ACRT Journal

Introduction

IUDs are highly effective long-acting reversible contraceptives, valued for their efficacy, ease of use, and suitability for postpartum placement. However, malpositioning can occur, with some studies reporting rates of up to 10.4% [1].

Malpositioning can present in various ways: the IUD frame may rotate on its axis or shift transversely, with the arms unfolded or extended in different positions. Non-fundal IUDs are commonly located in the lower uterine segment or cervix, often identified through ultrasonography.

In cases of displacement, the arms of an IUD might become embedded in the uterine wall or even perforate it, potentially

embedding in the bowel or other intraperitoneal structures [2]. Symptoms of malposition can include changes in bleeding patterns and pain, though the severity of symptoms varies, and not all patients may be aware of the malposition. If an IUD is confirmed to be embedded in the uterine wall, it may often be removed in the office by grasping the strings with a clamp and applying gentle traction. If removal is difficult with moderate traction or if the strings are not visible, hysteroscopic removal is the next step, which may be performed in the office or the operating room, depending on the complexity. In complex cases where IUD location is uncertain, intraoperative imaging may be required.

We report a case that demonstrates the use of intra-operative radiographic imaging to guide the dissection and removal of a fully embedded IUD. We also discuss the key surgical steps involved in addressing an embedded IUD.

Case Presentation

A 37-year-old G0 patient presented for hysteroscopic removal of a fully embedded Mirena IUD. She had previously undergone a robotic myomectomy while the IUD was in place and a uterine manipulator was used. Three months post-operatively, she reported electric-type uterine pain. Upon examination, the IUD strings were not visible at the cervix, leading to a hysteroscopic investigation. This revealed the strings protruding into the cavity from the posterior uterine wall. Attempts to remove the IUD hysteroscopically by pulling on the strings were unsuccessful, resulting in detachment of the strings and leaving the cavity appearing normal.

The patient then sought consultation for a re-attempt at surgical removal. Prior to the procedure, a CT pelvis was performed to assess the distance of the IUD from the serosa and the uterine cavity to determine the appropriate surgical approach. The CT scan, chosen over MRI based on the radiologist’s recommendation, confirmed the presence of the IUD within the uterus but reported it as normally placed in the cavity, despite direct visualization suggesting otherwise. The patient was subsequently consented for both hysteroscopic and potentially robotic retrieval of the embedded IUD.

We began the procedure with a hysteroscopic approach. The hysteroscope was inserted through the cervix and guided into the uterine cavity. Upon inspection, the Mirena IUD was not visible.

Next, we introduced the MyoSure Reach device into the cavity. Using the device’s tip, we palpated the posterior uterine wall where the IUD strings were seen prior to detachment. To precisely locate the IUD, portable X-ray imaging was performed with the MyoSure device in place to serve as a reference point.

We then systematically excised endometrial tissue at the radiographic site of the IUD, taking multiple X-ray images throughout the dissection to confirm the accurate location of the IUD in reference to the MyoSure instrument and to ensure precise dissection planes. Once a portion of the IUD was exposed, we carefully resected the surrounding tissue to liberate a significant part of the device. Hysteroscopic forceps were used to completely remove the IUD. It was found to be lying parallel to the uterine wall, requiring a larger area of exposure to achieve adequate traction for removal. Notably, we injected vasopressin into the myometrium with a hysteroscopic needle to decrease blood loss during dissection (Figures 1-5).

Figure 1: CT imaging showing the IUD within the uterine cavity (indicated by the red arrow).

Figure 2: Hysteroscopic global survey showing inability to visualize the Mirena IUD.

Figure 3: X-ray imaging guiding the initial dissection point of the MyoSure device along the posterior wall of the uterine cavity.

Figure 4: Hysteroscopic resection of the embedded IUD using the MyoSure device, following confirmation of its location with X-ray.

Figure 5: The entire Mirena IUD (without strings) following hysteroscopic endometrial dissection.