Original Research
Utility of Office Hysteroscopy in Diagnosing
Retained Products of Conception Following
Early Pregnancy Loss After In Vitro Fertilization
Jenny S. George, MD, Mackenzie N. Naert, MD, Andrea Lanes, PhD, Sophia Yin,
Sonya Bharadwa, MD, Elizabeth S. Ginsburg, MD, and Serene S. Srouji, MD
OBJECTIVE: To evaluate the utility of office hysteroscopy
in diagnosing and treating retained products of concep-
tion in patients with infertility who experience early
pregnancy loss (EPL) after in vitro fertilization (IVF).
METHODS: We evaluated a retrospective cohort of 597
pregnancies that ended in EPL in patients aged 18–45
years who conceived through fresh or frozen embryo
transfer at an academic fertility practice between January
2016 and December 2021. All patients underwent office
hysteroscopy after expectant, medical, or surgical man-
agement of the EPL. The primary outcome was presence
of retained products of conception at the time of office
hysteroscopy. Secondary outcomes included incidence
of vaginal bleeding, presence of intrauterine adhesions,
treatment for retained products of conception, and
duration of time from EPL diagnosis to resolution. Log-
binomial regression and Poisson regression were per-
formed, adjusting for potential confounders including
oocyte age, patient age, body mass index, prior EPL
count, number of prior dilation and curettage proce-
See related editorial on page 1017.
From the Center for Infertility and Reproductive Surgery, Department of
Obstetrics and Gynecology, Brigham and Women’s Hospital, and Harvard Med-
ical School, Boston, Massachusetts.
Each author has confirmed compliance with the journal’s requirements for authorship.
Published online ahead of print September 28, 2023.
Corresponding author: Jenny S. George, MD, Center for Infertility and
Reproductive Surgery, Department of Obstetrics and Gynecology, Brigham and
Women’s Hospital, Boston, MA; jsgeorge@bwh.harvard.edu.
Financial Disclosure
Andrea Lanes reports receiving payment from BORN Ontario. Elizabeth S.
Ginsburg receives royalties from UpToDate, stipends from Elsevier and ASRM,
and is a medical consultant for Hall Matson Esq., Teledoc, and CRICO. Serene
S. Srouji receives royalties from UpToDate and served on the medical advisory
board for Ferring. The other authors did not report any potential conflicts of
interest.
© 2023 by the American College of Obstetricians and Gynecologists. Published
by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/23
VOL. 142, NO. 5, NOVEMBER 2023
© 2023 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
MD,
dures, leiomyomas, uterine anomalies, and vaginal
bleeding.
RESULTS: Of the 597 EPLs included, 129 patients
(21.6%) had retained products of conception diag-
nosed at the time of office hysteroscopy. The majority
of individuals with EPL were managed surgically
(n5427, 71.5%), in lieu of expectant management
(n5140, 23.5%) or medical management (n530,
5.0%). The presence of retained products of concep-
tion was significantly associated with vaginal bleeding
(relative risk [RR] 1.72, 95% CI 1.34–2.21). Of the 41
patients with normal pelvic ultrasonogram results
before office hysteroscopy, 10 (24.4%) had retained
products of conception detected at the time of office
hysteroscopy. When stratified by EPL management
method, retained products of conception were signif-
icantly more likely to be present in individuals with
EPL who were managed medically (adjusted RR 2.66,
95% CI 1.90–3.73) when compared with those man-
aged surgically. Intrauterine adhesions were signifi-
cantly less likely to be detected in individuals with
EPL who underwent expectant management when
compared with those managed surgically (RR 0.14,
95% CI 0.04–0.44). Of the 127 individuals with EPL
who were diagnosed with retained products of con-
ception at the time of office hysteroscopy, 30 (23.6%)
had retained products of conception dislodged during
the office hysteroscopy, 34 (26.8%) chose expectant or
medical management, and 63 (49.6%) chose surgical
management. The mean number of days from EPL
diagnosis to resolution of pregnancy was significantly
higher in patients who elected for expectant manage-
ment (31 days; RR 1.18, 95% CI 1.02–1.37) or medical
management (41 days; RR 1.54, 95% CI 1.25–1.90)
when compared with surgical management (27 days).
CONCLUSION: In patients with EPL after IVF, office
hysteroscopy detected retained products of conception
in 24.4% of those with normal pelvic ultrasonogram
results. Due to the efficacy of office hysteroscopy in
OBSTETRICS & GYNECOLOGY 1019
diagnosing and treating retained products of conception,
these data support considering office hysteroscopy as an
adjunct to ultrasonography in patients with infertility
who experience EPL after IVF.
(Obstet Gynecol 2023;142:1019–27)
DOI: 10.1097/AOG.0000000000005382
R etained products of conception describes residual
trophoblastic tissue present in the uterus after mis-
carriage, termination, or delivery. Diagnosing retained
products of conception is challenging because many
patients do not present with abnormal bleeding,
abdominal pain, a persistently dilated cervix,1 or
ultrasonographic findings of a hyperechogenic mass
in the uterine cavity with positive color Doppler
flow.2 In patients undergoing in vitro fertilization
(IVF), the prompt diagnosis and treatment of retained
products of conception is paramount, because its pres-
ence may compromise treatment success. Due to the
low sensitivity of ultrasonography for detecting re-
tained products of conception,3 our fertility practice
performs flexible office hysteroscopy in patients who
have early pregnancy loss (EPL) after embryo trans-
fer, with the aim of detecting and resecting retained
tissue before subsequent embryo transfer.
The goal of this study was to evaluate the utility of
office hysteroscopy in diagnosing retained products of
conception in patients who experience EPL after IVF.
We hypothesized that office hysteroscopy would detect
retained products of conception more frequently in
patients who undergo medical or expectant manage-
ment of EPL after embryo transfer and that these
patients are more likely to require surgical management
for retained products of conception when compared
with patients who undergo initial surgical management.
We also hypothesized that patients with persistent
vaginal bleeding, prior uterine surgery (dilation and
curettage [D&C], cesarean delivery, myomectomy), and
ultrasonographic evidence of retained products of con-
ception have a higher likelihood of having retained
products of conception visualized at office hysteroscopy
compared with patients without persistent bleeding.
METHODS
This was a retrospective cohort study of 597 pregnancies
that ended in EPL in patients aged 18–45 years who
conceived through IVF and had fresh or frozen embryo
transfer at an academic fertility practice between January
2016 and December 2021. An EPL was defined as a
failed pregnancy that occurred after an intrauterine ges-
tational sac was visualized on ultrasonography or by
pathologic confirmation of trophoblastic tissue from a
surgical or miscarriage specimen. All patients underwent
1020 George et al Hysteroscopy for Retained Products of Conception After IVF
© 2023 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
office hysteroscopy with a 3.5-mm Storz flexible hys-
teroscope on cycle day 5–12 after EPL management.
Office hysteroscopy was performed in the follicular
phase of the first menstrual cycle after EPL management
to prevent confusion between progestin effect of the
endometrium and presence of retained products of con-
ception. If a patient had multiple qualifying EPLs during
the study period, each pregnancy was included. Gesta-
tional carrier cycles and pregnancies in patients with a
history of pelvic radiation were excluded.
Electronic medical records were reviewed to
obtain demographic and baseline characteristics. Dallas
et al4 demonstrated that Black patients are more likely
to undergo open abdominal myomectomy when com-
pared with White patients. Because surgical manipula-
tion of the uterus is a risk factor for retained products of
conception,1 we evaluated race to understand the effect
of EPL management methods on all groups we treat.
The exposure groups were categorized as expectant
management, medical management (misoprostol 800
micrograms vaginally), or surgical management with
suction D&C. Suction D&C was performed by 7 of
the 10 physicians at our practice, using the Berkeley
Vacurette Cannulae with the Olympus Berkeley VC-
10 System. The size of the suction cannula employed
was determined by the crown–rump length of the EPL.
If more than one management method was required, it
was categorized as the most invasive method (ie, if a
patient opted for medical management but ultimately
required surgery, the EPL treatment was categorized
under surgical management).
The primary outcome was presence of retained prod-
ucts of conception on office hysteroscopy, defined as the
visualization of focal, avascular, or necrotic-
appearing tissue adherent to the endometrium. If tis-
sue was dislodged and collected at the time of office
hysteroscopy, it was sent for pathologic confirmation
of retained products of conception. Office hystero-
scopy was performed by 1 of 10 physicians at our
practice, who have been performing office hystero-
scopy for approximately 20 years, on average. Nine
of these 10 physicians completed fellowship training
at our center, minimizing variability in technique.
Patients were advised to medicate with 1,000 mg
acetaminophen by mouth and 600 mg ibuprofen by
mouth before the office hysteroscopy procedure. The
uterine cavity was visualized by instilling normal
saline, using a manual pressure bag with pressure
limit set at 100 mm Hg. If retained products of
conception were seen, the physician attempted to
dislodge the products by undermining focal, adherent
tissue at the endometrial site of implantation; this
process was standardized among all physicians.
OBSTETRICS & GYNECOLOGY
 The date of the office hysteroscopy procedure,
presence of retained products of conception, and
evidence of intrauterine adhesions were recorded
based on the procedure note. If retained products of
conception were detected, the management method
was documented as either expectant, medical, dis-
lodged at time of office hysteroscopy, or surgical. For
patients who had ultrasonograms before office hys-
teroscopy, the report was recorded as normal, consis-
tent with retained products of conception (defined as an
echogenic mass with blood flow), or unable to rule
out retained products of conception. Phone calls and
electronic messages from patients were reviewed to
index episodes of vaginal bleeding and abdominal
pain between the time of EPL diagnosis and office
hysteroscopy. The date of EPL resolution was defined
as the last documented serum human chorionic
gonadotropin level after embryo transfer, documenta-
tion of obtained trophoblastic tissue, surgery for EPL
management, or surgery for retained products of
conception.
Means and SDs were generated for continuous
variables and frequencies and proportions for cate-
gorical variables. Chi square and Fisher exact tests
were performed for demographic categorical vari-
ables. Relative risks (RRs) and 95% CIs were gener-
ated using log-binomial regression for dichotomous
outcomes and Poisson regression for count outcomes.
Models were adjusted for number of prior D&Cs,
EPLs, oocyte age, body mass index (BMI, calculated
as weight in kilograms divided by height in meters
squared), patient age, leiomyomas, uterine anomalies
(defined as uterine anomalies present in the cohort:
uterine septum, unicornuate uterus, or bicornuate
uterus), and vaginal bleeding. Generalized estimating
equations were used to account for multiple records
from the same patient. Two sensitivity analyses were
performed—one including EPLs that used only one
treatment method for resolution and a second that
included only the first EPL per patient. An alpha of
0.05 was considered statistically significant. All statis-
tical analyses were performed with SAS 9.4.
This project was approved by the Mass General
Brigham IRB (Protocol #2022P000671). There was
no funding for this study.
RESULTS
A total of 597 EPLs after embryo transfer were
included: 210 EPLs after fresh embryo transfer and
387 EPLs after frozen embryo transfer. The pro-
portion of frozen embryo transfers in the expectant
management (66.4%), medical management (66.7%),
and surgical management groups (64.2%) were similar
VOL. 142, NO. 5, NOVEMBER 2023 George et al Hysteroscopy for Retained Products of Conception After IVF
© 2023 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
(P5.87). Most EPLs were managed surgically (n5427,
71.5%), compared with expectant management
(n5140, 23.5%) or medical management (n530,
5.0%) (Table 1). Patients were predominantly White
(74.5%), non-Hispanic or Latina (94.1%), and pri-
vately insured (89.6%). The mean (SD) oocyte age,
patient age, and BMI were 35.7 years (4.4 years),
36.8 years (4.1 years), and 26.9 (SD 7.0), respectively.
The most common infertility diagnoses were unex-
plained (26.0%) and male factor (19.6%), with uterine
factor representing 1.7% of the cohort.
Baseline characteristics of patients were compa-
rable across the three management groups. Black
patients comprised a higher percentage of patients
who elected medical management (16.7%) when
compared with expectant management (4.4%) or
surgical management (4.0%) (P,.01). Thirteen per-
cent of patients who chose medical management had
a prior history of Asherman syndrome, compared
with 1.4% of patients who chose expectant manage-
ment and 1.9% of patients who chose surgical man-
agement (P,.01). Nulliparous patients were more
predominant in the medical management group
(76.7%) compared with the expectant management
(58.6%) or surgical management (64.6%) groups
(P,.01). Patients in the surgical management group
were less likely to be self-pay (4.9%) as compared with
those in the expectant management (12.9%) or medi-
cal management (10.0%) groups (P,.01).
Of the 597 EPLs included, 129 patients (21.6%)
had retained products of conception diagnosed at the
time of office hysteroscopy (Table 2). Ninety-four
patients had ultrasonograms performed before office
hysteroscopy: 42 patients without retained products of
conception diagnosed on office hysteroscopy (9.0%)
compared with 52 patients with retained products of
conception diagnosed on office hysteroscopy (40.3%).
The presence of retained products of conception was
significantly associated with vaginal bleeding (RR
1.72, 95% CI 1.34–2.21) but was not associated with
gestational age at EPL, uterine factor infertility, his-
tory of Asherman syndrome, uterine anomaly, history
of prior EPL, prior uterine surgery, prior vaginal
delivery, reported abdominal pain, frozen embryo
transfer, euploid embryo transfer, or presence of sub-
mucosal leiomyomas.
Patients without retained products of conception on
office hysteroscopy were more likely to have normal
pelvic ultrasonogram results (RR 0.26, 95% CI 0.14–
0.47). Of the 41 patients with normal pelvic ultrasono-
gram results before office hysteroscopy, 10 (24.4%) had
retained products of conception detected at the time of
office hysteroscopy (Table 2). Of the 53 patients with
1021
Table 1. Demographic Characteristics by Early Pregnancy Loss Management Method

EPL Management Method

Characteristic Surgical (n5427) Expectant (n5140) Medical (n530)

Patient age (y) 36.764.2 36.964.2 36.663.3

Oocyte age (y) 35.764.5 35.664.5 36.063.5
Gravidity
1 131 (30.7) 46 (32.86) 12 (40.0)
2 143 (33.5) 35 (25.0) 9 (30.0)
More than 2 153 (35.8) 59 (42.1) 9 (30.0)
Parity
0 276 (64.6) 82 (58.6) 23 (76.7)
1 127 (29.7) 44 (31.4) 6 (20.0)
2 21 (4.9) 13 (9.3) 0 (0.0)
More than 2 3 (0.7) 1 (0.7) 1 (3.3)
Race
Asian 66 (15.7) 20 (14.5) 6 (20.0)
Black 17 (4.0) 6 (4.4) 5 (16.7)
None of the above or multiple 20 (4.8) 10 (7.3) 0 (0.0)
White 318 (75.5) 102 (73.9) 19 (63.3)
Missing 6 2 0
Ethnicity
Non-Hispanic or Latina 389 (94.4) 123 (92.5) 28 (96.6)
Hispanic or Latina 23 (5.6) 10 (7.5) 1 (3.5)
Missing 15 7 1
Insurance
Private 394 (92.3) 115 (82.1) 26 (86.7)
Public 12 (2.8) 7 (5.0) 1 (3.3)
Self-pay 21 (4.9) 18 (12.9) 3 (10.0)
BMI (kg/m2) 26.866.8 26.666.9 28.468.9
BMI category
Lower than 18.5 7 (1.6) 5 (3.6) 2 (6.7)
18.5–24.9 211 (49.4) 69 (49.3) 14 (46.7)
25.0–29.9 113 (26.5) 35 (25.0) 4 (13.3)
30.0–34.9 45 (10.5) 17 (12.1) 2 (6.7)
35.0–39.9 22 (5.2) 4 (2.9) 2 (6.7)
40.0–44.9 17 (4.0) 6 (4.3) 5 (16.7)
45 or higher 12 (2.8) 4 (2.9) 1 (3.3)
Infertility diagnosis
DOR 55 (12.9) 15 (10.7) 3 (10.0)
Uterine 7 (1.6) 2 (1.4) 1 (3.3)
Ovulatory dysfunction 36 (8.4) 14 (10.0) 4 (13.3)
Tubal 18 (4.2) 5 (3.6) 0 (0.0)
Endometriosis 11 (2.6) 6 (4.3) 1 (3.3)
Male factor 85 (19.9) 27 (19.3) 5 (16.7)
Other 36 (8.4) 7 (5.0) 2 (6.7)
Unexplained 112 (26.2) 36 (25.7) 7 (23.3)
Male and female factors 41 (9.6) 15 (10.7) 5 (16.7)
Multiple female factors 26 (6.1) 13 (9.3) 2 (6.7)
Uterine anomaly 10 (2.3) 2 (1.4) 0 (0.0)
Leiomyomas 117 (27.4) 43 (30.7) 14 (36. 7)
Submucosal leiomyoma*
Yes 7 (6.3) 2 (4.8) 1 (7.1)
No 104 (93.7) 40 (95.3) 13 (92.9)
Missing 6 1 0
Prior vaginal delivery 95 (22.3) 25 (17.9) 2 (6.7)
Prior uterine surgery 202 (47.3) 78 (55.7) 17 (56.7)
Prior cesarean delivery 58 (13.6) 34 (24.3) 5 (16.7)
Prior D&C
(continued )

1022 George et al Hysteroscopy for Retained Products of Conception After IVF OBSTETRICS & GYNECOLOGY

© 2023 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 1. Demographic Characteristics by Early Pregnancy Loss Management Method (continued )
EPL Management Method
Characteristic Surgical (n5427) Expectant (n5140) Medical (n530)

0 287 (67.2) 103 (73.6) 20 (66.7)

1 102 (23.9) 26 (18.6) 6 (20.0)
2 27 (6.3) 8 (5.7) 4 (13.3)
3 8 (1.9) 1 (0.7) 0 (0.0)
More than 3 3 (0.7) 2 (1.4) 0 (0.0)
History of Asherman syndrome 8 (1.9) 2 (1.4) 4 (13.3)
Donor oocyte 24 (5.6) 5 (3.6) 0 (0.0)
EPL, early pregnancy loss; BMI, body mass index; DOR, diminished ovarian reserve; D&C, dilation and curettage.
Data are mean6SD or n (%).
* Includes only patients with documented baseline leiomyomas.

ultrasonographic findings indicative of or equivocal for
retained products of conception, 11 (20.8%) had normal-
appearing uterine cavities at the time of office hystero-
scopy (Table 2). The mean number of days from EPL
diagnosis to office hysteroscopy was significantly lower
in patients with retained products of conception diag-
nosed on office hysteroscopy when compared with
patients without retained products of conception diag-
nosed on office hysteroscopy (49.73 days vs 65.93 days,
RR 0.75, 95% CI 0.68–0.84, Table 2).
The presence of retained products of conception
was significantly more likely for patients with EPLs
treated medically when compared with those treated
surgically (53.3% vs 18.3%, adjusted relative risk
[aRR] 2.66, 95% CI 1.90–3.73) (Table 3), but there
was no significant difference in the presence of re-
tained products of conception between the expectant
management and surgical management groups (aRR
1.24, 95% CI 0.87–1.77). The presence of adhesions
was significantly less likely in the expectant manage-
ment group compared with the surgical management
group (2.1% vs 15.5%, RR 0.14, 95% CI 0.04–0.44).
The presence of intrauterine adhesions was not statis-
tically different between the medical management and
surgical management groups.
Two patients with EPLs complicated by retained
products of conception declined further follow-up. Of
the remaining 127 EPLs, 30 patients (23.6%) had
retained products of conception dislodged during office
hysteroscopy, 34 (26.8%) had expectant management
or medical management, and 63 (49.6%) underwent
surgical management (Table 4). There were no signif-
icant differences in management method for patients
with retained products of conception based on initial
management method of EPL. Patients who had medi-
cal management of EPL were the least likely to have
retained products of conception dislodged during office
hysteroscopy (12.5%) compared with patients who
underwent expectant management (25.7%) or surgical
management (25.0%).
The mean length of time from EPL diagnosis to
resolution among all pregnancies, irrespective of re-
tained products of conception, was significantly longer
for patients with medical management (41 days; aRR
1.44, 95% CI 1.18–1.76) compared with surgical man-
agement (27 days) (Table 5). Among pregnancies com-
plicated by retained products of conception, mean time
to EPL resolution was significantly longer in the medical
management group as compared with the surgical man-
agement group (51 days vs 38 days, aRR 1.27, 95% CI
1.02–1.58). Among pregnancies without retained prod-
ucts of conception, mean time to EPL resolution was
significantly longer in the expectant management group
as compared with the surgical management group (30
days vs 24 days, aRR 1.23, 95% CI 1.03–1.48).
Sensitivity analyses including EPLs treated with
only one modality revealed no clinically relevant
differences when compared with the main analyses
(Appendices 1–5, available online at http://links.lww.
com/AOG/D406). Sensitivity analyses including only
the first EPL did not reveal clinically significant dif-
ferences when compared with the main analyses
(Appendices 6–10, available online at http://links.
lww.com/AOG/D406).
DISCUSSION
Within a large cohort of women with infertility under-
going IVF, 21.6% of patients had retained products of
conception visualized on office hysteroscopy after EPL.
Office hysteroscopy is particularly useful in this pop-
ulation given the limited sensitivity of ultrasonography
in detecting retained products of conception3; 24.4% of
patients with normal ultrasonogram results and 35.7% of
patients with equivocal ultrasonogram results were diag-
nosed with retained products of conception at the time
of office hysteroscopy. Office hysteroscopy is also

VOL. 142, NO. 5, NOVEMBER 2023 George et al Hysteroscopy for Retained Products of Conception After IVF 1023

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Unauthorized reproduction of this article is prohibited.
Table 2. Clinical Features Associated With Retained Products of Conception

No Retained
Products of Retained Products of
Conception on Conception on OH
OH (n5468) (Ref) (n5129)
Characteristic RR (95% CI)

Gestational age at EPL (wk)

Based on ET dating 7.7861.6 8.0261.9 1.03 (0.99–1.08)
based on ultrasonographic CRL 6.2661.1 6.5861.6 1.05 (1.00–1.11)
Time from EPL diagnosis to OH (d) 65.93648.7 49.73623.4 0.75 (0.68–0.84)
No. of embryos transferred 1.6861.2 1.4760.9 0.88 (0.77–1.00)
Cryopreserved embryo 309 (66.0) 78 (60.5) 0.92 (0.78–1.07)
Euploid embryo 40 (8.6) 7 (5.4) 0.63 (0.29–1.38)
Prior EPL 222 (47.4) 56 (43.4) 0.92 (0.73–1.14)
No. of prior EPLs
0 246 (52.6) 73 (56.6)
1 140 (29.9) 30 (23.3)
2 44 (9.4) 13 (10.1)
3 23 (4.9) 10 (7.8)
4 8 (1.7) 3 (2.3)
5 5 (1.1) 0 (0.0)
6 2 (0.4) 0 (0.0)
Uterine factor infertility 16 (3.4) 6 (4.7) 1.36 (0.57–3.22)
Prior uterine surgery 231 (49.4) 66 (51.2) 1.04 (0.85–1.26)
Prior cesarean delivery 74 (15.8) 23 (17.8) 1.13 (0.73–1.75)
Prior D&C 147 (31.4) 40 (31.0) 0.99 (0.74–1.33)
No. of prior D&Cs
0 321 (68.6) 89 (68.7)
1 105 (22.4) 29 (22.5)
2 32 (6.8) 7 (5.4)
3 6 (1.3) 3 (2.3)
More than 3 4 (0.9) 1 (0.8)
Prior vaginal delivery 96 (20.5) 26 (20.2) 0.98 (0.66–1.45)
History of Asherman syndrome 8 (1.7) 6 (4.7) 2.72 (0.91–8.12)
Uterine anomaly 11 (2.4) 1 (0.8) 0.33 (0.04–2.65)
Leiomyomas 142 (30.4) 32 (24.8) 0.82 (0.58–1.14)
Submucosal leiomyoma* 8/135 (5.9) 2/32 (6.3) 1.05 (0.24–4.71)
Vaginal bleeding 118 (25.2) 56 (43.4) 1.72 (1.34–2.21)
Abdominal pain 49 (10.5) 21 (16.3) 1.55 (0.96–2.51)
Ultrasonogram result†
Ultrasonographic evidence diagnostic of retained 11 (26.19) 42 (80.77)
products of conception or cannot rule out
retained products of conception
Normal 31 (73.81) 10 (19.23) 0.26 (0.14–0.47)
OH, office hysteroscopy; Ref, reference; RR, relative risk; EPL, early pregnancy loss; ET, embryo transfer CRL, crown–rump length; D&C,
dilation and curettage.
Data are mean6SD, n (%), or n/N (%) unless otherwise specified.
Bold indicates significant results.
* Includes only patients with documented baseline leiomyomas.
†
Includes only patients with ultrasonograms after early pregnancy loss management.

therapeutic: 23.6% of patients with retained products of
conception were successfully treated during office hys-
teroscopy by dislodging tissue, eliminating the need for
subsequent medication management or operative hys-
teroscopy under general anesthesia. These data support
considering office hysteroscopy as an adjunct to ultraso-
nography in patients with infertility who experience
EPL after IVF.
We found that patients who underwent medical
management were two times more likely to have
retained products of conception detected on office
hysteroscopy when compared with patients who under-
went surgical management. This is consistent with
literature demonstrating the success of surgical evacua-
tion of EPL to approach 99%, compared with 84%
success of medical management with misoprostol.5

1024 George et al Hysteroscopy for Retained Products of Conception After IVF OBSTETRICS & GYNECOLOGY

© 2023 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 3. Presence of Retained Products of Conception and Intrauterine Adhesions on Office Hysteroscopy
by Early Pregnancy Loss Management Method

EPL Management Method

Surgical Expectant (n5140) Medical (n530)
(n5427)
(Ref)
OH Finding n (%) RR (95% CI) aRR (95% CI)* n (%) RR (95% CI) aRR (95% CI)*

Retained 78 (18.3) 35 (25.0) 1.37 (0.97–1.94) 1.24 (0.87–1.77) 16 (53.3) 2.92 (1.98–4.31) 2.66 (1.90–3.73)
products of
conception
Intrauterine 66 (15.5) 3 (2.1) 0.14 (0.04–0.44) NA 2 (6.7) 0.43 (0.11–1.68) —†
adhesions
OH, office hysteroscopy; EPL, early pregnancy loss; Ref, reference; RR, relative risk; aRR, adjusted relative risk.
Data are n (%) unless otherwise specified.
Bold indicates significant results.
* Adjusted for prior dilation and curettage count, prior EPL count, oocyte age, body mass index, patient age, leiomyomas, uterine anomaly,
and vaginal bleeding.
†
Unable to run algorithm due to small cell size.

Although patients who elected expectant management
were more likely to have retained products of concep-
tion detected on office hysteroscopy (25.0%) compared
with patients who underwent surgical management
(18.3%), this difference was not statistically significant.
Patients who elected expectant management may have
experienced symptoms of abdominal pain and vaginal
bleeding at the time of EPL diagnosis, indicating a mis-
carriage in process. Contrastingly, patients who chose
medical management may have been diagnosed with
EPL in the absence of symptoms, increasing the likeli-
hood of retained products of conception after treatment.
The majority of miscarriages in our study were
managed surgically. It is unclear whether this was
driven by patient preference or variations in physician
counseling. Although D&C is the most invasive
method offered, patients may prefer this method due
to their desire for prompt resolution and initiation of
the subsequent embryo transfer cycle. Physicians may
favor surgical management to perform karyotype or
chromosomal microarray analysis on the products of
conception to clarify the etiology of the EPL. A pro-
spective Dutch study assessing factors influencing
patient preferences for miscarriage treatment found
that patients were most concerned with the probabil-
ity of success.6 Our data confirm that surgical man-
agement is the most efficient method for pregnancy
resolution; even among pregnancies complicated by
retained products of conception requiring additional
intervention, time to EPL resolution was significantly
longer in the medical management group compared
with the surgical management group.

Table 4. Incidence of Treatment Options for Retained Products of Conception by Early Pregnancy Loss
Management Method*

EPL Management Method

Treatment for Surgical Expectant (n535) Medical (n516)
Retained (n576)
Products of (Ref)
Conception n (%) RR (95% CI) aRR (95% CI)† n (%) RR (95% CI) aRR (95% CI)†

Dislodged at OH 19 (25.0) 9 (25.7) 1.03 (0.52–2.04) 1.11 (0.55–2.23) 2 (12.5) 0.50 (0.13–1.93) 0.55 (0.14–2.19)
Expectant or 21 (27.6) 7 (20.0) 0.72 (0.34–1.55) 0.64 (0.30–1.36) 6 (37.5) 1.36 (0.65–2.82) 1.18 (0.58–2.41)
medical
Surgical 36 (47.4) 19 (54.3) 1.15 (0.78–1.68) 1.15 (0.80–1.65) 8 (50.0) 1.06 (0.62–1.81) 0.97 (0.58–1.63)
EPL, early pregnancy loss; Ref, reference; RR, relative risk; aRR, adjusted relative risk; OH, office hysteroscopy.
Data are n (%) unless otherwise specified.
* Denominator includes when retained products of conception were found on OH and subsequently treated (excludes 2 patients with
retained products of conception on OH without subsequent treatment documented).
†Adjusted for prior dilation and curettage count, prior EPL count, oocyte age, body mass index, patient age, leiomyomas, and vaginal

bleeding.

VOL. 142, NO. 5, NOVEMBER 2023 George et al Hysteroscopy for Retained Products of Conception After IVF 1025

© 2023 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
Table 5. Time to Early Pregnancy Loss Resolution by Early Pregnancy Loss Management Method

Time From EPL Diagnosis to Resolution (d)

Surgical Expectant (n5119) Medical (n527)
(n5427)
(Ref)
Mean6SD RR (95% CI) aRR (95% CI)* Mean6SD RR (95% CI) aRR (95% CI)*

All EPLs 26.5624.5 31.3621.0 1.18 (1.02–1.37) 1.15 (0.99–1.34) 40.7620.8 1.54 (1.25–1.90) 1.44 (1.18–1.76)
EPLs with n578 n534 n516
retained 38.0625.7 34.9622.8 0.92 (0.70–1.20) 0.91 (0.69–1.19) 51.4618.1 1.35 (1.08–1.69) 1.27 (1.02–1.58)
products of
conception
EPLs without n5349 n585 n511
retained 23.9623.5 29.9620.2 1.25 (1.05–1.49) 1.23 (1.03–1.48) 25.2613. 5 1.05 (0.77–1.45) 1.05 (0.77–1.43)
products of
conception
EPL, early pregnancy loss; Ref, reference; RR, relative risk; aRR, adjusted relative risk.
Data are mean6SD unless otherwise specified.
Bold indicates significant results.
* Adjusted for prior dilation and curettage count, prior EPL count, oocyte age, body mass index, patient age, leiomyomas, uterine anomaly,
and vaginal bleeding.

The mere presence of retained products of concep-
tion may prompt additional surgical intervention; 49.6%
of all patients diagnosed with retained products of
conception ultimately required operative resection.
Recent studies have demonstrated hysteroscopic
resection to be effective in surgically evacuating the
uterus for initial treatment after EPL.7–10 Because our
physicians surgically treat EPL with suction D&C, further
research is needed to determine whether directed hystero-
scopic resection decreases the incidence of retained prod-
ucts of conception after surgical management.
We found that vaginal bleeding and ultrasono-
graphic evidence of retained products of conception
are significantly associated with the presence of retained
products of conception at the time of office hystero-
scopy. Patients often experience uterine bleeding after
miscarriage, making it challenging to identify clinically
abnormal bleeding. Prospective studies of patients with
miscarriage report a mean of 8–11 days of bleeding after
EPL diagnosis, with some patients experiencing bleed-
ing for 12–14 days if opting for medical manage-
ment.11,12 Our data reinforce the importance of closely
monitoring bleeding after EPL management, because
heavy or prolonged bleeding may be indicative of re-
tained products of conception warranting intervention.
We found the presence of intrauterine adhesions
on office hysteroscopy to be significantly less likely in
EPLs managed expectantly (2.1%) when compared
with EPLs managed surgically (15.5%). This is consis-
tent with a prior study demonstrating suction D&C to
be significantly associated with the development of
intrauterine adhesions (15.4%), compared with a com-
bined rate of 1.2% for patients managed expectantly
and medically.13 In a systematic review of reproductive
outcomes after management for retained products of
conception, Hooker et al1 found a 29.6% intrauterine
adhesion rate after D&C, significantly greater than the
12.8% intrauterine adhesion rate after hysteroscopic
resection of retained products of conception. Given
the effects of intrauterine adhesions on reproductive
outcomes, patients must be adequately counseled on
the risks associated with surgical management of EPL.
We found that the number of days from EPL
diagnosis to office hysteroscopy was significantly lower
in patients with retained products of conception diag-
nosed on office hysteroscopy when compared with
patients without retained products of conception diag-
nosed on office hysteroscopy. Our study included only
those patients with infertility who experienced EPL after
failed embryo transfer. Our patient population is eager
to conceive and often wish to proceed with the next
embryo transfer as soon as possible. Because our
patients undergo office hysteroscopy in the follicular
phase of the first cycle after EPL management, retained
products of conception may be visualized more fre-
quently in this population when compared with patients
who are amenable to waiting two to three cycles to allow
spontaneous expulsion of products of conception.
Due to the paucity of published literature on the
utility of office hysteroscopy in patients who sponta-
neously conceive and experience EPL, the findings of
this study are not applicable to the general population.
This study assesses the utility of office hysteroscopy in
diagnosing and treating retained products of conception

1026 George et al Hysteroscopy for Retained Products of Conception After IVF OBSTETRICS & GYNECOLOGY

© 2023 by the American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
in patients who experience EPL after IVF. Further
research and cost analyses are required before imple-
menting broad practice changes across fertility practices.
A primary strength of this study was its size and
breadth of detailed clinical information obtained from
electronic medical records. This study was performed at a
single clinical site with uniform protocols for EPL
management, thereby limiting heterogeneity in treatment
modalities. We used retrospective data, which are subject
to biases: physicians may incorrectly report patient
demographics, or risk factors such as history of prior
retained products of conception or abnormal placentation
or fail to document operative findings completely.
Similarly, patients may be reticent to report symptoms
of vaginal bleeding or abdominal pain. Consequently,
these data are subject to potential misclassification bias.
In our study, only 30 miscarriages were managed
medically with misoprostol. Due to the results of the
MifeMiso trial demonstrating a significantly lower
rate of surgical intervention in the misoprostol+mife-
pristone group when compared with misoprostol
alone,14 more physicians are using misoprostol with
mifepristone for treatment of miscarriage in the first
trimester. Due to this practice change, further research
assessing the presence of retained products of concep-
tion after combination therapy is warranted.
This study assessed the utility of office hystero-
scopy in diagnosing and treating retained products of
conception in patients with infertility who experience
EPL after embryo transfer. Within a large cohort of
patients undergoing IVF, 21.6% had retained products
of conception visualized on office hysteroscopy during
the first cycle after EPL management, of whom 23.6%
were successfully treated by dislodging retained prod-
ucts of conception from the uterine cavity during office
hysteroscopy. Office hysteroscopy detected retained
products of conception in 24.4% of patients with
normal ultrasonogram results and ruled out retained
products of conception in 20.8% of patients with
ultrasonographic findings suggestive of retained prod-
ucts of conception. Given the superior sensitivity of
office hysteroscopy in detecting retained products of
conception and the potential for retained products of
conception to delay treatment in patients eager to
conceive, these data support considering office hystero-
scopy as an adjunct to ultrasonography in patients with
infertility who experience EPL after IVF.
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PEER REVIEW HISTORY
Received April 12, 2023. Received in revised form June 16, 2023.
Accepted June 22, 2023. Peer reviews and author correspondence
are available at http://links.lww.com/AOG/D407.
1027