An intrauterine device (IUD) is a contraceptive device placed in the uterine cavity. It is widely used worldwide as a long-acting contraceptive due to its safety, cost-effectiveness, high efficiency, and reversibility. According to the Fourth International Conference on IUDs, more than 100 million people use IUDs globally, with more than 80 million in China, accounting for approximately 40% of contraceptive use among women of reproductive age (1).

However, in addition to contraceptive failure, IUDs can lead to complications, including ectopic pregnancy, detachment, and uterine incarceration (2, 3). Incarceration is the most common complication, with perforation due to incarceration and the consequences of damage to adjacent organs being potentially more severe; its incidence has been reported to be between 0.2 and 3.6 per 1,000 (3–5). Therefore, for women who choose IUD contraception, how to avoid the occurrence of complications, especially for postmenopausal women, and how to safely remove the IUD while preventing complications such as IUD incarceration due to organ atrophy have become challenging problems in clinical practice. Serious complications related to IUDs and their remedial measures have been reported in the literature (6), but for IUD incarceration, especially in postmenopausal women, employing the least damaging surgical technique to remove the IUD completely and safely is rarely described in detail. Therefore, in this study, we share our surgical experience in removing an incarcerated IUD that reached the serosal surface of the uterus by using hysteroscopy alone to provide new clinical diagnosis and treatment ideas.

A 63-year-old Chinese woman presented with a 12-year history of menopause, 1-0-1-1, spontaneous delivery. She had an IUD placed after an abortion more than 30 years ago. The patient reported having regular menses lasting 3/30 days and no physical examination after menopause. The past surgical history included vaginal delivery and IUD placement after abortion, with no other past medical history. In 2022 and March 2023, she experienced a small amount of unprovoked vaginal bleeding for several days, neither of which was seen by a physician. Over the last 6 months, she had occasional small amounts of reddish vaginal discharge. In January 2024, an ultrasound performed at an outside hospital revealed an incarcerated V-type copper IUD and possible uterine fluid. In March 2024, she came to our hospital. She underwent an ultrasound, which showed a posterior uterus measuring 32 mm in length, 40 mm in width, 28 mm in thickness, with a single layer of endometrium measuring 2.2 mm in thickness, a 6.5 mm in uterine cavity separation, and 22 mm in long diameter of the cervix. The IUD was located in the myometrium of the right anterior wall and appeared to reach the extraserosa on the right side (Figure 1A). No free pelvic effusion was noted. A pelvic computed tomography (CT) scan revealed an incarcerated IUD with margins protruding from the serosal surface (Figure 1B). Gynecological examination revealed the following: cervix atrophy, light, pinpoint appearance of the external orifice; corpus uteri: posterior position, atrophy; and adnexa: negative.

Hysteroscopic exploration was performed first after adequate communication and discussion with the patient, while laparoscopic preparation was also made. Hysteroscopic surgery was conducted under general anesthesia on 1 April 2024. Cervical atrophy and pinpointing of the external orifice were observed during the procedure. A probe was used to explore the uterine cavity under ultrasound monitoring, encountering resistance. After breaking through the resistance, a No. 2 dilator rod was used to explore the middle and posterior positions of the uterus, reaching a depth of 6.5 cm. After dilating to No. 7.5, a small amount of pale brown effusion was released. Hysteroscopy was then performed revealing no obvious IUD shadow in the cervical canal or uterine cavity with maintained pressure at 100 mmHg by inflation instrument (Figure 2A). The endometrium was thin, and local white scar-like adhesions were observed in the right anterior wall of the fundus (Figure 2B). The opening of the right fallopian tube was visible, while the opening of the left fallopian tube was not discernible. Under direct vision, microscissors were employed to cut along the white adhesion band, revealing a faintly visible metal wire (Figure 2C). As the scar-like adhesion band around the IUD was gradually broken from the outside, approximately 1 cm of iron wire and silicone sleeve was exposed. Under direct vision, microforceps and microscissors were used to gradually release the adhesion surrounding the IUD. Microforceps were then used to clamp the IUD. The V-type IUD was slowly pulled and removed (Figure 3). Hysteroscopy again revealed no obvious abnormalities in utero (Figure 4).

Intraoperatively and hysteroscopically, no intrauterine residue was observed. Although the removed IUD was intact, it had a patina on the surface. Postoperatively, we reviewed the plain abdominal film to check for any residue. The plain abdominal film revealed a punctate, slightly high-density shadow approximately 2 mm in length located 5.4 cm above the pubic symphysis in the pelvic cavity (Figure 5). After discussion with the patient, the possibility of residual copper rust was considered, noting that there was no obvious abnormality in utero on hysteroscopy at the end of the surgery. Reoperation might not detect high-density shadows, so the patient was scheduled for outpatient follow-up. The patient consented to publication and agreed to follow-up. Currently, more than 5 months after surgery, the patient has reported no abdominal pain, vaginal bleeding, or other discomfort during follow-up.

Technology developments have led to continuous updates in IUD design, an increasing number of users, and an expanding scope of use (7). However, in postmenopausal women who no longer require contraception, the IUD should be removed to reduce complications from organ atrophy. Compared to premenopausal women, removing IUDs in postmenopausal women is more challenging and significantly increased risks. Therefore, this study shares the surgical experience after IUD incarceration to provide new insights for reducing complications, limiting surgical risk, and minimizing the scope of surgery in clinical practice.

The incarceration of an IUD is influenced by many factors, which are most closely related to the individual, type of IUD, timing of placement, placement process, and duration of placement.

A history of multiple abortions, abnormal uterine location (e.g., severe uterine flexion and congenital malformations), and fibroids can increase the risk of incarceration (3, 8, 9). In addition, IUD incarceration, especially those in the deep myometrium and extrauterine incarceration, is most commonly associated with “V” shaped IUDs (10). In postmenopausal women, IUD incarceration primarily involves “O” shaped IUDs (11). Finally, the timing of placement also matters; insertion during lactation or following induced abortion heightens the risk (12–14). In addition to the above factors, the longer the placement time, the greater the risk of incarceration (10, 11, 15).

In postmenopausal patients, the removal of intrauterine devices is more challenging due to uterine atrophy and the presence of adhesions. Comprehensive preoperative evaluation, patient counseling, and imaging guidance are essential to minimize surgical risks. For incarcerated IUDs, initiating less invasive hysteroscopic techniques while maintaining surgical flexibility is recommended. If necessary, promptly transitioning to laparoscopic or open surgery ensures patient safety. The primary objective is successful removal with minimal trauma, underscored by meticulous planning, precise technique, and adaptability.