A 51 year old woman presented for removal of her expired levonorgestrel intrauterine device (IUD). The IUD arms appeared absent upon IUD removal. Further examination of the device revealed that the arms were concealed inside the hormonal cylinder. Recognizing abnormal presentations of the levonorgestrel IUD upon removal can avoid unnecessary procedures.
Intrauterine devices (IUDs) are becoming an increasingly popular choice for contraceptive management. The use of long-acting reversible contraception, either an IUD or implant, among US women was 8.5% in 2009, up from 2.4% in 2002, with the majority of these women using IUDs.
To remove the device, gentle traction on the IUD strings causes the arms of the device to fold upward to allow passage through the cervix. After device removal, it is important that the device is closely examined to ensure its integrity. Potential reasons for a nonintact device include uterine perforation, IUD migration, embedding of the device in the uterine wall, and damage to the device during insertion or removal.
When partial or complete uterine or abdominal IUD retention is suspected following attempted removal, further investigation may include a pelvic ultrasound or abdominopelvic radiograph to help determine the location of the missing device. Further evaluation may also include hysteroscopy or laparoscopy. Retention of a device, or part of an IUD, can lead to bleeding, pain, or bowel injury. In the case of desired fertility, incomplete removal of the levonorgestrel IUD may cause continued contraceptive effect (Mirena IUD; full prescribing information, Bayer HealthCare Pharmaceuticals Inc., Whippany, NJ).
Torbé et al reported a case wherein the arms of the levonorgestrel IUD appeared to be missing upon device removal. The authors reported concern about possible uterine perforation and retention of IUD arms after attempted removal of the device. Their patient underwent a transvaginal ultrasound and hysteroscopy with no evidence of retained arms. After these procedures, the device was reevaluated, and the arms were discovered intact, concealed firmly within the hormonal cylinder. No graphic depictions were provided in the report. This case emphasizes the importance of recognizing malpresentation of the levonorgestrel IUD upon removal because failing to do so can lead to unnecessary procedures.
Case Report
A 51 year old nulligravid woman presented to our clinic for removal of an expired levonorgestrel IUD. Her IUD was placed at an outside institution 5 years prior for contraception with no noted complications. At the time of presentation for removal, she denied any pelvic pain since insertion, with reported amenorrhea beginning at 6 months after insertion. Her gynecological history included a prior low-grade squamous intraepithelial lesion on screening cervical cytology, for which a loop electrosurgical excision procedure and cone biopsy were performed 1 year prior to the insertion of the expired device.
During the IUD removal, minimal traction of the strings was required. Upon initial close inspection of the removed device, the arms appeared to be absent ( Figure 1 ). On further investigation, the hormonal cylinder was removed with a hemostat, and the arms were revealed to be intact ( Figure 2 ). The patient was asymptomatic after the procedure and discharged from clinic.
