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Introduction
Intrauterine devices (IUDs), particularly the levonorgestrel-releasing intrauterine system (Mirena), are among the most effective forms of reversible contraception, being increasingly utilized for non-contraceptive indications such as menorrhagia(1,2). With over 180 million users worldwide, IUDs offer long-term protection, with high satisfaction rates and low complication profiles. Despite the generally safe and uncomplicated nature of IUD insertions and removals, certain clinical scenarios can pose significant challenges. These include postmenopausal status, nulliparity, previous cervical procedures and uterine anomalies, all of which may contribute to difficulty in locating or extracting the device. The absence of visible IUD threads further complicates the process, often necessitating imaging or more invasive techniques for successful removal. While several strategies exist for managing difficult intrauterine device removals – such as cervical ripening agents, ultrasound guidance and hysteroscopy –, the entrapment of the removal instrument itself is a rare but notable complication. This situation requires careful clinical judgment to avoid iatrogenic injury, while ensuring complete removal of both the device and the entrapped tool.
We present a unique case involving the entrapment of an IUD removing hook during Mirena retrieval. The case illustrates the importance of recognizing early signs of resistance, employing appropriate pharmacologic and procedural interventions, and maintaining a structured, minimally invasive approach to ensure optimal outcomes.
Case report
A 45-year-old multiparous woman presented to the outpatient gynecology clinic for elective removal of a Mirena intrauterine device that had been inserted six years earlier for the management of idiopathic menorrhagia. The patient reported no current symptoms, and she had no history of pelvic inflammatory disease, prior uterine surgery or cervical dysplasia. She had regular menstrual cycles, and she was not using any other form of hormonal contraception. On speculum examination, the cervix appeared normal, but no IUD threads were visible. A bimanual exam revealed a normal-sized anteverted uterus with no tenderness or adnexal masses. Given the absence of visible threads, a transvaginal ultrasound was performed to confirm the presence and position of the Mirena. Ultrasound demonstrated the device located in the mid-cavity of the uterus, with no evidence of displacement or perforation. Under aseptic conditions and with informed consent, an attempt was made to remove the Mirena using a standard IUD removing hook. The hook was introduced through the cervix into the uterine cavity and carefully maneuvered to engage the stem of the IUD. However, upon attempting to withdraw the hook, firm resistance was encountered. Multiple gentle attempts at repositioning and rotating the hook failed to release the device or allow withdrawal of the instrument. Given concerns about possible cervical stenosis or uterine spasm, the procedure was temporarily halted to avoid causing trauma. The patient remained asymptomatic, with no signs of distress or pain beyond mild discomfort. A repeat transvaginal ultrasound was performed to assess the position of both the IUD and the hook. The imaging showed the hook adjacent to the IUD stem, without evidence of uterine perforation or displacement of the device. After discussing the situation with the patient, it was decided to administer 200 mcg of vaginal misoprostol to promote cervical softening and dilation. The patient was advised to return four hours later for the continuation of the procedure. Upon return, the cervix was noted to be softer and slightly more dilated on physical examination. Under local paracervical block, the hook was gently rotated and withdrawn without resistance. Subsequently, a hysteroscope was introduced into the uterine cavity under ultrasound guidance. Using grasping forceps, the Mirena was successfully removed, without complications. The patient tolerated the procedure well, and she was discharged home with instructions to monitor for any signs of infection or abnormal bleeding. The follow-up one week later confirmed no adverse events.
Discussion
Difficult IUD removals are relatively common in clinical practice, particularly in postmenopausal women, nulliparas, or those with prior cervical surgeries such as conization or loop electrosurgical excision procedure (LEEP)(3). These populations often exhibit cervical stenosis or reduced cervical elasticity, making access to the uterine cavity challenging. Additionally, factors such as retroverted uteri, embedded IUD arms, or fibroid distortion can further complicate the procedure. Instrument entrapment during IUD removal is an infrequent but important complication that has received limited attention in the literature(4). To our knowledge, only a handful of cases have been reported where the removal hook became lodged during the procedure. Possible mechanisms include improper angulation of the hook, cervical narrowing creating a mechanical barrier, or unintentional engagement of the hook with endometrial tissue rather than the IUD itself.
In this case, several key principles guided the successful management of the complication:
1. Recognition of resistance and avoidance of force
Early recognition of resistance is critical. Continuing to apply force risks cervical laceration, endometrial damage, or even uterine perforation. Halting the procedure allowed time for reassessment and planning without compromising patient safety.
2. Use of imaging for accurate assessment
Transvaginal ultrasound played a pivotal role in confirming the location of both the IUD and the hook, ruling out perforation, and guiding subsequent steps. Real-time imaging helps clinicians visualize the anatomy and avoid blind manipulations.
3. Cervical priming with misoprostol
Misoprostol, a synthetic prostaglandin E1 analog, is widely used for cervical ripening in various gynecologic settings, including IUD removal. Its effectiveness in softening and dilating the cervix has been well documented, especially in postmenopausal women or in those with stenotic cervices. In this case, the administration of 200 mcg vaginally led to sufficient cervical changes that facilitated the safe removal of the hook and IUD.
4. Stepwise escalation of techniques
Rather than resorting immediately to operative hysteroscopy or general anesthesia, a gradual escalation from basic to advanced techniques minimized procedural burden and preserved fertility potential(4). The use of local anesthesia and targeted ultrasound-guided intervention avoided unnecessary exposure to systemic sedation.
5. The role of hysteroscopy
Hysteroscopy provides the direct visualization of the uterine cavity and allows for precise manipulation of instruments. In cases where standard removal methods fail, hysteroscopy is considered the gold standard for safe and effective IUD retrieval(5). Here, it enabled the secure engagement and removal of the Mirena once the hook was dislodged.
Clinical implications and recommendations
This case underscores several important clinical takeaways:
Clinicians should maintain a high index of suspicion for cervical stenosis in patients with absent IUD threads or difficulty accessing the uterine cavity.
Early use of cervical ripening agents like misoprostol can significantly improve the procedural success.
Imaging modalities, particularly transvaginal ultrasound, are essential tools in assessing IUD position and guiding interventions.
Instrument entrapment, although rare, should be recognized as a distinct complication requiring careful handling.
A stepwise approach – starting with conservative measures and escalating only as needed – is safer and more cost-effective than immediate surgical intervention.
Finally, clinician experience and familiarity with advanced removal techniques play a vital role in managing these cases effectively. Training programs should emphasize the recognition and management of rare complications such as instrument entrapment to ensure preparedness in clinical practice.
Data availability. All data supporting the findings are included within the article. No additional source data are required.
Competing interests. The authors declare no competing interests.
Acknowledgments. We thank the patient for her cooperation and the staff of the gynecology unit for their support.
Corresponding author: Smit Bharat Solanki E-mail: drsmitbharat@gmail.com
Conflict of interest: none declared.
Financial support: none declared.
This work is permanently accessible online free of charge and published under the CC-BY licence.
