Hysteroscopic Management of the Fully Embedded IUD Using Real-Time Intraoperative X-Ray

INTRODUCTION: IUDs are highly effective long-acting reversible contraceptives, valued for their efficacy, ease of use, and suitability for postpartum placement. However, malpositioning can occur, with some studies reporting rates of up to 10.4%. In cases of displacement, the arms of an IUD might become embedded in the uterine wall or even perforate it, potentially embedding in the bowel or other intraperitoneal structures. Symptoms of malposition can include changes in bleeding patterns and pain, although the severity of symptoms varies, and not all patients may be aware of the malposition. If an IUD is confirmed to be embedded in the uterine wall, it may often be removed in the office by grasping the strings with a clamp and applying gentle traction. If removal is difficult with moderate traction or if the strings are not visible, hysteroscopic removal is the next step, which may be performed in the office or the operating room, depending on the complexity. An IUD that is fully embedded in the uterine wall—defined as one that has completely penetrated the myometrium without extending to the serosa—is a rare complication, with an incidence rate of less than 1% of all IUD insertions. In these types of complex cases where IUD location is uncertain, intraoperative imaging may be required. OBJECTIVE: To highlight the utility of real-time intraoperative X-ray to both confirm a fully embedded IUD’s exact location and ensure accurate dissection planes. METHODS: This video will illustrate a case showcasing the use of intraoperative radiographic imaging to guide the dissection and removal of a fully embedded IUD. Additionally, it will discuss the key surgical steps involved in addressing this condition. RESULTS: N/A. CONCLUSIONS: Three key surgical takeaways are essential when removing a fully embedded IUD: 1. Preoperative imaging limitations: Preoperative imaging alone may not always provide sufficient information to determine the optimal surgical approach. 2. Cautious endometrial dissection: Endometrial dissection should be performed with caution to minimize the risk of complications. 3. Timing of IUD replacement: Replacement of the IUD can be done immediately at the patient’s discretion unless significant endometrial resection has occurred, in which case waiting may be advisable. These takeaways emphasize the importance of a careful surgical approach and the use of real-time intraoperative X-ray to confirm the IUD’s precise location and ensure accurate dissection planes, contributing to a more successful IUD removal.