Does Abortion Affect Future Fertility? What the Evidence Says

No. A safe, legal abortion — medical or surgical, in the first trimester — does not reduce your future fertility. The most thorough review of this question was published by the US National Academies of Sciences, Engineering, and Medicine in 2018, and its conclusion is quotable in one line: having an abortion does not increase a woman's risk of secondary infertility, pregnancy-related hypertensive disorders, abnormal placentation after a D&E abortion, preterm birth, or breast cancer. The same committee concluded that legal abortion by medication, aspiration, D&E or induction is safe and effective, and that serious complications are rare.

WHO says the same thing about the procedure itself: abortion is a simple health care intervention that can be safely and effectively managed by a wide range of health workers, when a WHO-recommended method appropriate to the pregnancy duration is used by someone with the necessary skills.

Worth saying plainly: most of the fear attached to this question in India comes from stigma rather than from the medical record. Those are two different things, and it is worth separating them before you carry either into a consultation.

Sooner than most people expect, and usually before the first period. The measurement comes from a study that checked plasma progesterone in a cohort of 67 women after abortion: ovulation had recurred in 34% of them by three weeks and in 78% by six weeks.

That figure has two practical consequences, in opposite directions. If you do not want to be pregnant, contraception is a conversation for the same appointment, not for after the next period. If you do want to conceive, the biology is usually back before the calendar suggests it is.

Whether to wait before trying again is a clinical judgement that depends on how the abortion went and whether there were complications. This page does not give a number of weeks, because no source retrieved for it supports a general one — it is a question to ask the doctor who managed the procedure.

Instrumenting the uterine cavity can leave adhesions — bands of scar tissue inside the uterus, sometimes called Asherman's syndrome when they are extensive. This is the one mechanism by which abortion can affect fertility, and it is worth being precise about what is actually known.

The systematic review of adhesions specifically after termination of pregnancy searched to November 2015 and found no randomised trials, two prospective cohorts, and — importantly — no study at all of women after medical termination. In the first cohort, adhesions were detected by hysteroscopy at a prevalence of 21.2% after first-trimester surgical termination, and were moderate to severe in 48% of those cases. In the second cohort, adhesions were detected by hysterosalpingography in 16.2% of women after second-trimester termination by prostaglandin induction followed by D&C.

The larger evidence base is after miscarriage, where the pattern is clearer. Pooling 10 prospective studies and 912 women examined by hysteroscopy within 12 months, adhesion prevalence was 19.1% (95% CI 12.8-27.5). Of 124 women whose adhesions were graded, the split by severity was 58.1% mild, 28.2% moderate and 13.7% severe.

And here is the sentence that changes how you should read all of those percentages: that review states that in more than half of cases the adhesions were mild, with unknown clinical relevance, and that no study reported long-term reproductive outcomes following them. Finding scar tissue on a hysteroscopy is not the same as being unable to conceive.

What the same review did identify is the risk factor that matters: repetition. Relative to women with one miscarriage, women with two had a pooled odds ratio for adhesions of 1.41 and women with three or more had 2.1 — and the number of dilatation and curettage procedures appeared to be the main driver behind those associations. One uncomplicated procedure and four of them are not the same clinical situation.

A medication abortion and a surgical abortion carry different mechanisms of risk, because only one of them involves putting instruments into the uterine cavity. That is the whole basis of the adhesion concern, and it does not apply to pills.

This matters more in India than almost anywhere. In 2015 an estimated 15.6 million abortions took place in India. Of 15.6 million, 12.7 million (81%) were medication abortions, 2.2 million (14%) were surgical, and 0.8 million (5%) used other methods that were probably unsafe. Only 3.4 million of 15.6 million (22%) happened in a health facility; 11.5 million were medication abortions taken outside one.

The honest position on medication abortion and adhesions: the systematic review found no study that looked. There is no evidence of an adhesion risk, and there is also no study that would have found one. Those are different statements from “proven safe”, and this page will not collapse them.

Everything above describes abortion done properly. Abortion done badly is a genuine threat to fertility, and conflating the two is how the myth survives. WHO estimates that around 45% of the 73 million induced abortions performed worldwide each year are unsafe — a prevalence of 45% — and lists the physical complications: incomplete abortion, haemorrhage, infection, uterine perforation, and damage to the genital tract and internal organs.

Two of those — infection and perforation — are the routes by which fertility can actually be harmed. Infection that reaches the tubes can leave them blocked. Perforation and aggressive curettage are what produce severe adhesions rather than mild ones. Scale: WHO cites a 2012 estimate that 7 million women a year were treated in hospital in developing countries for complications of unsafe abortion.

The practical implication is about conditions, not about the decision. A legal facility, a WHO-recommended method, and someone trained to use it are what separate the safe column from the unsafe one.

Abortion is legal in India within the framework of the Medical Termination of Pregnancy Act, as amended in 2021. The provisions worth knowing, read from the Act itself:

• Up to 20 weeks, a pregnancy may be terminated on the opinion of one registered medical practitioner, formed in good faith on the grounds the Act sets out.
• From 20 to 24 weeks, termination is permitted for categories of women prescribed by rules under the Act, on the opinion of not fewer than two registered medical practitioners.
• The gestational limits do not apply where termination is necessitated by a substantial foetal abnormality diagnosed by a Medical Board constituted by the State or Union territory. That board comprises a gynaecologist, a paediatrician, a radiologist or sonologist, and any further members notified.
• Section 5A, added in 2021, makes it an offence for a registered medical practitioner to reveal the name or other particulars of a woman whose pregnancy has been terminated, except to a person authorised by law. The penalty is imprisonment of up to one year, a fine, or both.
• The 2021 Act defines termination of pregnancy as a procedure using medical or surgical methods — both are within the law.

That confidentiality provision is worth knowing about for its own sake. It exists because disclosure, not the procedure, is what a lot of women are actually afraid of.

Start from the base rate. After a safe abortion, the likeliest reason a couple is not conceiving is one of the ordinary reasons any couple is not conceiving — which is why both partners get assessed, not just the one who had the procedure.

The one signal that points specifically at adhesions is a change in your periods. Lighter bleeding, much shorter periods, or periods that stopped after the procedure and have not come back is the pattern worth reporting unprompted, because it is what the cavity tests are looking for.

1. History first: how the abortion was done, whether there was infection or heavy bleeding afterwards, how many procedures in total, and what your periods have done since.
2. Hysteroscopy — a thin camera passed through the cervix — is the test that looks directly inside the cavity and is how the adhesion studies on this page made their diagnoses.
3. Hysterosalpingography, an X-ray with dye, checks the cavity and whether the tubes are open. It is the test used in the second-trimester cohort described above.
4. A semen analysis for the male partner, at the same time rather than afterwards.
5. The rest of the standard assessment — ovulation, ovarian reserve, thyroid — because nothing about a previous abortion makes those questions go away.

Related on this site: common causes of female infertility, who gets tested first, and fertility after miscarriage.

The reassurance on this page is strong but it is not unlimited, and the gaps are specific:

• Nobody has studied adhesions after medication abortion. The 2016 systematic review searched from inception to November 2015 and found no such study. That is absence of evidence, not evidence of absence — and it covers the method used in 81% of Indian abortions.
• No study links post-procedure adhesions to long-term fertility. The 2014 review of 1,770 women in eight prospective studies reports that no study reported long-term reproductive outcomes following post-miscarriage adhesions.
• The mild-adhesion outcome data has no control group. A 2022 meta-analysis of 229 women with hysteroscopically identified and treated mild adhesions found a pregnancy rate of 62.3% and a live birth in 86.6% of those pregnancies, and compared them to a general population because, in the authors' own words, there was no control group. A hysteroscopy-referred group is not comparable to the general population, so this cannot show that mild adhesions caused the difference. The authors call for controlled studies.
• The National Academies conclusions describe legal, facility-based abortion. They were drawn from the United States context. They do not describe unsafe or unattended abortion, and should not be read as if they do.
• The ovulation figures are old and small. The figures of 34% by three weeks and 78% by six come from plasma progesterone measured in a cohort of 67 women, published in 1980. The direction is not in doubt; the precision should not be over-read.
• Cervical insufficiency after repeat abortion is not asserted here. The previous version of this page claimed it. No primary source was retrieved to support it, and the National Academies review specifically concluded that abortion does not increase the risk of preterm birth. The claim has been removed rather than softened.