Uterine dimensions and intrauterine device malposition: can ultrasound predict displacement or expulsion before it happens?

OBJECTIVE: Intrauterine devices (IUDs) are the most commonly used method of long-acting reversible contraception. IUD malpositions are described as expulsion, embedding, displacement, and perforation, which may cause contraception failure, organ injury, hemorrhage, and infection. The aim of the study was to evaluate the relationship between displacement and IUD positioning in the uterus, and uterine dimensions as measured using transvaginal ultrasonography. MATERIALS AND METHODS: Three-hundred and eighty-four patients who had TCu380A devices inserted at a tertiary hospital were evaluated at insertion and at 1 month, 3 months, and 6 months after insertion. At the insertion visit, demographic characteristics, history of menorrhagia, dysmenorrhea, previous IUD displacement, and obstetric history were recorded. Transvaginal ultrasonographic measurement of the uterine cavity, uterine length, uterine width, cervix length, cervix width, transverse diameter of the uterine cavity, the distance between the tip of the IUD and the fundus, and endometrium were measured to evaluate IUD displacement. RESULTS: Sixteen of 384 patients had displacement. There were significant differences in times between last pregnancy outcomes and IUD insertion and dysmenorrhea history (p = 0.004 and p = 0.028, respectively). Among TCu380A users, women with 7.5 mm IUD endometrium distances had a higher risk for displacement with a sensitivity of 81% and specificity of 37.5% (AUC: 0.607, 95% CI 0.51-0.70). Women with uterus width less than 41.5 mm were more likely to have displacement with a sensitivity of 53.8% and a specificity of 75% (AUC: 0.673, 95% CI 0.60-0.75). CONCLUSION: IUD endometrium distance and uterus width are important parameters for displacement for TCu380A.

Uterine structural abnormality and intrauterine device malposition: analysis of ultrasonographic and demographic variables of 517 patients.

BACKGROUND: Intrauterine devices are currently one of the leading forms of reversible contraception in the world. However, in approximately 10-25% of women, intrauterine devices can become malpositioned, leading to consequences including pain, bleeding, as well as possible decreased contraceptive efficacy. OBJECTIVE: We sought to determine whether certain reproductive and uterine characteristics are associated with an increased risk of intrauterine device malposition. We hypothesized that anatomical characteristics such as the presence of any uterine anomalies, particularly congenital anomalies and fibroids that may lead to cavitary distortion, would be associated with a higher incidence of intrauterine device malposition. MATERIALS AND METHODS: We conducted a retrospective case-control study in an academic medical center. All patients presenting for scheduled ultrasound appointments for gynecologic indication between June 2004 and February 2016 were included (1,253 ultrasound reports identified). Of these, 236 demonstrated malpositioned intrauterine devices. With a control group of 281 patients with normal intrauterine device location, a total of 517 patients were included in the study. Transabdominal and transvaginal ultrasounds were performed followed by 3-dimensional rendering (as per our institution's protocol for patients with intrauterine devices) using Voluson 730 and Voluson E8 ultrasound machines. Demographic and reproductive characteristics, indication for ultrasound, intrauterine device, and uterine characteristics were all extrapolated from the electronic medical record. χ2 Tests were performed for categorical variables. Generalized linear models for Poisson distributed variables, and multiple logistic regression were used to ascertain significant independent predictors of IUD malposition. Ninety-five percent confidence intervals and effect sizes were calculated, and P < .05 was considered statistically significant. RESULTS: In this study, we found a cumulative IUD malposition rate of 19%. In patients with malpositioned intrauterine devices, there was increased incidence of retroflexed uterine positions (7.6% vs 1.8%, P = .001), and all uterine anomalies (this includes septate and bicornuate uteri and fibroids, 31.9% vs 23.5%, P = .02) compared with controls. The anterior midline uterine position was more commonly noted in controls (28.5% vs 11%, P < .001). A higher total number of fibroids was noted in the malpositioned group (3.7 vs 1.8, P = .01); however, fibroid size was not statistically significant. In particular, there was an increased incidence of submucosal fibroids in women with malpositioned intrauterine devices (P = .01). Multivariable logistic regression revealed that anterior midline position (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.20-0.57) and absence of uterine anomalies (OR, 0.59; 95% CI, 0.38-0.93) were factors associated with a lower risk of IUD malposition; whereas vaginal bleeding (OR, 2.25; 95% CI, 1.38-3.67), pain (OR, 2.85; 95% CI, 1.84-4.44), or missing IUD strings at time of presentation (OR, 3.58; 95% CI, 1.88-6.82) were associated with an increased risk of malposition. CONCLUSION: Retroflexed uterine positions and all uterine malformations are associated with higher incidence of malpositioned intrauterine devices. Presence of increased number of fibroids and specifically submucosal fibroids showed a positive association with intrauterine device malposition, as did symptoms of bleeding, pain, and missing IUD strings at time of presentation. These findings pertain to women presenting for gynecologic ultrasound evaluation and may not be generalizable to all women with IUDs.

A Pilot Study Comparing 2- and 3-dimensional Ultrasound Imaging for Confirmation of Essure Fallopian Tube Pregnancy Prevention Implants.

STUDY OBJECTIVE: To show the feasibility of 2-dimensional (2D) ultrasound (US) imaging compared with 3-dimensional (3D) US to identify the location of implants and assess if the classification developed by Simorre et al in 2016 was applicable to the 2 types of US imaging (i.e., 2D and 3D). DESIGN: A prospective study (Canadian Task Force classification II-2). SETTING: The department of obstetrics and gynecology in a teaching hospital. PATIENTS: One hundred fifty patients who had undergone hysteroscopic sterilization with Essure (Bayer Pharma AG Laboratory, Lyon, France) fallopian tube pregnancy prevention implants were invited by letter to participate in the study; 50 replied positively between January and August 2017. INTERVENTIONS: An initial 2D US was performed followed by 3D US reconstruction. The primary end point was to compare the identification of device placement with 2D and 3D US imaging procedures according to this new classification. Secondary considerations were to evaluate the difficulty of attaining images, the quality of implant curvature, the duration of each imaging procedure, and the number of images performed for each technique. MEASUREMENTS AND MAIN RESULTS: Ninety-six percent of tubal implants were observed via 3D US compared with 100% via 2D US. The mean time of 2D US was 14.64 seconds for the right fallopian tube and 15.25 seconds for the left fallopian tube compared with 25.11 seconds for the right and 31.57 seconds for the left fallopian tube in 3D US (p <.01). The mean number of image acquisitions per patient was 1.02 (±0.14 standard deviation) for 2D US compared with 1.37 (±0.64 standard deviation) for 3D US (p <.01). The sonographer had no difficulty performing 2D US in 88% of cases compared with 58% of 3D US cases. CONCLUSIONS: Two-dimensional ultrasound appears to be an acceptable alternative to 3D US. We propose a 2D classification for cross section device localization to facilitate image interpretation.

Evaluation of predisposing factors, diagnostic and treatment methods in patients with translocation of intrauterine devices.

AIM: The purpose of this study was to evaluate the diagnostic methods, predisposing risk factors and surgical treatment options in patients with translocation of intrauterine devices (IUD). MATERIAL AND METHODS: Diagnosis, predisposing factors and treatment of 34 patients with translocation of IUD was evaluated in this retrospective study. RESULTS: Complaints of pain during insertion and history of cesarean section were present in 70.5% and 58.8% of patients, respectively. IUD-related complications were detected in 52.8% of patients. Transvaginal ultrasonography was used to detect translocation of IUD in 55.8% of cases. Laparoscopy was performed in 55.8% of patients. CONCLUSION: There were high rates of history of cesarean section, insertion in the puerperal period and insertion by midwives in patients with translocated IUD. These may be predisposing factors for IUD translocation. The clinician who inserts the IUD should be experienced in this area and obtain sufficient information from the pelvic examination prior to insertion of the device. Gynecological examination should be conducted for a proper diagnosis of translocation of IUD. In the event that the IUD string is not visible in the gynecological examination, transvaginal ultrasonography should be performed. If the IUD is still not visible, then abdominal radiography should be performed. As soon as diagnosis of translocation of IUD has been established, surgical treatment should be planned. First treatment of choice should be laparoscopy.

Intrauterine contraceptives that do not fit well contribute to early discontinuation.

BACKGROUND: To shed additional light on various aspects of intrauterine contraception discussed recently in a comprehensive review article and on the continued development of frameless copper intrauterine devices (IUDs). CONTENT: An essential feature of intrauterine contraceptives is their long duration of action. However, this only applies in the absence of side effects. The importance of dimensional compatibility of the IUD or intrauterine system (IUS) with the uterine cavity should be stressed: IUD/IUS designs that fit will lead to high acceptability, a prerequisite with regard to continuation of use. Dimensional incompatibility, on the other hand, is a cause of cramping pain, erratic bleeding or menorrhagia, dislocation or expulsion and, as a result thereof, pregnancy. The size of the intrauterine foreign body, in relation to that of the uterine cavity, determines its acceptability and influences menstrual bleeding. Abnormal and heavy menstrual bleeding is an issue which has not been fully resolved. It is the most common cause of discontinuation of this contraceptive modality. The size of the IUD can be reduced without jeopardizing its effectiveness provided the effective copper surface is sufficiently large. CONCLUSION: Properly designed and fitting IUDs and IUSs are associated with fewer side effects and greater user satisfaction. This, in turn, could increase usage of intrauterine contraception and thus reduce further the number of unintented pregnancies and induced abortions.

Laparoscopic management of a translocated intrauterine device embedded in the gastric serosa.

Intrauterine devices (IUD) are the most common contraceptive methods all over the world. Besides many advantages, there are also some complications of this method. The most important complication of IUD is uterine perforation. The reported incidence of IUD perforation ranges from 0.2 to 9.6 per thousand insertions. In this article we would like to report a case that has an IUD migrated to the gastric serosa. A 41 years-old Turkish woman presented with abdominal pain. Plain X-ray of the abdomen demonstrated two IUDs, one in the upper quadrant of the abdomen, the other in the pelvic area and determined in the endometrium by TV-USG (transvaginal ultrasonography). Laparascopy was performed and the IUD, lying over the omentum of stomach was removed. This report demonstrates the first case in the literature that has an IUD embedded in the gastric serosa and also a second IUD in uterine cavity. The management was performed laparoscopically. No complication was observed during and after operation.

Migration of an intrauterine device causing severe hydronephrosis progressing to renal failure: A case report.

RATIONALE: Intrauterine device (IUD) is commonly used in China. Its complications include uterine perforation, IUD ectopic migration, etc. However, a migrated IUD rarely leads to renal failure. PATIENT CONCERNS: IUD insertion in the patient was followed by unexplained pain in the left renal area, without bladder irritation or dysuresia. DIAGNOSES: Hydronephrosis, renal failure, migrated IUD. INTERVENTIONS: The patient underwent laparoscopic and retroperitoneoscopic left nephrectomy, partial ureterectomy, and migrated IUD extraction. OUTCOMES: No complications were found after 1 year of follow-up. LESSON: An IUD should be placed by an experienced doctor. If conditions permit, it is best to perform the procedure under the guidance of ultrasound. The patients should be advised to undergo regular check-ups after the procedure. If necessary, abdominal color Doppler examination should be performed. Importantly, patients with IUD pregnancy must be reviewed.

Migración de dispositivo intrauterino a vejiga / Intrauterine device migration to bladder

Introducción: La litiasis vesical secundaria se forma en el reservorio vesical y requiere la existencia de condiciones patológicas previas como lo son los cuerpos extraños. Objetivo: Describir dos casos clínicos de litiasis vesical secundaria a migración de un dispositivo intrauterino. Caso clínico: Se presentan dos casos de migración intravesical de dispositivo intrauterino con litiasis vesical secundaria. Se diagnosticaron años después de su inserción, ante la aparición de dolor pélvico, cistitis a repetición y hematuria. La laparoscopia no fue útil para su diagnóstico. En consulta de Urología la ultrasonografía y la radiografía de pelvis fueron herramientas diagnósticas útiles ante la sospecha inicial de esta patología. Presentaron buena evolución y regresión total de los síntomas tras cistolitotomía suprapúbica. Conclusión: Se debe pensar en la posibilidad de migración de un dispositivo intrauterino a vejiga ante la cronicidad de síntomas urinarios irritativos bajos en toda mujer que emplee este método anticonceptivo y desconozca su paradero(AU)

Introduction: Secondary bladder lithiasis is formed in the bladder reservoir and requires the existence of previous pathological conditions such as foreign bodies. Objective: To describe two clinical cases of bladder lithiasis secondary to intrauterine device migration. Clinical case report: Two cases of intravesical migration of an intrauterine device with secondary bladder stones are reported. They were diagnosed years after insertion, due to the appearance of pelvic pain, recurrent cystitis and hematuria. Laparoscopy was not helpful for its diagnosis. In Urology consultation, ultrasound and pelvic radiography were useful diagnostic tools in the event of the initial suspicion of this pathology. They showed good evolution and total regression of symptoms after suprapubic cystolithotomy. Conclusion: The possibility of an intrauterine device migration to the bladder should be considered when chronicity of irritative low urinary symptoms in every woman who uses this contraceptive method and which locations are unknown(AU)

Postplacental intrauterine device insertion at a teaching hospital.

OBJECTIVE: To determine whether postplacental intrauterine device (IUD) insertion can be safely and effectively performed within a teaching program. STUDY DESIGN: This was a prospective cohort of 177 subjects planning vaginal delivery enrolled antenatally who desired postplacental IUD insertion of either the copper T380A IUD or levonorgestrel IUS. Insertions were performed primarily by resident physicians following a training session. Follow-up included a 4- to 8-week visit and telephone calls at 3 and 6 months. RESULTS: Ninety-nine subjects underwent successful postplacental IUD insertion of 100 attempts. Seventeen expulsions (17%) were noted: 10 complete and 7 partial. The study identified no differences in outcome by training level; however, the study lacked statistical power to evaluate anything other than large differences. CONCLUSION: Postplacental IUD insertions can be safely and effectively performed within a training program. IMPLICATIONS: A training protocol may safely and feasibly be initiated among physicians, advanced practice clinicians or trainees with no prior experience with postplacental IUD insertion. By initiating this practice, access to highly effective contraception may increase for patients who have difficulty returning for a visit or otherwise receiving effective methods.

Tratamento videolaparoscópico para retirada de dispositivo intrauterino em fossa ilíaca direita / Laparoscopic treatment for removal of intrauterine device in the right iliac fossa

Dispositivo intrauterino pode sofrer expulsão da cavidade uterina. Objetivo: Descrever um caso de tratamento videolaparoscópico para retirada de dispositivo intrauterino de fossa ilíaca direita. Material e Métodos: Jovem do sexo feminino apresentou dor em fossa ilíaca direita de quatro dias de duração. No exame físico, apresentava dor abdominal localizada em fossa ilíaca direita, com discreta resistência de parede e dor à percussão e descompressão brusca na região. Em tomografia computadorizada, evidenciou-se dispositivo intrauterino fora do útero, na fossa ilíaca direita. Foram utilizadas as bases de dados SciELO, MedLine, Sobracil e PubMed no período compreendido de Abril a Junho de 2014. Vinte e dois artigos foram relacionados, entretanto somente os 10 artigos que compõem as referências bibliográficas foram selecionados por conter informações relevantes acerca do tema. Resultados: Na videolaparoscopia, pôde ser observado DIU em fossa ilíaca direita, próximo ao intestino, fora do útero, sem aderência, sem perfurações evidentes ou maiores complicações. Conclusão: A videolaparoscopia permite a retirada adequada de dispositivo intrauterino localizado indevidamente fora da cavidade uterina; permite inclusive avaliação adequada de toda a região pélvica para excluir lesões associadas.(AU)

Intrauterine device may suffer expulsion of the uterine cavity. Objective: To describe a laparoscopic treatment of the case for removal of intrauterine device right iliac fossa. Material and Methods: Young female presented pain in the right iliac fossa of four days. On physical examination, showed abdominal pain localized in the right iliac fossa, with thin wall of resistance and pain on percussion and rebound in the region. In CT scan it was seen an intrauterine device outside the uterus, in the right iliac fossa. The SciELO, MedLine, Sobracil and PubMed databases were used in the period April to June 2014. Twenty-two articles were related, though only 10 articles that make up the references were selected because they contain important information about the theme. Results: In the laparoscopy it could be observed the IUD in the right iliac fossa, near the intestine, outside the uterus, without grip, with no obvious or larger perforations complications.Conclusion: Laparoscopy allows adequate removal of intrauterine device located improperly outside the uterine cavity; even allows proper evaluation of the entire pelvic region to rule out associated injuries.(AU)

Assessment of three-dimensional ultrasound examination classification to check the position of the tubal sterilization microinsert.

OBJECTIVE: To assess the accuracy of three-dimensional (3D) ultrasound to determine the position of Essure microinserts. DESIGN: Prospective observational study. SETTING: Gynecology department in a teaching hospital. PATIENT(S): Forty women who underwent hysteroscopic sterilization from March through October 2008. INTERVENTION(S): Both 3D ultrasound and hysterosalpingography (HSG) were performed 3 months after the procedure to verify device position. Positions seen on 3D ultrasound were classified in four categories: a perfect position (1 + 2 + 3), a proximal position (1 + 2), a distal position (2 + 3), and a very distal position (3-only). MAIN OUTCOME AND MEASURE(S): Microinsert position on 3D ultrasound and correlation with HSG. RESULT(S): Overall, 93% of the devices for 40 patients were found to have been placed successfully. The final sample comprised 64 Essure devices. HSG showed tubal patency for only three devices, all classified as 3-only. No tubal permeability was noted for the other 61 positions. This 3-only location on 3D ultrasound was statistically associated with a failure of sterilization in comparison with the other locations (3/16 [18%] vs. 0/48 [0%]). CONCLUSION(S): 3D ultrasound is a simple and reproducible technique to assess the position of the Essure microinsert and appears to protect most patients from the negative aspects of pelvic radiography and of HSG. Using the 3D ultrasound classification presented in this study appears to make it possible to use HSG for backup confirmation only when Essure is found to be in the 3-only position on 3D ultrasound.

Translocación de dispositivo intrauterino. Reporte de un caso / Translocation of intrauterine device. Report of a case

La translocación de dispositivo intrauterino (DIU) es poco frecuente, con afección a órganos vecinos como el recto-sigmoide, la vejiga y el ovario; luego de la perforación uterina por migración de DIU se justifica su inmediata extracción de la cavidad abdominal. Presentamos el caso clínico de una mujer de 38 años de edad, que cursó con una perforación parcial de dispositivo intrauterino que causó dolor pélvico en la mujer.

Translocation of an intrauterine device (IUD), is slightly frequent, affecting neighboring organs like the rectal sigmoid, bladder and ovaries. After uterine perforation, because of IUD migration, immediate removal of the abdominal cavity is justified. We present a case of a 38 year-old woman who had a partial perforation by an intrauterine device causing pelvic pain.

Dispositivo intrauterino migrado a cavidad abdominal: características clínicas, diagnóstico y manejo / Intraabdominal migration of intrauterine devices: characteristics, diagnosis and treatment options

OBJETIVO: Describir las características clínicas, los factores predisponentes, complicaciones y la actitud terapéutica en pacientes con DIU migrado a cavidad abdominal. Material y MÉTODOS: Se analizaron de manera retrospectiva 17 casos de DIU migrado diagnosticados en el Hospital Universitario Virgen de las Nieves de Granada (España) entre 2002 y 2012. RESULTADOS: En 8 casos (47,1 %) el diagnóstico se hizo en el primer mes, mientras que en 5 (29,5 %) el diagnóstico se realizó transcurridos más de 4 años tras la implantación. El 35,2 % presentaron dolor abdominal, sin embargo el 52,9 % estaban asintomáticas y el diagnóstico se realizó de manera casual o tras un embarazo. Se llevó a cabo una extracción quirúrgica en todos los casos y fue realizada sin complicaciones mediante una laparoscopia en 15 pacientes, mientras que dos precisaron una laparotomía. CONCLUSIONES: La mayoría de las perforaciones uterinas por un DIU se inician durante la inserción por lo que debemos recomendar un examen pélvico exhaustivo, con una ecografía de control tras el primer mes de la inserción. Así mismo, si aparece dolor abdominal en estas pacientes se debe realizar una ecografía para descartar la perforación uterina. Nuestra recomendación ante un DIU fuera de la cavidad uterina es la extracción por laparoscopia en todos los casos

OBJECTIVE: To describe the clinical characteristics, predisposing factors, complications and surgical treatment options of patients with intraabdominal, mislocated intrauterine devices (IUD). MATERIAL AND METHODS: We retrospectively analyzed 17 cases of migrated IUD diagnosed at Virgen de las Nieves Hospital of Granada, Spain between 2002 and 2012. RESULTS: 8 cases (47,1 %) were diagnosed within the first month post-insertion and 5 of them (29,5 %) were diagnosed after more than 4 years. 35.2 % of the patients suffered abdominal pain, however 52,9 % were asymptomatic and the diagnosis was made by chance or as a result of pregnancy. A surgical extraction was performed in all cases. 15 patients were managed by laparoscopy without complications, whereas laparotomy was required in two. CONCLUSIONS: Most of the uterine perforations by an IUD are initiated during the insertion; therefore, a thorough pelvic examination with an ultrasound control after the first month should be carried out. Likewise, in carriers of IUD with abdominal pain an ultrasound should be made to rule out uterine perforation. Our recommendation when a migration of an IUD takes place is a laparoscopic extraction in all cases