Early pregnancy loss occurs in ~ 15% of all pregnancies, while 10% of women have
experienced at least one pregnancy loss. The therapeutic options that are available in
these cases include surgical termination of pregnancy by suction curettage, medical
treatment with Misoprostol, and conservative management. The surgical termination of
pregnancy allows for relatively quick termination of the pregnancy, and prevention of
heavy vaginal bleeding requiring urgent curettage. However, although this is a common and
relatively safe procedure, it is associated with risks such as infection, residual
trophoblastic tissue or retained products of conception (RPOC), bleeding and uterine
perforation. In the long term, there is a risk of intrauterine adhesions formation, which
may cause infertility and in severe cases, Asherman's syndrome. It has been hypothesized
that RPOC following suction curettage occur because it is a "blind" operation. Therefore,
it is now common practice to use ultrasound imaging during and/or immediately after the
procedure in order to verify that all the pregnancy contents have been removed. However,
despite the use of ultrasound, RPOCs are diagnosed in 1% to 10% of these procedures.
Intrauterine adhesions following suction curettage are another significant risk of these
procedures. In a study by Hooker et al., intrauterine adhesions were found in
approximately 20% of suction curettage cases, while in women with repeated miscarriages
the risk of intrauterine adhesions was even higher. Intrauterine adhesions are of
critical importance in women of childbearing age, as they may cause infertility,
menstrual disorders, and recurrent miscarriages. Therefore, preventing adhesions or
reducing the rate of adhesions after surgical emptying of the uterine cavity is an issue
of utmost importance in women of childbearing age. Thus, in recent years, several studies
have investigated the use of operative hysteroscopy for surgical evacuation of early
pregnancy loss. Hysteroscopy allows a visual assessment of the uterine cavity (as opposed
to a "blind" suction curettage), possibly reducing the rates of RPOC. RPOC. In addition,
during hysteroscopy, the surgery is limited to the pregnancy implantation site, as
opposed to the "global" suction curettage. This may allow for reducing the risk of
postoperative intrauterine adhesions. These advantages of hysteroscopy compared to the
blind suction curettage have been previously shown regarding a similar procedure, removal
of RPOC by hysteroscopy compared to curettage, and nowadays it is indeed acceptable to
remove RPOC primarily by hysteroscopy. Thus, it can be hypothesized that operative
hysteroscopy for the management of early pregnancy loss compared with suction curettage
may be associated with reduced rates of RPOC and postoperative intrauterine adhesions. On
the other hand, operative hysteroscopy does have some disadvantages compared with suction
curettage - it requires expensive equipment, a slightly longer operative time, and
skilled surgeons. To date, few studies (mainly case series or small cohort studies) have
been carried out regarding the use of hysteroscopy for surgical evacuation of early
pregnancy loss. These studies found that it is an effective (feasible) and safe
operation. Weinberg et al. used the hysteroscopic tissue removal device for surgical
evacuation of early pregnancy loss up to 10th weeks in 10 patients. The procedure could
be completed in 8 patients, and there were no significant complications. Bar-on et al.
bipolar loop resectoscope in 15 women with early pregnancy loss up to 12 weeks, without
short term complications. More recently, a multicenter comparative prospective study from
France was published by Huchon et al. In this study, no differences were found in the
rate of subsequent pregnancies. However, this study included patients who were not
candidates for hysteroscopy (such as patients admitted incomplete abortion). To conclude,
further comparative studies are needed to determine the benefits of operative
hysteroscopy in patients with early pregnancy loss. In the present study, the
investigators will perform a prospective comparison between surgical evacuation of early
pregnancy loss by surgical hysteroscopy using the tissue removal device method versus the
traditional suction curettage. The investigators will evaluate both the feasibility and
safety (both short and long term) of the procedures, including an assessment of
postoperative intrauterine adhesions.