Misplaced I.U.C.D (Intra uterine contraceptive device) Localization of Misplaced I.U.C.D (Intra uterine contraceptive device) (Do you need help to localize it ?)

Dr.Narayan M.Patel Presented by M.D.,D.G.O. FICS Emeritus Professor Muni. Medical college Postal address-- Mahalaxmi Institute of medical teaching, 3, Shantiniketan park, Naranpura, Nr.Sardar Patel Colony, AHMEDABAD- 380 014 (Gujarat) INDIA T.N.(079) 27682572, Mobile;- 98252 95530 E mail:- nmpatel1932@wilnetonline.net

Grafenberg ring was quite a popular I. U. C Grafenberg ring was quite a popular I.U.C.D around year 1950-60-70 in my state of Gujarat (INDIA),where I am practicing and we have seen quite many complications due to G.B. Ring, Lippes loop & copper-T types of I.U.C.D.s This presentation is from my documented cases of that time. I strongly advocate still H.S.G. the best & cheapest, solution for localization of misplaced IUCD, even though T.V.S. and hysteroscopy are new modalities available at present. They were not available at that time.

Intra uterine position of Grafenberg ring confirmed by putting an uterine sound. Both are in the same line & together. Next slide shows same case after H.S.G.

Intra uterine position of Grafenberg ring confirmed by doing H.S.G. G.B. ring is partly seen at lower part of UT. as shown by arrow. Both G.B.Ring and contrast are radio opaque.

X-ray showing Grafenburg ring in the pelvis Is it intra or extra uterine? This Pt. had G.B. ring since 10 years. X-ray pelvis confirmed, presence of G.B. ring.

Extra uterine Grafenberg ring This patient had grafenberg ring put in, before 10 years. An attempt to remove by other was unsuccesful. H.S.G. was done to confirm its position. Extra uterine position of the Graffnberg ring was confirmed. Mini laparotomy was performed to remove it.

H.S.G shows extra uterine position of Grafenberg ring G.B. ring. H.S.G shows extra uterine position of Grafenberg ring

Broken G.B.ring. inserted before 12 years This Pt. went to an orthopedic surgeon for backache. X-ray shows 12 year old broken G.B.Ring, H.S.G. was done before attempting removal. View next slide.

Extra Uterine broken IUCD at H.S.G H.S.G. showing the extra uterine broken I.U.C.D. It was removed by mini laparotomy

The reasons of its rejection were:-- Lippes loop was introduced in India with lot of enthusiasm and publicity 1964-65. The reasons of its rejection were:-- (1)It was supplied in unsterile conditions and had to be sterilized by immersing in antiseptic solution before insertion. (2)Even general practitioners and paramedical staff were allowed to put Lippes loop Many complications like perforation of uterus, infection and failure were reported It was rejected by people in just few years.

This picture shows position of Lippes loop in uterus. Pl. note that each spiral is in contact with other spiral. Lippes loop when expanded means extra Uterine.

Lippes loop and uterine sound are in same line Slide shows intra uterine Lippes loop confirmed by inserting uterine sound and taking x-ray

Intra uterine position of Lippes Loop confirmed by injecting contrast medium in uterine cavity. Lippes loop faintly visible due to contrast, as both are radio opaque

Extra uterine Lippes loop. Lippes loop extra uterine. See the expanded spirals indicating it being extra uterine lying free in pelvis,(indicated by arrows)

Extra uterine Lippes loop in pelvis X- ray after inserting uterine sound in the uterine cavity. Ut. is at higher level. Lippies loop at lower position lying free in pelvis

HSG in the same Pt. Ut.Is seen at higher level. Loop seen in contrast Lippes loop is near the CX . Because of Contrast, loop is seen only partly as shown by arrow pointer HSG in the same Pt. Ut.Is seen at higher level. Loop seen in contrast

Expanded loops indicating X-ray pelvis showing Lippes loop in right iliac fossa Expanded loops indicating extra uterine position, as shown by arrow

Lippes loop removed from abdominal cavity. Pl. note portion of omentum attached to it.

Slide showing Lippes loop with a piece of omentum. Removed by laparotomy

Copper –T embedded in omentum. Removed by mini laparotomy

Very popular world wide. Copper-T( T cu-200) First medicated I.U.C.D Copper wire of 200 Sq. mm surface area wrapped on the stem Of I.U.C.D. Developed by Howard Tatum (USA) & Taime Zipper (Chile) in 1972. It has 2 tails. Very popular world wide.

Omentum has been rightly described as abdominal police man, in books. While searching for copper T or Lippes loop, by laparoscopy or laparotomy, one should trace the omentum and there you will find IUCD, entangled among omentum. On few occasions we failed to locate IUCD by laparoscopy and had to do laparotomy. We have learned a lesson, not to search for lost IUCD, unless we localize it first, with HSG. Now a days ultrasound imaging by Trans vaginal sonography, & Hysteroscopy may help.

H.S.G. showing Copper T extra uterine Arrow shows copper T. It was removed by Laparoscopy

Copper T was removed in this case by Laparoscopy. T is seen being held in the single puncture Laparocator

Copper T entangled in omentum. Removed by laparotomy

Is it Intra Uterine or extra uterine? Think. See next slide Copper T seen in pelvis at x-ray. Is it in or out of uterus? See next slide

H.S.G. done in same pt. Part of copper T is seen out of uterine cavity. Pt. was a multi parous & keen for hysterectomy. See the specimen in next slide.

You see Copper T embedded in the myometrium Arrow pointer shows a part rt. arm of Copper T, coming out of myometrium on rt. side of uterus.

Copper T as seen after removal by Mini lap. Copper T threads were broken in an attempt to remove it vaginally.

this Golden art should not be declared Conclusion:-- Missing IUCD threads is a common problem among gynecologist in day to day practice. I advice locating it, either by X-ray or H.S.G. or both, if required, before attempting its removal. Although Trans vaginal sonography and Hysteroscopy are easily available now, but they may fail to confirm extra ut. displacement. The art of doing H.S.G. is fading but this Golden art should not be declared Obsolete.

Thank You