Distortion of Intrauterine Device

“Sir, there is a patient who wants to get her IUCD removed. But the threads are not seen on speculum examination. She has an ultrasonic scan report which shows that the IUCD is in the uterine cavity” my new Assistant Professor said. “In that case the threads have either fallen off, or they are drawn up. If they are drawn up, the IUCD has most probably undergone a somersault” I said. I examined that patient. She had normal pelvic anatomy. There was a mild pelvic infection. “Let us try and get the threads of the IUD out using a brush” I suggested. Accordingly he inserted a cytobrush into the uterine cavity and rotated it around a number of times. Unfortunately the threads did not get entangled in the bristles of the brush and come out. He repeated the procedure two more times, but the threads remained where they were. So I inserted an IUCD removing hook into the uterine cavity and hooked the IUCD out. It came out smoothly at the very first attempt. It was hooked at the center of the vertical limb. It was Copper-T 380. The threads were along the vertical stem. The transverse bars were bent forward at an angle of about 160 degrees with each other. The vertical stem was bent forward at a similar angle at its midpoint. I knew what the problem must have been. So I asked the patient why she wanted the IUCD removed, whether for having another baby or any other reason. “I get intense pain in the lower abdomen and pelvis during and in between menses” she said and grimaced. That confirmed my diagnosis. “What must have bee her symptoms and what was the cause of the distortion of the IUCD?” I asked my Assistant Professors and fourth year resident. Based on the answers given by them, none of which was incidentally correct, I asked the same questions to all Assistant Professors in the department. No one out of 17 of them answered that question, which was a little disturbing, because they all were freshly qualified doctors and were expected to be very knowledgeable. One did not come for the survey, while another opted out after hearing the question. Their reasons for the distortion of the IUCDas follows. 1.The uterus must have been anteverted while the IUCD must have been inserted in a retroverted direction. 2.There must be a uterine fibroid. 3.The uterine cavity must have been distorted. 4.There must be a partial septum in the uterine cavity. 5.The IUCD must have been inserted by the push-out technique rather than by the withdrawal technique. 6.The IUCD must have lost its elastic memory. 7.The IUCD must have a manufacturing defect. 8.The hook must have distorted the IUCD while pulling it out. 9.The tips of the transverse bars must have been embedded in the myometrium. 10.The IUCD must have been embedded into the endometrium. 11.The IUCD is normal. There is no distortion. None of them had any clue about the symptoms the patient must have had. After I completed the survey, I told them the reason for the distortion and the patient's symptoms. “The IUCD may have been inserted into a uterus whose cavity was larger than normal, as after a first trimester abortion. That must have given the IUCD some extra space, so that it was a little malaligned. Uterine contractions trying to expel it out must have caused it to somersault. That would draw up its threads. Repeated uterine contractions would distort the IUCD, and that would cause severe pelvic pain and spasmodic dysmenorrhea. Distortion does not occur often with T-shaped devices due to their slim shape fitting well in the uterine cavity. The rate was much higher with first generation devices like Lippes' loop. This is not my imagination. The medical literature has a large number of such records for those who wish to find those.