CONTRACEPTION
UNUSUAL UTERINE PERFORATION BY THE COPPER-T INTRAUTERINE DEVICE AND REMOVAL BY LAPAROSCOPY
Ji_irgen R. Strecker, M.D. Herbert Kraus, M.D. Department of Obstetrics and Gynecology Universitats-Frauenklinik,Ulm Federal Republic of Germany
ABSTRACT
A case report on the perforation of the uterine corpus by a Copper-T intrauterine contraceptive device (IUD) followed by pregnancy is presented. The change of the Cu-T position inside the myometrium over 2 months of observationis described. The device was extracted from the perforation site by laparoscopy. It is suggested to thicken the tips of the Cu-T in order to diminish the perforation rate.
Revised Version of the Paper Presented at the Oberrheinische Gesellschaft fur Geburtshilfe und GynZkologie on May 2, 1975
Accepted for publicationOctober 31, 1975
JANUARY
1976 VOL. 13 NO. 1
47
CONTRACEPTION
The Copper-T has gained wide acceptance as an intrauterine contraceptive device (IUD) with good results. The insertion is easy,compared with earlier developed IUDs. Side effects and complications seem to occur in fewer cases. Until now there have been described only a few cases of cervical perforation (2, 3, 4, 6) and one case of uterine perforation (1) by the Cu-T IUD in the literature. The following is a report of an unusual case of a Cu-T IUD that perforated the uterine corpus, its localisation and extraction by laparoscopy. Case
Report
E.L., a 31-year-old gravida 3, para 3 had normal spontaneous deliveries, the last one was 4 years ago. A Cu-T 200 was inserted by a gynecologist in his office in July 1974. The first days after insertion,thepatient suffered from lower abdominal pain and increased vaginal bleeding. The complaints soon disappeared. The patient had regular menstrual periods in August and September, followed by a secondary amenorrhea. After the diagnosis of early pregnancy, the patient went to a foreign country for elective abortion in the 8th week of pregnancy. The attempt to remove the IUD by curettage failed, the thread was torn off. Three weeks later, in December 1974, the gynecologist who had inserted the Cu-T tried to again localize and remove it. Pelvic x-ray film indicated that the IUD was within the mid-pelvis. However, the device a peared to be displaced and to have rotated (Fig. 1P . A repeated D & C was again not able to detect and remove the Cu-T.
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JANUARY
1976 VOL. 13 NO. 1
CONTRACEPTION
Figure 1. Pelvic x-ray film indicates that Cu-T IUD is displaced.
Twelve weeks after termination of pregnancy,the patient was transferred to our clinic for removal of the device and sterilisation of the patient. The first diagnostic procedure - a hysteroscopy revealed a normal empty uterine cavity. No device could be seen. Since the patient had not given consent to further operation, an x-ray of the pelvis was taken with a sound lying in the endometrial cavity for additional localisation. Fig. 2 and 3 indicate the IUD in the right anterior wall of the uterus; the tip of the copper-wound shaft close to the cavity. The movements carried out with the intrauterine sound were followed directly by the device.
JANUARY 1976 VOL. 13 NO. 1
49
CONTRACEPTION
Figure 2. Rotation of IUD 3 months later.
Figure 3. Lateral x-ray of the pelvis shows the copper-wound shaft close to the intrauterine sound.
The following laparoscopy proved our diagnosis: The shaft of the Cu-T was stuck in the anterior wall of the myometrium. One arm of the device had partially perforated the abdominal cavity but was still covered by the peritoneum (Fig. 4 and 5). The site of perforation was close to the right uterine artery and the urinary bladder (Fig. 6).
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1976
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CONTRACEPTION
Figure 4 and 5. One arm of the device had perforated the anterior wall of the uterus.
Figure 6. The site of perforation was close to the right uterine artery and still covered by peritoneum.
The peritoneum was opened with a small forceps, the arm of the Cu-T grasped, and the entire device extracted through the sheath of the laparoscope. Minimal venous bleeding from the site of extraction ceased spontaneously. Both tubes were then coagulated for sterilization. The following day the patient was discharged from the clinic in good condition.
JANUARY 1976 VOL. 13 NO. 1
51
CONTRACEPTION
Discussion As far as we are aware, only 4 reports with 10 cases of cervical perforations and one case of uterine perforation (1) of Cu-T IUDs have so far been published. According to this literature the incidence of cervical perforation is approximately I:1200 insertions. Four perforations in 1220 insertions (2), 3 in 1050 insertions (3), and 2 in 4000 insertions (4). Timonen and associates observed no perforation in 4,109 insertions (5). It is remarkable that only one case of perforation through the uterine corpus is reported in the literature and that most of the cervical perforations were secondary and silent (2, 3, 4, 6). In all cases described the IUD perforated the cervical canal with one of the 3 sharp tips of the T, usually with the copper-wound shaft of the device. The interval between insertion and detection of perforation was 1 - 6 months. In our case, the Cu-T IUD not only perforated the anterior wall of the uterus, but also penetrated the myometrium performing a rotation over a period of 3 months(Fig. l-3). It is not certain whether a part of the IUD was inserted into the myometrium or if the correctly placed device penetrated the uterine wall, provoked by uterine contractions. The contractions had probably also caused the change of the Cu-T IUD position from December '74 until Februar '75. The relatively sharp points of the device seem to encourage penetration and perforation of the uterine wall. It is, therefore, suggested to search for a better shape of the Cu-T, possibly with thickened and dull ends.
52
JANUARY
1976
VOL.
13 NO. 1
CONTRACEPTION
References 1. Koetsawang, S. Laparoscopic removal of a perforated Copper-T IUD: A case report. Contraception 7: 327-332, 1973. 2. Rienprayura, D., Phaosavasdi, S.$ Somboonsuk, A. Cervical perforation by the Copper-T intrauterine device. Contraception 7: 515-521, 1973. 3. Cederqvist, L.L. and Fuchs, F. Cervical perforation by the Copper-T intrauterine contraceptive device. Am. J. Obstet. Gynecol. 119:854, 1974. 4. Lehfeldt, H. and Wan, L.S. Unusual uterine perforation with a new intrauterine device. Obstet. Gynec. 37:826, 1971. 5. Timonen, H., Toivonen, J., and Luukkainen, T. Use-effectiveness of the Copper-T 300 during the first year. Am. J. Obstet. Gynec. 120:466, 1974. 6. Baur, S., Baltzer. J., and Eigler, U. Zervikale Perforation unu intrauterine Graviditat bei liegendem Kupfer-T. Geburtsh. u. Frauenheilk. 35:298, 1975.
JANUARY
1976 VOL. 13 NO. 1
53
UNUSUAL UTERINE PERFORATION BY THE COPPER-T INTRAUTERINE DEVICE AND REMOVAL BY LAPAROSCOPY
Ji_irgen R. Strecker, M.D. Herbert Kraus, M.D. Department of Obstetrics and Gynecology Universitats-Frauenklinik,Ulm Federal Republic of Germany
ABSTRACT
A case report on the perforation of the uterine corpus by a Copper-T intrauterine contraceptive device (IUD) followed by pregnancy is presented. The change of the Cu-T position inside the myometrium over 2 months of observationis described. The device was extracted from the perforation site by laparoscopy. It is suggested to thicken the tips of the Cu-T in order to diminish the perforation rate.
Revised Version of the Paper Presented at the Oberrheinische Gesellschaft fur Geburtshilfe und GynZkologie on May 2, 1975
Accepted for publicationOctober 31, 1975
JANUARY
1976 VOL. 13 NO. 1
47
CONTRACEPTION
The Copper-T has gained wide acceptance as an intrauterine contraceptive device (IUD) with good results. The insertion is easy,compared with earlier developed IUDs. Side effects and complications seem to occur in fewer cases. Until now there have been described only a few cases of cervical perforation (2, 3, 4, 6) and one case of uterine perforation (1) by the Cu-T IUD in the literature. The following is a report of an unusual case of a Cu-T IUD that perforated the uterine corpus, its localisation and extraction by laparoscopy. Case
Report
E.L., a 31-year-old gravida 3, para 3 had normal spontaneous deliveries, the last one was 4 years ago. A Cu-T 200 was inserted by a gynecologist in his office in July 1974. The first days after insertion,thepatient suffered from lower abdominal pain and increased vaginal bleeding. The complaints soon disappeared. The patient had regular menstrual periods in August and September, followed by a secondary amenorrhea. After the diagnosis of early pregnancy, the patient went to a foreign country for elective abortion in the 8th week of pregnancy. The attempt to remove the IUD by curettage failed, the thread was torn off. Three weeks later, in December 1974, the gynecologist who had inserted the Cu-T tried to again localize and remove it. Pelvic x-ray film indicated that the IUD was within the mid-pelvis. However, the device a peared to be displaced and to have rotated (Fig. 1P . A repeated D & C was again not able to detect and remove the Cu-T.
48
JANUARY
1976 VOL. 13 NO. 1
CONTRACEPTION
Figure 1. Pelvic x-ray film indicates that Cu-T IUD is displaced.
Twelve weeks after termination of pregnancy,the patient was transferred to our clinic for removal of the device and sterilisation of the patient. The first diagnostic procedure - a hysteroscopy revealed a normal empty uterine cavity. No device could be seen. Since the patient had not given consent to further operation, an x-ray of the pelvis was taken with a sound lying in the endometrial cavity for additional localisation. Fig. 2 and 3 indicate the IUD in the right anterior wall of the uterus; the tip of the copper-wound shaft close to the cavity. The movements carried out with the intrauterine sound were followed directly by the device.
JANUARY 1976 VOL. 13 NO. 1
49
CONTRACEPTION
Figure 2. Rotation of IUD 3 months later.
Figure 3. Lateral x-ray of the pelvis shows the copper-wound shaft close to the intrauterine sound.
The following laparoscopy proved our diagnosis: The shaft of the Cu-T was stuck in the anterior wall of the myometrium. One arm of the device had partially perforated the abdominal cavity but was still covered by the peritoneum (Fig. 4 and 5). The site of perforation was close to the right uterine artery and the urinary bladder (Fig. 6).
50
JANUARY
1976
VOL.
13 NO. 1
CONTRACEPTION
Figure 4 and 5. One arm of the device had perforated the anterior wall of the uterus.
Figure 6. The site of perforation was close to the right uterine artery and still covered by peritoneum.
The peritoneum was opened with a small forceps, the arm of the Cu-T grasped, and the entire device extracted through the sheath of the laparoscope. Minimal venous bleeding from the site of extraction ceased spontaneously. Both tubes were then coagulated for sterilization. The following day the patient was discharged from the clinic in good condition.
JANUARY 1976 VOL. 13 NO. 1
51
CONTRACEPTION
Discussion As far as we are aware, only 4 reports with 10 cases of cervical perforations and one case of uterine perforation (1) of Cu-T IUDs have so far been published. According to this literature the incidence of cervical perforation is approximately I:1200 insertions. Four perforations in 1220 insertions (2), 3 in 1050 insertions (3), and 2 in 4000 insertions (4). Timonen and associates observed no perforation in 4,109 insertions (5). It is remarkable that only one case of perforation through the uterine corpus is reported in the literature and that most of the cervical perforations were secondary and silent (2, 3, 4, 6). In all cases described the IUD perforated the cervical canal with one of the 3 sharp tips of the T, usually with the copper-wound shaft of the device. The interval between insertion and detection of perforation was 1 - 6 months. In our case, the Cu-T IUD not only perforated the anterior wall of the uterus, but also penetrated the myometrium performing a rotation over a period of 3 months(Fig. l-3). It is not certain whether a part of the IUD was inserted into the myometrium or if the correctly placed device penetrated the uterine wall, provoked by uterine contractions. The contractions had probably also caused the change of the Cu-T IUD position from December '74 until Februar '75. The relatively sharp points of the device seem to encourage penetration and perforation of the uterine wall. It is, therefore, suggested to search for a better shape of the Cu-T, possibly with thickened and dull ends.
52
JANUARY
1976
VOL.
13 NO. 1
CONTRACEPTION
References 1. Koetsawang, S. Laparoscopic removal of a perforated Copper-T IUD: A case report. Contraception 7: 327-332, 1973. 2. Rienprayura, D., Phaosavasdi, S.$ Somboonsuk, A. Cervical perforation by the Copper-T intrauterine device. Contraception 7: 515-521, 1973. 3. Cederqvist, L.L. and Fuchs, F. Cervical perforation by the Copper-T intrauterine contraceptive device. Am. J. Obstet. Gynecol. 119:854, 1974. 4. Lehfeldt, H. and Wan, L.S. Unusual uterine perforation with a new intrauterine device. Obstet. Gynec. 37:826, 1971. 5. Timonen, H., Toivonen, J., and Luukkainen, T. Use-effectiveness of the Copper-T 300 during the first year. Am. J. Obstet. Gynec. 120:466, 1974. 6. Baur, S., Baltzer. J., and Eigler, U. Zervikale Perforation unu intrauterine Graviditat bei liegendem Kupfer-T. Geburtsh. u. Frauenheilk. 35:298, 1975.
JANUARY
1976 VOL. 13 NO. 1
53
