The intrauterine device ( IUD ) is gaining popularity as a reversible form of contraception. Ultrasonography serves as first-line image for the evaluation of IUD put in patients with pelvic pain, abnormal bleeding, or lacking recovery strings. This reappraisal highlights the visualize of both properly positioned and malpositioned IUDs. The problems associated with malpositioned IUDs include expulsion, translation, embedment, and perforation. management considerations depend on the badness of the malposition and the presence or absence of symptoms. three-dimensional sonography has proven to be more sensitive in the evaluation of more insidious findings of malposition, particularly side-arm embedment. familiarity with the ultrasonographic features of properly positioned and malpositioned IUDs is essential. Keywords:
Intrauterine devices, Contraceptive devices, female, Ultrasonography
first described for humans in 1909 by Dr. Richard Richter [ 1 ], the intrauterine device ( IUD ) is the most democratic reversible human body of contraception nowadays, with more than 168 million users worldwide [ 2 ]. however, there is placid large-scale regional variation in the use of IUDs. eighty-three percentage of IUD users worldwide live in Asia [ 3 ]. The use of IUDs in the United States has been traditionally much lower than in many european countries but is lento increasing. The most holocene statistics estimate that 5 % of the contracepting women in the United States opt for IUD placement ( up from 0.8 % in 1995 ) [ 4 ]. Most IUDs are inserted without image steering. Ultrasonography plays an essential function in evaluating IUD position and assessing for complications. This review focuses on the sonography of IUDs and presents critical imaging features of properly and improperly positioned IUDs .
IUD Types and Placement
Both bull and hormone-releasing IUDs are presently available in the United States. The copper TCu-380A ( ParaGard, Teva Women ’ s Health, Inc., North Wales, PA, USA ) is made of a t-shaped polyethylene frame with barium sulfate added for radiopacity ( ). Exposed copper on the arms and bow release copper ions, which both increase the local alien body incendiary answer and interfere with sperm mobility and viability preventing fertilization [ 5 ]. Two polyethylene monofilaments connected to the bow, referred to as recovery strings, allow for detection and removal. TCu-380A is approved for up to 10 years of use .Open in a separate window The available hormone-releasing IUD in the United States is the intrauterine levonorgestrel-releasing system ( Mirena, Bayer HealthCare Pharmaceuticals, Pittsburgh, PA, USA ). It is besides a radiopaque t-shaped device ( ). passing of the embedded levonorgestrel, a synthetic progesterone, leads to cervical mucosal thickening and suppression of the endometrium american samoa well as the prohibition of ovulation in some women [ 5 ]. It is approved for improving to 5 years of use but has been shown to maintain efficacy for at least 7 years [ 6 ]. Because of the endometrial suppression, levonorgestrel-releasing IUDs are besides approved to treat arduous menstrual run in women using intrauterine contraception. While this review focuses on the presently available t-shaped copper and hormone-releasing devices, inert IUDs such as the Lippes Loop ( Ortho Pharmaceutical, Raritan, NJ, USA ) ( ) and stainless steel rings ( ) can still be found in older patients. For model in China, stainless steel rings were democratic before copper IUDs became preferred in 1994 [ 7 ]. placement of IUDs is performed in an outpatient set by using available kits and aseptic proficiency. A sterile uterine sound is used to ensure a minimum uterine depth of 6 cm [ 8 ]. image guidance is broadly reserved for women with a history of difficult insertion, fleshiness that limits two-handed examination, or suspected contort uterine pit [ 9 ]. follow-up pelvic examen within 6 weeks of interpolation is recommended to ensure visual image of the retrieval strings, which should protrude through the external cervical oxygen by 2-3 curium. The correctly positioned IUD is located in the uterine cavity near the fundus ( ). The bow should extend toward the neck and the two arms should be in full unfold during interpolation, reaching laterally toward the uterine cornu .Open in a separate window
Imaging of IUDs
Imaging plays a all-important character in the management of patients with IUDs. Ultrasonography is the most common initial method acting of evaluation due to its cost-effectiveness, miss of ionizing radiation, and greater detail of pelvic human body [ 10 ]. The stem is normally easily identified on standard two-dimensional ( 2D ) transvaginal sonography ( TVUS ) as a linear echogenic structure ( – ). While the arms of the copper IUD are besides in full echogenic, the arms of the levonorgestrel-releasing IUD are only echogenic at the proximal and distal ends, with feature cardinal buttocks acoustic shadowing on cross images ( ) [ 11 ]. three-dimensional ( 3D ) reconstructions are increasingly being used, particularly in the wreath opinion, which allows for a more careful evaluation of the arm placement ( ) [ 12, 13 ]. In one study, all 28 cases of side-arm embedment into the myometrium could only be detected on the 3D wreath position [ 14 ].
Open in a separate window other imaging modalities can be accessory in choose cases. When the IUD can not be seen on pelvic sonography, abdominal radiogram can be used to evaluate IUD position, as all IUDs are radiopaque. Positioning on an abdominal radiogram varies with normal uterine positions, but the IUD should be located near the midplane low in the pelvis and orientated with the arms superior to the stem (, ). In cases where complications such as perforations or abscesses are suspected, computed imaging ( CT ) or magnetic rapport imagination ( MRI ) may be a helpful adjunctive modality given their larger field of view. however, the associated radiation sickness with CT and the cost of MRI limits their utility as a first-line mood for the evaluation of IUD military position. Of note, both bull and hormone-releasing devices are considered safe for up to 3-T MRI [ 15 ]. Stainless steel IUDs have not undergo testing. If an IUD is deliver on CT or MRI performed for indications other than the judgment of the IUD itself, it is important for the radiologist to evaluate for its proper situation (, ) .Open in a separate window
Uncommon IUD Complications and Mimics
IUDs may, rarely, be broken during expulsion or removal, including embedded retrieval strings ( ). few data are available on the long-run effects of retain strings or pieces of devices and no clear management guidelines have been established [ 25 ]. manual vacuum aspiration may be helpful in IUD removal in cases of embedment ; otherwise, surgery may be required .Open in a separate window
crust, the formation of calcium carbonate deposits on or near the IUD, is a well-described phenomenon that can be demonstrated as uneven echoes surrounding the normal IUD echoes ( ). The clinical significance of these calcifications is indecipherable. early concern over consociate incendiary complications [ 26 ] have not been far investigated .Open in a separate window
occasionally, linear echogenic intrauterine structures can be mistaken for an IUD. Retained fetal bone fragments are rare sequela of spontaneous or induce abortions. Ultrasonography findings include linear or angular echogenic shadowing structures within the uterine cavity or myometrium [ 27 ]. In the absence of a clear history, this line up may be misinterpreted as an IUD on sonography [ 28 ]. In fact, the retained fetal part is thought to act like an IUD, causing secondary sterility, which may be the only deliver symptom. Endometrial osseous metaplasia is a relate and evenly rare phenomenon, with the exploitation of a ripen bone in the endometrium, whose pathogenesis is controversial. Prevailing theories include development from retained fetal bone or true metaplasia of the endometrial tissue secondary to chronic ignition. This can besides be the lawsuit of secondary sterility and be mistaken for an IUD [ 29 ].
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As the IUD gains in popularity as a contraceptive device, it is becoming increasingly authoritative for the referring gynecologist and radiologist to be informed of the characteristic ultrasonographic imaging features of positioned and malpositioned IUDs. In detail, the 3D wreath view is crucial in assessing for IUD displacement or an embedded IUD branch or stalk within the myometrium. Radiography and CT scan imaging are helpful in confirming extrusion or assessing for perforation, intraperitoneal migration, and complications such as abscess or intestine injury. sonography is besides helpful in the management of complications such as contraceptive failure ( pregnancy ) and detection of fragmentation and calcification .
No potential conflict of interest relevant to this article was reported .