An intrauterine device (IUD) is a small, T-shaped contraceptive device placed inside the uterus for long-term contraception. This highly effective and reversible method of birth control is popular globally. Uterine perforation is a rare complication where the IUD moves partially or completely through the wall of the uterus. This occurs in approximately 1 to 2 out of every 1,000 insertions. Immediate consultation with a healthcare provider is necessary if there is any concern about the device’s position.
Recognizing the Signs of Perforation
The most common sign prompting investigation for perforation is the inability to feel the IUD’s retrieval strings. These strings hang a few centimeters out of the cervix, allowing the user to perform a self-check to confirm the device is in place. If the strings feel noticeably shorter, are completely missing, or are not palpable, the IUD may have been expelled or moved into the uterine wall or abdominal cavity.
Severe, persistent pain in the lower abdomen or pelvis often signals a problem. This discomfort is typically more intense than normal menstrual cramps, can be localized to one side, and may not subside with typical pain relief methods. While some cramping occurs after IUD insertion, pain that begins much later or suddenly worsens should be evaluated immediately.
Abnormal uterine bleeding, such as spotting between periods or heavy flow that deviates significantly from the established pattern, can also be a warning sign. If the IUD has migrated and is no longer providing effective contraception, an unintended pregnancy may occur. In rare cases where the device migrates far into the abdominal cavity, signs of infection, such as fever, chills, or unexplained nausea, might develop.
The combination of pain and missing strings requires prompt medical attention. Although missing strings often result from the threads retracting into the cervical canal, the potential for device malposition or perforation warrants professional assessment.
Medical Confirmation of Uterine Perforation
When symptoms suggest a misplaced IUD, the medical workup begins with a physical examination, including a pelvic exam to inspect the cervix for the strings. If the strings are not visible, the next step is usually a transvaginal ultrasound. This imaging technique uses sound waves to create an image of the pelvic organs and determine if the IUD is still located within the uterine cavity.
If the ultrasound confirms the IUD is extrauterine (not inside the uterus), a perforation has occurred. The healthcare provider will typically order a plain abdominal X-ray to pinpoint the exact location of the device within the pelvic or abdominal area. Most modern IUDs contain material visible on X-ray, allowing for clear localization.
The X-ray is useful for distinguishing between an IUD that has been spontaneously expelled and one that has migrated into the abdominal cavity. For more complex cases or when there is concern about injury to internal organs like the bowel or bladder, advanced imaging such as a Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI) may be utilized. These scans provide detailed cross-sectional images showing the IUD’s proximity to surrounding structures.
The comprehensive imaging process confirms the diagnosis of uterine perforation and provides the surgeon with a precise map for removal. Localization is important because the IUD may be embedded in the myometrium (partial perforation) or be free-floating in the peritoneal cavity (complete perforation). The definitive location guides the choice of the safest and least invasive removal procedure.
Treatment and Recovery After Diagnosis
Once uterine perforation is confirmed and the IUD is located, the device must be removed to prevent complications like infection, adhesion formation, or damage to abdominal organs. The method of removal depends directly on the degree of perforation and the device’s final resting place. If the IUD is only partially embedded in the uterine wall but still accessible from the cervix, a hysteroscopy may be performed.
Hysteroscopy is a minimally invasive procedure where a thin, lighted telescope is inserted through the cervix into the uterus. This allows the provider to visualize the device and remove it using specialized instruments. If the IUD has completely perforated the uterine wall and migrated into the abdominal cavity, a surgical procedure called laparoscopy is generally required.
Laparoscopy involves making a few small incisions in the abdomen, through which a camera and surgical instruments are inserted to locate and retrieve the IUD. This approach is preferred due to its minimally invasive nature, resulting in less pain, smaller scars, and a faster recovery compared to traditional open surgery (laparotomy). Laparotomy is reserved for extremely complicated cases, such as those involving significant bowel injury or when the device is difficult to access.
Following the removal procedure, recovery time varies, but most patients return to normal activities relatively quickly after laparoscopy. Monitoring for post-operative complications, such as internal bleeding or signs of infection, is a standard part of the recovery process. Patients can discuss options for future contraception, including a new IUD insertion, after the uterus has had several weeks to heal.