Case Sereies - Archives of Obstetrics and Gynaecology (2021) Volume 2, Issue 1
Intrauterine Device Embedment Resulting in Its Fracture: A Case Series
Carlos M. Fernandez, Elliot M. Levine*, Marie Cabiya, Imaan Ansari, Leah Delfinado
Advocate Illinois Masonic Medical Center Chicago, IL, USA
- *Corresponding Author:
- Elliot M. Levine
Received date: December 17, 2020; Accepted date: January 20, 2021
Citation: Fernandez CM, Levine EM, Cabiya M, Ansari I, Delfinado L. Intrauterine Device Embedment Resulting in Its
Fracture: A Case Series. Arch Obstet Gynecol. 2021; 2(1): 1-4.
Copyright: © 2021 Fernandez CM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Purpose: As long-acting reversible contraceptive choices are becoming more popular among young women, proper informed consent over potential complications should be addressed when such decisions are made. A local case series was analyzed to consider the risk of intrauterine device (IUD) fracture.
Materials and Methods: A retrospective review of provider experience with the intrauterine device over a seven-year period was undertaken, to specifically analyze the incidence of IUD embedment and fracture in the studied population. The type of IUD, length of time that it was in place, and the age and parity of the individual, were examined.
Results and Conclusion: The apparent incidence of IUD fracture was notable, with a suggestion of IUD type and individual parity as being correlated to fracture. A 1.25 % incidence rate of IUD fracture for the ParaGard was found, in contrast to what was seen for the Mirena IUD (0.03%), in our studied population.
Copper IUD, LNG-IUS, IUD side effects, IUD perforation
As gynecologic providers continue to provide intrauterine devices (IUDs) for long-acting reversable contraception (LARC) with insertion of those devices, the associated complication rate needs to be well-understood, so that patients can make properly informed shared healthcare decisions. There appears to be IUD embedment into the uterine wall that can occur over time, which can cause its fracture when retrieving it with grasp of its string. The authors previously published a case series  that described situations in which fractured IUDs were encountered after attempts at their removal occurred. Given that patients continue to be referred to the Director of Gynecologic Sonography at our institution for assistance in managing such complications when they are encountered, this case series was continued, and the authors believe it important to report these findings at this time.
The cases of these IUD fractures are listed in Table 1, revealing some relevant patient and IUD characteristics. Since these findings are retrospective in nature, and not prospectively collected, the proportion of IUD placement that this complication represents can only be estimated. For the population of patients described in this case series, we were able to approximate the number of IUD insertions, by our provider group practicing at multiple sites. The IUD insertions which were performed over the 7-year duration of this case series (2013 – 2019) are listed in Table 2, for the different types of devices, for this provider group, consisting of 18 different attending physicians. While some of the IUD insertions were performed by resident physicians, only 2 of the cases listed in Table 1 had an IUD inserted by a resident. None of the patients presented with complaints of pain at the time when IUD fracture was identified. There were also no visual or histologic evidence of inflammation or infection in the cases for which hysteroscopy was performed.
| #|| Insertion|| Removal||Duration of Use||Parity Status|| Type of IUD|| Management|
|1||2007||2013||6 years||Multiparous||ParaGard®||Spontaneous expulsion|
|2||2007||2013||6.5 years||Multiparous||ParaGard®||Hysteroscopic removal of IUD arm|
|3||2003||2013||10 years||Parous||ParaGard®||Hysteroscopic removal of IUD|
|4||2006||2013||7 years||Multiparous||ParaGard®||Hysteroscopic removal of IUD arm|
|5||2006||2013||7 years||Multiparous||ParaGard®||Incomplete hysteroscopic removal of IUD|
|6||2006||2013||7 years||Parous||ParaGard®||Hysteroscopic removal of IUD arm|
|7||2006||2014||8.5 years||Parous||ParaGard®||Hysteroscopic removal of IUD arm|
|8||2006||2015||8.5 years||Multiparous||ParaGard®||Hysteroscopic removal of IUD arm|
| 9|| 2008|| 2018|| 10 years|| Multiparous|| ParaGard®||Hysteroscopy – IUD fragments not identified|
|10||2009||2019||10 years||Parous||ParaGard®||Hysteroscopic removal of IUD arm and hook|
|11||2015||2019||4 years||Multiparous||Mirena®||Hysteroscopy – unable to remove embedded|
|12||2008||2019||11 years||Nulliparous||ParaGard®||Hysteroscopic removal of retained IUD arm|
|13||2015||2019||4 years||Nulliparous||ParaGard®||Hysteroscopic removal of retained IUD arm|
|14||2015||2019||4 years||Nulliparous||ParaGard®||Hysteroscopic removal of retained IUD arm|
IUD = Intrauterine device
Table 1: List of fractured IUDs encountered.
| IUD type|| IUD insertions|| IUD fractures||Incidence of IUD fractures per 100 insertions|
Table 2: IUD insertions and fractures, by type, over seven years (2013 – 2019).
Whether an IUD is a non-hormone containing copper device (e.g., ParaGard®) or a levonorgestrel intrauterine
system (LNG-IUS, e.g., Mirena®), the IUD term is applied. Each of these cases were identified as fractured IUDs,
found at the time of removal from the uterus. The IUD
fractures appear to have occurred after being embedded
into the uterine wall, fracturing when the usual effort was
exerted for the IUD removal (i.e., pulling on the string). It
is presumed that embedment of the IUD into the uterine
wall must have occurred, to result in the fractured IUD
which was found. This phenomenon may be similar to the
process of IUD perforation, alternatively referred to as
“migration”, in that it may occur over time, and is not necessarily temporally related to the IUD insertion. Figure
1 shows this with the use of 2D ultrasound, and Figure 2 illustrates this with the application of three-dimensional transvaginal sonography (3DTVS). Figure 3 shows a hysteroscopic view of an embedded IUD arm, at the time of its hysteroscopic removal.
As more young nulliparous women are using this LARC method , the number of larger frame devices being used, along with the duration of their potential use (5 years vs. 10 years), may be a relevant factor leading to the complication described in this case series. The size difference between a ParaGard® or Mirena® (having a diameter of 32 mm) and a Skyla® or Kyleena® (smaller frame size, having a diameter of 28 mm) may be clinically important. A difference in the intrauterine interostial diameter also exists between a nulliparous and a multiparous woman , which may also
be clinically relevant.
While embedment of an IUD into the uterine wall may not commonly occur, this case series describes its approximate incidence of occurrence. Though this embedment cannot be anticipated, there may be factors relevant to its occurrence . The patient and IUD features which are listed in Table 1, may represent identifiable conditions
worthy of note. The duration of IUD use, as well as the IUD
type, appears to be especially pertinent. The counting of
the IUD insertions among all of the physicians who would
typically refer for imaging of such complications, as well as
the patients who underwent hysteroscopy for resolving this
complication, yielded approximately 1000 IUD insertions
per year over the course of 7 years. Naturally, the number
of IUD insertions by this provider group, may not exactly
correlate with the entire number of IUDs which were
in place during the course of this case series, with some
resulting in this complication. Nonetheless, in spite of
the temporal discordance, these numbers may represent
a close approximation of the risk of this phenomenon. It
should be additionally noted that there may be limited
continuation rates of IUD users , making an estimate
of the true prevalence of IUD fracture to have limited
accuracy in this dataset. Though it may be more ideal to
present the described phenomenon in a prospectively
followed investigation, that is unlikely to ever be practically
performed. Thus, this case series is presented, for its
valuable clinical information, to inform the patient (and
physician) population. The low IUD complication rate
that has been reported  may not be consistent with the
experience in this case series, as we found the prevalence
of this phenomenon (i.e., embedment and IUD fracture) to
be about 1 per 500 IUD insertions for any IUD type, and
specifically, slightly more than 1 per 100 ParaGard IUD
insertions. The calculated relative risks of this particular
IUD complication in our experience are described in Table
2, and this phenomenon may occur more commonly than
what has been previously reported . This complication
may also be replicated by others who have the capability of
this type of surveillance with sonography in skilled hands.
The information contained in this present case series
should be considered when obtaining informed consent to
a patient considering this LARC method.
Chris Kabir, MS – for assistance with the statistical
None of the authors have any financial conflicts of
Elliot M. Levine, MD: Conducted the extensive supporting
literature review and data analysis
Carlos M. Fernandez, MD: Performed the sonography for
each described case in data set
Marie Cabiya, MD: Instituted the original case report and identified the clinical problem described
Imaan Ansari, MD: Resident physician who helped
organize data in presented table
Leah Delfinado, MD: Assistance in writing and editing
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