Sunday, July 5, 2009

Opinion: Abortion debate masks real issues on D&C safety

Unfortunately, I have become all too aware of the distortion of medical facts and findings since being diagnosed with Asherman' syndrome in 2007 following a D&C for incomplete miscarriage (I have never had an abortion). High on the list of misinformation about Asherman's syndrome, a complication of D&C, is that it is caused only by abortion. One can never repeat enough that Asherman's syndrome as well as other complications result from D&C, NOT 'abortion' per se. Abortion is just a 'reason' for performing the D&C, the same way a miscarriage, or retained placenta for example, are. As I explained in the introductory blog, D&C is (unfortunately) used commonly in gynecology and obstetrics to treat everything from fibroids and polyps to miscarriage and postpartum hemorrhage. There is sufficient evidence in the medical literature (and I will provide this in a future post) that the incidences of Asherman's syndrome are roughly the same or even lower following D&C performed for termination, than those following miscarriage and delivery.

It is well known that women who undergo repeated dilation and curettage (or even a single dilation of over 12 mm) are at a high risk of cervical incompetence (cervical insufficiency) which is thought to account for second trimester pregnancy loss in women with a history of Asherman's syndrome (1). This particular complication is not caused by the endometrial damage itself (ie. adhesions or fibrosis of Asherman's syndrome) but as a by-product of the stretching or dilating (as in 'dilation and curettage of D&C) of the cervix during D&C (which caused the Asherman's syndrome) and also during corrective surgery to remove adhesions (hysteroscopic adhesiolysis).

 Prolife proponents will often twist medical research findings to benefit their own anti-abortion agenda. Whenever a study shows increased obstetric or fertility complications following D&C, the message blaring from these lobbyists will be that abortion (not the medical technique of dilation and curettage) is the cause. As such, they completely ignore these risks apply equally to women who have a D&C for other causes, such as miscarriage, retained post partum placenta or other indications. By associating the procedure with such a highly contentious topic, all reasonable debate about the medical safety of the medical procedure is overtaken by an emotional moral debate about people's personal opinions regarding a woman's right to choose versus an embryos right to life.

For example, an oral presentation given at the recent 25th annual meeting of ESHRE (European Society of Human Reproduction and Embryology) in Amsterdam (28 June-1 July 2009. Click here to read the original press release on the oral presentation) "Complications early in pregnancy or in previous pregnancies adversely affect existing or subsequent pregnancies" summarized that:

"The researchers found that a history of one or more miscarriages nearly doubled the risk in an ongoing pregnancy of preterm premature rupture of the membrane that surrounds the baby in the womb, and increased the risk of premature or very premature delivery."


"Recurrent miscarriages (three or more miscarriages) increased the risk in a subsequent pregnancy of all of these conditions; in addition, it increased the risk of placenta praevia (where the placenta partially or completely blocks the cervix) six-fold and congenital malformations nearly two-fold."

Then there is the logical mention of abortion since the two are linked to D&C:

"If a previous pregnancy had to be terminated for any reason, this increased the risk of premature rupture of the membrane, premature and very premature delivery in subsequent pregnancies."

It seems obvious that the reason for these complications is that D&Cs are often used to treat miscarriages AND for terminations. Hence, women who have been exposed to D&Cs for either miscarriages or abortion would both be at a risk for D&C-related complications.

Yet prolife proponents insist on interpreting medical data as above with a moral view instead of a scientifically rigorous one. This is demonstrated by the scientifically illogical reasoning of Josephine Quintavalle, of the campaign group Comment On Reproductive Ethics, in response to the above findings:

"There's a logic. The body is protecting a healthy baby. By producing an abortion, you destroy that protection and make the cervix - the neck of the womb - more vulnerable.
And if you make the cervix more vulnerable, you are more at risk of a premature baby."

The problem with that explanation is that the cervix is weakened whether or not there is a 'baby' (healthy or not) in the womb because cervical dilation (D&C stands dilation and curettage) stretches the cervix open so that instruments can access the uterus. If the cervix had some sort of 'moral' sensor as Ms Quintavalle seems to believe, D&Cs and dilations for reasons other than abortion should not lead to cervical insufficiency or preterm births. The medical fact however is that the same complications occur after an abortion as after repeated dilation even if there is a dead baby inside (ie. a miscarriage) or the remains of a miscarriage, or polyps, or for any reason a D&C is used, or a cervix is mechanically stretched. 

What has been happening for decades is that complications of D&C are being hijacked by those on the prolife side of the abortion debate as 'arguments' against abortion. They also hope it can be used to scare women from terminating pregnancies. This simplistic argument overlooks the fact that there are ways to abort without surgery: mifepristone (RU486) and misoprostol (Cytotec), to name the most popular drugs which can be used instead of D&C. (Note: Not surprisingly, the prolifers in the know about this also disseminate false information about the risks of these drugs to scare women). They are also behind the movement banning these drugs from being carried by most pharmacies or prescribed by private doctors. Unfortunately, this fixation on the rights of embryonic life is at the expense of the thousands, if not millions, of women who are only given the option of D&C for other indications. It seems that to these prolifers, it is more important to prevent abortion than to prevent all women, even those who miscarry or have delivery complications, from being subjected to the risks and complications of D&C including future infertility and/or life-threatening obstetric complications such as placenta accreta. In other words, they consider an embryo to have have more of a right to life than an adult woman. The biggest irony, however, is that these drugs which can replace D&C are often only available in abortion clinics but not to women who miscarry! As a society, we should be asking ourselves why this is so.

Meanwhile, I frequently hear from those on the prochoice side of the abortion debate, denials about the risks associated with abortion probably because they do not want to have this 'inconvenient truth' tarnish women's 'freedom of choice'. Presumably they are also unaware that drugs can replace D&C so the argument is invalid to begin with. What they also fail to realize is that D&Cs are hardly a 'feminist'option. Consider what the procedure is: a doctor inserts sharp and/or an extremely powerful suctioning instrument into a sexual reproductive organ which contains fragile tissue (the endometrium) necessary for implantation and a normal pregnancy and then scrapes at it without even being able to see what they are doing! On top of this, the doctor usually doesn't tell them that complications are not uncommon and that if he makes a mistake and renders them infertile, chances are he will get away with it ($1,000 richer). In my opinion, a woman's right includes the right to be accurately informed about the true risks of a procedure and the right to be given other available options regarding what is done to her body.

So the real issue here-that is, the health and fertility risks of blind surgery (D&C)- is being clouded by the abortion debate. Who benefits from this? Certainly NOT women.

As someone who developed Asherman's syndrome after a D&C for incomplete miscarriage, I feel that the myth that only abortion causes complications should be actively dispelled. Firstly, it stigmatizes all women who have Asherman's syndrome by associating their condition with the highly controversial issue of abortion. It suggests that any woman with Asherman's syndrome is 'responsible' for her situation when in truth she may have done nothing of her choosing to cause it. It may also be one of the reasons that women with Asherman's syndrome often prefer to stay anonymous about it. The second reason it must be dispelled is because it is a distraction from the real issue-the risks of D&C. It hides the fact that in the 21st century, women are being subjected to blind surgery of the reproductive organs, which causes injury (possibly impairing fertility) in up to 31% of cases (2) DESPITE THE EXISTENCE OF SAFE, NON-INVASIVE, EFFECTIVE ALTERNATIVES. The uninformed view that only abortion causes complications will come as a rude shock to women who get these complications from D&Cs (or uterine surgery) for other reasons. But it is too late for them. The third and most important reason it must be debunked in particular is that the misinformation about risks is the reason why D&Cs continue to be performed for all types of reasons and why complications from them continue to occur. Prevention is not being practiced even though use of drugs could significantly reduce the number of D&Cs and subsequent complications.

There is undoubtedly much ignorance in the public arena concerning gynecological procedures and what they are used for unless people have undergone it themselves or have a medical or paramedical background. This explains in part why these false ideas continue to flourish. What is less clear is why the medical community does not step forward to dismiss these so-called arguments. Could this possibly be because D&Cs are one of the most common procedures on women of reproductive age and that admitting that all D&Cs carry a risk would mean this veritable 'industry' of blind surgery (and associated income)? Little experience is needed to perform D&Cs, unlike hysteroscopy, and if drugs such as misoprostol can replace D&Cs, the money will go to the pharmaceutical companies that produce it, instead of the ObGyn, Hospital and Anesthesiologist. Also, could an uneasiness with performing terminations be the reason why medical management is used for abortions but not for miscarriages? In other words, do doctors themselves, or medical bodies feel it is 'unethical' to perform abortions and so prefer to gain as little from it as possible or play a less active role in the procedure than with a D&C?

Surgery- and complications from that surgery-do not discrimminate between what is morally 'right' or 'wrong'- people do. Science cannot answer whether it is ethical to terminate a pregnancy but it can frame the debate by showing that complications from D&C exist, regardless of the moral context in which it is used. For the informed person, the issue should not be 'should abortions must be banned because of possible complications?' but 'should the medical community continue to perform D&Cs on women-for any reason- when these complications exist and alternatives are available?'


(1) Capella-Allouc S, Morsad F, Rongieres-Bertrand C, et al. (1999). "Hysteroscopic treatment of severe Asherman's syndrome and subsequent fertility". Hum Reprod 14 (5): 1230–1233.
PMID 10325268
(2) Adoni A, Palti Z, Milwidsky A, Dolberg M. (1982). "The incidence of intrauterine adhesions following spontaneous abortion". Int J Fertil. 27 (2): 117–118.

No comments:

Post a Comment