Hysteroscopic removal of IUD in first trimester viable option

Hysteroscopic removal of intrauterine devices (IUDs) during the first trimester is a viable option for patients who wish to continue their pregnancy, according to DI Nassie, MD, who presented on this topic at the 2019 American Association of Gynecologic Laparoscopists (AAGL) Global Congress on minimally invasive gynecologic surgery (MIGS) in Vancouver, British Columbia.

Background
Dr. Nassie, of the Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tiqva, Israel, and the Sackler School of Medicine, Tel-Aviv University, noted that while use IUDs has increased in recent years over oral contraceptives, there continues to be inherent failure rates with IUDs, which result in women becoming pregnant with a device in place.

The Food and Drug Administration (FDA) and the World Health Organization (WHO) both recommend IUD removal in the face of pregnancy, specifically due to the possibilities of miscarriage, placental abnormalities, chorioamnionitis, and preterm delivery. However, when the strings are not visible, the consensus is less clear. The choices are to leave the device in situ, attempt to blindly remove it, remove it with sonographic guidance, or attempt removal via hysteroscopy.

Methods
In Dr. Nassie’s study, seven women in the first trimester underwent IUD removal without anesthesia or cervical dilation utilizing a 3.5-mm Gynecare Versascope. Prior to the procedure, they were all were given prophylactic antibiotics and received vaginal prep with antiseptic solution. The uterus was distended with 0.9% saline until a clear view was achieved and then the infusion was stopped or slowed to decrease risk of hydro-dissection of the gestational sac. When the strings of the IUD were located, they were grasped using semirigid SF grasping forceps, and the device was gently removed. After removal, the fetal pulse was verified by ultrasound. All the women were discharged on the operative day.

Findings
Dr. Nassie reported that all patients went on to have spontaneous vaginal deliveries at term. All infants were reported to be of appropriate weight for their gestational ages. No complications of pregnancy or placentation were reported.

Conclusion

“Hysteroscopic removal of an IUD in the first trimester is a safe option when the strings are not visible. It is not associated, according to our data, with major adverse pregnancy outcomes,” said Dr. Nassie. “This procedure should be offered to gravid women in the first trimester who desire to preserve pregnancy.”