)

Why is dilation and curettage performed?

Dilation and curettage procedures can be categorized as diagnostic or therapeutic:

  • Diagnostic: Diagnostic D&C procedures are used to diagnose a medical condition in a non-pregnant patient, such as performing a biopsy for abnormal uterine bleeding to rule out endometrial cancer. In this case, the tissue that is removed from the uterus is examined under a microscope so a diagnosis can be made.ii In addition, a diagnostic D&C can be used in the case of a pregnancy with unknown location, to rule out ectopic miscarriage.iii
  • Therapeutic: A therapeutic D&C is used to treat a medical condition or problem and is performed in a pregnant or recently pregnant female — typically following a miscarriage or for elective termination of a pregnancy. It may also be used to remove either a molar pregnancy (when there is a problem with a fertilized egg that affects development after conception) or retained pregnancy tissue following delivery or incomplete miscarriage. The D&C will remove the products of conception from the uterus.

What are the signs of a miscarriage?

Symptoms of a miscarriage include pelvic cramping and vaginal bleeding. Miscarriages can also be asymptomatic (no symptoms). To confirm a miscarriage, doctors will examine beta human chorionic gonadotropin (b-hCG) using bloodwork. If b-hCG is not rising appropriately, it may indicate a miscarriage. Or if the b-HCG level is greater than 1,500 to 3,000 mIU/mL, but a viable pregnancy is not seen on ultrasound, a miscarriage may be suspected.iv Patients and providers may choose a D&C to manage the miscarriage.

What does a dilation and curettage involve?

These are the typical steps of a D&C before, during, and after the procedure.

Before a dilation and curettage procedure

Prior to the surgery, the healthcare provider may give the patient medication to help prepare the cervix to be dilated — known as “cervical priming.” The most used priming agent is misoprostol, which is placed in the vagina prior to surgery. Laminaria may also be used as a dilator but is typically used in more advanced pregnancies.v The healthcare provider may also complete bloodwork prior to the D&C to check hemoglobin levels or blood type, or to gain other routine information for the surgical procedure.

During a dilation and curettage procedure

A dilation and curettage is completed in an operating room (OR), or in an outpatient clinic outside of the hospital. It is typically completed as a day surgery, and the patient may return home a few hours after. Since anesthesia is typically used, the patient will require someone to drive them home.vi

This procedure generally takes between 15 and 30 minutes. A nurse will likely put an intravenous (IV) line in the patient's arm to administer medications and anesthetic agents, which may be either general anesthesia, or local anesthesia.vii Normally, this procedure is painless.

During the D&C, the patient will lie on her back and her legs will be placed in footrests. A speculum will be placed into the vagina to allow the healthcare provider to visualize the cervix, similar to what happens during a Pap test.

A surgical instrument known as a tenaculum is then used to hold the cervix in place, while a dilator is passed through the opening in the cervix into the uterus. Progressively larger cervical dilators are used sequentially, until the cervix is sufficiently dilated.

The dilator is then removed, and a curette is inserted into the uterus in order to remove the contents inside. Most often this step involves removal of the products of conception (i.e., pregnancy tissue), but other times the D&C is used for diagnostic purposes, as described above.viii

After a dilation and curettage procedure

After the procedure, the patient will be moved from the OR to the recovery room, where they will be monitored for some time in case there are any post-surgery complications. Some patients may experience nausea or vomiting due to the anesthetic medications, which will be treated in the recovery room.

Following a dilation and curettage, it is normal to have mild cramping, alongside some light vaginal bleeding, which can be treated with Tylenol or Advil. Normal activities can generally resume within one to two days after a D&C, and menstruation typically resumes within two to six weeks of D&C in the case of a miscarriage.ix

A patient experiencing any of these side effects should consult a physician, as they can be signs of possible complications:x

  • Pain that is getting worse rather than better
  • Heavy bleeding soaking more than two pads per hour for two consecutive hours
  • Fever
  • Abnormal vaginal discharge

What are the alternatives to a dilation and curettage?

A D&C is classified as surgical management of a miscarriage. However, there are other approaches to managing a pregnancy loss including medical management and expectant management. There are also additional forms of surgical management.

Expectant management of miscarriage

Expectant management involves waiting for the pregnancy tissues to expel naturally. With expectant management, the patient will need to be monitored, and medical or surgical management may ultimately be necessary if the tissues are not expelled spontaneously.xi

Medical management of miscarriage

One of the most common and effective forms of medical management for early pregnancy loss is Mifepristone/misoprostol. It involves taking 200 mg of mifepristone orally, followed by 800 mcg of misoprostol vaginally (or orally) 24 to 48 hours later. In some geographical locations, these medications are combined into one formulation (Mifegymsio).xii

  • Pros: Medical management is less invasive than surgery. It can be completed as an outpatient procedure, with follow-up with a clinician.
  • Cons: Bleeding may last for one to three weeks afterwards. The passage of tissue occurs gradually, whereas a D&C is quicker. These medications can cause intense cramping, and bleeding is typically heavier than a menstrual period. There is a risk that medical management may be unsuccessful, and that a D&C may still be required afterwards.xiii

Vacuum aspiration (MVA)

Known colloquially as “suction curettage,” a vacuum aspiration (MVA) is like a D&C in that the cervix is still progressively dilated. Instead of using only a curette to remove the uterine tissue, an instrument with suction is used to remove the contents. Suction is commonly added in the setting of fertility treatment, either with an MVA device or electric suction. It is similar to a D&C in terms of risks and efficacy.xiv,xv

Hysteroscopic D&C

An additional instrument that may be used during a D&C is a hysteroscope, which is a camera that allows the physician to see the inside of the uterus. A hysteroscope aids in the removal of uterine contents.

D&C vs. D&E

D&C and D&E (dilation and evacuation) are similar procedures but have some key differences due to their timing and the instruments used. D&E is typically performed later in pregnancy, so it often takes longer and requires the usage of more specialized instruments.

A D&C is typically used prior to 12 to 14 weeks gestation (within the first trimester of the pregnancy), while a D&E is typically used after 14 weeks’ gestation (in the second trimester of pregnancy). D&E is most used for induced termination or for intrauterine fetal demise. However, it is like D&C in that it may involve cervical priming, followed by progressive cervical dilation. Next, there is aspiration of the uterine contents, often requiring other instruments such as forceps to remove the uterine tissue.xvi

Dilation and Curettage (D&C) | Fertilitywise (2)

What are the risks of a dilation and curettage?

As with any surgical procedure, there are certain risks associated with a dilation and curettage. Some of these risks include infection, uterine perforation, scar tissue, bleeding, and retained tissue from conception.

Infection

Since the cervix is dilated during a D&C, it is possible for bacteria to enter the uterus and cause an infection. To prevent this problem, prophylactic antibiotics are recommended in pregnant or recently pregnant females. When a patient is not pregnant and the D&C is being completed for diagnostic purposes, prophylactic antibiotics are not usually required. There is a 1 to 2 percent chance of infection following a D&C.xvii

Perforation of the uterus

There is a small chance of uterine perforation, or perforation of other structures, such as the bladder and bowel.xviii A uterine perforation occurs when an instrument passes through the top of the uterus, known as the fundus, during a D&C. In a study of over 11,000 patients, the risk of uterine perforation following a D&C was 0.19 percent.xix While this study is older, it is unlikely that risks have increased. If anything, they may have diminished with improvements in technology.

Scar tissue

Asherman’s syndrome (AS) is the formation of scar tissue (adhesions) within the inside of the uterus, and it has been linked to D&C. Asherman’s syndrome can potentially cause these issues:xx

  • Cessation of menstruation
  • Decrease in frequency of menstruation
  • Decrease in fertility
  • Abnormal placentation in future pregnancies

Some studies have shown that AS can occur in up to 13 percent of patients who undergo elective termination of pregnancy during the first trimester, and up to 30 percent who undergo D&C of a late miscarriage.xxi The estimated frequency of Asherman’s syndrome linked to D&C does vary between studies, with a higher risk associated with repeated D&C procedures. Furthermore, the severity of AS is highly variable between individuals.

Bleeding

Spotting or light bleeding after a D&C is common.xxii,xxiii,xxiv More severe cases of bleeding (hemorrhage) are a rare complication.xxv,xxvi,xxvii

Retained tissue

If a D&C is incomplete, and all the tissue from a pregnancy is not removed from the uterus, it is known as retained products of conception (RPOC). It often requires a repeat D&C to remove the remaining tissue. Incomplete D&C occurs in approximately 6 percent of patients who undergo a D&C for elective termination or miscarriage.xxviii

How soon after a D&C can a woman get pregnant?

After a dilation and curettage, a clinician may discuss theoretical concerns of infection and recommend avoiding placing anything in the vagina for a certain period of time. For example, it is generally recommended to abstain from sexual intercourse for one to two weeks after a miscarriage to prevent possible infection.xxix

Patients often ask how long they need to wait before trying to conceive (TTC) after a D&C for miscarriage. The amount of time in between pregnancies is called the interpregnancy interval. In the past, patients were counselled to wait three months after miscarriage to begin trying to conceive in order to reduce the risk of recurrent miscarriage. However, recent research has indicated that this may not be necessary. In a study published in Obstetrics & Gynecology, of the 514 patients who had recently miscarried, the lowest rate of repeat miscarriage (7.3 percent) occurred within the patients who conceived again within three months of miscarrying.xxx

Other recent research has shown that live birth outcomes are similar in females who choose to wait over three months to conceive, versus those who did not wait. A study by Wong et al (2015) found that the overall live birth rate was 76.5 percent in females following pregnancy loss. The live birth rate was 80.4 percent in the group with an interpregnancy interval of three months or less, and a rate of 74.6 percent in the group with an interval of more than three months. Therefore, the live birth rate was similar in both groups; there was no statistically significant difference between the groups.xxxi

Another study focused specifically on patients undergoing D&C for miscarriage and evaluated patients who conceived again within six months of the D&C, compared with patients who underwent medical management (with misoprostol) or expectant management (no intervention). They found that there was no significant difference in the rate of preterm delivery, premature rupture of membranes, placental abruptions, or any other complications if the patient underwent a D&C versus trying medical or expectant management.xxxii In fact, there is no quality data to support delaying conception after miscarriage to prevent another miscarriage, or pregnancy complications, according to American College of Obstetricians and Gynecologists (ACOG) guidelines.xxxiii

Even though there may not be a physiological need to wait before TTC after a D&C, patients may choose to wait to maximize their emotional wellbeing. Some individuals require time to adequately process the loss, grieve, and emotionally heal before they feel ready again. Each person is different and there is no right or wrong way to approach the timing of TTC again after a D&C for miscarriage.

Can a D&C affect future fertility?

Evidence suggests that most of the time, dilation and curettage will not negatively impact future fertility. The most significant complication of a D&C that can affect fertility is through Asherman’s syndrome, as discussed above. It is estimated that patients with moderate to severe Asherman’s syndrome have a 19 percent combined rate of miscarriage, stillbirth, or preterm delivery.xxxiv

In many patients, Asherman’s syndrome can be treated with a procedure called “adhesiolysis,” in which the uterine scarring is broken up to restore the inside of the uterus. In a retrospective study of patients with Asherman’s syndrome treated with adhesiolysis, 95 percent of patients had restoration of the uterine cavity, with approximately 29 percent having recurrence of uterine adhesions afterwards.xxxv

In most females, future fertility is not affected after a D&C. As part of a meta-analysis, reproductive outcomes following miscarriage were analyzed. Across five studies involving a total of 511 females who underwent D&C after miscarriage, 75 to 98 percent were able to conceive. The range of ongoing cumulative pregnancy rates after conception was 72 to 87 percent.xxxvi However, the same review also suggested that treatment strategies to minimize the number of D&Cs should be employed to reduce the potential for intrauterine adhesions.xxxvii

Individuals hoping to conceive following a D&C should consult their doctor to determine the best path forward but should also feel assured that having had a D&C is generally not a major impediment to being able to conceive again.

Tissue (embryonic and placental) testing after D&C

Following a dilation and curettage, the removed uterine tissue is often sent for examination under a microscope, known as “histopathologic” examination. This exam can be useful to identify potential embryonic or uterine tissue abnormalities.xxxviii This type of embryonic tissue testing can also sometimes be done by patients experiencing a miscarriage at home in the case of expectant management. (They are provided with tubes in advance to collect the tissue themselves).

In some geographical locations, clinicians or patients can request a genetic analysis of the uterine tissue removed after a D&C in order to potentially identify a cause of the miscarriage.xxxix In some regions this step is done routinely, while in other areas (especially with universal health care) it will only be done in the cases of recurrent miscarriages. Genetic analysis of the uterine tissue removed after a D&C involves looking for chromosomal differences in the embryonic/fetal tissue, to investigate whether the cause of miscarriage was related to chromosome aneuploidy (abnormality).

In a large retrospective study of IVF patients that looked at the cytogenetic analysis of products of conception after blastocyst transfer, it was found that 19.4 percent were genetically normal embryos, while 80.6 percent had an abnormal number of chromosomes (aneuploid).xl Understanding whether the cause of miscarriage was related to aneuploidy in the embryo or not may help patients undergoing fertility treatment, and their providers, with future treatment planning.

Conclusion

A D&C may be indicated during an extremely traumatizing period of a female’s life, whether she has had a miscarriage, is dealing with health concerns that require diagnosis, or is struggling with other issues. Understanding this procedure, the risks, and potential alternatives can help patients determine how to navigate these challenging scenarios.

Evidence suggests that an individual need not wait significantly long after a miscarriage before trying to conceive again, which may help guide the next steps after a loss. However, emotional factors should be considered as well.

Anyone concerned about conceiving again after a D&C should speak with a clinician to map out a plan most appropriate to their individual circumstances.

Dilation and Curettage (D&C) | Fertilitywise (2024)

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