International Journal of Gynecology and Obstetrics 109 (2010) 52–54 Contents lists available at ScienceDirect International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o CLINICAL ARTICLE Use of intrauterine devices in women with uterine anatomic abnormalities Naomi K. Tepper ⁎, Lauren B. Zapata, Denise J. Jamieson, Kathryn M. Curtis Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA a r t i c l e i n f o a b s t r a c t Article history: Objective: To examine the evidence regarding the safety and effectiveness of intrauterine devices (IUDs) in Received 4 September 2009 women with uterine abnormalities. Methods: We searched PubMed for all peer-reviewed articles in any Received in revised form 26 October 2009 language that had been published on the topic from database inception to September 2009. Primary research Accepted 25 November 2009 articles were included if they addressed the safety or effectiveness of any type of IUD among women with Müllerian anomalies or uterine synechiae. Results: In total, 19 case reports or case series met the inclusion Keywords: criteria. Reported complications included expulsion, pregnancy, bleeding, perforation, and pain. In several Intrauterine device Müllerian anomaly case reports, no complications were reported. Conclusion: Evidence concerning the safety and effectiveness Uterine abnormality of IUD use among women with uterine abnormalities is very limited. Uterine synechiae Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. 1. Introduction cies with safe and effective contraception is crucial. Current guidelines from the World Health Organization [6] state that the use of intrauterine Abnormalities of the uterus are relatively uncommon, but their devices (IUDs) is contraindicated for women with abnormalities that presence can have a major impact on women's reproductive health. Most distort the uterine cavity, but that the benefits of IUD use generally uterine abnormalities are congenital (i.e. Müllerian) anomalies caused by outweigh the risks for those with abnormalities that do not distort the abnormal development or fusion of Müllerian ducts. Such abnormalities uterine cavity. In clinical practice, major uterine abnormalities are include uterine hypoplasia/agenesis, unicornuate uterus, uterine didel- generally considered a contraindication to IUD use [7]. phys, bicornuate uterus, septate uterus, arcuate uterus, and abnormalities The aim of the present study was to evaluate the evidence regarding related to in utero exposure to diethylstilbestrol [1]. Other abnormalities the safety and effectiveness of IUD use among women with uterine include uterine synechiae (or Asherman's syndrome), which develop abnormalities. most frequently as a result of scar formation caused by uterine surgery. The incidence of Müllerian anomalies has not been determined 2. Materials and methods conclusively. Reported estimates range from 0.16% to 10% [2], depend- ing on the patient population being examined. The true incidence in a We searched PubMed for all peer-reviewed articles in any population, however, is likely to be higher than reported estimates language—published from database inception to September 2009— because many women with these anomalies are asymptomatic and their that addressed the safety or effectiveness of IUD use among women condition may remain undiagnosed unless reproductive problems with uterine abnormalities. The search strategy was as follows: occur. Similarly, the incidence of intrauterine adhesions in the general (((“uterus/abnormalities”[Mesh] OR (uterus and abnormalit*) OR population is unknown, although these adhesions have been found in (uterine and abnormalit*) OR (uterus and anomal*) OR (uterine and 1.5% of women referred for infertility treatment and in up to 40% of anomal*))) OR ((“tissue adhesions”[Mesh] OR “gynatresia”[Mesh] OR women undergoing repeated curettage [3]. The reported incidence of (uterus AND synechiae) OR (uterine AND synechiae) OR Asherman's intrauterine adhesions may be rising because of increasing rates of syndrome))) AND (((“intrauterine devices”[Mesh] OR “intrauterine iatrogenic endometrial trauma, improved diagnostic techniques, or both devices, medicated”[Mesh] OR “intrauterine devices, copper”[Mesh]) [4]. OR intrauterine device OR IUD)). Müllerian anomalies occur with similar frequency among infertile To identify additional articles, we also searched the reference lists and fertile women—indicating that these defects may have little impact of review articles and manuscripts identified by the PubMed search on fertility [4]. Because such abnormalities can lead to pregnancy strategy. Articles in languages other than English were translated if, complications (e.g. spontaneous abortion, premature delivery, abnormal after initial review, we determined that they met the inclusion criteria fetal position, and dystocia [5]), the prevention of unplanned pregnan- [8–11]. No attempt was made to identify relevant abstracts from scientific conferences. ⁎ Corresponding author. 4770 Buford Highway, MS K-34, Atlanta, GA 30341, USA. We hypothesized that articles would report complications or adverse Tel.: + 1 770 488 6506; fax: + 1 770 488 6391. effects of IUD use in women with uterine abnormalities. In addition, we E-mail address: ntepper@cdc.gov (N.K. Tepper). hypothesized that the effectiveness of IUDs at preventing pregnancy 0020-7292/$ – see front matter. Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. doi:10.1016/j.ijgo.2009.10.022  N.K. Tepper et al. / International Journal of Gynecology and Obstetrics 109 (2010) 52–54 53 would be compromised in the setting of an abnormal uterine cavity. had uterine synechiae [12]. The types of IUD used were Copper-T, Therefore, we included primary-research articles that addressed the levonorgestrel-releasing IUD (LNG-IUD), Lippes loop, Saf-T-Coil, Corolle, safety or contraceptive effectiveness of IUD use (any type) among women Dana Super, Dalkon Shield, and Multiload-250. Five studies did not with uterine synechiae or Müllerian anomalies. Articles were excluded if specify the type of IUD used [13,15–17,19]. Complications of IUD use they did not report women with uterine abnormalities, if they evaluated included pregnancy, perforation, expulsion, and bleeding. IUD insertion following adhesiolysis or metroplasty, if they included The studies of women with Müllerian anomalies included 12 cases of women with fibroids only, or if they were review articles. bicornuate uterus [7,9,13,16–19,21,22,24,25], 9 cases of arcuate uterus [23,25], 8 cases of septate uterus [10,15,23,25], and 3 cases of uterine 3. Results didelphys [8,11,14]. One study included cases of arcuate and septate uteri, but did not specify how many cases there were of each anomaly The PubMed search strategy identified 289 articles, of which 19 met [20], and 1 study did not identify the uterine anomaly in 3 cases [25]. the inclusion criteria [7–25] (Table 1). All 19 articles were case reports or Eleven studies reported a failure of IUDs to prevent pregnancy case series, with the numbers of women with uterine abnormalities [8,9,13,15–19,22,24,25] and identified a total of 12 pregnancies—10 ranging from 1 to 10. In 18 of the articles, the women described had of which were diagnosed while the IUD was still in place; of these Müllerian anomalies [7–11,13–25], and in the other article the woman pregnancies, 7 occurred in the other uterine horn of women with Table 1 Reviewed studies of uterine anatomic abnormalities and IUD use. Author, year Study design Type of uterine Type of IUD Abnormality known Outcome (No. of subjects) abnormality at time of IUD insertion? Müllerian anomalies Mazher et al. [25], 1967 Case series Bicornuate (2), Lippes loop No Bleeding (2); IUD expulsion (4); colic (100 [9 with uterine arcuate (3), septate (1); concurrent pregnancy with IUD abnormalities]) (1), unspecified (3) displaced downward (1); pregnancy with IUD location not reported (1) Vago and Spira [24], 1967 Case report (1) Bicornuate Lippes loop No Concurrent pregnancy with IUD in uterus (specific location not reported) Chaabouni et al. [8], 1969 Case report (1) Didelphys Saf-T-Coil, Lippes loop, Yes Concurrent pregnancy with IUD in Corolle other uterus; spontaneous abortion; IUD expulsion El-Zeneiny et al. [23], 1969 Case series (25 cases Septate (4), Lippes loop No IUD expulsion among 10 women of IUD expulsion arcuate (6) with uterine abnormalities [10 with uterine abnormalities]) Gupta [22], 1970 Case report (1) Bicornuate Lippes loop No Perforation (timing not reported); pregnancy; spontaneous abortion Chaturachinda and Case report (1) Bicornuate Lippes loop No Perforation; hysterectomy Ajjimakorn [21], 1971 Kamal et al. [20], 1971 Case series Septate, arcuate Lippes loop Not stated Irregular bleeding (7) (172 [7 with uterine (numbers not specified) abnormalities]) Hoffmann and Case report (1) Bicornuate Dana Super No Concurrent pregnancy with IUD in Rommel [9], 1974 other horn Sievers and Case report (1) Septate Dalkon Shield No Pain; hysterectomy Grumbrecht [10], 1974 Wagner and Case report Didelphys Copper-T No Pain; perforation Schmidt [11], 1976 (3 [1 with uterine abnormality]) Seibel and Hann [19], 1982 Case report (1) Bicornuate Not stated No Concurrent pregnancy with IUD in other horn; pelvic infection Fliegner [18], 1986 Case report (6 Bicornuate Multiload-250 No Concurrent pregnancy with IUD in [1 with uterine other horn abnormality]) Furst et al. [17], 1992 Case report (1) Bicornuate Not stated No Concurrent pregnancy with IUD in other horn Acharya and Mills [7], 1998 Case report (1) Bicornuate, intrauterine LNG-IUD (inserted for Yes No complications reported synechiae menorrhagia) Amsalem and Case report (1) Bicornuate Not stated No Concurrent pregnancy with IUD in Yagel [16], 2005 other horn; spontaneous abortion Dikensoy et al. [15], 2005 Case series (2) Septate Not stated No Concurrent pregnancy with IUD in other horn Septate Not stated No No complications reported Espey et al. [14], 2006 Case report (1) Didelphys, vaginal CuT380A (1 inserted into Yes No complications reported septum each uterus; 1 crossbar removed for insertion into smaller uterus) Sanyal et al. [13], 2007 Case report (1) Bicornuate Not stated No Concurrent pregnancy with IUD in other horn; spontaneous abortion Uterine synechiae Eke and Okpani [12], 2003 Case report (5 cases Synechiae Lippes loop Yes Perforation into bladder of uterine perforation [1 with synechiae]) Abbreviations: IUD, intrauterine device; LNG-IUD, levonorgestrel-releasing intrauterine device. 54 N.K. Tepper et al. / International Journal of Gynecology and Obstetrics 109 (2010) 52–54 bicornuate or septate uteri [9,13,15–19], 1 occurred in the other uterus safe; case control or cohort studies with larger numbers of women could of a woman with uterine didelphys [8], 1 was confirmed in a woman provide more information about which patients may safely use an IUD. with a bicornuate uterus in which the IUD was displaced downward In conclusion, evidence regarding the safety and effectiveness of [25], and 1 occurred in a unspecified location in the uterus [24]. In 1 case, IUD use in women with uterine abnormalities is limited. Several types the IUD was found in the abdominal cavity at the time the pregnancy of IUD have been inserted in women with these abnormalities, some was diagnosed; however, the timing of perforation was not known [22]. of whom experienced complications and some of whom did not. In another case, the article did not indicate whether the IUD remained in Reports of concurrent pregnancies indicate that IUD effectiveness may the uterus when the pregnancy was diagnosed [25]. be reduced among women with 2 uterine cavities. Although IUD use Eight studies reported complications, including 15 instances of IUD has traditionally been contraindicated for women with major uterine expulsion [8,23,25], 9 of bleeding [20,25], 3 of perforation [11,21,22], abnormalities, there may be abnormalities for which IUD use can be and 3 of pain [10,11,25]. In 3 case reports, no complications of IUD use recommended, and larger studies are needed to explore the safety and were reported [7,14,15]. potential use of IUDs by these women. In 14 of the 19 studies, the uterine anomaly was not known at the time of IUD insertion [9–11,13,15–19,21–25]. In 1 study, it was not stated Conflicts of interest whether the anomaly was known at the time of insertion [20], whereas it had been diagnosed prior to IUD insertion in 4 case reports [7,8,12,14]. In The authors have no conflicts of interest. 1 case report, the woman was diagnosed with uterine didelphys—using hysterosalpingogram—following several preterm deliveries [8]; 3 Disclaimer attempts at IUD insertion into the larger uterine cavity resulted in expulsion on 2 occasions and concurrent pregnancy in 1 instance. The The findings and conclusions in this article are those of the authors woman ultimately had 2 IUDs placed, 1 in each cavity, without and do not necessarily represent the official position of the Centers for complications. In another case report in which the anomaly was Disease Control and Prevention. known, the woman presented with menorrhagia and was diagnosed, via ultrasound, with bicornuate uterus [7]. After she failed medical management and uterine artery embolization, an LNG-IUD was placed— References under hysteroscopic guidance—to control her bleeding, without com- [1] The American Fertility Society classifications of adnexal adhesions, distal tubal plication; nevertheless, the patient was advised to use condoms because occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Müllerian the contraceptive effectiveness of the IUD could not be assured. In the anomalies and intrauterine adhesions. Fertil Steril 1988;49(6):944–55. [2] Shulman LP. Müllerian anomalies. Clin Obstet Gynecol 2008;51(2):214–22. third case report in which the anomaly was known, the woman [3] Thomson AJ, Abbott JA, Deans R, Kingston A, Vancaillie TG. The management of experienced an unplanned pregnancy while using oral contraceptives, intrauterine synechiae. Curr Opin Obstet Gynecol 2009;21(4):335–41. and consequently desired IUD placement [14]. The results of an [4] Fedele L, Bianchi S, Frontino G. Septums and synechiae: approaches to surgical examination and ultrasound indicated that she had uterine didelphys correction. Clin Obstet Gynecol 2006;49(4):767–88. [5] Lin PC. Reproductive outcomes in women with uterine anomalies. J Womens and vaginal septum, so 2 IUDs were inserted—1 in each cavity. One of the Health (Larchmt) 2004;13(1):33–9. crossbars of the CuT380A was removed for placement in the smaller [6] World Health Organization. Medical Eligibility Criteria for Contraceptive Use. cavity. The woman retained both IUDs without complications. Third Edition. Geneva: World Health Organization; 2004. [7] Acharya GP, Mills AM. Successful management of intractable menorrhagia with a In the single case report of a woman with uterine synechiae [12], levonorgestrel-releasing intrauterine device, in a woman with a bicornuate uterus. the existence of the abnormality was known at the time of IUD J Obstet Gynaecol 1998;18(4):392–3. insertion, and the IUD was inserted to achieve adhesiolysis; however, [8] Chaabouni M, Kamoun A, Chaabouni Z. Intrauterine contraception in a “double uterus”. Tunis Med 1969;47(5):367–72. the IUD strings were subsequently not visible, and the IUD was found [9] Hoffmann J, Rommel L. Pregnancy in uterus bicornis unicollis with IUD. Zentralbl to have perforated the woman's bladder. Gynakol 1974;96(1):25–6. [10] Sievers S, Grumbrecht C. IUD in a uterus septus with vagina simplex. Geburtshilfe Frauenheilkd 1974;34(7):582–3. 4. Discussion [11] Wagner H, Schmidt EH. Contraindications for the use of copper T intrauterine pessaries. Med Welt 1976;27(35):1631–4. We identified limited evidence regarding the safety and effectiveness [12] Eke N, Okpani AO. Extrauterine translocated contraceptive device: a presentation of five cases and revisit of the enigmatic issues of iatrogenic perforation and of IUD use in women with uterine abnormalities. In the 19 reviewed migration. Afr J Reprod Health 2003;7(3):117–23. articles of women with Müllerian anomalies or uterine synechiae, [13] Sanyal R, Banerjee S, Taori K. Pregnancy and IUD in different horns of the uterus. J complications of IUD use included pregnancy, perforation, expulsion, Clin Ultrasound 2007;35(1):40–1. and bleeding. The IUD was still in place in the majority of the pregnancies [14] Espey E, Ogburn T, Hall R, Byrn F. Use of intrauterine device in the setting of uterus didelphys. Obstet Gynecol 2006;108(3 Pt 2):774–6. that occurred in these studies, most often in the other horn of a bicornuate [15] Dikensoy E, Kutlar I, Gocmen A, Graves CR. Two cases of uterine septum with uterus—indicating that the use of a single IUD may be less effective if a intrauterine device. Br J Radiol 2005;78(934):952–3. woman has 2 uterine cavities. The major limitation of the present study [16] Amsalem H, Yagel S. Three-dimensional sonography of a fetus and an intrauterine device in a bicornuate uterus. J Ultrasound Med 2005;24(2):254. was that, because all of the reviewed studies were case reports or case [17] Furst A, Harats H, Mor-Yosef S. Intrauterine contraceptive device and embryo series, we were unable to estimate complication or failure rates. sharing a bicornuate uterus: case report. Br J Gen Pract 1992;42(356):129–30. In most cases of women with Müllerian anomalies, the presence of [18] Fliegner JR. Uncommon problems of the double uterus. Med J Aust 1986;145(10):510–2. [19] Seibel MM, Hann L. Pregnancy and an IUD in separate horns of a bicornate uterus. the anomaly was not known at the time of IUD insertion; therefore, JAMA 1982;247(6):753–4. extrapolation to women with known uterine anomalies was limited. [20] Kamal I, Hefnawi F, Ghoneim M, Talaat M, Abdalla M. Dimensional and However, complication rates are likely to be lower among women architectural disproportion between the intrauterine device and the uterine cavity. A cause of bleeding. Fertil Steril 1971;22(8):514–21. with known anomalies because ultrasound guidance could be used [21] Chaturachinda K, Ajjimakorn S. Perforation of bicornuate uterus by Lippes loop. during IUD insertion. J Med Assoc Thai 1971;54(9):656–9. Although the use of IUDs in women with significant uterine [22] Gupta SD. Perforation of bicornuate uterus by intrauterine contraceptive device. J Obstet Gynaecol Br Commonw 1970;77(12):1140–1. abnormalities has traditionally been contraindicated, there were some [23] el-Zeneiny AH, Ammar AR, Badawi SZ. Expulsion of the intrauterine devices Lippes reports of successful IUD insertion without complications in such cases. loop size 30 mm. J Egypt Med Assoc 1969;52(1):46–55. These instances occurred among women with varied uterine abnor- [24] Vago T, Spira H. Pregnancy in a bicornuate uterus after insertion of a lippes loop malities (bicornuate uterus, uterine didelphys, and septate uterus). (on the horns of a dilemma). Am J Obstet Gynecol 1967;97(6):872–3. [25] Mazher K, Kamal I, Hefnawi F, Talaat M, Younis N, Tagi AE. A simple technic of Therefore, no conclusions could be made about specific patient hysterography for evaluating side effects and mode of action of intrauterine characteristics or uterine abnormalities for which an IUD might be devices. A study of 100 cases. Fertil Steril 1967;18(3):353–66.