1. 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 ?)

2. 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 (Gujarat) INDIA
T.N.(079) , Mobile;
E mail:-

3. Grafenberg ring was quite a popular I. U. C
Grafenberg ring was quite a popular I.U.C.D around year 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.

4. 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.

5. 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.

6. 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.

7. 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.

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

9. 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.

10. 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

11. The reasons of its rejection were:--
Lippes loop was introduced in India
with lot of enthusiasm and publicity
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.

12. 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.

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

14. 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

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

16. 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

17. 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

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

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

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

21. Copper –T
embedded in
omentum.
Removed by
mini
laparotomy

22. 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.

23. 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.

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

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

26. Copper T entangled in omentum. Removed by laparotomy

27. 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

28. 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.

29. 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.

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

31. 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.

32. Thank You