The width of the uterine cavity is narrower in patients with an embedded intrauterine device (IUD) compared to a normally positioned IUD

The impact of embedment of the side arms of 52 mg levonorgestrel-intrauterine device on bleeding and pain: A prospective cohort study

PURPOSE

The purpose of this study was to analyse the impact of embedment of side arms of the levonorgestrel 52 mg intrauterine device (LNG-IUD) in the myometrium (assessed by three-dimensional transvaginal ultrasound (3D-TVUS)) on uterine bleeding and pain.

MATERIALS AND METHODS

We performed a prospective cohort study in a large Dutch teaching hospital between February 2015 and December 2016. Participants over 18 years of age who selected a LNG-IUD for contraception or because of heavy menstrual bleeding were eligible for inclusion. Six weeks after insertion, a 3D-TVUS was performed to diagnose embedment of the side arms. At that moment participants filled in questionnaires about their bleeding pattern and pelvic pain. Menstruation patterns 'no bleeding', 'regular menstruation', 'sometimes a day of spotting (maximum once a week)' were classified as favourable bleeding pattern. Menstruation patterns 'heavy menstrual bleeding', 'several days a week bleeding days', 'several days a week spotting days', 'continuously spotting', and 'completely irregular cycle' were classified as unfavourable bleeding pattern. Univariate and multivariate logistic regression analysis was used to calculate odds ratios (OR) and 95 %-confidence intervals (CI). The multivariate analysis included endometrial thickness, reason for insertion and parity. The analysis of pelvic pain additionally included previous insertion.

RESULTS

A total of 220 participants were evaluated for the study of whom 176 returned the questionnaires. Embedment of the side arms was observed in 43 of the 176 responding participants (24.4 %). Favourable bleeding pattern was reported by 25/43 (58.1 %) participants with embedment and 53/133 (39.8 %) participants without embedment (ORadj 1.8, 95 % CI 0.9-3.9). Pelvic pain was reported by 4/43 (9.3 %) participants with embedment and 24/133 (18.1 %) participants without embedment (ORadj 0.3; CI 0.1-1.2).

CONCLUSIONS

The present study suggests that embedment of the side arms of the LNG-IUD in the myometrium assessed by 3D-TVUS is not associated with a unfavourable bleeding pattern nor pelvic pain six weeks after insertion. From this point of view, we do not recommend to perform standard 3D-TVUS for the purpose of excluding or demonstrating embedment.

Early GnRH-agonist therapy does not negatively impact the endometrial repair process or live birth rate

Study objective

To investigate whether different timings of GnRH-a downregulation affected assisted reproductive outcomes in infertile women with moderate-to-severe intrauterine adhesions (IUAs) accompanied by adenomyosis.

Design

A retrospective case series.

Setting

An assisted reproductive technology center.

Patients

The study reviewed 123 infertile women with moderate-to-severe IUAs accompanied by adenomyosis undergoing their first frozen-thawed embryo transfer (FET) cycles between January 2019 and December 2021.

Measurements and main results

The majority of patients had moderate IUA (n=116, 94.31%). The average Basal uterine volume was 73.58 ± 36.50 cm3. The mean interval from operation to the first downregulation was 21.07 ± 18.02 days (range, 1-79 days). The mean duration of hormone replacement therapy (HRT) was 16.93 ± 6.29 days. The average endometrial thickness on the day before transfer was 10.83 ± 1.75 mm. A total of 70 women achieved clinical pregnancy (56.91%). Perinatal outcomes included live birth (n=47, 67.14%), early miscarriage (n=18, 25.71%), and late miscarriage (n=5, 7.14%). The time interval between uterine operation and the first downregulation was not a significant variable affecting live birth. Maternal age was the only risk factor associated with live birth (OR:0.89; 95% CI: 0.79-0.99, P=0.041).

Conclusions

The earlier initiation of GnRH-a to suppress adenomyosis prior to endometrial preparation for frozen embryo transfer did not negatively impact repair of the endometrium after resection.

CT imaging of intrauterine devices (IUD): expected findings, unexpected findings, and complications

Intrauterine devices (IUDs) are a commonly used form of long-acting reversible contraception, which either contain copper or levonorgestrel to prevent pregnancy. Although symptomatic patients with indwelling IUDs may first undergo ultrasound to assess for device malposition and complications, IUDs are commonly encountered on CT in patients undergoing evaluation for unrelated indications. Frequently, IUD malposition and complications may be asymptomatic or clinically unsuspected. For these reasons, it is important for the radiologist to carefully scrutinize the IUD on any study in which it is encountered. To do so, the radiologist must recognize that normally positioned IUDs are located centrally within the uterine cavity. IUDs are extremely effective in preventing pregnancy, though inadvertent pregnancy risk is higher with malpositioned IUDs. Presence of fibroids or Mullerian abnormalities may preclude proper IUD placement. Radiologists play an important role in identifying complications when they arise and special considerations when planning for an IUD placement. There is a wide range of IUD malposition, affecting IUDs differently depending on the type of IUD and its mechanism of action. IUD malposition is the most common complication, but embedment and/or partial perforation can and can lead to difficulty when removed. Retained IUD fragments can result in continued contraceptive effect. Perforated IUDs do not typically cause intraperitoneal imaging findings.

Risk factors for intrauterine device embedment in postmenopausal women: an analysis of 731 participants undergoing hysteroscopy

OBJECTIVE

This study aimed to explore the risk factors for intrauterine device (IUD) embedment in postmenopausal women.

METHODS

A total of 731 women who underwent hysteroscopy for IUD removal from January 2019 to December 2021 were included in the trial, of whom 301 were diagnosed with IUD embedment (embedded group) and 430 had a normal IUD location (control group). The following data were collected from electronic medical records: demographic traits, ultrasound findings, IUD shapes, uterine features, and hysteroscopy findings. Bivariate contingency analysis and multiple logistic regression were performed to identify the significant independent variables that affect IUD embedment.

RESULTS

Prior IUD removal failure (14.3% vs 5.1%; adjusted odds ratio [aOR], 3.29; 95% CI, 1.90-5.71) and V-shaped IUD (18.9% vs 10.7%; aOR, 2.05; 95% CI, 1.33-3.16) were risk factors that were independently linked with IUD embedment. Uterine volume (22.7 [20.9-24.5] cm 3 vs 27.9 [24.8-30.9] cm 3 ; aOR, 0.99; 95% CI, 0.982-0.999) was negatively linked with IUD embedment. There were no differences in age, parity, menopause length, years with an IUD in situ, uterine position, or abortion times between the two groups. There were no differences in existing leiomyoma, prior cervical LEEP (loop electrosurgical excision procedure), or myomectomy between the two groups.

CONCLUSIONS

Prior IUD removal failure, V-shaped IUD, and a smaller uterine volume were risk factors for IUD embedment in menopausal women.

Continuation rates of two different-sized copper intrauterine devices among nulliparous women: Interim 12-month results of a single-blind, randomised, multicentre trial

BACKGROUND

The most widely used copper intrauterine device (IUD) in the world (the TCu380A), and the only product available in many countries, causes side effects and early removals for many users. These problems are exacerbated in nulliparous women, who have smaller uterine cavities compared to parous women. We compared first-year continuation rates and reasons/probabilities for early removal of the TCu380A versus a smaller Belgian copper IUD among nulliparous users.

METHODS

This 12-month interim report is derived from a pre-planned interim analysis of a sub population and focused on key secondary comparative endpoints. In this participant-blinded trial at 16 centres in the USA, we randomised participants aged 17-40 in a 4:1 ratio to the NT380-Mini or the TCu380A. In the first year, participants had follow-up visits at 6-weeks and 3, 6, and 12-months, and a phone contact at 9 months; we documented continued use, expulsions, and reasons for removal. Among participants with successful IUD placement, we compared probabilities of IUD continuation and specific reasons for discontinuation using log-rank tests. This trial is registered with ClinicalTrials.gov number NCT03124160 and is closed to recruitment.

FINDINGS

Between June 1, 2017, and February 25, 2019, we assigned 927 nulliparous women to either the NT380-Mini (n = 744) or the TCu380A (n = 183); the analysis population was 732 (NT380-Mini) and 176 (TCu380A). Participants using the NT380-Mini, compared to the TCu380A, had higher 12-month continuation rates (78·7% [95% CI: 72·9-84·5%] vs. 70·2% [95% CI: 59·7-80·7], p = 0·014), lower rates of removal for bleeding and/or pain (8·1% vs. 16·2%, p = 0·003) and lower IUD expulsion rates (4·8% vs. 8·9%, p = 0·023), respectively.

INTERPRETATION

The NT380-Mini offers important benefits for a nulliparous population compared to the TCu380A in the first twelve months, when pivotal experiences typically occur. Higher continuation rates with the NT380-Mini may avert disruptions in contraceptive use and help users avoid unintended pregnancy.

FUNDING

Bill & Melinda Gates Foundation, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Mona Lisa, N.V. (Belgium).

Incidence and Risk Factors for a Malpositioned Intrauterine Device Detected on Three-Dimensional Ultrasound Within Eight Weeks of Placement

OBJECTIVES

To estimate the incidence of intrauterine device (IUD) malpositioning detected on three-dimensional (3D) transvaginal ultrasound within 8 weeks of placement and identify risk factors for malpositioning.

METHODS

Retrospective study of women who had an IUD placed at a large obstetrics and gynecology practice from January 1, 2015, to December 31, 2020. All patients underwent two-dimensional ultrasound at the time of insertion and routine three-dimensional ultrasound within 8 weeks. Baseline characteristics and potential risk factors were compared between women with correctly positioned and malpositioned IUDs. Odds ratios were calculated by logistic regression to identify risk factors independently associated with malpositioning.

RESULTS

A total of 763 IUD placements were included, and 127 malpositioned IUDs were identified representing an overall rate of malpositioning of 16.6% (95% confidence interval [CI] 14.0-19.3) with 8.8% (95% CI 6.8-10.8) requiring removal. Patients with malpositioned IUD had higher rates of morbid obesity (13.4% versus 3.8%, adjusted odds ratio [aOR] 2.46, 95% CI 1.10-5.50), prior uterine window or rupture (9.0% versus 2.2%, aOR 2.78, 95% CI 1.06-7.30), copper IUD placement (64.2% versus 47.4%, aOR 1.99, 95% CI 1.31-3.03), and symptoms such as bleeding or pain at follow-up (35.8% versus 20.1%, aOR 2.58, 95% CI 1.67-3.98). Parity, breastfeeding, difficult insertion, and uterine size and positioning were not significant.

CONCLUSIONS

The incidence of malpositioned IUD within 8 weeks of placement on 3D ultrasound is 16.6%, with 8.8% requiring removal. Significant risk factors for malpositioning include morbid obesity, prior uterine window or rupture, and copper IUD placement. These findings support the importance of routine follow-up 3D ultrasound after seemingly successful IUD placement.

The added value of three-dimensional ultrasonography in uterine pathology

The rapid development achieved over the last decades in volume rendering of ultrasound data, known as three-dimensional (3D) ultrasound technique, leads to new opportunities for refining the diagnosis in many gynaecologic conditions. The aim of the present study was to evaluate the advantages of 3D ultrasound over two-dimensional (2D) ultrasound in uterine pathology and to establish the optimal time point during the menstrual cycle to perform 3D ultrasound examination in order to achieve the maximum of useful information. A cross-sectional study on 200 patients who underwent gynaecologic 2D and 3D ultrasound examinations was performed. The addition of 3D examination to 2D ultrasound in uterine pathology provided the most useful information concerning: Congenital uterine anomalies, intrauterine devices (IUDs), adenomyosis, and submucous myomas. The findings showed that the 3D ultrasound scan is a useful tool in gynaecology, especially in cases with congenital uterine anomalies, myoma, and IUD. Although initially it was used for research purposes only, recent findings suggest its usefulness in routine ultrasound scan and the possibility of witnessing its introduction as a recommended examination procedure in the foreseeable future. Further research should be conducted in order to establish the sensitivity of 3D ultrasound in the detection of minor endometrial conditions, by correlating the imaging findings with the hysteroscopic results.

Uterine dimensions and intrauterine device malposition: can ultrasound predict displacement or expulsion before it happens?

OBJECTIVE

Intrauterine devices (IUDs) are the most commonly used method of long-acting reversible contraception. IUD malpositions are described as expulsion, embedding, displacement, and perforation, which may cause contraception failure, organ injury, hemorrhage, and infection. The aim of the study was to evaluate the relationship between displacement and IUD positioning in the uterus, and uterine dimensions as measured using transvaginal ultrasonography.

MATERIALS AND METHODS

Three-hundred and eighty-four patients who had TCu380A devices inserted at a tertiary hospital were evaluated at insertion and at 1 month, 3 months, and 6 months after insertion. At the insertion visit, demographic characteristics, history of menorrhagia, dysmenorrhea, previous IUD displacement, and obstetric history were recorded. Transvaginal ultrasonographic measurement of the uterine cavity, uterine length, uterine width, cervix length, cervix width, transverse diameter of the uterine cavity, the distance between the tip of the IUD and the fundus, and endometrium were measured to evaluate IUD displacement.

RESULTS

Sixteen of 384 patients had displacement. There were significant differences in times between last pregnancy outcomes and IUD insertion and dysmenorrhea history (p = 0.004 and p = 0.028, respectively). Among TCu380A users, women with 7.5 mm IUD endometrium distances had a higher risk for displacement with a sensitivity of 81% and specificity of 37.5% (AUC: 0.607, 95% CI 0.51-0.70). Women with uterus width less than 41.5 mm were more likely to have displacement with a sensitivity of 53.8% and a specificity of 75% (AUC: 0.673, 95% CI 0.60-0.75).

CONCLUSION

IUD endometrium distance and uterus width are important parameters for displacement for TCu380A.

How do women and health care professionals view hormonal long-acting reversible contraception? Results from an international survey

Purpose: Evidence from real-world settings is important to provide an accurate picture of health care delivery. We investigated use of long-acting reversible contraception (LARC) in women aged 15-49 years.Materials and methods: Two surveys, one of women and one of health care professionals (HCPs), were conducted in parallel across seven countries. Participating women completed an online survey to assess contraceptive awareness, current method of contraception, age, and experience with current contraceptive method. HCPs participated in an online survey to provide practice-level information and three anonymous charts of hormonal LARC users.Results: Of 6903 women who completed the survey, 3225 provided information about their current primary contraception method. Overall, 16% used LARC methods, while 52% used oral contraceptives (OCs). Of hormonal intrauterine system users, 72% described their experience as 'very favourable', compared with only 53% of women using OCs. Anonymous patient records (n = 1605) were provided by 550 HCPs who completed the online survey. Most women (64%) had used short-acting reversible contraception before switching to LARC. Physicians perceived 56-84% of LARC users to be highly satisfied with their current form of contraception.Conclusions: Although usage of LARC was low, most women using LARC were highly satisfied with their method of contraception.

The Management of a patient with a fragmented intrauterine device embedded within the cervical canal

A 28-year-old woman presented with a malpositioned intrauterine device (IUD) that was fragmented and significantly entrenched within the cervical canal and myometrium. IUD malposition with concomitant device fragmentation and embedded segments, albeit rare, should be a consideration given the device's prevalence.

Factors associated with low-lying intrauterine devices: a cross-sectional ultrasound study in a cohort of African-American women

OBJECTIVE

The object of this study is to examine factors and symptoms associated with low-lying IUDs as defined by ultrasound.

STUDY DESIGN

This is a cross-sectional sub-study of participants in the Study of Environment, Life-style, and Fibroids (SELF). SELF participants had screening ultrasounds for fibroids at study enrollment; those with an IUD in place are included in this sub-study. Low-lying IUDs were identified and localized. Logistic regression was used to identify factors and symptoms associated with low-lying IUDs.

RESULTS

Among 168 women with IUDs at ultrasound, 28 (17%) had a low-lying IUD. Having a low-lying IUD was associated with low education level (≤high school: aOR 3.1 95% CI 1.14-8.55) and with increased BMI (p=.002). Women with a low-lying IUD were more likely to report a "big problem" with dysmenorrhea (the highest option of the Likert scale) as compared to women with a normally-positioned IUD (OR 3.2 95% CI 1.07-9.54).

CONCLUSION

Our study found that women with a low-lying IUD are more likely to be of lower education and higher BMI, and to report more dysmenorrhea.

IMPLICATIONS

Women who are obese may benefit from additional counseling and closer follow-up after IUD placement. Future research is warranted to investigate IUD placement and possible IUD migration among women who are obese.

Complications After Gynecologic and Obstetric Procedures: A Pictorial Review

Gynecologic and obstetric procedures require careful dissection in to high real-estate regions in the pelvis and abdomen where many structures lie in close proximity: the urinary bladder, ureter, and bowel. Damage to one of these structures can cause significant morbidity. Recognition of the patient who has an acute complication of gynecologic or obstetric surgery on imaging can precipitate quick and effective medical management. Imaging can appropriately diagnose the underlying problem and provide critical information for the clinical team. In this review, we present acute complications of gynecologic and obstetric procedures and their imaging appearances.

Femilis(®) 60 Levonorgestrel-Releasing Intrauterine System-A Review of 10 Years of Clinical Experience

OBJECTIVE

The aim of this study was to update the clinical experience with the Femilis® 60 levonorgestrel-releasing intrauterine system (LNG-IUS), now up to 10 years in parous and nulliparous women, particularly with regard to ease and safety of insertion, contraceptive performance, retention, acceptability, continuation of use, impact on menstrual blood loss (MBL), and duration of action.

STUDY DESIGN

Using the Femilis® 60 LNG-IUS releasing 20 µg of levonorgestrel/day, the following studies were conducted: an open, prospective noncomparative contraceptive study, an MBL study, a perimenopausal study, a study for the treatment of endometrial hyperplasia, and early cancer of the uterus, a residue study.

RESULTS

A total of 599 Femilis LNG-IUS were inserted in various clinical trials, the majority for contraceptive purposes. The total exposure in the first and second contraceptive studies, covering 558 parous and nulliparous women, was 32,717 woman-months. Femilis has high contraceptive effectiveness as only one pregnancy occurred. Expulsion of the LNG-IUS was rare with only two total and no partial expulsions (stem protruding through the cervical canal) occurred. Femilis was well tolerated, with continuation rates remaining high. Several MBL studies were conducted, totaling 80 heavy and normal menstrual bleeders, using the pictorial bleeding assessment chart method or the quantitative alkaline hematin technique. Virtually all women responded well with strongly reduced menstrual bleeding. Amenorrhea rates were high, up to 80% after three months, and ferritin levels simultaneously increased significantly. The Femilis LNG-IUS was tested in 104 symptomatic perimenopausal women for seamless transition to and through menopause, adding estrogen therapy when required. Patient tolerability appeared high as >80% requested a second and a third LNG-IUS. Twenty women presenting with nonatypical and atypical hyperplasia and one woman presenting with early endometrial carcinoma were treated with Femilis LNG-IUS. All histology specimens showed full regression, and patients remained in remission without signs of hyperplasia or cancer at yearly and ongoing follow-up examinations up to 10 years. Residual content of LNG was measured in 37 women having the Femilis LNG-IUS for up to 10 years. In 10 of the 102 women who had the Femilis 60 in situ for 10 years between 20% and 30% of the original 60 mg was recovered confirming the long duration of action of the Femilis 60 LNG-IUS.

CONCLUSION

These studies suggest that the Femilis 60 LNG-IUS releasing 20 µg of LNG/day is an effective, well-tolerated, and well-retained contraceptive both in parous and in nulliparous women. The design of the LNG-IUS, with flexible transverse arm(s) length of 28 mm, allows for a simplification of the insertion technique and training requirements facilitating the use by nonspecialist providers in either developed or developing countries. For nulliparous women, additional evaluation of devices with a 24 mm transverse arm(s), as it relates to tolerability, retention, and continuation of use, still needs to be undertaken.

Transmural migration and perforation of a levonorgestrel intrauterine system: a case report and review of the literature

INTRODUCTION

Uterine perforation is an uncommon yet well-known complication of copper intrauterine devices and the levonorgestrel intrauterine system (IUS). While initial extrauterine placement at the time of insertion is felt to be the cause of perforation in most cases, some hypothesize that delayed transmural migration and subsequent perforation can occur with slightly malpositioned or even properly placed devices.

CASE

A 46-year-old female had a 52-mg levonorgestrel IUS inserted for menstrual management and contraception. We arranged a follow-up ultrasound as the uterus was enlarged on bimanual examination and the cavity sounded to 11cm. This ultrasound was completed 6days after insertion and reported the IUS to be in the "upper uterine cavity". Over time, transmural displacement and perforation of the horizontal arms of the device occurred. Computed tomography scans performed over 2years for nongynecologic indications document this gradual migration. A retrospective review of initial ultrasound images showed no evidence of uterine defect, embedment or perforation but the cavity length did appear to be less than 11cm.

CONCLUSIONS

While initial extrauterine placement at the time of insertion is the most common mechanism of perforation, delayed transmural migration is another mechanism that can occur.

Intrauterine device quo vadis? Why intrauterine device use should be revisited particularly in nulliparous women?

Background

Long-acting reversible contraceptive (LARC) methods, including intrauterine devices (IUDs) and the contraceptive implant, are considered the best methods for preventing unintended pregnancies, rapid repeat pregnancy, and abortion in young women. An opinion paper of 2012 by the American College of Obstetricians and Gynecologists recommends Mirena and Paragard for use in nulliparous and adolescent women. However, these IUDs are not designed for young women and are not optimal as they often lead to early discontinuation.

Objective

This article was written with the objective to respond to the urgent need to improve intrauterine contraception as it is likely that the objectives of LARC will not be met without significant improvement of IUD design. Anatomical variations in size and shape of the uterus are not sufficiently considered, producing harm and suffering, which often lead to early removal of the IUD.

Proposed problem solving

The article describes why IUDs should be revisited to meet the challenge of LARC and proposes how to solve these problems. The opinion statement presented here may be considered provocative but is based on hundreds of women with IUD problems who consult or are referred to the practices of the authors of this article due to the disproportion between the IUD and their small uterine cavity. The solution is simple but requires a revision of the current design of IUDs. One-dimensional (longitudinal) IUDs are likely to be the first option. Framed devices with shortened transverse arm and IUDs which adapt to the width of the given uterus are viewed as second best.

Conclusion

One of the reasons of the high unintended pregnancy rate in the USA may be the paucity of suitable IUDs. Also, the legal climate in the USA seems to be a problem for developers as many lawsuits have recently been reported. Clinical studies conducted in young nulliparous and adolescent women suggest that IUDs that fit well in the uterine cavity, like a shoe, result in better tolerance, less side effects, and last but not least, higher use continuation rates.

Predicting painful or difficult intrauterine device insertion in nulligravid women

OBJECTIVE

To assess the relationship of preinsertion vaginal ultrasound assessment and menstrual and gynecologic history as predictors of difficult or painful intrauterine device insertion in nulligravid women.

METHODS

Nulligravid women seeking contraception were invited to participate in this nonrandomized study and given the choice between the levonorgestrel-releasing intrauterine system or a copper-releasing intrauterine device. All 165 enrolled women were interviewed and a pelvic examination, including vaginal ultrasonography, was performed before insertion. Insertion difficulties and pain intensity were recorded and assessed against uterine measurements and background characteristics.

RESULTS

Most insertions were assessed as easy (n=144 [89.4%]) and only two (1.2%) failed. Most women had uterine measurements smaller than the studied devices. Odds for difficulties at insertion decreased with every increasing millimeter in total uterine length (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.78-0.96, P=.006) and cervical length (OR 0.85, 95% CI 0.74-0.97, P=.02) and similarly with every decreasing degree of (straighter) flexion angle (OR 0.96, 95% CI 0.94-0.99, P=.005). No absolute threshold measurements could be determined. Still, the majority of insertions in small and flexed uteri were uneventful. Severe insertion pain was common (n=94 [58.4%]). Severe dysmenorrhea was the only predictor of insertion pain (OR 8.16 95% CI 2.56-26.02, P<.001).

CONCLUSION

Ultrasonographic evaluation does not give additional information compared with clinical pelvic examination and sound measure. Although smaller uterine length measurements and steeper flexion angle more often predicted difficulties, the majority of insertions were uneventful in women with small measures. Dysmenorrhea was the only predictor of pain.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01685164.

LEVEL OF EVIDENCE

II.

Practical applications of 3D sonography in gynecologic imaging

Volume imaging in the pelvis has been well demonstrated to be an extremely useful technique, largely based on its ability to reconstruct the coronal plane of the uterus that usually cannot be visualized using traditional 2-dimensional (2D) imaging. As a result, this technique is now a part of the standard pelvic ultrasound protocol in many institutions. A variety of valuable applications of 3D sonography in the pelvis are discussed in this article.

Use of frameless intrauterine devices and systems in young nulliparous and adolescent women: results of a multicenter study

BACKGROUND

The purpose of this study was to provide additional data on the experience with frameless copper and levonorgestrel (LNG) intrauterine devices (IUDs) in nulliparous and adolescent women.

METHODS

Nulliparous and adolescent women, 25 years of age or younger, using the frameless copper IUD or the frameless LNG-releasing intrauterine system (IUS), were selected from previous studies and a current multicenter post-marketing study with the frameless copper IUD. The small copper-releasing GyneFix(®) 200 IUD consists of four copper cylinders, each 5 mm long and only 2.2 mm wide. The frameless FibroPlant(®) LNG-IUS consists of a fibrous delivery system releasing the hormone levonorgestrel (LNG-IUS). The main features of these intrauterine contraceptives are that they are frameless, flexible, and anchored to the fundus of the uterus.

RESULTS

One hundred and fifty-four nulliparous and adolescent women participated in the combined study. One pregnancy occurred with the GyneFix 200 IUD after unnoticed early expulsion of the device (cumulative pregnancy rate 1.1 at one year). Two further expulsions were reported, one with the GyneFix 200 IUD and the other with the FibroPlant LNG-IUS. The cumulative expulsion rate at one year was 1.1 with the copper IUD and 2.2 with the LNG-IUS. The total discontinuation rate at one year was low (3.3 and 4.3 with the copper IUD and LNG-IUS, respectively) and resulted in a high rate of continuation of use at one year (96.7 with the copper IUD and 95.7 with the LNG-IUS, respectively). Continuation rates for both frameless copper IUD and frameless LNG-IUS remained high at 3 years (>90%). There were no cases of perforations or pelvic inflammatory disease reported during or following insertion.

CONCLUSION

This report confirms earlier studies with frameless devices and suggests that the high user continuation rate is attributable to the optimal relationship between the IUD and the uterine cavity. IUD studies have shown that an IUD that does not fit well will often lead to side effects (ie, pain, bleeding, embedment, expulsion) and subsequent removal of the IUD. Early discontinuation is not the aim of long-acting reversible contraception.

Comparison of two- and three-dimensional transvaginal ultrasound in the visualisation of intrauterine devices

The aims of the study were to evaluate whether three-dimensional transvaginal ultrasound (3D TV US) is superior to two-dimensional transvaginal ultrasound (2D TV US) at visualising intrauterine devices and determining their position. This prospective study included 52 participants with an intrauterine device fitted, who underwent 2D TV US and 3D TV US. 2D TV US and 3D-reconstructed coronal images were reviewed by two gynaecological radiologists to assess ease of visualisation and position of the intrauterine devices. Statistical analysis was performed using Wilcoxon signed-rank, McNemar and Chi-squared tests. The inter-observer agreement was measured using Cohen's Kappa. Intrauterine device visualisation scores were significantly higher with 2D TV US compared with 3D TV US (Radiologist 1 p = <0.001, Radiologist 2 p = 0.007). A significant number of T-arms appeared to perforate into the adjacent myometrium on the 3D-reconstructed coronal image, but were normal on the 2D images (Radiologist 1 p = <0.001, Radiologist 2 p = 0.008). Radiologist 1 found 19 perforated T-arms on 3D TV US compared with four on 2D TV US. Radiologist 2 found 13 perforated T-arms on 3D TV US compared with five on 2D TV US. Both radiologists agreed on the positions of the intrauterine devices substantially with 3D TV US (Kappa = 0.69) and moderately with 2D TV US (Kappa = 0.55). The 3D TV US did not visualise an intrauterine device better than 2D TV US. The 3D-reconstructed coronal image of the uterus can reliably display cases of T-arm perforation into the adjacent myometrium, which could be missed on 2D TV US images. The 3D TV US should be used in addition to 2D TV US in all cases where an intrauterine device is under evaluation.

Association of the Position of the Copper T 380A as Determined by the Ultrasonography Following its Insertion in the Immediate Postpartum Period with the Subsequent Complications: An Observational Study

PURPOSE

Incorrectly placed copper T 380A leads to increased contraception failure. This study aimed to find an association between the ultrasonographic position of the copper T 380A in the immediate postpartum period and the adverse effects observed during the period of 6 months after its insertion.

METHODS

This descriptive study was carried out in the Department of Obstetrics & Gynaecology of a tertiary-care-center of India from September 2011 to February 2013. The women eligible for immediate postpartum copper T 380A insertion with previous regular menstrual cycles for at least 6 months before the current pregnancy, and those who were willing for follow-up visits and had easy accessibility to the hospital, were recruited. A clinical evaluation and ultrasonographic assessment of Intra-Uterine-Contraceptive-Device (IUCD) after insertion was carried out after enrolment. The complications (expulsions, vaginal discharge, menstrual irregularity, and lower abdominal pain) were subsequently assessed during a 6-month follow-up period. The primary objective was the ultrasonographic assessment of the placement of IUCD immediately after insertion. The incidence of complications and their association with the presence of malposition was also studied.

RESULTS

Hundred patients were evaluated during the study period. Forty-four (44 %) women were found to have malpositioned IUCDs on ultrasonographic evaluation done following insertion. The complications among the IUCD users included menstrual irregularity (27.17 %), pain in lower abdomen (20.65 %), vaginal discharge (7.6 %), and expulsions (9.7 %). The IUCD expulsions, menstrual irregularities, and pain were significantly more in patients with malpositions (p < 0.05).

CONCLUSIONS

Malpositioning of IUCD is common immediately following insertion and is significantly associated with more complications during the follow-up.

A new experimental three-dimensional, reticular intrauterine device (3-DRIUD) composed of nitinol and silicone rubber

BACKGROUND

The aim of this study was to explore a new three-dimensional, reticular intrauterine device (3-DRIUD) composed of nitinol and silicone rubber and to observe the contraceptive effect of the device in rats.

STUDY DESIGN

Two contraceptive experiments were performed. In the first, female rats underwent bilateral placement of a 20.0-35.0-mm 3-DRUID (experimental group, n=30) via an abdominal incision or a sham operation with no IUD (control group, n=30). Two weeks after the operation was performed, the rats from either group were caged together with male rats. The contraceptive effects of the 3-DRIUD were observed at 1 to 3 months postoperation, after which the 3-DRIUDs were removed. One month after this second operation, the rats from the two groups were again coupled with fertile male rats. In a second experiment, female rats underwent bilateral placement of a 10.0-mm 3-DRUID (n=5) via an abdominal incision or a two-dimensional IUD (2-DIUD, n=20) and mated 1 month after surgery. The single-pipeline IUD was placed in 10 rats, while the enfolded-pipeline IUD was placed in 10 different rats.

RESULTS

In the first experiment, none of the females in the experimental 3-DRIUD group became pregnant (0/30, 0%) after 3 months, compared to 28/30 (93.3%, p<.0001) rats in the control group. After the 3-DRIUDs were removed from the experimental group after 3 months, 27/30 (90%) became pregnant, compared with 29/30 (97%, p>.05). The litter size (mean±SD) did not differ between groups (10.9±1.5 3-DRUID, 11.2±1.1 control, p>.05). In the second experiment, five rats had a 10.0-mm 3-DRUID (which was one third the length of one uterine horn) inserted into the bilateral uterine horns, and three of the five rats became pregnant. All 20 rats were pregnant 1 month after the insertion of the 2-DIUD. Thus, the contraceptive rate for the 2-DIUD group was 0.

CONCLUSIONS

The primary contraceptive mechanism effect of the new 3-DRIUD in rodents appears to be a result of occupying physical space in the uterus.

Migration of intrauterine devices: radiologic findings and implications for patient care

Intrauterine devices (IUDs) are a commonly used form of contraception worldwide. However, migration of the IUD from its normal position in the uterine fundus is a frequently encountered complication, varying from uterine expulsion to displacement into the endometrial canal to uterine perforation. Different sites of IUD translocation vary in terms of their clinical significance and subsequent management, and the urgency of communicating IUD migration to the clinician is likewise variable. Expulsion or intrauterine displacement of the IUD leads to decreased contraceptive efficacy and should be clearly communicated, since it warrants IUD replacement to prevent unplanned pregnancy. Embedment of the IUD into the myometrium can usually be managed in the outpatient clinical setting but occasionally requires hysteroscopic removal. Complete uterine perforation, in which the IUD is partially or completely within the peritoneal cavity, requires surgical management, and timely and direct communication with the clinician is essential in such cases. Careful evaluation for intraabdominal complications is also important, since they may warrant urgent or emergent surgical intervention. The radiologist plays an important role in the diagnosis of IUD migration and should be familiar with its appearance at multiple imaging modalities.