The intrauterine device is a safe contraceptive method, with a 99% of effectiveness and widely used worldwide [4 Nonetheless, one of its more serious complications is the uterine perforation that occurs with an incidence of 1.6 to 2.1 per 1000 insertions . Perforations are reported to be mostly located in the myometrium and the greater omentum, with a frequency of 21%. In the second place, the colon sigmoid with a frequency of 17% and the left uterosacral ligament and bladder with a 10% frequency . Risk factors for perforation include IUD insertion during lactation, first time using the IUD, insertion during the first 6 months of postpartum, and anatomic abnormalities, such as cervical stenosis and a retroverted uterus [4, 5].
In terms of its clinical presentation, up to 85% of the perforation cases may be asymptomatic . However, a 5-year follow-up research carried out in Europe by Barnet et al. found that after 12 months of the IUD insertion, the most frequent complication was abdominal pain and vaginal bleeding in 50% of the cases. On the other hand, patients diagnosed with perforation after 12 months of the insertion were asymptomatic in 50% of the cases, being only diagnosed by accident after a routine checkup of the position of the device, and 25% of the diagnosed cases presented bleeding and abdominal pain [3In this case, our patient was asymptomatic for two years; she eventually attended consultation for pelvic pain and dysmenorrhea and through the transvaginal ultrasound, we observed the fragmented and intramyometrial IUD, thus, we decided to perform a hysteroscopy to retrieve the device.
According to the WHO guidelines, a fragmented or migrated IUD must be removed as soon as possible, regardless its location . The most frequent surgical procedure is laparoscopy, which is also considered first treatment option. However, its success rate varies between 44% and 100%, depending on the presented complication and the surgeon’s expertise. Up to 25% may have the necessity of conversion to laparotomy [3, 6, 8].
In our case, we were not able to retrieve the device through hysteroscopy; for that reason, we had to perform a laparoscopy tha5t revealed a colouterine fistula (Figure 1). We performed removal of the intraperitoneal IUD, we sutured, and we repaired the perforated sigmoid colon (Figure 5). The patient’s 2-day postoperative course had no early or latter complications. The advantages of performing this technique include removal of the device found in the peritoneal cavity, repair through intracorporeal suture, trauma reduction in the affected tissue, pain lessening and reduction of postoperative observation times .