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