Objective: To determine whether manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA) improves physicians’ ability to accurately identify products of conception (POC) in abortions at less than 6 weeks’ gestation. Methods: 498 pregnant women presenting for surgical abortion with mean gestational sac diameter of <12mm or no visible sac on ultrasound were randomized to either MVA or EVA. Tissue exam was performed by the operating physician, not blinded to group assignment, and by a trained medical assistant, blinded to group assignment. Patients with no POC on gross inspection underwent repeat aspiration as necessary and serial hCG monitoring. All patients were scheduled for a follow-up visit 2-3 weeks post-operatively. The primary outcome was detection of POC in subjects with subsequently confirmed completed abortion. Results: 251 subjects were randomized to MVA and 247 to EVA. 84% of subjects in the MVA group had POC identified and subsequently confirmed completed abortion compared with 77% EVA subjects (P=.06, RR=0.78, 95% CI 0.60-1.03). In pregnancies of sac size 3mm or less, including no visible sac, 20% MVA subjects had accurate identification of POC compared with 13% in the EVA group (P=0.05, RR=0.78, 95% CI 0.40-1.53). Tissue reports of physicians and medical assistants had 90% concordance. 70 subjects required hCG monitoring to confirm completed abortion. There were seven ongoing pregnancies and one ectopic pregnancy. Conclusions: MVA was neither more nor less sensitive than EVA for the detection of POC in very early surgical abortion. Early aspiration is very effective, although hCG monitoring may be necessary to confirm complete abortion.