Abstract
Patients using an intrauterine device (IUD) who require a loop electrosurgical excision procedure (LEEP) for cervical dysplasia have traditionally had the IUD removed prior to the procedure. The only other options have been methods that lead to suboptimal sampling or risk cutting the strings. Our study suggests a procedure for performing the LEEP without removing the IUD, and review of the literature suggests that this method has not been reported before. The LEEP is performed using a conization electrode or a cone biopsy excisor. After noting that the IUD strings are of adequate length, a 0-polyglactin free tie is secured around the visible portion of the IUD strings without applying tension on the strings. A large, sterile absorbent-tipped applicator with a hollow handle becomes an 8 cm hollow plastic tube by removing the cotton tip with sterile scissors. The long end of the suture is threaded through the sterile tube. Without pulling on the IUD, the tube is then passed over the strings into the cervical canal approximately 2.5 cm to protect the strings from the excisor well into the cervical canal. Then, the LEEP is performed. After the specimen is removed, hemostasis can be obtained using a ball cautery electrode, keeping the protecting tube with the enclosed IUD strings out of the way. The tube is then carefully removed. The suture is now cut close to the polyglactin knot around the IUD strings, making certain not to shorten the IUD strings and making certain the visible length of the strings is the same as before the procedure. Ferric subsulfate is applied to the operative area to provide continued hemostasis. Follow-up for the LEEP is unchanged. This procedure may be performed on either levonorgestrel-releasing or copper IUDs.
Problem: patient’s contraception is interrupted
Colposcopy can be performed with an intrauterine device (IUD) in place. However, if a loop electrosurgical excision procedure (LEEP) is subsequently required for treatment of cervical dysplasia, the IUD is usually removed to facilitate excision of the cervical tissue. Patients must then use a short-acting method of birth control before another IUD can be placed, or they expose themselves to the risks of an unplanned pregnancy. Also, the patient incurs additional charges for replacing the IUD. The only alternatives to removal can lead to suboptimal sampling or to inadvertent shortening of the IUD strings. We have devised a technique for performing a LEEP with the IUD in situ that avoids these pitfalls. A review of the literature indicates this method has not been reported before. Approval to study our method was obtained from the University of Virginia Institutional Review Board (#14248).
Our solution
The procedure begins with standard preparations for a LEEP. Lugol solution is applied to the cervix, and the proper size electrode is selected. We use a conization electrode or a cone biopsy excisor rather than a loop-type electrode. The cervix is then circumferentially injected with 5-10 mL of lidocaine 1% with 1:100,000 epinephrine. After ensuring that the IUD strings are of adequate length, we create a loose knot in size 0 polyglactin suture and slip the knot over the visible portion of the IUD strings near the external cervical os. The free end of the suture is grasped with a Kelly clamp, and the knot is tightened under direct visualization–using a finger to push the knot down would obscure the view. We are careful not to put tension on the IUD strings. This technique might be impossible if the IUD has very short strings.
A large, sterile, absorbent-tipped applicator with a hollow handle is transformed into an 8-cm hollow plastic tube by removing the cotton tip with sterile scissors. The long end of the suture is threaded through the proximal end of the sterile tube until the suture can be gently grasped at the distal end. Again applying minimal tension, the IUD strings are guided into the tube, and without pulling on the IUD, the tube is passed over the strings and into the cervical canal to a depth of approximately 2.5 cm ( Figure 1 ).
