When IUP meets IUD

Abstract

One of the great opportunities to move beyond routine practice comes when patients have medical problems that should not have occurred. Despite being one of the most effective and cost-effective methods of contraception, women still can conceive in spite of an intrauterine device (IUD). If excluding expulsion, approximately 0.02% of women using a levonorgestrel IUD and 0.5% of women using a copper IUD will have an intrauterine pregnancy (IUP) in the first year of use (1Heinemann K. Reed S. Moehner S. Minh T.D. Comparative contraceptive effectiveness of levonorgestrel-releasing and copper intrauterine devices: the European Active Surveillance Study for Intrauterine Devices.Contraception. 2015; 91: 280-283Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar). Removal is associated with a 2.7- to 3.2-fold lower risk for spontaneous abortion and a 2.3- to 3.2-fold decrease in risk for preterm delivery (2Brahmi D. Steenland M.W. Renner R.M. Gaffield M.E. Curtis K.M. Pregnancy outcomes with an IUD in situ: a systematic review.Contraception. 2012; 85: 131-139Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar). However, with removal posing risk for trauma to the gestational sac and potential immediate or shortly subsequent pregnancy loss, appropriate technique is essential. In this issue of Fertility and Sterility, Drs. Ari and Barry Sanders (3Sanders A.P. Sanders B. Hysteroscopic removal of intrauterine devices in pregnancy.Fertil Steril. 2018; 110: 1408-1409Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar) efficiently explain how to hysteroscopically remove an IUD in pregnancy. With a clear video, explanation, and labeling of images, clinicians should have a reasonable sense of how to potentially help affected patients. Although informed consent is essential, the rates of spontaneous abortion and preterm delivery are sufficiently high enough that IUD removal would typically be appropriate for patients with a concurrent IUP. If physicians know how to remove IUDs in pregnancy and if benefits frequently outweigh risks, there are still obstacles to patients receiving appropriate care. The first is technological—many gynecologists and reproduction endocrinology and infertility professionals (REIs) use large-caliber hysteroscopes, when minimizing trauma through smaller-caliber equipment may result in less cervical abrasion and uterine irritability. Although smaller instrumentation can affect inflow and distention, in this situation in which cervical dilation is avoided or minimized and inflow is also as low as reasonably achievable, smaller-caliber hysteroscopes may hold an advantage. The next obstacle is experience, in which many obstetrics and gynecology professionals have decreasing operative volume and many REIs have focused on office practice to the point of surgical atrophy. A solution to this would be broader uptake by our field of office hysteroscopy. The video resolution and caliber of office endoscopes have advanced to a point that most physicians can perform office hysteroscopy gently, accurately, and safely. After a single simulation session, even junior residents can perform their first diagnostic office hysteroscopies in an average of less than 6 minutes (4Parry J.P. Riche D. Aldred J. Isaacs J. Lutz E. Butler V. et al.Proximal tubal patency demonstrated through air infusion during flexible office hysteroscopy is predictive of whole tubal patency.J Minim Invasive Gynecol. 2017; 24: 646-652Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar). The more hysteroscopic skill is developed in the office, the more facile reproductive surgeons will be when exploring operative hysteroscopy in the office or a surgical suite. Although other barriers remain, malpractice concerns also are one of the primary obstacles to access to care for women with IUDs and an IUP. Despite REIs arguably being first-trimester specialists, many do not want to perform surgeries that pose risk of immediate miscarriage for fear of being sued. Even without the medicolegal climate evolving to a healthier appreciation for the balance of risk and benefit, opportunities exist for better informed consent. These include enhanced systematic communication through use of video and team members, more thorough documentation, and heeding input from counsel regarding broader aspects of the informed consent process. These broader issues do not detract from the quality of the Sanders' video article (3Sanders A.P. Sanders B. Hysteroscopic removal of intrauterine devices in pregnancy.Fertil Steril. 2018; 110: 1408-1409Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar). Clear and succinct education regarding surgical technique are an essential first step to delivering quality care. However, for REIs and gynecologists to achieve their full potential in helping patients, we need to appropriately leverage technology, enhance opportunities for surgical skill, and strive for medicolegal balance. Our patients deserve nothing less. Hysteroscopic removal of intrauterine devices in pregnancyFertility and SterilityVol. 110Issue 7PreviewTo introduce and demonstrate an approach to the hysteroscopic removal of retained intrauterine devices (IUDs) in pregnancy. Pregnancy risks associated with retained IUDs are also discussed, specifically spontaneous abortion and preterm labor. Full-Text PDF