Where can an iud migrate to?

Intrauterine device (IUD) is a highly effective method of reversible contraception . Although it carries an acceptable safety record, some complications may arise during its insertion or its long-term use. Intra-abdominal IUD migration following uterine perforation at insertion is a rare complication . Spontaneous trans-tubal migration is even rarer. This type of migration was not reported following trauma. Herein, we report a case of trans-tubal migration of a copper T380A IUD and perforation of the tubal isthmus following a fall-down trauma.

A 26-year-old G3P3A0L3 previously healthy woman presented to the emergency department (ED) because of moderate left iliac fossa pain, 1 day following a fall-down of the stairs. The pain was not associated with nausea, vomiting, vaginal bleeding or any other symptom. On physical examination, her vital signs were within normal ranges, and her abdomen was soft and non-distended. A localized left iliac fossa tenderness was noted without rebound tenderness. Vaginal examination was not performed. Basic laboratory tests showed normal urine analysis and hemogram. Pregnancy test was negative. Facing this clinical picture, the ED physician elected to perform a standing KUB that showed an IUD in the left iliac fossa (Fig. 1). The patient was then asked about the history of the IUD insertion. She stated that a copper IUD was inserted 3 months earlier by a trained gynecologist, 4 weeks postpartum. At routine follow-up 1 month post-insertion, a pelvic ultrasound showed properly placed IUD. After initial assessment in the ED, the patient was transferred to our service. CT scan of the pelvis with intravenous and oral contrast was done and confirmed the presence of the IUD in the left adnexa (Fig. 2). During diagnostic laparoscopy, we found that the IUD had perforated the left fallopian tube at the level of its isthmus creating an acute inflammatory response and adhesions of the omentum around it (Fig. 3). The gross appearance of the tube was otherwise normal, and no hydro- or pyosalpinx was seen. Using monopolar electrocautery, we lysed the adhesions and removed the IUD. The tubal perforation was left open. The patient was discharged on day 1 postoperatively. She was seen 1 month later in the clinic and her physical examination was unremarkable.

Contraceptive methods are widely used by female patients for birth control. No single method can suit all women. Age, personal history, socio-economic status and other factors play an important role in the selection of the most suitable contraceptive tool. Among others, IUD is an effective non-surgical long-acting reversible contraceptive method with a pregnancy rate of less than 1 in 100 women per year . Although it is highly safe, it may lead to some undesirable side effects ranging from menorrhagia, infection, expulsion, to the rare faulty insertion leading to uterine perforation .

Uterine perforation following IUD insertion is rare and accounts for 0.1% of cases . The perforation may be either complete if the IUD was found outside the uterus or partial when only a part of it has penetrated the myometrium. Following complete perforation, the IUD can migrate to different intra-abdominal structures such as the omentum, bowels, peritoneal cavity and bladder among others. Presenting signs and symptoms include missing thread, abnormal uterine bleeding, abdominal pain and pregnancy .

Instead of directly perforating the myometrium, the IUD can rarely reach the abdominal cavity after migrating via the fallopian tubes .

We conducted a literature search on MEDLINE database between 1976 and 2017 for articles reporting similar cases. All articles published with English abstracts were included. The search terms were: “intrauterine device” AND “trans-tubal migration”. The lists of references of these articles were also reviewed. In total we could find seven cases of trans-tubal IUD migration (Table 1), and none was due to trauma.

After reviewing the text of the aforementioned cases, we could not identify a common pattern related to the timing, method of insertion or the type of IUD. The exact mechanism of spontaneous trans-tubal migration remains obscure. Previous studies assumed that either the IUD was placed in the uterine cornua close to the tubal ostium at the time of insertion , or it was displaced toward the ostium due to the profound involution of the myometrium during the postpartum and lactation period . However, in our patient the migration was not spontaneous. The IUD was in place as shown on pelvic ultrasound during routine follow-up, 1 month post-insertion. The single inciting event preceding migration was the trauma sustained 1 day before presenting to the ED.

Following trauma, it is wise to check the IUD location during the first 24 - 48 h in women wearing IUDs, even if they are asymptomatic. Imaging studies are the cornerstone in patients with a missed IUD thread. A simple abdominal X-ray can easily discern expulsion from migration. An ultrasound, CT scan or MRI of the abdomen and pelvis can then map the exact location of the migrating IUD and identify any associated visceral complication .

When an IUD is found in the abdominal cavity, whether to remove it or not is controversial, especially if the patient is asymptomatic . It would, however, be desirable to remove it because of the high incidence of adhesions’ formation that can afflict permanent infertility, possible visceral injury and subsequent acute abdominal pain if left in place. Laparoscopy can be used as a first-line treatment even in the presence of adhesions or visceral injury . In two out of the seven cases reviewed, laparoscopy was used to remove the IUD but the chronicity of migration and the tubal infection resulted in tubal sacrifice in both patients. In our case, the tube was minimally harmed and tubal preservation was feasible after securing good hemostasis.

The IUD remains one of the safest and highly effective methods of contraception even if some complications occur during its use. Intra-abdominal IUD migration via the fallopian is an extremely rare complication. Trauma-induced trans-tubal migration was not reported before. Hence, it is advisable to check the IUD location in patients using this method of contraception, in the first 24 - 48 h following trauma.

Funding

No source of financial support was obtained for the report.

Intrauterine devices (IUDs) are considered a safe, convenient and effective method of birth control. But occasionally these small devices can slip out of place.

Inserted inside the uterus, IUDs eliminate the need for a daily pill and prevent pregnancy with 99 percent effectiveness for three to 12 years, depending on the type of device used.

While side effects are possible with any contraception, complications with IUDs occur in less than 1 percent of women. But it’s important to recognize the signs and symptoms if your IUD moves.

IUDs are generally placed through the vagina, past the cervix and into the uterus, where the strings hang about two inches down from the uterus into the vagina.

It is rare for the IUD to move from where your doctor initially places it, but it does happen. An IUD may:

When this happens, patients might experience discomfort, which could require a doctor’s visit to retrieve the IUD.

General discomfort is expected following the insertion of an IUD. Cramping, backaches and even spotting are normal and usually resolve within three to six months. If you experience any of the following, however, your IUD may be out of place:

The most common symptoms associated with a displaced IUD are pain and bleeding. If you suspect your IUD has moved out of position, don’t try to take the device out on your own. Your healthcare provider will be able to determine movement with an exam and testing.

Some women do not experience any symptoms when their IUD shifts, which is why many doctors advise a monthly self-check to ensure the strings are still present.

There are several factors that can contribute to the movement or absorption of an IUD. The shape, size and positioning of the uterus, as well as uterine abnormalities, can all affect the body’s response to an IUD. Women with uterine fibroids, or noncancerous growths on the uterus, may also have a higher risk of IUD expulsion.

Ultrasounds are not typically conducted, but your OB-GYN will factor in medical history such as the known presence of fibroids or rare anomalies before recommending an IUD. If an IUD is not advised, your practitioner will suggest alternative methods of birth control.

Treatment will depend on the positioning of the IUD, whether it’s migrated into the cervix or been absorbed by the uterus. An ultrasound can determine positioning and treatment.

There are several ways an IUD can be removed:

1.    Hoşcan MB, Koşar A, Gümüştaş U, Güney M. Intravesical migration of intrauterine device resulting in pregnancy. Int J Urol. 2006;13(3):301-302.

2.    Heinemann K, Reed S, Moehner S, Minh TD. Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices. Contraception. 2015;91(4):274-279.

3.    Singh SP, Mangla D, Chawan J, Haq AU. Asymptomatic presentation of silent uterine perforation by Cu-T 380A: a case report with review of literature. Int J Reprod Contracept Obstet Gynecol. 2014;3(4):1157-1159.

4.    Akpinar F, Ozgur EN, Yilmaz S, Ustaoglu O. Sigmoid colon migration of an intrauterine device. Case Rep Obstet Gynecol. 2014;2014:207659.

5.    Rahnemai-Azar AA, Apfel T, Naghshizadian R, Cosgrove JM, Farkas DT. Laparoscopic removal of migrated intrauterine device embedded in intestine. JSLS. 2014;18(3).

6.    Zakin D, Stern WZ, Rosenblatt R. Complete and partial uterine perforation and embedding following insertion of intrauterine devices. II. Diagnostic methods, prevention, and management. Obstet Gynecol Surv. 1981;36(8):401-417.

7.    Gill RS, Mok D, Hudson M, Shi X, Birch DW, Karmali S. Laparoscopic removal of an intra-abdominal intrauterine device: case and systematic review. Contraception. 2012;85(1):15-18.

8.    Paterson H, Ashton J, Harrison-Woolrych M. A nationwide cohort study of the use of the levonorgestrel intrauterine device in New Zealand adolescents. Contraception. 2009;79(6):433-438.

9.    Gorsline JC, Osborne NG. Management of the missing intrauterine contraceptive device: report of a case. Am J Obstet Gynecol. 1985;153(2):228-229.

10.   Mederos R, Humaran L, Minervini D. Surgical removal of an intrauterine device perforating the sigmoid colon: a case report. Int J Surg. 2008;6(6):e60-e62.

IUDs typically migrate to the adnexa, appendix, bladder, colon, peritoneum, omentum, rectosigmoid, small bowel, and iliac vein.