How Do You Know if Your Iud Has Perforated

Open Access J Contracept. 2016; 7: 19–32.

Intrauterine devices and risk of uterine perforation: electric current perspectives

Sam Rowlands

¹Heart of Postgraduate Medical Research and Education, Faculty of Health and Social Sciences, Bournemouth University, Dorset, Britain

Emeka Oloto

²Staffordshire and Stoke on Trent Partnership NHS Trust, Leicester, United kingdom

David H Horwell

^threeSpire Harpenden Hospital, Harpenden, United kingdom of great britain and northern ireland

Abstract

Uterine perforation is an uncommon complexity of intrauterine device insertion, with an incidence of ane in 1,000 insertions. Perforation may be complete, with the device totally in the intestinal cavity, or partial, with the device to varying degrees within the uterine wall. Some studies show a positive association betwixt lactation and perforation, but a causal human relationship has non been established. Very rarely, a device may perforate into bowel or the urinary tract. Perforated intrauterine devices can generally exist removed successfully at laparoscopy.

Keywords: uterine perforation, intrauterine device, intrauterine arrangement

Introduction

The aim of this review is to raise awareness of the circumstances in which perforation of the uterus by intrauterine devices (IUDs) tin occur, the consequences of such perforations, and approaches to the direction of suspected or actual perforation.

IUDs for contraception were showtime introduced by Richterⁱ in 1909 and were farther developed and deployed by Gräfenberg² from 1929; there was then a resurgence with the modern era beginning in 1959 when flexible plastic IUDs were introduced.³ Over the years, in that location have been many design modifications to ameliorate effectiveness, acceptability, and safety.³ IUDs are a highly effective course of long-acting reversible contraception.

Use of intrauterine contraception worldwide is extensive: 13.nine% of the world's 1.16 billion women aged xv–49, married or in a union, are using this method.⁴ Uptake of intrauterine contraception in Red china is even higher at 40.6% of their 269 million women aged xv–49.

Perforation of the uterus with IUDs was kickoff described in the 1930s.^{5 , 6} Initially, at that place was denial that this could happen at the fourth dimension of insertion, and information technology was postulated that devices were always forced through the uterine wall by uterine contractions.⁷ Consensus opinion is now that the most common mechanism is that the device is forced into or through the uterine wall at the time of insertion. Other terms such as "the wandering IUD", the misplaced/displaced or missing IUD, ectopic IUD, migration, mislocation, transmigration, or translocation are therefore somewhat misleading. Less commonly, an IUD may penetrate into merely remain within the myometrium; this is termed partial perforation.^eight It appears that uterine contractions can sometimes force such a device through the uterine wall.

Although uterine perforation is a potentially serious complication of intra-uterine contraceptive utilize, it is uncommon and information technology can often exist asymptomatic. Some cases are not identified until months or years after insertion.^{9 – eleven} In i series, the longest interval that had elapsed between insertion and diagnosis was 43 years.¹² It is therefore important to put uterine perforation into context. It very rarely leads to harmful sequelae, and information technology does not detract from the overall excellent safe tape of IUDs.³

Literature search

A formal Medline search using the search terms uterine perforation, displac*, migrat*, perforat*, penetrat*, and translocat* together with intrauterine devices or intrauterine devices copper or intrauterine devices medicated gave 629 English language language results. Of these, 347 were constitute to be relevant. A similar search in EMBASE produced 418 relevant articles out of a total of 914. Further references were found within these manufactures.

Methodological considerations

Perforation of the uterus with an IUD is an uncommon phenomenon. Of the perforations that exercise occur, virtually do non cause long-term harm, although women are more often than not advised to go through a surgical removal process that has some risks. Still, a significant harm associated with perforation may exist the loss of the IUD's contraceptive issue, resulting in unplanned, and often unwanted, pregnancy. Sometimes a perforation leads to trauma to internal structures; such cases are thought to exist very rare.

Quantification of the incidence of perforation from large cohort studies has been done and is probable to exist precise. How many of these perforations keep to become more than complicated is not known at all. Assessing the strength of gamble factors for perforation is difficult. For example, the definition of breast-feeding is imprecise, as many women reduce the corporeality they feed gradually over time and so it is non an "all or nothing" variable. Although 1 study with no association at all was establish, there may be other negative studies that editors did non run across fit to publish. There may also be smaller negative studies without the statistical power to give a valid issue. There is therefore a potential risk of publication bias.

Apart from the information on incidence from cohort studies, much of the literature on this bailiwick consists of isolated case reports; there are too some relatively pocket-size example series. This is the lowest quality of evidence in the hierarchy of evidence apart from "expert stance".¹³ This situation means that when presenting the information there will inevitably be choice bias. Clinicians like to written report unusual cases. In general, this bias will exaggerate the risks associated with uterine perforation.

The authors take non cited all case reports that were institute in the literature. We have selected citations that describe each facet of the subject well, choosing for preference papers that have a case series rather than an individual case written report, and papers that take reasonable literature reviews.

As this review is of necessity based mainly on findings from accomplice studies, small serial, and case reports, it cannot by its nature exist a systematic review. However, the authors accept attempted to collate electric current knowledge and opinion on this topic.

Terminology

Initially modernistic devices were "inert", made entirely of metal or plastic. In the late 1960s, copper was added to plastic devices to increment their efficacy; a "frameless" copper-only device, GyneFix^® (Contrel, Ghent, Belgium), also became bachelor in 1996. Hormone-releasing devices were adult to ameliorate IUD efficacy and to reduce certain complications such as haemorrhage and pain. Copper-containing and hormone-releasing types of device are sometimes termed as "medicated" IUDs.

The abbreviation used for intrauterine devices known every bit a whole and for a conventional (nonhormone releasing) intrauterine device is IUD. Many types of IUD take been bachelor over the years, latterly all with added copper. Several types of progestin-releasing IUD are now bachelor; these will be referred to collectively equally the IUS, the abridgement for intrauterine organization. Examples of past and currently available IUDs are shown in Figure one.

Types of device.

Notes: (A) Ota Ring, (B) Birnberg Bow, (C) Majzlin Spring, (D) Lippes Loop, (E) GyneFix^®, (F) copper-bearing device: CuTT380 slimline, and (G) Levonorgestrel intrauterine organisation: Mirena^®. Types (A–D) all obsolete. Images (A–D) courtesy of the Museum of Contraception and Ballgame, Vienna (world wide web.muvs.org). Images (Due east–One thousand) courtesy of Durbin PLC, South Harrow, Middlesex, UK (world wide web.durbin.co.uk).

Mechanism of perforation

Esposito et al¹⁴ postulated that two mechanisms of uterine perforation exist.

1. Firsthand traumatic perforation

2. Afterwards "secondary" perforation acquired past gradual erosion through the myometrium

Confirmation of the latter machinery has been achieved past serial computed tomography (CT) scans performed for nongynecologic purposes.^fifteen

In the early days of IUDs, insertion instruments were rigid and so perforation was more probable equally a effect.¹⁶ An early on version of the Birnberg bow had a perforation charge per unit of one in 200 because of the rigidity of its inserter.^{17 , 18} With the Progestasert device, there was documented testify of a reduction in perforation charge per unit when the inserter was made more than flexible and a uterine sound included in the package.¹⁹ Nowadays, insertion tubes are made then that they are more flexible, just not so soft that they buckle easily. Other take a chance factors are employ of a button-out insertion technique, or lack of an insertion tube, every bit was the case with the Dalkon Shield (Dalkon Corporation, Defiance, OH, U.s.).

Perforation tin also happen with a uterine sound. Traditionally, metallic sounds were used to mensurate the uterine cavity length. Plastic sounds are almost certainly safer as they are less rigid. Perforation of the uterus may occur when the uterus is being sounded, or a false track may be created which is then followed by the IUD.

The forces required to insert an IUD increment linearly with increasing inserter tube diameter.²⁰ The force required to insert an IUD is mostly ane.5–vi.v N. The forces generated physiologically within the uterus have been estimated to exist theoretically as loftier as 50 North, sufficient to produce uterine perforation. This would explain the so-called "secondary" perforation as a consequence of embedment of a device. Except in cases of lactation or uterine atrophy (eg, due to long-term use of injectable progestins), it is thought that the forces required to cause perforation are higher than the forces needed to carry out insertion of an IUD.

Classification

Uterine perforation by IUDs was analyzed in detail by Zakin et al⁸ in a now-classic paper. The authors based their assay on the 356 cases that they found in the literature in 1981. They described complete perforation, which is the device passing through all uterine layers – endometrium, myometrium, and serosa – to lie freely in the peritoneal cavity or enveloped by omentum or traveling into other rarer locations. In a minority of cases, the IUD penetrates only into the myometrium, which they termed fractional perforation. Zakin et al^eight made the of import points that missing removal threads exercise not necessarily imply that a device is incorrectly located and conversely that the threads may be visible when a device has perforated.

Three anatomical compartments are considered, disregarding the endometrium and serosa. These are as follows:

1. Uterine crenel

2. Myometrium

3. Peritoneal cavity

Partial perforation

The partially perforated device may exist present in one, two, or all three anatomical compartments (Figure 2). A device with a blazon A perforation that is mainly situated in the uterine cavity (A1) will be easier to remove than ane in which the IUD is mainly in the myometrium (A2). Indeed, removal of the latter tin can be difficult or even hazardous. Post-obit a blazon B perforation the IUD lies entirely within the myometrium and then that information technology cannot exist seen either at hysteroscopy or laparoscopy. In a type C perforation the device has protruded into the peritoneal cavity merely is still stock-still in the myometrium. In a type D perforation, portions of the device are situated in all three compartments and a detailed cess volition be needed to plan the mode of removal; D2 will be more complex to remove laparoscopically than D1.

Classification of partially perforated devices.

Notes: Type A: IUD present in uterine cavity and myometrium; Type B: IUD nowadays entirely in myometrium; Blazon C: IUD nowadays in myometrium and peritoneal crenel; Type D: IUD nowadays in all iii compartments. A copper-T device is depicted: any device can perforate the uterus. The size of the IUDs relative to the uterus has been slightly reduced for illustrative purposes.

Abbreviation: IUD, intrauterine device.

A partial perforation may remain equally such or it may convert into a complete perforation within a matter of days. This latter conversion is almost certainly due to uterine contractions pushing the device through the myometrium, the force needed depending on the shape of the device.

In a very unusual example, an IUD moved during pregnancy from a location in the lower uterine segment at sixteen weeks' gestation to the posterior fundal myometrium at the time of a twenty-week miscarriage, to erosion into pocket-sized bowel, establish at laparoscopic sterilization vi weeks later.²¹

Complete perforation

With a complete perforation of the uterus, the device may remain almost the uterus or it may motion within the abdominal crenel. Zakin et al⁸ found that the most common location for a completely perforated IUD is the pouch of Douglas. In nearly half of complete perforations, the device is located in the omentum, either loosely or adherent to it; in the latter example it may be so densely adherent that a portion of omentum needs to be excised in order to remove the device. The threads of a completely perforated device will generally non be visible at the neck past the time of follow-up.

Embedment

Hither, a device impinges on the endometrium with a strength sufficient to cause pressure necrosis of underlying tissue and penetration into the superficial layers of the myometrium.²² This phenomenon was seen in the past in women using the Majzlin spring device. When removal of an embedded device is attempted, trauma to tissues may occur. Great intendance is needed in cases of embedment if marked pain is caused at attempted removal. In one case, this caused a tear which resulted in a ii-liter hemorrhage.²³

Incidence of perforation

Perforation of the uterus is uncommon: estimates in larger studies range from 0.4 to ane.six per 1,000 insertions.^{ix , 19} A nationwide prospective cohort study from New Zealand over a 10-year period establish 28 perforations among 17,469 insertions of the Multiload^® Cu375 IUD (Merck and Co., Inc., White-house Station, NJ, USA), giving an incidence of ane.six per 1,000 insertions.⁹ A iii-year study by the same group constitute iii perforations in 3,519 IUS insertions, giving an incidence of 0.9 per ane,000.²⁴ Both these studies represent "real-life" results, which give a truer picture than clinical trials, especially when IUDs are being inserted by generalists. A Turkish infirmary-based study of the T-380A IUD followed upwards women at 1 year and found an incidence of 2.2 per one,000 insertions.²⁵ Other studies that could non be so sure of the denominator have institute lower rates; for instance a Finnish study calculated an incidence of 0.4 per one,000 sold devices.²⁶ One written report constitute a higher perforation rate in women using an IUD for the outset time compared to women who had used the method previously.²⁷

The long-continuing debate about whether or not lactation is a risk factor for perforation with IUD insertion is described in the "Effect of insertion after pregnancy or during lactation" section.

Rates of perforation with any IUD may in part be influenced past the experience or the maintenance of skill of the operator. This was beginning mooted in a report from Singapore, in which more perforations were seen in insertions by junior doctors or full general practitioners than by experienced gynecologists.⁷ In a big prospective accomplice study of a copper IUD, doctors who had inserted fewer than ten IUDs during the x-yr study menstruum (73% of the sample) had significantly higher perforation rates than those who had inserted between x and 99.⁹ The European Active Surveillance (EURAS) written report showed a college perforation rate in insertions performed by clinicians who inserted fewer than 50 devices per twelvemonth compared to those inserting 50 or more per year.²⁷

Although spontaneous reporting to national databases gives no experience for incidence due to the lack of a denominator, information technology is interesting to note that since its launch in 1996, there have been 114 reports of uterine perforation with the levonorgestrel IUS in the Great britain and 23 reports of such devices becoming embedded in the uterus, cervix, or other local tissues.²⁸

Dissimilar device types

Perforation occurs with all device types, whether IUDs or IUSs (Figure 1). This includes frameless copper devices such as the GyneFix^®.^{29 – 31} Perforation with the sharp tip of the GyneFix^® stylet is potentially dangerous. A Cochrane review ended that it is not known if the perforation charge per unit for framed devices differs from frameless devices; one perforation was noted with GyneFix^® in the studies reviewed (approximately 3,000 insertions) compared to none with the TCu380 framed device.³² The possibility has been raised that the GyneFix^® anchoring knot may sometimes exist located on the serosal surface of the uterus at the end of the insertion process,³³ either because the thickness of the fundal myometrium may in some cases exist less than originally thought when GyneFix^® was designed or considering of thinning associated with long-term injectable progestin utilise.^{33 , 34}

The type of framed device does not announced to be an influencing factor in perforation rates.³² A large European cohort report (EURAS) institute no clinically of import differences in perforation rates between copper IUDs and the Mirena^® IUS (Bayer Schering Pharma, Turku, Finland)²⁷. In that location is no pregnant difference in perforation rates betwixt Levosert^® (Actavis, Hafnarfjörður, Iceland) and Mirena^® IUSs.³⁵ Early experience with newer depression-dose levonorgestrel IUSs in clinical trials has found a depression crude incidence for consummate or partial perforation (0%–0.03%).^{36 , 37}

Hazard factors for uterine perforation

Possible risk factors for perforation are listed beneath. However, the associations are either weak or inconsistent, and so causality has non been demonstrated.

• Insertion past less experienced clinicians^{7 , 9 , 27}

• Lactation: see the "Effect of insertion after pregnancy or during lactation" section

• Postpartum insertion (<6 months since delivery)^{25 , 27}

• Lower parity²⁵

• College number of previous abortions²⁵

Age of the adult female, history of dilation and curettage, and history of cesarean section have been found not to be associated with take chances of uterine perforation.^{25 , 27}

Upshot of insertion subsequently pregnancy or during lactation

The myometrium is softer when in the pregnant state and for a time after, so is more vulnerable to existence torn or punctured during instrumentation. Involution starts immediately subsequently commitment and is rapid during the first week; by 2 weeks postpartum the uterus is independent within the pelvis; by near 4 weeks it is close to normal size. During full chest-feeding, estrogen levels are very low and the uterus is consequently small. As noted by Chi et al,³⁸ IUD insertion is less painful in lactating women; this may be due to increased levels of β-endorphins.³⁹ Perforation during insertion at this fourth dimension may be associated with picayune hurting and may therefore be less likely to be noticed at the time of its occurrence.

Perforation in the postpartum period is generally rare. A Singaporean study in the 1960s (in which 2,487 of 8,977 insertions were postplacental, ie, within 48 hours of delivery) recorded 93 perforations with the Lippes loop,⁷ where the perforation risk was possibly high due both to its mode of release from its insertion tube and to its linear form if it did non conform to the shape of the uterine cavity. A later Californian study of insertions between 4 and 8 weeks postpartum showed a zero perforation rate with copper-7s and copper-Ts.^twoscore In a Turkish study of copper T380A insertions, no perforations were observed at up to six weeks postpartum, but at that place were some when insertions were washed after half dozen weeks.⁴¹

The possibility that women who are lactating are more susceptible to perforation of the uterus when an IUD is inserted was first raised in 1966.^{xvi , 42} This phenomenon was first investigated in a Us example-control study.⁴³ This study showed a tenfold college risk of perforation in women who were lactating at the time of IUD insertion compared to women with at least 1 live birth who were not lactating.

However, subsequent studies did non confirm this finding. A multicenter vi-calendar month follow-up report of i,149 women who underwent copper-T 380A IUD insertion establish no perforations in any of the women, breast-feeding or not breast-feeding.³⁸

Analysis of fifty perforations reported to a Swedish insurance scheme register constitute that 27 of the women (54%) were breast-feeding at the time of insertion.³⁹ A multicenter pharmacovigilance written report found that 42% of women with IUS perforations were breast-feeding at the time of diagnosis.^ten Also, in the EURAS study, a sixfold increase in hazard of perforation associated with breast-feeding was found.²⁷

It is therefore non possible to requite a definitive respond every bit to whether chest-feeding increases the adventure of perforation. Current professional guidance gives no restriction on eligibility for IUD insertion later on 4 weeks from commitment (postpartum), regardless of whether or not a woman is breast-feeding.⁴⁴ For IUD insertion between 48 hours and 4 weeks postpartum, WHOMEC⁴⁵ and UKMEC⁴⁶ assign category iii (risks generally outweigh advantages), but USMEC⁴⁷ assigns category 2 (advantages mostly outweigh risks). In June 2015, the Uk Medicines and Healthcare Products Regulatory Bureau (MHRA) reviewed risk factors for perforation in light of the EURAS written report results²⁷ and concluded that the benefits of intrauterine contraception strongly outweigh the risks, including in those who are lactating or who accept recently given birth.⁴⁸

A systematic review of studies of surgical abortion and of miscarriage treated surgically, followed immediately by IUD insertion, showed perforation rates of 1 per 1,000 and 0.9 per 1,000, respectively.⁴⁹

Perforation sites

Perforation typically occurs into the uterorectal pouch (pouch of Douglas, cul-de-sac) with an anteverted uterus (Figure 3A) or the vesicouterine pouch if it is retroverted⁸ (Figure 3B). Flexion of the uterus is also a factor. In 1 series, ultrasound examination of women with perforated IUDs showed a significant number with an astute angle of flexion of the uterine body in relation to the cervix.¹² Perforation tin likewise occur through the fundus, particularly if the uterus is in an axial orientation. Information technology has also been reported to occur into the uterosacral ligament,^l broad ligament,^{50 – 52} fallopian tube,⁵³ and ovary.⁵⁴ In that location is a written report of IUD threads coming through the posterior fornix; later failed localization at laparoscopy, the IUD was removed by colpotomy.⁵⁵ In ane case, an IUD was found within an ovarian carcinoma.⁵⁶ Very rare sites take been described such as the anterior abdominal wall.^{57 – 59} There is one recorded case of sciatica later on a posterior perforation.⁶⁰

Diagrams showing direction of perforation in unlike uterine positions.

Notes: (A) Posterior perforation in an anteverted uterus; (B) Anterior perforation in a retroverted uterus.

Most commonly the perforated device is plant free in the peritoneal cavity. However, ultimately, information technology usually becomes attached to an organ, the bowel, the mesentery, or about commonly the omentum.⁶¹ Rarely, adhesion formation stimulated by a perforated device has resulted in abdominal obstruction.⁶²

Perforation of the cervix is very rare and unremarkably asymptomatic. It is postulated that some degree of malposition of the device afterward results in force exerted past the vertical stem with slow, repetitive uterine contractions which gradually propel the device through the cervical tissues.^{viii , 63} Fortunately, removal tin be relatively piece of cake, commonly by freeing the device initially by pushing it up toward the uterine cavity. There are reported cases of cervical perforation by the threads only,⁶⁴ which were establish running in a fistulous tract along the ectocervix. I writer postulated that this may have been preceded by trauma to the cervix from a tenaculum. However, this phenomenon can occur at sites other than where the tenaculum has been placed.⁶⁵

Perforation into bowel

Perforation of large and small-scale bowel, appendix, and rectum have been described.^{66 – 68} Removal sometimes has to involve resection of a segment of bowel. There are occasional reports of successful removal of an IUD per rectum past proctoscopy or colonoscopy.^{69 , 70} At that place is one case study of a perforated frameless IUD which apparently disappeared from the body, presumably via the intestine.⁷¹

Perforation with a modernistic T-shaped IUD has been known to cause fractional abdominal obstruction. In a Danish case report, a perforation next to the sigmoid colon presented 5 years after insertion with thickening of the bowel wall causing acute abdominal pain.⁷² Zakin et al⁸ described the "stopper effect" whereby a device that had perforated into bowel leaves a defect in the bowel wall on removal through which bowel contents can pass, with resultant peritonitis. An exceedingly rare complication is fistula formation between different sections of bowel.^{73 , 74} A case of intestinal gangrene has besides been reported.⁷⁵

Perforation into the urinary tract

There are more than seventy cases of perforation involving the urinary tract reported in the literature.⁷⁶ Perforation through to the float or ureter is an uncommon merely regularly reported complication of IUD insertion. In some cases, in that location is urinary calculus formation around the device.⁷⁷ In ane instance report, the IUD was mainly situated in the urethra.⁷⁸ There is 1 report of menouria (vesical menses) due to a vesicouterine fistula,⁷⁹ and some other study of germination of a colovesical fistula.⁸⁰ At that place are 3 reported cases of retroperitoneal location of a perforated IUD with fibrosis around the right pelvic ureter leading to correct hydronephrosis.^{81 , 82} IUDs and associated bladder calculi tin can be removed cystoscopically.^{77 , 78}

Localization of devices that have perforated

The first warning sign, and the most common reason for investigation, of possible uterine perforation is the finding of missing or lost IUD/IUS threads. The bedrock of diagnosis of perforation and localization of a perforated device is ultrasound scanning. Localization of devices is more precise using transvaginal scanning than with transabdominal scanning. Ultrasound scanning is a better modality for identifying devices that are intrauterine rather than extrauterine. IUDs are easier to place than IUSs on an ultrasound scan (Effigy 4) equally ultrasound imaging of the original (52 mg) levonorgestrel IUS (Mirena^®) depends principally on the finding of an audio-visual "shadow" rather than on visualizing the device itself. The inclusion of a silvery ring at the junction between the vertical stem and side arms of the smaller dimension 13.5 mg IUS (Jaydess^® and Skyla^®; Bayer AG, Leverkusen, Frg) permits easier visualization of the device by ultrasound scanning and distinguishes it from Mirena^® on ultrasound scan and from Mirena^® and other devices on X-ray.

Ultrasound scan images of intrauterine IUDs and an IUS.

Notes: (A) Sagittal view of framed IUD, (B) frameless IUD, and (C) sagittal view of IUS showing triangular acoustic shadow of device. Pictures courtesy of Emeka Oloto.

Abbreviations: IUD, intrauterine device; IUS, intrauterine system.

In one series, ultrasound scanning failed to show the perforated device in more than half of cases.¹² In this series, IUSs were more than likely than IUDs to exist missed. A perforated IUS that was ultimately shown on X-ray and CT scan had been missed by ultrasound scan alone.⁸³ In another series, in that location was a noticeable discrepancy between the location of IUSs indicated by ultrasound imaging and subsequent actual location at surgery.⁸⁴ Ultrasound can easily miss IUDs located in the upper abdomen.⁸⁴ Both IUDs and IUSs are radiopaque, so if they are in the abdominal cavity they will always be visible on a whole-abdominal and pelvic Ten-ray view, but the precise location may however exist uncertain (Figure 5); a CT scan or magnetic resonance imaging will exist able to localize devices of any type more accurately.⁸⁵

X-ray images of extrauterine IUD and IUS.

Notes: (A) Nova-T 380 IUD and (B) Mirena^® IUS. Pictures courtesy of Emeka Oloto.

Abbreviations: IUD, intrauterine device; IUS, intrauterine system.

Clinical features

A scenario that has occurred regularly, specially in the more distant past, is that a clinician makes a presumption that "lost" threads are due to an IUD having been expelled, leading to long delays in diagnosis if an ultrasound scan, and if necessary an X-ray, is not performed to confirm the absenteeism of the device. Sometimes another device is inserted so that both an intrauterine and an extrauterine device are nowadays. Rarely, a perforation is not detected by ultrasound scanning and a second perforation occurs in the aforementioned individual.^{86 , 87}

Assessment of the size and position of the uterus is essential before insertion of an IUD. Use of a uterine sound and traction with a tenaculum was suggested in 1966^xvi and has become part of routine practice. This is especially important where there is abrupt ante- or retroversion of the uterus, acute ante- or retroflexion, or a severe mismatch of flexion and version¹² (Figure 3); if these angulations are not straightened with traction using a tenaculum then perforation is probably more than likely.⁸⁸ Setting the flange on the introducer accurately to the uterine cavity length as measured with the sound is also important.

Uterine perforation can occur with the sound, with the device itself, or with both. If the sound or inserter laissez passer further than ane would ordinarily expect (over 10–eleven cm) and if no resistance is felt, then this should be regarded as suspicious and the instrument or device immediately withdrawn from the uterus and the procedure abandoned. If perforation is suspected following insertion of the device, an ultrasound browse may be carried out immediately if the facilities and skills are available, or arranged via an imaging department.

In around xc% of cases, perforation is not recognized at the fourth dimension of IUD insertion.^{9 , x} The threads are generally nevertheless emerging from the cervical os at the terminate of the procedure, even with a complete perforation. Sometimes perforation is suspected betwixt the time of insertion and follow-upwardly, due to persistent symptoms, mainly mild lower abdominal pain. 1 of the main purposes of follow-upwards about 6 weeks subsequently insertion is to exclude expulsion and perforation. In virtually cases of perforation the threads are not visible at 6 weeks. Still, not all women attend for this follow-upwardly test. In a few cases in which the IUD is located in the pouch of Douglas, the device can exist palpated on vaginal or rectal examination.^eight

Many instances of perforation are diagnosed later on than the follow-up examination, oft because of the occurrence of a pregnancy, which may be ectopic.⁸⁹ Other indicators of perforation are "lost" threads and persistent lower intestinal hurting. In the 10-year New Zealand cohort study, over half of perforations were diagnosed more than than 1 year after insertion.⁹

It should be borne in mind that when a perforated IUS lies close to the uterus, the woman may notwithstanding experience amenorrhea from local progestin release;⁹⁰ the IUS may besides have an adequate "remote" contraceptive event.⁹¹ A perforated IUS has been reported as a rare crusade of secondary infertility.^{92 , 93} In one case of IUS perforation, plasma levonorgestrel levels were higher from intraperitoneal release than are generally institute from intrauterine release.⁹⁴ In the Finnish study, women with perforations were less likely to go meaning if their perforated device was an IUS rather than an IUD.¹¹ However, a case written report described a pregnancy occurring with a perforated IUS well within the expected five-year IUS life span. Information technology was removed from the omentum at cesarean section.⁹⁵

When the bowel is perforated, a triad of symptoms has been described: abdominal pain, fever, and intermittent diarrhea.⁶⁶ Rectal haemorrhage is besides possible.⁹⁶ Occasionally, bowel perforation is asymptomatic with discovery equally an incidental finding, for instance at hysterectomy.⁹⁷ When the urinary tract is perforated, symptoms may include dysuria, frequency, suprapubic pain, hematuria, and recurrent urinary tract infections. In one case, a perforated device was missed at hysterectomy and found subsequently in the correct lower quadrant, 35 years after insertion and 14 years later on the hysterectomy.⁹⁸ In another case, an IUS was found in the abdomen despite the patient having had a vaginal hysterectomy and admissions to hospital on account of abdominal pain.⁸³ In the unmarried reported instance of right-sided sciatica, an IUD was resting on the lumbosacral plexus; information technology was postulated that the left side is protected past the sigmoid colon.⁶⁰

Prevention of uterine perforation

Actions that tin help to reduce the take a chance of uterine perforation associated with insertion of IUDs include:

• Avoidance of insertion or taking extra intendance (with special consent) from 48 hours to 4 weeks postpartum, especially if the adult female is breast-feeding

• Utilise of a plastic rather than a metal sound

• Use of a suitable tenaculum and applying appropriate traction to it

• Provision of less rigid introducers by device manufacturers

• Authentic setting of the flange on the introducer according to the sounding distance and the specific instructions for the device

• A pull-back, rather than a button-out, release machinery for the device

• Skilled insertion training for clinicians

• Insertion by experienced clinicians

There is no prove that utilise of ultrasound control during the routine insertion of IUDs reduces the risk of perforation occurring. Even so, circuitous insertions (eg, after failed insertion elsewhere as a effect of acute uterine ante- or retroversion or in cases of coexisting fibroids) are carried out under ultrasound guidance in many specialist centers, which will assist to minimize the risk of uterine perforation. Ultrasound is also a very useful tool in verifying the location of an IUD/IUS afterwards insertion, especially if there is concern most possible perforation.

Removal of devices that have perforated

Information technology is conventional clinical do to remove all devices that have completely perforated the uterine wall. Originally, this was considered vital⁹⁹ as older, now obsolete, devices were "closed" (examples are Gräfenberg ring, Ota ring, Incon ring, Hall-Stone ring, Antigon and Birnberg bow – Effigy one) and a loop of bowel could laissez passer through the device with resultant abdominal obstruction.^{100 – 103} Ring-shaped IUDs have connected to be used in China until recent years.

At that place is no such take a chance with newer, mainly T-shaped, devices (Figure 1). Many of these devices remain in the abdomen, for periods of years in some cases, without doing any harm before they are discovered. Some authorities have suggested that removal of a mod IUD is not warranted and that the risks of laparoscopy or even laparotomy are not justifiable when a woman with a perforated device is asymptomatic.¹⁰⁴ One time report, a 62-year old woman who had a Lippes loop in her abdomen for 42 years was followed upward without recourse to surgery.¹⁰⁵ Some other reason for conservative direction would be a adult female with complex medical problems who is deemed unfit for surgery.¹⁰⁶

There is, yet, the question as to whether the components of IUDs (plastic frame and copper) or IUSs (plastic frame, progestin, silicone matrix and sleeve, and silverish in the instance of Jaydess^®/Skyla^®) induce peritoneal adhesions. A study on rabbits found that polyethylene foreign bodies elicited a peritoneal reaction with adhesion formation in most animals after 2 weeks.¹⁰⁷ Several human studies have shown but local and delicate peritoneal adhesion formation; bands of adhesions that could cause bowel obstruction did not develop.^{104 , 108 – 110} An Israeli study showed no difference in the peritoneal reaction between IUDs and the IUS,¹¹⁰ simply two other studies found that adhesion formation was more common with IUDs than the IUS.^{eleven , 12} Adoni and Ben Chetrit¹⁰⁴ were of the opinion that adhesions course during a express menstruation only; once formed, the authors suggested that they do non develop further. Still, in one series, adhesions were more than common when the interval from insertion to surgical intervention was greater than viii months.¹² If they form, adhesions are localized to the IUD/IUS site and prevent the device from moving farther.¹⁰⁹

The precise surgical details of removal of IUDs from the abdomen are exterior the scope of this commodity. The first laparoscopic removal of an IUD took place in 1969.¹¹¹ Laparoscopic removals accept been successfully performed in pregnancy.¹¹² Perforated IUSs accept been purposely left in situ during pregnancy¹¹³ or mistakenly thought to be intrauterine⁹⁵ and then removed at cesarean department.

Minimally-invasive laparoscopic removal is to be preferred, but when the removal is more complicated open laparotomy may exist safer. In a 2012 systematic review of laparoscopies carried out for removal of perforated IUDs, 64% were successful and 35% needed to be converted to laparotomy.¹¹⁴ The example series in that review were reported between 1972 and 2002, and the scope of laparoscopic surgery has certainly progressed in contempo years. It could therefore be argued that a woman whose perforated IUD cannot be removed at initial laparoscopy should be referred to a surgeon with special skills in minimal access surgery, who may be more likely to remove a device successfully and safely than a full general gynecologist. Occasionally "discretion is the better role of valor" and laparoscopy or laparotomy is abandoned when retrieval is unsuccessful in cases where the device has become densely adherent to, or buried in, vital structures. It should be noted that surgery to remove an IUD may itself crusade adhesion formation.¹⁰⁹ Laparoscopic removal is non feasible in type A and B perforations.¹¹⁵ However, type A perforations may well be amenable to removal of the device at hysteroscopy.

In certain cases, early laparoscopy is not the preferred approach. In a retrospective series of 95 cases of perforation, two devices were removed at cesarean section and one at post-partum sterilization.¹¹⁶ Nitke et al⁸⁴ noted that in several of their cases IUSs were located at a college level in the abdomen at laparoscopy than had been indicated by the diagnostic erect X-ray. They postulated that IUSs adhere to omentum which then shifts from pelvis to upper abdomen when the patient is in the Trendelenburg position for laparoscopy. This may also explain the more precise localization by CT scanning, during which the patient is supine. Some surgeons use X-ray imaging when the patient is positioned for surgery.

Healing of the myometrium after perforation is rapid. Often at laparoscopy a few days or weeks after IUD insertion and perforation, no scar is visible on the uterus to bear witness the exit point.¹¹⁷ In the Kho and Chamsy¹² series, the perforation site was identifiable in only one-third of cases. Zakin et al^viii concluded that scars would disappear by 2 months after perforation. This is, however, not invariably truthful and sometimes a scar does persist long-term.¹¹⁸

Medicolegal aspects

Perforation of the uterus is a recognized complication of IUD insertion. Provided that preinsertion counseling and cess accept been carried out, with provision of written information, and the procedure is carried out using a safe technique and the patient and so followed upwards with full documentation in the medical records, clinicians should not exist vulnerable to litigation.¹¹⁹ Perforation is a risk each fourth dimension IUD insertion is carried out in the same private; risks should be explained at every process, non simply the offset.¹²⁰

Consent for IUD insertion does not need to exist in written form for nonanesthetized women, merely a brief explanation of perforation along with the other complications is needed in order to obtain valid consent, including the information that the one in 1,000 hazard of perforation is uncommon. This level of risk can exist presented on a hazard scale to make it easier to comprehend.¹²¹

Conclusion

While being an uncommon phenomenon, uterine perforation with an IUD is an important risk that must be explained to patients, prevented if possible by taking all steps to insert devices safely, and diagnosed and managed appropriately. Most cases are due to traumatic perforation that occurs at the fourth dimension of insertion. However, "secondary" perforation can also occur by gradual erosion. A partial perforation may catechumen into a complete perforation.

Perforation occurs in i in one,000 IUD or IUS insertions and occurs with all types of devices. The evidence on perforation and lactation is alien: although some studies show a positive clan, others do not and then a causal human relationship has non been established. About perforations are uncomplicated, with the device lying in a quiescent country in the abdomen. However, rarely other organs can exist afflicted, either by direct trauma at the time of insertion or by subsequent erosion. Both the bowel and the urinary tract prevarication in shut proximity to the uterus and can be afflicted.

Well-nigh cases are "silent" and not recognized at the time of insertion. IUSs are quite unremarkably missed when abdominal ultrasound is the only imaging modality used. Transvaginal ultrasound scanning by the clinician searching for a "missing" device is unremarkably the first line of investigation, simply there is still much to be said for requesting a plain X-ray of abdomen and pelvis if the device is not located immediately past ultrasound scan. When perforation is diagnosed, well-nigh devices can be and should exist removed. This can most often exist accomplished by laparoscopy; sometimes laparotomy may be needed.

IUDs are remarkably simple, safe and cost-effective, long-acting contraceptives. Overall, this review demonstrates the depression morbidity associated with their use, even when uterine perforation occurs.

Acknowledgments

We thank the staff at the Library, Regal Bournemouth Hospital Education Centre, for conducting the literature searches and for providing references.

Footnotes

Disclosure

The authors have received fees for consultancy and provision of training from the manufacturers of intrauterine devices. The authors study no other conflicts of interest in this piece of work.

References

1. Richter R. Ein Mittel zur Verhütung der Konzeption [A ways of preventing conception] Deutsch Med Wochenschr. 1909;35:1525. German. [Google Scholar]

ii. Gräfenberg Due east. Die intrauterine methode der konzeptionverhütung. In: Haire N, editor. Proceedings of the Third World League for Sexual Reform Congress, London 1929. London, UK: Kegan Paul, Trench, Turner and Company; 1929. pp. 166–175. [Google Scholar]

3. Sivin IB. State-of-the-art on non-hormonal methods of contraception: III. Intrauterine devices. Eur J Contracept Reprod Wellness Care. 2010;15:96–112. [PubMed] [Google Scholar]

5. Potato MC. Migration of a Gräfenberg ring. Lancet. 1933;2:1369–1370. [Google Scholar]

half dozen. Andrews CJ. Migrating Gräfenberg contraception ring. JAMA. 1936;107:279. [Google Scholar]

vii. Ratnam SS, Tow SH. Translocation of the loop. In: Zatuchni GI, editor. Mail service-partum Family Planning: A Report on the International Program. New York, NY: McGraw-Hill; 1970. pp. 371–384. [Google Scholar]

8. Zakin D, Stern WZ, Rosenblatt R. Complete and partial perforation and embedding following insertion of intrauterine devices. I. Classification, complications, mechanism, incidence, and missing cord. Obstet Gynecol Surv. 1981;36:335–353. [PubMed] [Google Scholar]

nine. Harrison-Woolrych M, Ashton J, Coulter D. Uterine perforation on intrauterine device insertion: is the incidence higher than previously reported? Contraception. 2003;67:53–56. [PubMed] [Google Scholar]

ten. van Grootheest K, Sachs B, Harrison-Woolrych G, Caduff-Janosa P, van Puijenbroek Eastward. Uterine perforation with levonorgestrel-releasing intrauterine device. Drug Saf. 2011;34:83–88. [PubMed] [Google Scholar]

xi. Kaislasuo J, Suhonen S, Gissler Chiliad, Lähteenmäki P, Heikinheimo O. Uterine perforation acquired by intrauterine devices: clinical course and treatment. Hum Reprod. 2013;28:1546–1551. [PubMed] [Google Scholar]

12. Kho KA, Chamsy DJ. Perforated intraperitoneal intrauterine contraceptive devices: diagnosis, management and clinical outcomes. J Minim Invasive Gynecol. 2014;21:596–601. [PMC free article] [PubMed] [Google Scholar]

14. Esposito JM, Zarou DM, Zarou GS. A Dalkon shield imbedded in a myoma: case report of an unusual deportation of an intrauterine device. Am J Obstet Gynecol. 1973;117:578–581. [PubMed] [Google Scholar]

15. Ferguson CA, Costescu D, Jamieson MA, Jong L. Transmural migration and perforation of a levonorgestrel intrauterine system: a example report and review of the literature. Contraception. 2016;93:81–86. [PubMed] [Google Scholar]

sixteen. Ledger WJ, Willson R. Intrauterine contraceptive devices: the recognition and management of uterine perforations. Obstet Gynecol. 1966;28:806–811. [PubMed] [Google Scholar]

17. Hall RE. A comparative evaluation of intrauterine contraceptive devices. Am J Obstet Gynecol. 1966;94:65–77. [PubMed] [Google Scholar]

xviii. Tietze C. Contraception with intrauterine devices 1959–1966. Am J Obstet Gynecol. 1966;96:1043–1054. [PubMed] [Google Scholar]

nineteen. WHO Scientific Group . Mechanism of Action, Safety and Efficacy of Intrauterine Devices. Geneva, Switzerland: Globe Health Organization; 1987. (Technical Study Serial 753). [PubMed] [Google Scholar]

twenty. Goldstuck ND, Wildemeersch D. Role of uterine forces in intrauterine device embedment, perforation, and expulsion. Int J Women'south Health. 2014;6:735–744. [PMC free commodity] [PubMed] [Google Scholar]

21. Glass T, Bakery T, Kauffman RP. Migration of an intrauterine contraceptive device during the class of a pregnancy: a case report. J Minim Invasive Gynecol. 2009;16:81–83. [PubMed] [Google Scholar]

22. Tatum HJ. Clinical aspects of intrauterine contraception: circumspection. Fertil Steril. 1977;28:3. [PubMed] [Google Scholar]

23. Goldman JA, Feldberg D, Dicker D. Massive hemoperitoneum due to IUD. Eur J Obstet Gynecol Reprod Biol. 1983;fourteen:239–240. [PubMed] [Google Scholar]

24. Zhou Fifty, Harrison-Woolrych Grand, Coulter DM. Use of the New Zealand Intensive Medicines Monitoring Programme to study the levonorgestrel-releasing intrauterine device (Mirena) Pharmacoepidemiol Drug Saf. 2003;12:371–377. [PubMed] [Google Scholar]

25. Caliskan Eastward, Özturk Northward, Dilbaz BÖ, Dilbaz Due south. Analysis of run a risk factors associated with uterine perforation past intrauterine devices. Eur J Contracept Reprod Health Intendance. 2003;8:150–155. [PubMed] [Google Scholar]

26. Kaislasuo J, Suhonen Southward, Gissler M, Lähteenmäki P, Heikinheimo O. Intrauterine contraception: incidence and factors associated with uterine perforation – a population-based report. Hum Reprod. 2012;27:2658–2663. [PubMed] [Google Scholar]

27. Heinemann K, Reed S, Moehner S, Minh TD. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Written report on Intrauterine Devices. Contraception. 2015;91:274–279. [PubMed] [Google Scholar]

29. Gandhi JD, Whitmore J, Iskander MN. Uterine perforation by GyneFix frameless IUD: two case reports. J Fam Plann Reprod Health Intendance. 2001;27:153–154. [PubMed] [Google Scholar]

xxx. Aust TR, Kirwan JN, Herod JJ, McVicker JT. Perforation with the GyneFix intrauterine implant: is there a mutual gene? J Fam Plann Reprod Health Care. 2003;29:155–156. [PubMed] [Google Scholar]

31. Sajjad Y, Selvan Grand, Kirwan JM, Kingsland CR. GyneFix frameless IUD: cause of bowel resection. Eur J Contracept Reprod Health Care. 2006;11:241–242. [PubMed] [Google Scholar]

32. O'Brien PA, Marfleet C. Frameless versus classical intrauterine device for contraception. Cochrane Database Syst Rev. 2005;25(one):CD003282. [PubMed] [Google Scholar]

33. Wildemeersch D. Further information and recommendations to prevent perforation with the frameless GyneFix IUD. J Fam Plann Reprod Health Care. 2001;27:241. [PubMed] [Google Scholar]

34. Vekemans G, Verougstraete A. Belatedly uterine perforation with an anchored IUD, the GyneFix: a instance study. Contraception. 1999;60:55–56. [PubMed] [Google Scholar]

36. Gemzell-Danielsson K, Schellschmidt I, Apter D. A randomized, phase II report describing the efficacy, bleeding profile, and rubber of two depression-dose levonorgestrel-releasing intrauterine contraceptive systems and Mirena. Fertil Steril. 2012;97:616–622. [PubMed] [Google Scholar]

37. Nelson A, Apter D, Hauck B, Schmelter T, Rybowski S, Rosen K. Two low-dose levonorgestrel intrauterine contraceptive systems: a randomized controlled trial. Obstet Gynecol. 2013;122:1205–1213. [PubMed] [Google Scholar]

38. Chi IC, Potts M, Wilkens LR, Champion CB. Operation of the copper T-380A intrauterine device in breastfeeding women. Contraception. 1989;39:603–618. [PubMed] [Google Scholar]

39. Andersson K, Ryde-Blomqvist E, Lindell K, Odlind Five, Milsom I. Perforations with intrauterine devices. Contraception. 1998;57:251–255. [PubMed] [Google Scholar]

40. Mishell DR, Roy S. Copper intrauterine contraceptive device event rates following insertion iv to eight weeks post partum. Am J Obstet Gynecol. 1982;143:29–35. [PubMed] [Google Scholar]

41. Eroglu K, Akkuzu G, Vural Chiliad, et al. Comparison of efficacy and complications of IUD insertion in immediate postplacental/early post-partum period with interval period: 1 year follow-up. Contraception. 2006;74:376–381. [PubMed] [Google Scholar]

42. Macfarlan SM. Perforation of the postpartum uterus with an intrauterine contraceptive device. Am J Obstet Gynecol. 1966;94:283–284. [PubMed] [Google Scholar]

43. Heartwell SF, Schlesselman S. Risk of uterine perforation among users of intrauterine devices. Obstet Gynecol. 1983;61:31–36. [PubMed] [Google Scholar]

44. Clinical Effectiveness Unit . Intrauterine Contraception. 3rd ed. London, UK: Faculty of Sexual and Reproductive Healthcare; 2015. [Google Scholar]

46. Faculty of Sexual and Reproductive Healthcare . UK Medical Eligibility Criteria for Contraceptive Use. 2nd ed. London, UK: Kinesthesia of Sexual and Reproductive Healthcare; 2009. [Google Scholar]

47. Centre for Disease Control and Prevention . United states of america Medical Eligibility Criteria for Contraceptive Apply. 4th ed. Atlanta, GA: Department of Wellness and Human Services, Center for Affliction Control and Prevention; 2010. 2010. [Google Scholar]

49. Stanwood NL, Grimes DA, Schulz KF. Insertion of an intrauterine contraceptive device afterwards induced or spontaneous abortion: a review of the evidence. BJOG. 2001;108:1168–1173. [PubMed] [Google Scholar]

50. Adiyeke M, Sanci M, Karaca I, Gökçü Yard, Töz E, Öcal E. Surgical management of intrauterine devices migrated towards intra-abdominal structures: twenty-twelvemonth feel of a tertiary centre. Clin Exp Obstet Gynecol. 2015;42:358–360. [PubMed] [Google Scholar]

51. Mallik MK. Lippes loop in the broad ligament (report of a instance of extraperitoneal migration of the loop) J Obstet Gynaecol India. 1968;18:336–337. [PubMed] [Google Scholar]

52. Cederqvist LL, Sarry ZI, Zervoudakis IA. Translocation of the Dalkon Shield into the broad ligament. Obstet Gynecol. 1975;46:239–242. [PubMed] [Google Scholar]

53. Sindos 1000, Pisal North, Setchell Chiliad, Singer A. Tubal migration: a rare complication of an intrauterine contraceptive device leading to formation of a hydrosalpinx. Am J Obstet Gynecol. 2003;188:1109–1110. [PubMed] [Google Scholar]

54. Verma U, Verma North. Ovarian embedding of a transmigrated intrauterine device: a case written report and literature review. Arch Gynecol Obstet. 2009;280:275–278. [PubMed] [Google Scholar]

55. Nigam A, Biswas R, Mishra A. Misplaced intrauterine contraceptive device: an enigma. Open Access J Contracept. 2011;2:1–3. [Google Scholar]

56. Koo Hr, Oh YT, Kim YT, Kim SW, Kang JH, Kim KW. Intrauterine device found in an ovarian carcinoma. J Comput Assist Tomogr. 2008;32:69–71. [PubMed] [Google Scholar]

57. Borkotoky RK, Mampilli KJ. Translocation of intrauterine contraceptive device. J Indian Med Assoc. 1976;67:147–149. [PubMed] [Google Scholar]

58. Ansari MM, Harris SH, Haleem S, Fareed R, Khan MF. Strange body granuloma in the inductive abdominal wall mimicking an acute appendicular lump and induced by a translocated copper-T intrauterine contraceptive device: a instance report. J Med Case Rep. 2009;iii:7007. [PMC gratis article] [PubMed] [Google Scholar]

59. Chell KI, Lipscomb GH. Abdominal wall abscess presenting 35 years after insertion of an intrauterine contraceptive device. Obstet Gynecol. 2010;115:458–459. [PubMed] [Google Scholar]

threescore. Elmer RM. Sciatica acquired by an intrauterine device afterward silent uterine perforation. J Bone Articulation Surg Am. 1978;60:265–266. [PubMed] [Google Scholar]

61. Sengül Ö, Dilbaz B, Kavak D, Dede S, Yerebasmaz N, Altinbas S. Surgical management of extrauterine mislocated intrauterine contraceptive devices and related risks. J Obstet Gynaecol. 2014;34:lxx–73. [PubMed] [Google Scholar]

62. Loveless A, Dhari A, Kilpatrick CC. Perforated levonorgestrel-releasing intrauterine organization resulting in pocket-sized bowel obstacle: a case report. J Reprod Med. 2014;59:611–613. [PubMed] [Google Scholar]

63. Savardekar LS, Shah RS, Vandana W. Asymptomatic cervical perforation past intrauterine copper bearing contraceptive device: two unusual cases. Eur J Obstet Gynecol Reprod Biol. 2005;120:236–237. [PubMed] [Google Scholar]

64. Gbolade BA. Perforation of the cervix by the threads of a levonorgestrel-releasing intrauterine organisation: a case report. J Womens Health (Larchmt) 2010;19:2277–2279. [PubMed] [Google Scholar]

65. Gönenç I, Zeynep Due east, Vural T, Aka N. Cervical perforation past the strings of a levonorgestrel releasing-intrauterine system: a case report. Eur J Contracept Reprod Health Care. 2013;18:415–418. [PubMed] [Google Scholar]

66. Central TC, Kreutner AK. Gastrointestinal complications of modern intrauterine devices. Obstet Gynecol. 1980;55:239–244. [PubMed] [Google Scholar]

67. Chen CP, Hsu TC, Wang Westward. Ileal penetration past a Multiload-Cu 375 intrauterine contraceptive device. Contraception. 1998;58:295–304. [PubMed] [Google Scholar]

68. Singhai SR, Marwah DS, Paul A, Singhai SK. Missed intrauterine device: a rare indication for appendicectomy – case report with review of literature. Due east Cent Afr J Surg. 2010;15:156–158. [Google Scholar]

69. Assarian AQ, Raja MA. Colonoscopic retrieval of a lost intrauterine contraceptive device: a case report and review of articles. Eur J Contracept Reprod Health Care. 2005;x:261–265. [PubMed] [Google Scholar]

seventy. Eichengreen C, Landwehr H, Goldthwaite L, Tocce K. Rectal perforation with an intrauterine device: a instance study. Contraception. 2015;91:261–263. [PubMed] [Google Scholar]

71. Reuter Southward, Krishnamurthy S. Intra-uterine implant (GyneFix) lost via abdominal route? J Fam Plann Reprod Health Care. 2001;27:159–160. [PubMed] [Google Scholar]

72. Grønlund B, Blaabjerg J. Serious abdominal complexity five years after insertion of Nova-T. Contraception. 1991;44:517–521. [PubMed] [Google Scholar]

73. Abbasoglu O, Karakayali H, Akyürek 1000, Cebi Y. Uterine perforation and ileosigmoid fistula acquired past an intrauterine contraceptive device (case report) Eur J Surg. 1994;160:189–190. [PubMed] [Google Scholar]

74. Pirwany IR, Boddy K. Colocolic fistula acquired by a previously inserted intrauterine device (case written report) Contraception. 1997;56:337–339. [PubMed] [Google Scholar]

75. Barranco CJ. IUD gangrene of small intestine. Am J Surg. 1978;135:717. [PubMed] [Google Scholar]

76. Rowlands Southward. Lost IUD penetrating bladder wall. J Fam Plann Reprod Health Care. 2010;36:255. [PubMed] [Google Scholar]

77. Nouira Y, Rakrouki S, Gargouri M, Fitouri Z, Horchani A. Intravesical migration of an intrauterine contraceptive device complicated by bladder rock: a report of six cases. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18:575–578. [PubMed] [Google Scholar]

78. Ko PC, Lin YH, Lo TS. Intrauterine contraceptive device migration to the lower urinary tract: report of 2 cases. J Minim Invasive Gynecol. 2011;eighteen:668–670. [PubMed] [Google Scholar]

79. Schwartzwald D, Mooppan UM, Tancer ML, Gomez-Leon 1000, Kim H. Vesicouterine fistula with menouria: a complication from an intrauterine device. J Urol. 1986;136:1066–1067. [PubMed] [Google Scholar]

80. Sinha PK, Shaw Grand, Sarkar K, Pathak H, Ghosal P, Sarkar KK. A mystery of a lost and forgotten Copper-T: a case report. Indian J Urol. 2015;31(5) Supplement. [Google Scholar]

81. El-Hefnawy Every bit, El-Nahas AR, Osman Y, Bazeed MA. Urinary complications of migrated intrauterine contraceptive device. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19:241–245. [PubMed] [Google Scholar]

82. Malik T, Khan S. An unusual cause of hydronephroureter. J Coll Physicians Surg Pak. 2014;24:766–767. [PubMed] [Google Scholar]

83. Pappa A, Shambhu S, Phillips 1000, Guthrie Yard. A levonorgestrel-releasing intauterine system embedded in the omentum in a adult female with abdominal hurting: a case written report. J Med Example Rep. 2009;3:9301. [PMC free article] [PubMed] [Google Scholar]

84. Nitke Southward, Rabinerson D, Dekel A, Sheiner E, Kaplan B, Hackmon R. Lost levonorgestrel IUD: diagnosis and therapy. Contraception. 2004;69:289–293. [PubMed] [Google Scholar]

85. Peri N, Graham D, Levine D. Imaging of intrauterine contraceptive devices. J Ultrasound Med. 2007;26:1389–1401. [PubMed] [Google Scholar]

86. Özdemir H, Mahmutyazicioglu M, Tanriverdi A, Gündogdu S, Savranlar A, Özer T. Migration of an intrauterine contraceptive device to the ovary. J Clin Ultrasound. 2004;32:91–94. [PubMed] [Google Scholar]

87. Blanas Thousand, Theodora Grand, Hassanaien 1000. Incidental discovery of two levonorgestrel-releasing intrauterine systems misplaced in the peritoneal cavity. Eur J Contracept Reprod Health Care. 2010;15:441–444. [PubMed] [Google Scholar]

88. Bromham DR. Intrauterine contraceptive devices – a reappraisal. Br Med Bull. 1993;49:100–123. [PubMed] [Google Scholar]

89. Kwong FN, Rai H, Mayne C. Ectopic pregnancy with a translocated Mirena intrauterine arrangement. J Fam Plann Reprod Health Care. 2002;28:95–96. [PubMed] [Google Scholar]

90. Bobrow C, Cooling H, Bisson D. Amenorrhoea despite displaced levonorgestrel intra-uterine organisation. J Fam Plann Reprod Health Care. 2000;26:105–106. [PubMed] [Google Scholar]

91. Kalu Eastward, Thonet R. Oligomenorrhoea and contraception despite extrauterine location of the levonorgestrel intrauterine system: a case report. J Fam Plann Reprod Health Care. 2005;31:163–164. [PubMed] [Google Scholar]

92. Botros M, Haddad Northward. Fertility and endocrine furnishings of intra-abdominally misplaced intrauterine organization for more than 2 years: a case report. Hum Fertil (Camb) 2009;12:119–121. [PubMed] [Google Scholar]

93. Doris North, Shabib One thousand, Corbett S, Leader A, Blackness A. Does an intraabdominally placed LNG-IUS have an adverse result on fertility? a case report. Contraception. 2014;89:63–66. [PubMed] [Google Scholar]

94. Haimov-Kochman R, Amsalem H, Adoni A, Lavy Y, Spitz IM. Management of a perforated levonorgestrel-medicated intrauterine device – a pharmacokinetic study: example report. Hum Reprod. 2003;18:1231–1233. [PubMed] [Google Scholar]

95. Budiman H, Kümper C, Mylonas I, Thaler CJ, Friese K, Weissenbacher ER. Pregnancy in a patient with a displaced levonorgestrel-releasing intrauterine system: a example report. Arch Gynecol Obstet. 2007;276:263–264. [PubMed] [Google Scholar]

96. Kim TH, Lee HH, Chung SH, Jeon DS. Hematochezia caused by intrauterine device perforation. Contraception. 2015;91:430. [PubMed] [Google Scholar]

97. Disu S, Boret A. Asymptomatic ileal perforation of an intrauterine device. Arch Gynecol Obstet. 2004;269:230–231. [PubMed] [Google Scholar]

98. Fortunato MA. The long lost IUD. Westward V Med J. 2007;103:22–23. [PubMed] [Google Scholar]

99. Hall RE. A reappraisal of intrauterine contraceptive devices. Prompted by the delayed discovery of uterine perforation. Am J Obstet Gynecol. 1967;99:808–813. [PubMed] [Google Scholar]

100. Toll CW. An unusual case of abdominal obstruction. Med J Aust. 1955;42:106–107. [PubMed] [Google Scholar]

101. Esposito JM. Perforation of the uterus, secondary to insertion of IUCD. Obstet Gynecol. 1966;28:799–805. [PubMed] [Google Scholar]

102. de Villiers EH, Rosenstein PF. Intestinal obstruction following perforation of the uterus with an intrauterine contraceptive device. Am J Obstet Gynecol. 1966;96:592. [PubMed] [Google Scholar]

103. Haspels AA. Minor bowel obstruction due to perforation by a airtight band type intrauterine device (Antigon) J Obstet Gynaecol Br Commonw. 1969;76:178. [PubMed] [Google Scholar]

104. Adoni A, Ben Chetrit A. The management of intrauterine devices following uterine perforation. Contraception. 1991;43:77–81. [PubMed] [Google Scholar]

105. Sezer SD, Odabasi AR, Kücük M, Yüksel H. Lost intrauterine contraceptive device inserted 42 years before: a example written report. Clin Exp Obstet Gynecol. 2011;38:90–93. [PubMed] [Google Scholar]

106. Majd HS, El Hamamy Eastward, Chandrasakar R, Ismail 50. Migration of levonorgestrel IUS in a patient with complex medical issues: what should be done? Arch Gynecol Obstet. 2009;279:385–386. [PubMed] [Google Scholar]

107. Echenberg R, Ledger WJ. Peritoneal response to polyethylene foreign bodies. Obstet Gynecol. 1968;31:795–798. [PubMed] [Google Scholar]

108. Silva PD, Larson KM. Laparoscopic removal of a perforated intrauterine device from the perirectal fat. J Soc Laparosc Surg. 2000;iv:159–162. [PMC costless article] [PubMed] [Google Scholar]

109. Markovitch O, Klein Z, Gidoni Y, Holzinger M, Beyth Y. Extrauterine mislocated IUD: is surgical removal mandatory? Contraception. 2002;66:105–108. [PubMed] [Google Scholar]

110. Haimov-Kochman R, Doviner V, Amsalem H, Prus D, Adoni A, Lavy Y. Intraperitoneal levonorgestrel-releasing intrauterine device following uterine perforation: the role of progestins in adhesion formation. Hum Reprod. 2003;18:990–993. [PubMed] [Google Scholar]

111. Smith DC. Removal of an ectopic IUD through the laparoscope. Am J Obstet Gynecol. 1969;105:285–286. [Google Scholar]

112. Dunn JS, Zerbe MJ, Bloomquist JL, Ellerkman RM, Bent AE. Ectopic IUD complicating pregnancy. J Reprod Med. 2002;47:57–59. [PubMed] [Google Scholar]

113. Hopkins MR, Agudelo-Suarez P, El-Nashar SA, Creedon DJ, Rose CH, Famuyide AO. Term pregnancy with intraperitoneal levonorgestrel intrauterine system: a case report and review of the literature. Contraception. 2009;79:323–327. [PubMed] [Google Scholar]

114. Gill RS, Mok D, Hudson One thousand, Shi 10, Birch DW, Karmali Southward. Laparoscopic removal of an intra-abdominal intrauterine device: case and systematic review. Contraception. 2012;85:15–18. [PubMed] [Google Scholar]

115. Zakin D, Stern WZ, Rosenblatt R. Complete and partial uterine perforation and embedding following insertion of intrauterine devices. Two. Diagnostic methods, prevention and management. Obstet Gynecol Surv. 1981;36:401–417. [PubMed] [Google Scholar]

116. Turok DK, Gurtcheff SE, Gibson K, Handley Eastward, Simonsen S, Murphy PA. Operative management of intrauterine device complications: a case series written report. Contraception. 2010;82:354–357. [PubMed] [Google Scholar]

117. Margarit LM, Griffiths AN, Vine SJ. Management of levonorgestrel-releasing intrauterine arrangement (LNG-IUS) uterine perforation. J Obstet Gynaecol. 2004;24:586–587. [PubMed] [Google Scholar]

118. Selo-Ojeme DO, Eking ME, Welch CC. Uterine perforation and laparoscopic retrieval of a levonorgestrel intrauterine system (Mirena) J Obstet Gynaecol. 2003;23:445–446. [PubMed] [Google Scholar]

120. Stillwell South, Searle S. Informed consent for IUD plumbing equipment. J Fam Plann Reprod Health Intendance. 2009;35:132–133. [PubMed] [Google Scholar]

How Do You Know if Your Iud Has Perforated

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683155/

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