Will a dilation and curettage (D&C) affect fertility?

Will D&C Affect Fertility?

D&C performed for miscarriage or pregnancy termination is associated with an increased risk of subsequent preterm birth and may temporarily impair fertility, but does not typically cause permanent infertility in most women. 1

Impact on Subsequent Pregnancy Outcomes

Preterm Birth Risk

• Women with a history of D&C have a 29% increased risk of preterm birth <37 weeks (OR 1.29,95% CI 1.17-1.42) compared to women without such history 1
• The risk is even higher for very preterm births: 69% increased risk for births <32 weeks (OR 1.69) and 68% increased risk for births <28 weeks (OR 1.68) 1
• Multiple D&Cs compound the risk significantly, with a 74% increased risk of preterm birth (OR 1.74) compared to no D&C history, suggesting a dose-dependent causal relationship 1
• Spontaneous preterm birth specifically shows a 44% increased risk (OR 1.44) in women with prior D&C 1

Temporary Fertility Impairment

• The endometrium requires approximately 6 months to recover normal reproductive function after D&C, affecting both live birth rates and pregnancy loss rates 2
• Women who undergo frozen embryo transfer ≤6 months after D&C show significantly reduced endometrial thickness and lower live birth rates compared to those who wait >6 months 2
• The relative risk for live birth is 1.65 times higher when waiting >6 months after D&C before attempting pregnancy 2

Conception and Pregnancy Rates

• Despite these risks, most women do conceive after D&C: conception rates of 59.7-71% have been reported within 12 months following the procedure 3
• Median time to conception ranges from 5.5 to 7.1 months after D&C 3
• In women desiring pregnancy after D&C, ongoing pregnancy rates of 67-75% have been documented 4

Mechanism of Fertility Impact

Intrauterine Adhesions (Asherman Syndrome)

• D&C can cause intrauterine adhesions, which may affect menstrual patterns and fertility 4, 3
• Reduced menstrual blood loss occurs in 7.5-20.3% of women after D&C 4
• Dysmenorrhea develops in 14.9-34.4% of women following the procedure 4

Endometrial Damage

• The extent of endometrial damage is not always reflected in endometrial thickness measurements 2
• Direct trauma to the endometrium from curettage may impair implantation and placentation in subsequent pregnancies 1

Clinical Context: D&C for Fertility Preservation

When D&C Is Part of Fertility-Sparing Treatment

In the specific context of endometrial cancer or atypical hyperplasia where fertility preservation is desired, D&C serves a diagnostic rather than therapeutic role and is actually a required step 5, 6:

• Patients with atypical hyperplasia/endometrial intraepithelial neoplasia (AH/EIN) or Grade 1 endometrial cancer requesting fertility-preserving therapy must undergo D&C with or without hysteroscopy for accurate diagnosis 5
• This diagnostic D&C must be performed at specialized centers with confirmation by a specialist gynaecopathologist 5, 6
• Pelvic MRI is required to exclude myometrial invasion and adnexal involvement 5, 6

Practical Recommendations

Timing of Subsequent Pregnancy Attempts

• Women should ideally wait at least 6 months after D&C before attempting pregnancy to optimize reproductive outcomes 2
• This waiting period allows for endometrial recovery and normalization of reproductive function 2

Monitoring and Follow-Up

• Women with prior D&C should be considered at higher risk for preterm birth in subsequent pregnancies and require specialized perinatal care 5
• Assessment for intrauterine adhesions via hysteroscopy 8-12 weeks after D&C may be warranted if menstrual abnormalities develop 4, 3

Alternative Management Considerations

• Given the association with preterm birth and temporary fertility impairment, less invasive options for miscarriage management (such as medical management) should be considered when clinically appropriate 1
• The increased risk with multiple D&Cs indicates that alternative approaches should be strongly considered for women who may desire future pregnancies 1

Important Caveats

• While D&C increases risks of adverse pregnancy outcomes, it does not typically cause permanent infertility—most women successfully conceive and deliver after the procedure 4, 3
• The fertility impact appears to be temporary and reversible in most cases, with recovery occurring over several months 2
• Confounding factors in observational studies cannot be completely excluded, though the dose-response relationship with multiple D&Cs supports causality 1