A Safer Surgery For Miscarriage Exists. Most Women Never Hear About It

The Procedure Women Are Rarely Told About

Miscarriage affects 10% to 20% of pregnancies in the United States. Among privately insured women who seek outpatient care after one, 24% receive surgical management. That translates to hundreds of thousands of procedures each year, nearly all performed the same way for generations. “It’s one of the first procedures you learn as a new physician,” Sasaki notes, “and it’s kind of crazy because it carries with it great risk, too.”

The risk is structural. By clinical definition, D&C is a blind procedure. A surgeon places an instrument past the cervix and removes tissue based entirely on feel—no camera, no targeted removal, no real-time visualization.

Hysteroscopic morcellation replaces feel with sight. A miniature camera enters the cervix, the surgeon watches a monitor, and tissue is removed under full visualization with simultaneous ultrasound guidance. In Sasaki’s cohort of 208 patients treated at two sites in Park Ridge, Illinois, from 2019 through 2024, 73% of procedures were performed in a physician’s office rather than a hospital operating room. The IUA rate in exclusively hysteroscopic cases was zero.

“We don’t always tell them that if we do [D&C] procedure, we could cause scar tissue that could affect their ability to get pregnant in the future,” Sasaki acknowledges. “It probably should be more at the forefront of the conversation.”

When The Treatment Creates The Next Problem

The clinical consequences of IUAs compound over time. A 2025 systematic review in Human Reproduction Update, authored by researchers at UCLA, the University of Texas at Austin Dell Medical School, and the University of Wisconsin-Madison, found that women with IUAs following uterine surgery may experience absent or light menstruation, infertility, pre-term delivery, and peripartum hemorrhage. In the most severe cases, the condition is classified as Asherman syndrome. After severe adhesions, full-term pregnancy rates can fall to 20% to 40%.

The standard procedure also forfeits diagnostic information women deserve. Chromosomal abnormalities account for roughly 50% of first-trimester miscarriages. Identifying them can spare a woman years of unexplained grief and unnecessary testing. “Just avoiding having those adhesions improves their likelihood of future successful pregnancies,” Sasaki explains. “It also means there are fewer obstacles ahead of them to achieve their next pregnancy.”

The Cost Cascade Nobody Is Running

The financial logic that entrenches D&C as the default collapses under scrutiny. According to FAIR Health, a national nonprofit that tracks healthcare costs using claims data from more than 51 billion records, the average D&C bill for uninsured women runs approximately $8,000 to $9,000. When adhesions develop, a corrective cost cascade follows: $2,383 for a corrective hysteroscopy, $3,937 for lysis of adhesions, and up to $10,342 for placenta accreta spectrum, a dangerous placental complication increasingly linked to prior uterine surgery, according to research by Sasaki and colleagues.

With hysteroscopic morcellation, the patient misses just one day, Sasaki explains, rather than having multiple appointments going forward to deal with complications from the first treatment.

Employers offering fertility benefits through platforms like Carrot Fertility, which may cover aspects of miscarriage support depending on an employer’s specific plan, are well-positioned to recognize that upstream procedural quality reduces downstream fertility costs.

Who Bears The Highest Cost Of A Cheaper Default

The D&C default does not fall equally. Black and Hispanic/Latinx patients are significantly more likely to receive post-miscarriage surgical care in emergency settings, where procedural delays lead to higher rates of hemorrhage, incomplete tissue expulsion, and emergency D&Cs. White and higher-income women are more likely to receive scheduled D&Cs in controlled outpatient settings, offices, and ambulatory surgery centers, where a surgeon familiar with hysteroscopic morcellation is more likely to practice.

Among women who miscarry in emergency department settings, the share receiving surgical management is lower (14%) than in outpatient clinics (24%), but the conditions are markedly worse. The women most harmed by the D&C default are the women least likely to ever be offered the alternative.

The Training Gap And What Needs To Change

How many U.S. surgeons are trained to perform hysteroscopic morcellation for primary miscarriage management? “A handful worldwide,” Sasaki estimates. Her paper notes that all 208 procedures were performed by her senior partner, Dr. Charles E. Miller, a surgeon with more than 40 years of complex gynecological experience, which the authors acknowledge may limit generalizability. The technique requires mastering polypectomy, myomectomy, and retained-products management as prerequisites, a sequence that itself demands fellowship training that very few OB/GYNs pursue.

The path forward runs through ACOG and ASRM. “I’m hoping that with more acceptance from our societies, that might encourage other OB-GYNs to adopt this,” Sasaki says. Her message to the physician who has been performing D&Cs for 20 years and has never encountered this technique is direct: “I would love to introduce you to a new technique that may be a great benefit to both you and your patients.”

Her message to the woman who has been through a miscarriage and was never offered a choice is harder to absorb. “We don’t always tell them,” Sasaki reflects. “But it probably should be more at the forefront of the conversation.”