Unsuspected Multiple Intrauterine Contraceptive Devices In An Infertile Woman: A Case Report

摘要

A 36 year old Para 1+2 patient presented for infertility management and was found to have 4 intrauterine contraceptive devices loaded apparently in previous attempts at treating intrauterine adhesions. Ultrasound scan revealed that three of the devices were outside the uterus. The patient had no knowledge she had any device on her and had remained infertile for 15 years. The intrauterine device was removed with a retrieval hook while the intraperitoneal devices were identified and removed at laparotomy. Introduction When a patient presents with infertility, it is unexpected to discover an indwelling intrauterine contraceptive device in situ. However when an interplay of clinical manifestations resulting from intrauterine adhesions is incompetently managed, multiple complications are inevitable. Infertility remains one of the commonest reasons for gynaecological clinic attendance in Sub Saharan Africa and tubo-peritoneal factors have been implicated most frequently. 1 Routine investigations therefore include hysterosalpingography at which uterine pathologies such as fibroids, endometrial synaechia, congenital malformations can also be detected,Severe endometritis following prolonged obstructed labour especially when treated with caesarean section is a probable cause of intrauterine synaechia . 2 , 3 Asherman syndrome presents clinically with infertility, recurrent abortion and menstrual aberration and radiologically, as non or unevenly filled uterine cavity on HSG. 2 , 3 Management involves lysis of the adhesions, preferably hysteroscopically, and mechanical distension of the endometrial cavity with hormonal treatment to facilitate endometrial regrowth and optimisation of fertility outcome. It might require multiple procedures to achieve satisfactory anatomical results. 2 , 4 Intrauterine contraceptive device, IUCD, is an effective and safe form of contraception and it is also used for the mechanical distension of the endometrial cavity in the management of uterine adhesion or synechia. 4 , 5 Uterine perforation remains its most serious complication. 5 It is however standard practice that the patient should be adequately counselled on the nature of procedures performed on her, otherwise a patient with an indwelling intrauterine contraceptive device would not seek treatment for infertility . It is therefore very essential that proper clinical history and relevant investigations are required to avoid unwarranted treatment and expense. It is important to ascertain that women who had IUCD inserted at some time had indeed had the device removed, and to ensure that the whole device was removed, leaving no part in the uterine cavity. This is especially important in cases of infertility, before embarking on any invasive procedure. This article illustrates the incidental finding of four IUCDs on radiological investigations of an infertile woman who was obviously being treated for Asherman's syndrome. Case Report A.O, a 36year old female fashion designer, gravida 3 para 1 +2, the only wife of her husband, a 44 year old baker, came to the gynaecology clinic with a 5 year history of irregular menses , intermittent lower abdominal pains, and inability to conceive for 15 years inspite of regular unprotected sexual exposure following the delivery of her last child through caesarean section (CS) for obstructed labour. The child was alive and breastfed for 1 year. She claimed to have been amenohorreic for 7 years after which her periods resumed irregularly following various treatments that involved vaginal instrumentation. She was told she had an intrauterine contraceptive device inserted and this was removed 6 months later. She had occasional whitish foul odoured vaginal discharge. Menstrual flow was scanty but not related to the lower abdominal pain. Pains were dull and had no specific radiation. There were no urinary symptoms. . She had no history of galactorrhoea. Her menarche was at 16 years and cycle remained regular until her last confin