Chauhan AR
Intrauterine contraceptive device (IUCD) like the copper T (CuT) is an ideal spacing method for women. It is safe, effective, reversible, easy to insert, does not interfere with intercourse and does not require any action on the part of the woman once inserted. As per WHO Medical Eligibility Criteria (MEC), copper IUCDs are safe in the majority of women; there are very few situations, like active pelvic inflammatory disease, where it is contraindicated. Unlike other reversible methods like oral contraceptive pills or condom which have higher pregnancy rates for typical use compared to correct or ideal use, there is no such difference in IUCD use. In fact, failure rates for most IUCDs are low at < 2%. Over the last few years, with the introduction of the postpartum IUCD programme to increase contraceptive coverage, there has been a resurgence in the number of users. Despite this, according to the National Family Health Survey of 2005- 2006, the commonest method of family planning in India is still tubectomy in about a third of women; IUCDs account for only an estimated 2%. The IUCD which is most often used in the public sector is the CuT 380 and in the private sector, CuT 375 (multiload design).
Unfortunately, apart from side effects like heavy menstrual bleeding and vaginal discharge, the two most common complications with IUCD are expulsion and displacement/ perforation. Of these, expulsion rate is high; it occurs in approximately 1 in 20 women, typically during the menses within the first 1- 3 months post- insertion. On the other hand, perforation occurs in less than 1 to 2 per 1000 women, and usually at the time of insertion. Acute severe pain or loss of resistance on sounding the uterus, or hemorrhage at the time of insertion are signs that perforation may have occurred and the procedure should be immediately abandoned. Previous cesarean section appears to be a risk factor for increased chance of perforation. There are no real differences in perforation rates among the various types of IUCD, especially the copper bearing ones; levonorgestrel intrauterine system is associated with least perforations, less than 1 per 1000 insertions.
Irrespective of whether expulsion or perforation has occurred, the patient will present with either pregnancy and contraceptive failure, or inability to feel the threads or tail of the device. If pregnancy has occurred an ultrasound will help to locate the gestation sac relative to the position of the device; patient should be thoroughly counseled about risks of continuation vs termination of pregnancy. Management algorithm for missing threads includes thorough clinical examination along with sounding of the uterus, X-rays in anteroposterior and lateral positions with the uterine sound in situ, and abdominal and pelvic ultrasonography. This should be followed mandatorily by removal of the device, either by minimally invasive technique or laparotomy. If embedded in the intestine and ignored, patients can present with perforation or obstruction of small or large bowel.
Perforation may displace or dislodge the IUCD partially or completely; if incomplete, it may be embedded within the myometrium and some part may be in outside the uterus. If completely expelled, the IUCD may be in any part of the pelvis and abdomen, and terms such as "wandering" and "migrating" are used to describe unusual locations when it is found. Migration of the IUCD may in some cases be due to faulty training and insertion wherein perforation occurs at the time of insertion, or secondarily due to a chronic inflammatory process with slow erosion of the uterine wall. Areas where the IUCD is found are the omentum, large and small intestine, and bladder, where it may also form a calculus. Though a rarity, literature is full of case reports of retrieval of IUCD from these unusual locations, usually with laparoscopic surgery. This issue carries an unusual case report of displaced IUCD with concomitant intrauterine viable pregnancy which we hope will be of interest to our readers.