The incidence rate is reported at ~2 in 1000 2.
Perforation at the time of insertion may be clinically silent, or cause significant pelvic pain. A late perforation may be asymptomatic, or present with nonspecific lower abdominal pain. In all cases, the visible 'strings' will be missing at direct inspection. Peritoneal sepsis is a rare presentation.
IUD perforation ranges from embedment in the myometrium to complete transuterine perforation with migration of the IUD into the peritoneal cavity.6
Embedment refers to penetration of IUD into the endometrium or myometrium without extension through the serosa.
Intraabdominal migration occurs when the IUD is freely floating in the abdomen or pelvis encased in adhesions or adherent to bowel or omentum. Adhesions can lead to infertility, chronic pain, and intestinal obstruction.6
- atrophic / postpartum uterus
- uterine structural abnormalities 5
- large fibroids 5
Ultrasound is the recommended first line investigation 3 in all women in whom the ‘strings’ cannot be visualised. Orthogonal radiographs are often the second line. CT can be used in complex cases where visceral involvement or surgical difficulty is suspected.
- an IUCD lying lateral to midline may suggest the diagnosis
- may have a normal endometrial cavity on ultrasound
- hyperechoic linear structure lying outside the uterus
Treatment and prognosis
Treatment depends on the degree of perforation and whether there are any complications (such as peritoneal sepsis or intestinal obstruction).
- 1. Heinberg EM, McCoy TW, Pasic R. The perforated intrauterine device: endoscopic retrieval. JSLS. 2008;12 (1): 97-100. Free text at pubmed - Pubmed citation
- 2. Harrison-Woolrych M, Ashton J, Coulter D. Uterine perforation on intrauterine device insertion: is the incidence higher than previously reported?. Contraception. 2003;67 (1): 53-6. Pubmed citation
- 3. Caliskan E, Oztürk N, Dilbaz BO et-al. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care. 2004;8 (3): 150-5. Pubmed citation
- 4. Zakin D, Stern WZ, Rosenblatt R. Complete and partial uterine perforation and embedding following insertion of intrauterine devices. I. Classification, complications, mechanism, incidence, and missing string. Obstet Gynecol Surv. 1981;36 (7): 335-53. - Pubmed citation
- 5. Amirbekian S, Hooley RJ. Ultrasound Evaluation of Pelvic Pain. Radiol. Clin. North Am. 2014;52 (6): 1215-1235. doi:10.1016/j.rcl.2014.07.008 - Pubmed citation
- 6. Boortz HE, Margolis DJ, Ragavendra N et-al. Migration of intrauterine devices: radiologic findings and implications for patient care. Radiographics. 2012;32 (2): 335-52. doi:10.1148/rg.322115068 - Pubmed citation
Ultrasound - gynaecology
- ultrasound (introduction)
- acute pelvic pain
- chronic pelvic pain
- Mullerian duct anomalies
- ovarian follicle
- ovarian torsion
- pelvic inflammatory disease
- ovarian cysts and masses
- ovarian cyst
- corpus luteum
- haemorrhagic ovarian cyst
- ruptured ovarian cyst
- ovarian epithelial tumours
- granulosa cell tumours of the ovary
- paraovarian cyst
- polycystic ovaries
- ovarian hyperstimulation syndrome
- post-hysterectomy ovary
- fallopian tube