Journal of Obstetrics and Gynaecology

ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20

Management of intra-abdominally translocated

contraceptive devices, is surgery the only way to
treat this problem?

Mustafa Gazi Uçar, Fatih Şanlıkan, Tolgay Tuyan Ilhan, Ahmet Göçmen &
Çetin Çelik

To cite this article: Mustafa Gazi Uçar, Fatih Şanlıkan, Tolgay Tuyan Ilhan, Ahmet Göçmen
& Çetin Çelik (2017): Management of intra-abdominally translocated contraceptive devices,
is surgery the only way to treat this problem?, Journal of Obstetrics and Gynaecology, DOI:
10.1080/01443615.2016.1268577

To link to this article: http://dx.doi.org/10.1080/01443615.2016.1268577

Published online: 10 Feb 2017.

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JOURNAL OF OBSTETRICS AND GYNAECOLOGY, 2017
http://dx.doi.org/10.1080/01443615.2016.1268577

ORIGINAL ARTICLE

Management of intra-abdominally translocated contraceptive devices, is surgery

the only way to treat this problem?
€çmenb and Çetin Çelika
Mustafa Gazi Uçara, Fatih Şanlıkanb, Tolgay Tuyan Ilhana, Ahmet Go
a
Department of Obstetrics and Gynaecology, Selçuk University Medicine Faculty, Selçuklu Konya, Turkey; bDepartment of Obstetrics and
€
Gynaecology, Umraniye Education and Research Hospital, Istanbul, Turkey

ABSTRACT KEYWORDS
This study was a multi-centre retrospective review of patients with uterine perforation caused by intra- Conservative management;
uterine contraceptive devices (IUDs). A total of 15 patients were registered, in a seven year period. contraception; complica-
Among them, five were asymptomatic and the rest were symptomatic. Asymptomatic patients were tions; intrauterine device;
intrauterine device
managed conservatively, except in one case in which the patient requested surgery because she also migration; uterine
wanted a tubal ligation. Symptomatic patients all underwent surgery. All the surgeries were elective perforation
and all the surgical procedures were initiated laparoscopically. There were seven complications in the
surgically managed group: conversion to laparotomy (n ¼ 3), bowel injury (n ¼ 2), bladder injury (n ¼ 1),
and wound infection (n ¼ 1). Mild and severe adhesions (81.8%), and abscess (18.1%) formation related
to translocated IUD (TIUD) were observed during surgery. All the patients were uneventful at 1 to 5
years of follow-up. A TIUD, by causing adhesions, complicates future laparoscopic surgery and increases
the likelihood of conversion to laparotomy. While surgery is indicated to prevent TIUD-induced adhesive
complications, it may also be the cause of both adhesions and complications, resulting in a vicious
cycle. Some asymptomatic women, especially elderly patients with comorbidities, may not need or may
be better managed without treatment.

IMPACT STATEMENT
 In this study we try to find an answer for the question of “Should removal of a translocated intra-
uterine contraceptive device (TIUD) routinely be performed even if patients are asymptomatic?”
From only the theoretical point of view there were some reports supporting conservative man-
agement in asymptomatic patients. The other studies addressing this issue were case reports
including few patients with a short-term follow-up. The novelties of the present study include
multi-centre design, detailed clinical and surgical information about the patients and the long
period of follow-up.
 Most clinicians have limited experiences in managing TIUD because perforation is a rare event. So
it can be difficult to know exactly what the surgeon will encounter intraoperatively. We undertook
this study with the aim of providing a perspective about patients with TIUD for those faced with
this situation.
 This is a descriptive study reporting 15 cases of TIUDs and management. Asymptomatic patients
were managed conservatively, and symptomatic patients were operated. There are important
implications resulting from this study that in asymptomatic patients leaving the IUD in place may
be a reasonable option, mostly as the risk of surgical intervention is quite high with a high rate
of complications with surgical management.

Introduction to rising use, IUD-related complications are likely to become

Intrauterine contraceptive devices (IUDs) are safe, economic,
highly efficient and reversible long-acting tools for family
planning. These features account for their widespread use
throughout the world. The Levonorgestrel intrauterine system
(LNG-IUS) provides superior non-contraceptive benefits com-
pared to copper IUDs in addition to reducing menstrual
bleeding and dysmenorrhoea (Robinson et al. 2008). In
Turkey, a further advantage of IUDs is that they are inserted
free of charge at primary health care centres. However, due
more frequent and treatment options are needed.
Among the complications of IUD use are migration, expul-
sion, uterine embedment, and partial or complete uterine
perforation. Of these, perforation is a rare but serious compli-
cation, with a reported incidence of 0.2–3.6 per 1000 inser-
tions (Cetinkaya et al. 2011; Kho & Chamsy 2014; Heinemann
et al. 2015). However, as the majority of studies on IUD-
related complications were based only on symptomatic
patients or those with regular follow-up, the actual incidence
is likely to be higher (Kaislasuo et al. 2012). In addition to

CONTACT Mustafa Gazi UÇAR mustafa_gazi_ucar@hotmail.com Alaeddin Keykubat Campus, Department of Obstetrics and Gynecology, Selçuk University
Faculty of Medicine, Zip: 42075, Selçuklu/Konya, Turkey
ß 2017 Informa UK Limited, trading as Taylor & Francis Group
2 M. G. UÇAR ET AL.
Figure 1. (a) The X-ray image of translocated IUD. (b) MR image of extrauterine Lippes Loop (arrow).
contraceptive failure, migration of the IUD into the peritoneal
cavity after uterine perforation places the patient at risk for
further complications, potentially leading, to adhesion-fistula
formation, infection, abscess formation, and perforation of
the bowel, bladder, or neighbouring blood vessels (Kaislasuo
et al. 2012; Heinemann et al. 2015). In common practice,
‘missing’ IUDs must be located and removed to prevent com-
plications. This strict recommendation is based on the poten-
tial to damage adjacent organs as well as the risk of medico-
legal problems of TIUDs.
Breastfeeding and proximity of the IUD insertion to a
recent delivery (up to 36 weeks) are independently associated
with an increased risk of uterine perforation (Heinemann
et al. 2015). Other well-known associated factors are the skill
and experience of the physician performing the insertion, a
history of caesarean delivery, and the position of the uterus
or the presence of a uterine anomaly (Cetinkaya et al. 2011;
Kaislasuo et al. 2012; Kho & Chamsy 2014); inadequate pelvic
examination before insertion also contributes (Balci et al.
2010). Although perforation most often occurs at the time of
IUD insertion (Zakin et al. 1981), subsequent migration of the
device may occur spontaneously, leading to dislocation into
the abdominal cavity, making detection extremely difficult
(Uçar et al. 2015). Thus, most IUD manufacturers recommend
that recipients undergo a routine check-up 3 months after
the insertion of the device to ascertain its position within the
uterine cavity.
Intra-abdominally translocated IUDs (TIUD)s are a cause of
worry for both patients and clinicians. Previous studies have
reported the incidence of important and potentially serious
complications that might ensue from an IUD that remains in
the abdomen. The standard management for an intra-abdom-
inal translocated IUD is surgical removal, with laparoscopy as
the currently accepted method in these cases.
The clinical presentation of patients with an IUD-related
uterine perforation is highly variable. Indeed, a remarkable
number of patients with intra-abdominally TIUD are asymp-
tomatic for a prolonged period. These results have encour-
aged us to consider conservative management as a treatment
option in asymptomatic patients. From only the theoretical
point of view there were some reports supporting conserva-
tive management in asymptomatic patients. Other studies
addressing this issue were including a few patients with a
short-term follow-up. In this study, we asked whether in
these patients a TIUD should be removed.
Materials and methods
This study was a multi-centre retrospective review of patients
with uterine perforation caused by an IUD. All data used in
the study were derived from hospital records. After the study
approval by the Selcuklu Medical Faculty Ethics Committee of
Selçuk University, 15 patients with intra-abdominal TIUDs
who were seen at two tertiary referral centres, from January
2008 to June 2015 were registered. In territory referral hospi-
tals, we do not routinely insert IUDs and they are inserted
free of charge at primary health care centres, in Turkey.
That’s why; in this series all cases were referred to our institu-
tion or detected during routine gynaecological examination.
Demographic characteristics, diagnostic imaging workup,
management approach, and clinical data were collected and
documented. Details of IUD type and placement, intraopera-
tive findings (position, perforation site, location of the IUD,
degree of adjacent adhesive disease, additional surgical inter-
vention) and associated complications were evaluated. All the
patients were diagnosed based on a physical examination,
transvaginal pelvic ultrasonography, and anteroposterior
abdominopelvic X-ray. In some cases, patients underwent
computed tomography (CT) or magnetic resonance imaging
(MRI) to assess IUD positioning and evaluate complications.
Representative examples of X-ray and MR images from the
study patients are shown in Figure 1(a,b). The patients with
incomplete medical records, IUD embedment in the uterine
wall, partial uterine perforation, or patients in whom the
TIUD was removed hysteroscopically were excluded from the
study. The diagnosis and management flowchart shown in
Figure 2 was developed retrospectively, based on our experi-
ence. Asymptomatic patients were managed conservatively,
except in one case in which the patient requested surgery
because she also wanted a tubal ligation. Information on the
asymptomatic period, American Society of Anaesthesiologist
(ASA) classification, menopausal status, comorbidities, and
disease status was also used in the therapeutic decision-mak-
ing process in asymptomatic patients. All the patients were
fully informed of the procedures and possible risks of both
surgical and conservative management. Written informed
consent was provided by all the study participants. The data
 JOURNAL OF OBSTETRICS AND GYNAECOLOGY 3

Gynecologic examination
(during a routine control/check-up visit of IUD and/or cases are referred from other health centers)

Transvaginal sonography
(If IUD strings are not visualized)

X-ray
(If an ultrasound scan confirmed that the device was not in uterus,
perforation must be considered, although expulsion is more common.)

If x-ray revealed the IUD within theabdomen

Symptomatic Asymptomatic

Surgical management
Computerized tomography or magnetic
(if symptomatic or if pathologic
imaging findings were detected) resonance imaging**

( CT/MR providesinformation about the

relation of the IUD to adjacent organs)
Laparoscopy*
Laparoscopy is the first preferred **CT is usually used for the assessment of
method of removal IUD positioningand for evaluation of
complications.
**Although MR imaging is not typically used
for the evaluation of IUDs, MR provides good
Laparotomy* tissue characterization and modern IUDs are
(If laparoscopy is unsuccessful, the procedure safely imaged with both 1.5-T and 3.0-T
should be converted to a laparotomy) magnets.

* Intraoperative fluoroscopy may be useful for

localization of missing IUD
Conservativemanagement
(if no pathologies were found in the pelvic genital
structures, the IUD can remain in place)

***In postmenopausal women and/or

***Patients in ASA class III and IV and/or
***Patients with comorbidities and/or
***Asymptomatic period lasting more than 5 years.

***Conservative management is preferred.

Otherwise conservative treatment should be considered as
an option.

Figure 2. Flowcharts for diagnosis and management.

were analysed using SPSS for Windows software (ver. 16.0;
SPSS Inc., Chicago, IL).
Results
Among the 15 patients with documented IUD-related uterine
perforation, the IUD types were as follows: LNG-IUS (n ¼ 4),
Lippes loop (n ¼ 3), and copper IUDs (n ¼ 8). The patients had
a mean age of 43.7 ± 14.1 years (range: 29–74 years) and a
mean parity of 3.4 ± 1.2 births (range: 2–6 births). Five
patients were asymptomatic and the lost IUD was either dis-
covered incidentally during imaging performed because of
unrelated symptoms or were eventually diagnosed during a
check-up. The minimum asymptomatic period was 15 years
in the conservatively managed group. Ten patients were
symptomatic. Their most common complaint was abdominal
pain, followed by abnormal vaginal bleeding and unintended
pregnancies. Bleeding related to miscarriage, dyspareunia,
constipation and dysuria were the other relevant clinical
symptoms. After the surgery, complete resolution or signifi-
cant improvement of the presenting symptoms (pain, dyspar-
eunia, constipation, dysuria) was noted in almost all the
patients. The success rate in symptomatic patients who
presented with abnormal vaginal bleeding was 50%.
4 M. G. UÇAR ET AL.

Table 1. The demographic and clinical characteristics of patients. of surgery. Representative images of the adhesions are shown
Age (Years) Mean ± SD (range) in Figure 3(a–b).
In conservatively managed group 64.5 ± 8.2 (55–74) The intraoperative findings, management approach, add-
In surgically managed group 36.1 ± 5.0 (29–45) itional surgical intervention, and complications in all 15
In all cases 43.7 ± 14.1 (29–74)
Parity (n) patients are presented in Table 2. All patients were unevent-
In conservatively managed group 4.7 ± 0.9 (4–6) ful at 1 to 5 years of follow-up. The length of follow-up was
In surgically managed group 2.9 ± 0.7 (2–4) 3–5 years in asymptomatic patients. All of the patients in the
In all cases 3.4 ± 1.2 (2–6)
conservatively managed group were in menopause. Of these,
n (%) two were classified as ASA III–IV and had comorbidities.
Asymptomatic/discovered incidentally 5 (33, 3%)
Symptomatic 10 (66. 6%)
Abdominal pain 7 (46. 6%)
Abnormal bleeding pattern 4 (26. 6%)
Discussion
Unintended pregnancies 2 (13. 3%)
Bleeding related to miscarriage 2 (13. 3%) In this study we try to find an answer for the question of
Dyspareunia 2 (13. 3%) “Should removal of translocated IUDs routinely be performed
Constipation 1 (6. 6%) even if patients are asymptomatic?” This is a descriptive study
Dysuria 1 (6. 6%)
History of uterine surgery 7 (46, 6%) reporting 15 cases of intraperitoneal IUDs and management.
Caesarean section 5 (33. 3%) Asymptomatic patients were managed conservatively, and
Myomectomy 1 (6. 6%) symptomatic patients were operated. There are important
Hysterectomy 1 (6. 6%)
Dilatation curettage 3 (20%) implications resulting from this study that in asymptomatic
Time interval between IUD insertion and patients leaving the IUD in place may be a reasonable option,
last delivery mostly as the risk of surgical intervention is quite high with a
3 months 4 (26. 6%)
3 < n  12 months 6 (40%) high rate of complications with surgical management.
12 < n  24 months 3 (20%) If an IUD, regardless of its type, is no longer detected in
n > 24 months 2 (13. 3%) the uterus, then the World Health Organisation (WHO 1987)
Insertion while breastfeeding 6 (40%)
The time interval between IUD insertion recommends its retrieval and removal as soon as possible.
and the onset of symptoms in surgically The WHO study was carried out many years ago, although
managed group more recent reports have similarly advocated the prompt
6 months 4 (36.3%)
6 < n  12 months 5 (45.4%) removal of a TIUD (Balci et al. 2010; Kho & Chamsy 2014). By
n > 12 months 1 (11%) contrast, Markovitch et al. (2002) recommended not interven-
Asymptomatic 1 (11%) ing surgically in asymptomatic patients, as did Kaislasuo et al.
Time interval between IUD insertion and
the diagnosis of translocated IUD (2013). The latter group also concluded that asymptomatic
Symptomatic patients TIUDs may not need any form of treatment if the risk of
6 months 3 (20%) pregnancy is low or the contraceptive effect of the IUD is no
6 < n  12 months 4 (26.6%)
12 < n  24 months 2 (13.3%) longer needed (Kaislasuo et al. 2013). Thus, the optimal man-
2 < n  5 years 1 (6.6%) agement of a TIUD remains controversial, largely due to the
Asymptomatic patients lack of rigorous studies.
5 < n  10 years 1 (6.6%)
n > 10 years 4 (26.6%) Although the most common extrauterine localisation of
Asymptomatic period in conservatively managed group the TIUD is the omentum (Şeng€ ul et al. 2014), a TIUD can
Case 1 >15 years migrate to a position that compromises adjacent structures
Case 2 >21 years
Case 3 >35 years or complicates surgical removal (Ozgun et al. 2007). Both
Case 4 >25 years damage to the surrounding tissues and bleeding may occur
n, indicates the number of patients. during the removal of fixed devices. In 85% of cases of per-
foration, no other organs except the uterus are involved;
however, the remaining 15% are associated with complica-
The patients’ demographic and clinical characteristics are pre- tions involving adjacent visceral organs, most often the intes-
sented in Table 1. tines and bladder (Zakin et al. 1981). In our series two
Four (26.6%) patients were managed conservatively and intraoperative bowel injuries and one bladder injury occurred
11 (73.3%) were managed surgically. All surgeries were elect- during surgical intervention.
ive and all surgical procedures were initiated laparoscopically. Traditionally, TIUDs have been managed by open surgery
Eight of the 11 patients were managed by laparoscopy; the but minimally invasive approaches are currently preferred.
remaining three were treated by laparotomy. The overall rate Mini-laparotomy provides an alternative to laparoscopy as a
of open surgery was 20%. Reason for conversion to laparot- cost-saving procedure that requires less equipment (Ertopcu
omy included poor visualisation and inadequate access due et al. 2015). However, laparoscopic TIUD removal should be
to adhesions (2) and inability to tolerate steep Trendelenburg considered. While the choice of surgical technique will
positioning (1). There were seven complications in the surgi- depend on the location of the TIUD and the extent of adhe-
cally managed group: conversion to laparotomy (n ¼ 3), sions, laparoscopic surgery has several advantages. Perhaps
bowel injury (n ¼ 2), bladder injury (n ¼ 1), and wound infec- most importantly, in addition to being minimally invasive,
tion (n ¼ 1). Mild and severe adhesions (9/11) and abscess laparoscopy allows TIUD detection by panoramic visualisation.
(2/11) formation related to TIUD were observed at the time An IUD that is fully floating in the peritoneal cavity or fixed
 JOURNAL OF OBSTETRICS AND GYNAECOLOGY 5

Figure 3. (a) Intraoperative laparoscopic image of adhesions from study subjects and location of the extrauterine IUD (arrow). (b) A patient presented with irritative
voiding symptoms and the missing IUD was discovered in the vesicouterine area (arrow).

Table 2. Type of management, intraoperative findings, additional surgical intervention and complications.
Uterus position Management &
(Type of IUD) Abdominal entry Additional surgical
Perforation site techniques intervention Intraoperative findings Location of the IUD Complication(s)
1 Retroverted Laparoscopy, None No properties Free within the None
(Mirena) Peri-umbilical abdomen
Uterine incision for Verres
caesarean section
2 Anteverted Laparoscopy Left partial Omentum, peritoneum Adnexal localisation None
(Copper) Palmer's point. salpingectomy and adnexa formed
Left cornual horn Verres a conglomerate
mass
3 Anteverted Laparoscopy Repair of bowel injury Dense adhesion On the serosal surface Bowel serosal injury
(Copper) Peri-umbilical. between sacrouter- of the sigmoid
Posterior wall at the Verres ine ligament colon
level of the uterine and the sigmoid
isthmus colon
4 Anteverted Laparoscopy Partial omentectomy Mild pelvic peritoneal Adherent to omentum None
(Copper) Open Hasson and omental
Uterine fundus technique adhesions
5 Retroverted Laparoscopy, Adhesiolysis Mild pelvic peritoneal Posterior cul-de-sac, Minimal bowel serosal
(Mirena) Palmer's point. tubal ligation adhesions lying on the injury (not require
Posterior wall of Verres Mesentery of the intervention)
uterine corpus rectum
6 Anteverted Laparotomy Abscess drainage, Extensive adhesions, Adherent to omentum Conversion to
(Copper) adhesiolysis obliterated cul laparotomy
Posterior wall of de sac
uterine corpus
7 Retroverted Laparoscopy Abscess drainage Pelvic peritoneal Lying on posterior Wound infection
(Mirena) Open Hasson adhesions cul-de-sac, covered
Broad ligament technique with peritoneum,
8 Retroverted Laparoscopy, Tubal ligation No properties Free within the None
(Mirena) Direct trocar posterior cul-de-sac
Not visible technique
9 Retroverted Laparotomy Adhesiolysis Omentum, peritoneum Adnexal localisation Conversion to
(Copper) Salpingectomy, and adnexa formed laparotomy
Not visible Partial omentectomy a conglomerate
mass
10 Anteverted Laparotomy Cystoscopy Dense generalised In the vesicouterine Conversion to laparot-
(Copper) adhesions between area, the horizontal omy
Uterine incision for anterior wall of the arm of the IUD was Bladder injury, (wall
caesarean section uterus, bladder and embedded in the was continuously
omentum bladder wall sutured as two
layers)
11 Anteverted Laparoscopy, Adhesiolysis Massive adhesions Deeply embedded into None
(Copper) Direct trocar between bladder, uterovesical space
Not visible technique uterine fundus and
omentum,
12 Anteverted Conservative Pelvic sidewall
(Copper)
13 Anteverted Conservative Pelvic sidewall
(Lippes loop)
14 Anteverted Conservative In the right lower
(Lippes loop) front part of the
abdomen
15 Unknown Conservative Pelvic sidewall
(Lippes loop)
6 M. G. UÇAR ET AL.
to the omentum can change its position during body move-
ment, such that open surgery may not be sufficient to allow
its localisation.
The seven complications in the surgically managed group
consisted of conversion to laparotomy (n ¼ 3), bowel injury
(n ¼ 2), bladder injury (n ¼ 1), and wound infection (n ¼ 1).
The overall rate of open surgery was 20%. Three of the 15
patients (20%) had peri-umbilical adhesions. The most
important issue to be considered during laparoscopic surgery
is the prevention of complications associated with the initial
abdominal entry. In the study of Kho and Chamsy (2014),
conversion to laparotomy was required in 11% of the patients
because of failed laparoscopic entry, the presence of dense
adhesions, and the need to repair a recto-uterine fistula. Scar
tissue and adhesions can hinder safe entry into the abdom-
inal cavity and predispose the bowel or other intra-abdominal
organs to injury (Seetahal et al. 2015). In the study of Nitke
et al. (2004), 14 patients had TIUDs and adhesions were pre-
sent in all cases, eight mild and six severe. Mild to severe
peritoneal adhesions were observed in almost all patients in
our study as well. Difficulties associated with possible adhe-
sions may thus be anticipated and minimised by using an
open laparoscopy technique or left upper quadrant insertion
(Palmer’s point). Based on our experience, TIUD complicates
future laparoscopic surgery by increasing the incidence of
adhesions and conversion to laparotomy.
In addition to adhesions, a TIUD can cause chronic pain,
intestinal obstruction, and infertility (Balcı et al. 2010).
Nonetheless, additional surgery is not always the appropriate
option in patients with complex medical problems
(Soleymani Majd et al. 2009). Similarly, in older patients, espe-
cially those with comorbidities, extensive surgical procedures
to remove a TIUD may create more complications than those
that may potentially arise from the TIUD itself. The result may
be a vicious cycle in which surgery is the cause of adhesions
and complications, necessitating further surgery, etc.
The accurate localisation of a TIUD is essential in the clin-
ical preoperative assessment of these patients. Mosley et al.
found that the location of the IUD influences the risk of con-
version to laparotomy and the potential need for additional
intraoperative procedures, such as cystoscopy and proctos-
copy (Mosley et al. 2012). A high index of suspicion is the key
to the diagnosis of a TIUD, the detection of which is often
facilitated by the use of various imaging modalities; however,
combined vaginal ultrasonography and abdominal X-ray is
often diagnostically sufficient. CT is used to assess IUD posi-
tioning and to evaluate complications. MRI is seldom needed
but offers high contrast resolution and good tissue character-
isation. Modern IUDs are safely imaged with 1.5-T and 3.0-T
magnets (Boortz et al. 2012).
The asymptomatic patients in our study were diagnosed
during routine follow-up visits or following incidental discov-
ery. Because perforation itself does not necessarily cause
unusual symptoms, it may go unnoticed (Nitke et al. 2004). If
the IUD strings are not visible, attempts should be made to
locate the IUD. In this study, one-third of the included
patients were asymptomatic and unaware of the shifted IUD
for a prolonged period of time. The vast majority of symp-
tomatic patients presented with abdominal pain and
abnormal bleeding patterns. Similar to our study, abdominal
pain and abnormal bleeding were the earliest triggers as well
as the most common causes of uterine perforations, as
reported in the study of van Grootheest et al. (2011).
Nonetheless, it is important to confirm correct IUD position-
ing, because neither pain nor bleeding is a reliable predictor
of IUD position (Van Schoubroeck et al. 2013).
This study was limited by its retrospective nature. In add-
ition, the number of cases was small, because perforation is a
rare event. Our study included only surgically treated symp-
tomatic patients and asymptomatic patients in whom the lost
IUD was discovered incidentally. Asymptomatic patients not
attending regular follow-up were not identified. The strengths
of our studies include the multi-centre design, detailed clin-
ical and surgical information about the patients and the long
period of follow-up especially in asymptomatic patients.
Although we observed that the outcomes of patients with
perforations caused by copper IUDs differed from those of
patients with perforations due to LNG-IUS and inert IUDs,
many of the relevant variables could not be evaluated in a
multivariate analysis because of the small sample size.
Conclusions
In conclusion, our study allowed us to identify important
issues in the management of patients with intra-abdominal
TIUDs: (1) if surgery is necessary, laparoscopy is the method
of choice. (2) A TIUD, by causing adhesions, complicates
future laparoscopic surgery and increases the likelihood of
conversion to laparotomy. It is therefore important to take
adequate precautions to avoid complications during abdom-
inal access. While surgery is indicated to prevent TIUD-
induced adhesive complications, it may also be the cause of
both adhesions and complications, resulting in a vicious
cycle. (3) Some asymptomatic women, especially elderly
patients with comorbidities, may not need or may be better
managed without treatment. Thus, overall, we recommend an
individualised management approach that balances the risks
and benefits of treatment, whether surgical or conservative.
Disclosure statement
The authors report no conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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