DISCUSSION:
Intrauterine device (IUD) is one of the most frequently used
contraceptive methods worldwide, and the pregnancy rate of the
intrauterine device as a contraceptive method is around 1-2 pregnancies
per 100 women-years (Pearl Index: Copper Spiral 0.9-3.0 failure/10
years, LNG-IUS 52 mg 0.16 failure/10 years, Gynefix 0-2.5 failures/10
years).1 Amongst Copper containing IUDs, the T-shaped
models with a surface area of 380 mm² of copper have the lowest failure
rates i.e. a one-year failure rate of 0.8% and a cumulative 12-year
failure rate of 2.2%. The models with less surface area of copper have
higher failure rates.4
IUDs are more effective in preventing unintended pregnancies than
contraceptive pills, patches, and rings. It’s worthwhile to clarify that
ectopic pregnancies are less common when using contraception with an
intrauterine contraceptive device than without contraception.
LNG-IUS and copper-bearing IUDs are long-acting reversible
contraceptives (LARC) imparting high contraceptive effectiveness.
Heinemann, et al performed a multinational, prospective,
non-interventional cohort study of new users of LNG IUS (releasing 20
mcg LNG daily) and copper IUDs to measure the rate of unintended
pregnancies in a typical population of IUD users which concluded that
the contraceptive failure rate was low with both IUDs. Comparatively the
LNG IUS resulted in significantly lower risk of pregnancy, including
ectopic pregnancy, than the copper IUDs.5
Despite being excellent contraception, such failure rates may lead to a
substantial number of unwanted pregnancies and subsequently induced
abortions. Typical pregnancy symptoms occur during pregnancies with the
IUDs. Importance of counseling about the risk of pregnancy before
insertion is necessary.
Options are available to continue a pregnancy with or without IUDs. A
retrospective cohort study including 12297 pregnancies, of which 196 had
an IUD, concluded that pregnant women with an IUD are at very high risk
for adverse pregnancy outcomes i.e. late miscarriage, preterm delivery,
vaginal bleeding, clinical chorioamnionitis, and placental abruption
than those without an IUD.6 The likely reason are the
high prevalence of intra-amniotic infection and placental inflammatory
lesions prevalent in pregnancies with an IUD. As our patient was
properly counseled on the pros and cons of continuing the pregnancy, she
chose not to.
Provided the IUD is in a favorable location, the removal of an IUD is
recommended in the early weeks of pregnancy i.e. 9th -11th gestational
week.1 Meanwhile an early removal of an IUD decreases
the risk of above mentioned adverse pregnancy outcomes.
Amongst various method to terminate pregnancy, World Health Organization
(WHO) discourages use of dilatation and sharp curettage (D&C) due to
possibility of Asherman’s syndrome. A randomized control trial concluded
that manual vacuum aspiration (MVA) has safety and efficacy similar to
those of conventional methods such as D&C and Electronic Vacuum
Aspiration (EVA).2 Meanwhile, a prospective
interventional study concluded that retrieval of IUCDs with missing
strings with MVA is a novel method and can be an initial approach in low
resource settings like ours.7
Continuing pregnancy after removal of IUDs has shown promising results
of full-term pregnancy with good maternal and fetal outcomes. A case
series of Twenty-six patients retrospectively evaluated procedural and
pregnancy-related outcomes where participants underwent saline
hysteroscopy with or without concurrent ultrasound guidance for
retrieval of a retained IUD in early pregnancy. This study concluded
that saline hysteroscopy is a safe and effective method for retrieval of
a retained IUD in early pregnancy. And concurrent ultrasound guidance
can facilitate IUD localization.8
Whilst lost IUDs can be troublesome, for pregnant women without any
apparent complications, office hysteroscopy promises to be a safe
alternative option and as means to remove a lost IUD during the 1st
trimester of pregnancy. It is considered the gold standard procedure for
uterine cavity assessment as it provides direct visualization/biopsy and
concurrent treatment of intracavitary pathology, IUCDs as foreign body
in our case.7