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| CASE REPORT |
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| Year : 2018 | Volume
: 7
| Issue : 3 | Page : 183-185 |
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Ovarian penetration by copper intrauterine device: A rare phenomenon
Muhammad Baffah Aminu1, Lamaran Makama Dattijo1, Muhammad Shittu Adamu2
1 Department of Obstetrics and Gynaecology, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi, Nigeria
2 Department of Obstetrics and Gynaecology, Federal Medical Centre, Gusau, Zamfara State, Nigeria
| Date of Web Publication | 6-Feb-2019 |
Correspondence Address:
Dr. Muhammad Baffah Aminu
Department of Obstetrics and Gynaecology, Abubakar Tafawa Balewa University Teaching Hospital, Bauchi
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sjhs.sjhs_62_18
The insertion of a piece of object inside the uterus has been practiced as a form of birth control since antiquity; one of these devices used nowadays is the intrauterine contraceptive devices which have gained a wide range of acceptance because of their safety, efficacy, and cost-effectiveness. There have been cases of migration of intrauterine devices (IUDs) to adjacent peritoneal structures, but ovarian migration has not been widely reported in West Africa. This case report highlights one of the rare complications of IUD migrating to the left ovary of a 24-year-old woman with no complication. It is imperative that insertion should be done timely by well-trained personnel to avoid the incidence of complications.
Keywords: Displacement, intrauterine contraception, laparotomy, ovary
How to cite this article:
Aminu MB, Dattijo LM, Adamu MS. Ovarian penetration by copper intrauterine device: A rare phenomenon. Saudi J Health Sci 2018;7:183-5 |
| Introduction | |  |
Intrauterine contraceptive devices (IUDs) are the commonest form of birth control method in use globally.[1] There are different types in use, hormonal and nonhormonal. The most widely used nonhormonal method in Africa and other developing nation[2] is the copper (Cu) T 380A and T 200 whose strings serve as the pointers to appropriate insertion, absence of these strings should prompt the need for further evaluation.
Intrauterine devices (IUDs) like other contraceptives may be associated with risks. The major risk includes embedment, uterine perforation with migration, and/or expulsion[1],[3],[4] Minor risks include abnormal bleeding, headache, acne, and mastalgia, which may be observed in people using levonorgestrel-releasing device. Migration of IUDs occurs in <4 per 1000 insertions[5] and could be due to the structure of the uterus, the time and type of insertion, and the technical knowhow. IUDs could migrate to the bladder, sigmoid colon, and other adjacent organs, but not much have been reported on migration to the ovary.[3],[4] Migration of IUD to the ovary is a very rare phenomenon that has not been widely reported; published data showed not more than three reported cases of Cu T 380A migration to the ovary.[4],[5] A distended uterus from multiple pregnancy and fibroids or polyhydramnios may be a risk for migration. Similarly, wrong insertion techniques by unskilled personnel could result in migration or displacement. This case report is aimed at introducing another rare occurrence with perforation and migration of the IUD into the peritoneum, penetrating the left ovary with no adverse effects.
| Case Report | | |
The patient was a 24-year old P5 + 0, 6 alive. Her last child birth was 3 months prior to presentation to a set of twin with no puerperal complications. She presented with a history of lower abdominal pain and inability to feel the string of Cu T IUD that was inserted at 6 weeks postpartum by a community health worker at a secondary health facility. There was no history of abnormal vaginal bleeding, abdominal swelling, or urinary symptoms. She had a history of pain and bleeding following the insertion but was assured and given analgesics. The pain persisted and thus the reason for her presentation.
She was generally stable and calm. Abdominal examination revealed mild tenderness in the left iliac fossa. The cervix was closed with no string of IUD seen. There was mild tenderness in the left adnexa; pouch of Douglas was empty and no mass was felt.
Baseline hematological investigations were normal. Abdominal ultrasound revealed an empty uterus with a T-shaped hyperechoic substance in the left adnexa. She had another Cu T inserted and abdominal X-ray confirmed the presence of the extrauterine Cu T device [Figure 1]d. | Figure 1: (a) The left ovary showing the penetration site of the intrauterine device, (b) the site of perforation, (c) the intrauterine device in the peritoneum encroaching the left ovary, (d) plain abdominal X-ray confirming the migrated intrauterine device
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She had laparotomy and retrieval with findings of Cu T 380A perforating the uterus [Figure 1]b and penetrating the left ovary [Figure 1]a and c]. There was no hemoperitoneum, intraperitoneal collection, or evidence of bowel perforation. Hemostasis was ensued using 2-0 vicryl and the incision site was repaired. She did well postoperatively and was discharged on the 3rd day postoperatively.
| Discussion | | |
The exact mechanism of action of IUD is unknown.[6] However, it is thought to inhibit implantation and possibly interfere with sperm motility and function.[7] It is indicated in women in whom combined hormonal contraception is contraindicated, women who wish to have it as a form of contraceptive, also as an emergency contraceptive,[1] and in women desirous of long-term reversible contraception.[8]
A very common complication of IUDs is migration and expulsion, but it can be embedded in the endometrial cavity, especially in long-standing cases.[1] The migration can be intraperitoneal, intraluminal, intravesical, or may be expelled.[1],[8],[9] Uterine perforation may be evident at the time of IUD insertion with resultant pain and bleeding[8] or may occur later as a secondary event following pregnancy or subtle uterine contractions.[9] The migration to the ovary as seen in the index case may be attributed to poor insertion technique resulting in uterine perforation [Figure 1]b. This with further uterine contractions led to the migration of the Cu T 380A to the left ovary which is a structure close to the site of perforation [Figure 1]a and [Figure 1]c. The delivery of a set of twins and the resultant big size uterus can be attributed to as the risks for this rare occurrence.
Migration has been reported to occur to adjacent organs such as the rectum, appendix, and bladder with calculus formation, though this seems technically impossible but had been previously reported;[2],[9],[10] this is in contrast to ovarian migration as in this case which is rarely reported. Thus, IUCD displacement into the bladder should also be considered in evaluating a patient with missing string. Wherever the site of displacement, the IUCD should be removed as it can cause irritation, especially in those that are intraperitoneal or may cause menorrhagia, especially if embedded in the endometrial cavity.[1] A study has shown that >50% of clinically diagnosed cases of missing IUCD are located within the endometrial cavity.[1]
Ultrasound scan is one of the investigations of choice in locating IUDs,[11] where a hyperechoic area will be seen with evidence of acoustic shadows. Similarly, it can be used in predicting the occurrence of complications such as pain, bleeding, and expulsion. The ultrasound scan done was the pointer to the site of the displaced IUD in the case under review. Other methods for determining the possible site of the IUD include gentle probing using uterine sound or forceps, pelvic X-ray using two views (after introducing another IUD or a uterine sound so that the relationship between the two devices can be ascertained), hysteroscopy, and computed tomography scan.[11] Though our client had ultrasound scan which indicated that the IUCD was not within the uterine cavity, an additional investigation had to be ordered to ascertain its exact location in relation the later device inserted.
Simple retrieval with a pair of Alligator forceps (IUCD retrieval forceps) can be employed in cases where the device was located ultrasonographically within the uterine cavity; this form of retrieval is easy and less invasive. Retrieval can also be achieved using Artery forceps or Spencer forceps, especially in low-resource settings. Laparoscopy and/or cystoscopy could also be used for diagnosis and retrieval;[11],[12] these have less complications and early recovery is assured. Where facilities or expertise are lacking like in low-resource settings, the retrieval could be via laparotomy as in this case. This is important since damage to the ovary could lead to decrease in the ovarian responsiveness and reserve with resultant low yield for egg retrieval in in vitro fertilization clients, risk of early menopause menstrual instability, and/or infertility.
| Conclusion | | |
A good knowledge of the anatomy of the reproductive organs and the clinical skills and competence are necessary for appropriate insertion and function of intrauterine contraceptives. This will indeed help in avoiding complications such as ovarian migration.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Ibitoye BO, Aremu AA, Onuwaje MA, Ayoola OO. What is the fate of the missing intrauterine contraceptive device? Trop Doct 2009;39:221-3.  |
| 2. | Mustafa M. Erosion of an intrauterine contraceptive device through the bladder wall causing calculus: Management and review of the literature. Urol Int 2009;82:370-1. |
| 3. | Ozdemir H, Mahmutyazicioǧlu K, Tanriverdi HA, Gündoǧdu S, Savranlar A, Ozer T, et al. Migration of an intrauterine contraceptive device to the ovary. J Clin Ultrasound 2004;32:91-4. |
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| 8. | Gemzell-Danielsson K, Berger C, Lalitkumar PGL. Emergency contraception – Mechanisms of action. Contraception 2013;87:300-8. |
| 9. | Özgür BC, Yücetürk CN, Sarıcı H, Eroǧlu M. Bladder stone formation due to an intrauterine device migrating to different localizations. Cukurova Med J 2016;41:111-3 |
| 10. | Goswami D, Ravi AK, Sharma A. Missing IUCD strings: Role of imaging in locating the misplaced device. J Clin Diagn Res 2017;11:QJ01-2. |
| 11. | Sharma A, Andankar M, Pathak H. Intravesical migration of an intrauterine contraceptive device with secondary calculus formation. Korean J Fam Med 2017;38:163-5. |
| 12. | Gyasi-Sarpong CK, Maison PO, Morhe E, Aboah K, Appiah KA, Azorliade R, et al. Intravesical migration of an intrauterine device. BMC Res Notes 2016;9:4. |
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