Do Multiple Abortions Actually Harm Your Ability To Conceive?

There’s been some talk that (spoiler alert) one reason Joan on Mad Men didn’t have an abortion was because she was worried that a third procedure would harm her future ability to conceive. Is that true, then or now?

In the season finale, we learned that Joan Holloway, who has been trying to conceive with her husband only to get pregnant from a single incident of infidelity, walked out of an abortion clinic still pregnant. We already knew that Joan had had two abortions, one with her physician (seen in the clip above) and one with a woman who said she was a midwife, and that she was worried about whether it would affect her fertility.

Fear of future infertility from a third abortion has been cited as one of the many reasons that Joan may have decided to keep the baby. This week, Ezra Klein wrote on his Washington Post blog,

She didn’t get the abortion. And she’s lying to her husband, making him believe the baby is his. It’s not a nice thing to do. But in the 1960s, could a third abortion pose a risk to a 35-year-old woman who still wants to have children? The show certainly suggested so.

Are those fears founded? We talked to the experts, and the short answer is: a third abortion could have affected Joan’s future fertility in 1965, but it most likely would not today.

“Two things have changed drastically since 1965 that would affect whether or not there’d be an effect on someone’s fertility from an abortion procedure,” Dr. Anne Davis, medical director of Physicians for Reproductive Choice and Health, told us today.

The first is that back then, abortions were usually performed with sharp curretage, which is no longer used in the U.S. for the main procedure (though it may take place afterwards for cleaning.) A representative from the American College of Obstetricians and Gynecologists referred us to Tanfer Tunc’s Technologies Of Choice: A History of Abortion Techniques in the United States, 1850-1950 which states that “in 1965, 71 percent of legal abortions in the United States were performed using the surgical procedure of dilation and curettage. By 1972, approximately the same percentage, 72.6 percent, of legal abortions in the United States were performed using…the electrical vacuum aspirator.”

In other words, it’s since been replaced with suction curretage, which Davis called “a very non traumatic technique, which doesn’t lead to any scarring.” Sharp curretage carried with it risks of incomplete procedures and higher risk of scarring or adhesion (including Asherman Syndrome) in the uterus. “They weren’t common, but the chances of complications would have been higher back then,” Davis said.

The second is that when abortion was illegal, it was impossible to standardize training and level of care. “Most people got through it without complications,” Davis said, “but the rate of complications were much higher then.”

Another way to think about it, Erica Sackin, a spokeswoman for Planned Parenthood, told us, is that the abortion procedure itself does not affect future fertility, but complications would. In the decades since abortion was legalized, the risk of complications has lowered dramatically.

That was backed up by the folks at ACOG, who also referred us to their materials on risks and abortion, including the fact that fewer than 1 in 100 women have complication from early abortions. (For later abortions, it’s up to 2 in 100). With regards to future fertility, there is this risk (emphasis added):

During a surgical abortion, the tip of a device may pass through (perforate) the wall of the uterus or tear the cervix. If this happens, further surgery may be needed. Other organs, such as the bowel and bladder, also can be injured if this occurs. In these cases, surgery will be needed to repair the organ. The risk of perforation or tear of the cervix is less than 1 in 1,000 abortions. The risk increases with the length of the pregnancy.

As of now, Davis said emphatically, barring such complications, “There is no impact of repeat abortion on fertility.”

According to a Guttmacher Institute study, about one-half of the women who had abortions in 2002 had already had a prior abortion, and “given a rate of 21 abortions per 1,000 women aged 15–44, one out of every 100 women in this age-group obtained a second or higher-order abortion.” There has not been a widescale medical study of the future fertility of women who have had multiple abortions, but a 1983 review of the data found that “the risk of low birth weight, preterm delivery or midtrimester spontaneous abortion in a pregnancy following [suction curretage] is not significantly higher than the risk of adverse outcomes of a first pregnancy carried to term.”

Fertility is so complex and individual of an issue that it’s difficult to generalize about these matters, but the report also points out that “from a biological perspective, women who have had one abortion are already selectively more fecund than women who have not, and, in turn, are at greater risk of having a second pregnancy.” In other words, Joan might just be able to get pregnant again because her three pregnancies show that she’s fecund. Or she might not.

Still, there is a separate issue that probably went into the fictional character’s decision: Joan’s age. Given that modern fertility gains had yet to be made, being in your mid-thirties certainly lowered your chances of conceiving, something the character said she wanted. Show creator Matt Weiner said as much: “I felt she’s 34 years old. She knows there may not be another opportunity, so she’ll take the risk.”

Related: Induced Abortion [ACOG]
Repeat Abortion in the United States [Guttmacher Institute]
Mad Men Creator Matthew Weiner Explains Last Night’s Finale, Defends Betty Draper [NYMag]