The “Issue of Tissue,” MYA Network’s viral project showing photographs of actual pregnancy tissue removed from abortion, began uniquely. An unusual set of circumstances brought our medical work as doctors who provide abortion care into the public realm.
I was juggling the schedule at my practice, Early Options. I had a full day of patients and needed to squeeze in an interview with a journalist. I was unusually interested in talking with Poppy Noor, who worked at the Guardian. The subject of the interview was striking to me: miscarriage and abortion - what’s the difference? The question itself impressed me. How could I convey its significance to a journalist?
Distinguishing between miscarriage and abortion is a topic that comes up with my patients regularly. Since I specialize in early pregnancy, the time when most miscarriages occur, the line between abortion and miscarriage is especially gray. It is estimated that 25% of pregnancies end in miscarriage. Commonly, I treat a patient for an abortion, even when there are signs or symptoms of a potential miscarriage. And because I have time to talk with every patient, the gray area can be helpful in conversations about the decision to end a pregnancy.
As fate would have it, one of my patients that morning came in for treatment of a known miscarriage. Lena was distraught. At 39, she had invested her heart in having her first baby. Pregnant on her first round of IVF, initially, everything went well. At the first ultrasound, around six weeks, the pregnancy was normal. Two weeks later, at eight weeks of pregnancy, she went in for her prenatal visit and found out that the pregnancy was no longer viable. She was devastated.
She found her way to my practice to get a manual aspiration procedure. It’s a quick, simple, and gentle procedure that removes early pregnancy tissue - for both abortion and miscarriage. It also treats ongoing bleeding related to either one. At my practice, I complete these procedures in a regular examination room. My patients appreciate the privacy and personalized care we provide. They can have a loved one by their side during the entire visit.
I did the ultrasound to confirm the miscarriage. I immediately saw that the pregnancy had stopped growing shortly after Lena’s first prenatal visit. She was eight weeks pregnant by her dates, but the gestational sac on ultrasound showed her at six weeks. She still hadn’t bled, and she was still feeling pregnant.
This type of miscarriage is common. It’s called “missed miscarriage,” when a pregnancy stops growing but doesn’t pass from the body. Like Lena, the excited, expectant mom typically goes for a routine prenatal visit for an ultrasound. There, she finds that the pregnancy is no longer viable. The news can be devastating. And it’s especially hard because the pregnancy hormones are still there. It’s hard to go about life knowing that the pregnancy is still inside.
After receiving this sad news, Lena and her husband, Dave, came to me to have the pregnancy removed. She researched and opted for a manual aspiration at my practice. Compared to a D&C, manual aspiration carries fewer risks and utilizes a handheld device. Because it’s so simple and gentle, it’s completed in a regular exam room rather than an operating room without anesthesia. Compared to taking pills or “watching and waiting” for the tissue to pass naturally, Lena preferred the immediate resolution offered by manual aspiration.
The manual aspiration procedure itself isn’t any different from a missed miscarriage or an abortion. Emotionally, however, they are typically very different experiences.
Lena was on the examination table. Dave was beside her, talking with her as I set up. The actual procedure only took a few minutes to complete. When it was over, she immediately cried tears of sadness. She released the pain of losing her deeply wanted pregnancy. Dave stood up and then draped himself over her on the exam table. Their intimacy in this moment was touching, and my heart sank for their loss. I left them to have some time alone.
I took the tissue I had removed to another room to rinse and do a routine evaluation. We do this after every procedure to ensure its completion. After rinsing off the blood, I floated the remaining tissue in a dish on a lightbox. As expected, there was a six-week gestational sac and decidual tissue (similar to the lining that sheds with each menstrual period). It looked like a normal six-week pregnancy.
Six-week pregnancy, removed with a manual aspiration procedure. There is no way to tell whether it is a miscarriage rather than an abortion by looking at the tissue.
I looked up at the clock. It was time for my interview with Poppy! Since it was empty and quiet, I decided to call her from the same room I had just used to examine the tissue.
Poppy didn’t disappoint. She was interested in the medical aspects of abortion and miscarriage but also wanted to talk about emotional and philosophical differences and how these might impact what was going on politically. It was September of 2022, two months after the Dobbs decision, that took away our constitutional right to make choices that are right for our lives. Poppy was prescient in researching how the treatment of abortion and miscarriage were intertwined for women.
Lena’s story was fresh on my mind. Hers was a deeply wanted pregnancy, yet when she miscarried, she had to come to a practice that specializes in abortion to get this simple, gentle procedure.
I spoke with Poppy about other gray areas that Poppy ended up reporting in her article: What’s the difference between abortion and miscarriage? For some women, it’s hard to tell.
There are many medical gray areas. Miscarriages can happen for any number of reasons: some knowable, some unknowable. There can be abnormalities in the chromosomes, or the environment isn’t right for the growth of a pregnancy.
Many patients come to my practice for an abortion, and when I do the ultrasound, it doesn’t look completely normal. Those patients often feel some relief from this information. We complete the procedure, not knowing whether the pregnancy would have miscarried naturally.
Patients who initiate an abortion with pills will bleed identically to a miscarriage. In both situations, they may end up with ongoing or heavy bleeding and need to seek medical treatment. The same procedures (manual aspiration or D&C) and medications are used to treat both.
And there are philosophical gray areas. When I talk with my patients who are seeking abortion care, I sometimes describe abortion as a kind of miscarriage - the time simply isn’t right for this particular pregnancy. The foundation and the environment aren’t ready for raising a child at this moment in one’s life.
As we closed the interview in the examination room, I noticed the lightbox with the tissue I had removed from Lena’s miscarriage. I realized Poppy might want to see it. “You won’t believe what this miscarriage tissue looks like,” I told her. “Apropos to our conversation about gray areas, It looks no different from tissue removed for an early abortion.”
I asked her to Facetime me. We briefly “met” and saw each other’s faces before I turned the phone upside down and showed her a tissue exam.
Poppy was shocked. After years of covering abortion as a reporter, she had never seen what the tissue looked like. Even she had assumed there was a formed fetus. I pulled out some pathology vials from the cabinet. I had saved tissue from pregnancies from 4-9 weeks for teaching purposes. I floated them in the dish to compare them for her.
“Poppy, honestly, I think this could be a big story. Everyone I’ve ever shown the tissue to is surprised to see it. I often show it to patients, and they are stunned. The anti-abortion movement has created so much misinformation that it influences how we think and feel about abortion. Go ahead and Google the images online. They all show intact, developed fetuses, most looking like miniature babies. I’ve never seen accurate images of early abortion tissue anywhere.”
She agreed. She would go to her editors to discuss the story. Had I not seen Lena that day, I wouldn’t have thought to share this aspect of medical care during our interview.
Lena and Dave went home, grateful for their experience in my practice. She was especially relieved that the pregnancy could be removed in such a gentle way and that they had time to process the miscarriage in privacy. I reassured her that she had successfully gotten pregnant and she could get pregnant again. They could start trying again right away. They were relieved to put closure to this experience and to move on.
Poppy called the next day. She was excited that she had gotten the approval from the Guardian. They wanted to publish photographs of tissue I had removed from abortions. They wanted the article as soon as possible!
I urgently called Erika Bliss and Michele Gomez. During the pandemic, we three family doctors co-founded MYA Network. They immediately agreed that publishing these photos would advance our mission to normalize abortion medically and culturally. We would go to the other clinicians involved at MYA Network to ensure they agreed. And now I had to find a way to photograph tissue in a publishable way! How?
This question began a journey that is the basis of this Substack column and community. I hope you’ll keep following along!