Entrapment of the intrauterine device removing hook during difficult Mirena removal: a case report

Mirena (levonorgestrel-releasing intrauterine system) is a widely used long-acting reversible contraceptive known for its efficacy and safety in both contraception and ma­nage­ment of heavy menstrual bleeding. While routine re­mo­vals are typically straightforward, various anatomical and technical challenges can complicate the procedure. We present a rare case of mechanical entrapment of an in­tra­ute­rine device (IUD) removing hook during attempted re­trie­val of a Mirena device in a 45-year-old multiparous wo­man. The patient presented for elective Mirena removal after six years of use. On examination, the IUD threads were not visible, and transvaginal ultrasound confirmed that the device was correctly positioned within the uterine ca­vi­ty. During attempted removal using a standard IUD hook, resistance was encountered, and the instrument be­came entrapped within the cervical canal. After the initial at­tempts at gentle manipulation failed, the procedure was paused to reassess the situation. Transvaginal ultrasound ruled out perforation, but suggested cervical stenosis as a likely contributing factor. To facilitate cervical dilation, 200 mcg of misoprostol were administered vaginally. Four hours later, with the cervix softened and partially dilated, the hook was successfully removed under local anesthesia. Sub­sequently, the Mirena was retrieved using hysteroscopic gras­pers under ultrasound guidance without complications. This case highlights the importance of a calm, stepwise ap­proach when managing difficult IUD removals. It also em­pha­sizes the utility of misoprostol for cervical priming and the role of ultrasound and hysteroscopy in safely na­vi­gating complex cases. Instrument entrapment is a rare but important complication that clinicians should be aware of, especially in patients with suspected cervical stenosis or prior uterine surgery. Recognizing early signs of resistance and avoiding forceful extraction are crucial to prevent iatrogenic trauma.