The “Lost” and “Found” IUD: a case of concurrent intrauterine and intraperitoneal devices with delayed recognition

Abstract

Background:

Intrauterine devices (IUDs) are widely used and highly effective long-acting reversible contraceptives; however, rare complications such as uterine perforation and device migration may occur. A critical and preventable clinical pitfall is the misinterpretation of missing retrieval strings as spontaneous expulsion, which may lead to reinsertion without imaging confirmation, resulting in dual IUD retention, delayed diagnosis, and potential complications including visceral organ injury.

Case presentation:

We report a case of a 45-year-old woman with an incidental finding of dual IUDs. Imaging revealed one device within the uterine cavity and a second device that had migrated intraperitoneally. Laparoscopic retrieval was successful, and the postoperative course was uneventful.

Conclusion:

This case highlights the importance of the systematic evaluation of “missing” IUD strings, including a pelvic examination and radiographic confirmation prior to reinsertion to prevent dual-device scenarios and associated morbidity. Early recognition, prompt imaging, and minimally invasive surgical management are essential for optimal outcomes.

Introduction

Intrauterine devices (IUDs) are highly effective long-acting reversible contraceptives^[1^]. Uterine perforation is a rare complication, occurring in approximately 0.1%–0.9% of cases, and may be asymptomatic^[2,3^]. Migration can involve abdominal or pelvic organs and lead to serious complications^[3,4^]. Diagnosis is often delayed, making imaging essential for accurate localization^[2,4^]. We report a rare case of intraperitoneal IUD migration with dual IUD retention, emphasizing a preventable diagnostic pitfall. This case report has been prepared in accordance with the updated SCARE 2025 guidelines.

Case presentation

Patient history and clinical presentation

A 45-year-old multiparous woman with no significant past medical or surgical history presented with a 4-month history of abdominal wall swelling and intermittent, progressively worsening left-sided abdominal pain. She denied nausea, vomiting, or other symptoms suggestive of bowel obstruction or an acute abdomen. The patient reported that a copper intrauterine contraceptive device (IUD) had been inserted 1 year prior to her recent pregnancy. Upon conceiving, she assumed that the initial device had been spontaneously expelled. Following delivery, a second copper IUD was placed. Her current abdominal symptoms began shortly after the insertion of this second device.

HIGHLIGHTS

• Missing IUD strings should not be assumed to indicate spontaneous expulsion.

• IUD reinsertion without imaging confirmation can result in unrecognized extrauterine migration.

• Cross-sectional imaging is essential for accurate localization of migrated IUDs.

• Laparoscopic retrieval is safe and effective, even in the presence of adhesions.

• Early diagnosis prevents serious complications such as visceral injury and fistula formation.

• A structured evaluation protocol is critical in all cases of non-visualized IUD strings.

Diagnostic evaluation

Prior to her surgical consultation, the patient was initially evaluated in a spine clinic for back pain. Lumbosacral radiographs incidentally revealed two IUDs: one situated within the uterine cavity and a second projecting over the left lumbar region, highly suggestive of extrauterine intraperitoneal migration (Fig. 1). Upon subsequent evaluation in the general surgery clinic, the physical examination showed that the patient was afebrile and hemodynamically stable. Her abdomen was soft, with a reducible paraumbilical hernia, and showed no localized tenderness, guarding, or clinical signs of peritonitis. All routine laboratory investigations were within normal limits. To further characterize the findings, a contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis was performed. Imaging confirmed the presence of two IUDs, with one appropriately located within the endometrial cavity and the second located outside the uterus in the left lower abdomen. There was no radiological evidence of visceral perforation, free intra-abdominal air, or fluid collections (Fig. 2). Additionally, the CT scan delineated a 1.2 cm fat-containing paraumbilical hernia.

Figure 1.

Lumbosacral spine radiographs (AP and lateral views) demonstrating two intrauterine contraceptive devices (IUCDs). The upper red arrow indicates the migrated extrauterine IUCD projecting over the left lumbar region, consistent with intraperitoneal migration. The lower red arrow indicates the second IUCD within the uterine cavity.

Figure 2.

Contrast-enhanced computed tomography (CT) of the abdomen and pelvis demonstrating the locations of the two intrauterine contraceptive devices (IUCDs). (A) Axial CT image demonstrating the intraperitoneally migrated extrauterine IUCD in the left lower abdomen (red arrow). (B) Axial CT image demonstrating the second IUCD within the uterine cavity (red arrow). (C) Coronal CT image demonstrating the migrated extrauterine IUCD in the left lower abdomen (red arrow). No evidence of hollow viscus perforation, free intraperitoneal air, or intra-abdominal collection was identified.

Management and postoperative course

The patient was initially lost to follow-up but re-presented 4 months later due to persistent symptoms, at which point she was admitted for elective surgical management. She underwent combined laparoscopic retrieval of the migrated IUD and paraumbilical hernia repair. Intraoperative exploration revealed the ectopic IUD firmly embedded within adhesions involving the omentum and the anterior abdominal wall. Careful adhesiolysis was performed, allowing for the complete and uncomplicated laparoscopic extraction of the device (Fig. 3). This was successfully followed by standard mesh repair of the paraumbilical hernia. The patient’s postoperative course was uneventful, with complete resolution of her abdominal symptoms, and she was discharged in stable condition. At her 1-month follow-up appointment, she remained entirely asymptomatic with well-healed surgical incisions and no clinical evidence of hernia recurrence. She was extensively counseled on the importance of structured postpartum follow-up and the necessity of confirming proper IUD positioning via imaging after insertion.

Figure 3.

Intraoperative laparoscopic findings and retrieval of a migrated intrauterine device (IUD). (A) fragment of the migrated IUD thread was identified on the omental surface during diagnostic laparoscopy. (B) The IUD was found firmly embedded within the greater omentum. (C) Careful dissection and mobilization of the omentum were performed using an electrothermal bipolar vessel sealing device. (D) The migrated IUD was successfully extracted from the vascular omental tissue with meticulous hemostasis and no intraoperative bleeding. (E) The intact Copper T intrauterine device is shown following successful and complete laparoscopic retrieval.

Discussion

IUDs are widely used reversible contraceptives due to their high efficacy, favorable safety profile, and cost-effectiveness; however, device-related complications, although uncommon, require careful post-insertion surveillance and patient education^[1^]. Complications such as expulsion, malposition, translocation, and uterine perforation may lead to contraceptive failure and necessitate prompt removal with consideration of reinsertion when appropriate^[2^]. Uterine perforation is a rare complication, with an incidence ranging from 0.1% to 0.9% and an estimate of approximately 1.6 per 1000 insertions^[3^]. It is frequently underdiagnosed due to its often asymptomatic course.

The proposed mechanism involves gradual pressure necrosis and progressive myometrial erosion following partial embedment at insertion^[4^]. Established risk factors include multiparity, prior uterine surgery, cesarean section, and abortion^[5^]. In the case of our patient, her history of multiparity served as a significant risk factor that increased her susceptibility to this complication. The risk is further heightened in postpartum and postabortion settings due to uterine involution, reduced myometrial thickness, and increased uterine contractility. Uterine malposition and scar-related distortion may further predispose to perforation, while movements of adjacent organs, such as intestinal peristalsis and bladder contractions, may facilitate progressive migration.

The specific type of IUD implicated – whether a non-hormonal copper device or a levonorgestrel-releasing (progesterone) device – plays a critical role in determining the severity of subsequent intraperitoneal complications following a perforation. Copper IUDs exert their contraceptive effect primarily by inducing a profound local cytotoxic and inflammatory response within the endometrium. Consequently, when a copper device migrates into the peritoneal cavity, this intense inflammatory effect accompanies it, triggering a severe, localized intra-abdominal tissue reaction. This pronounced foreign-body response frequently leads to the formation of dense, fibrous adhesions involving adjacent structures such as the omentum, bowel, and anterior abdominal wall. In contrast, progesterone-releasing IUDs tend to provoke a much milder peritoneal reaction and are associated with a lower incidence of severe intra-abdominal adhesion formation^[6^].

In our patient, the migrated device was a copper IUD. Consistent with the characteristic, highly reactive profile of extrauterine copper devices, the IUD elicited a marked, localized inflammatory response. This resulted in the device’s becoming firmly embedded within dense omental and anterior abdominal wall adhesions, as observed during intraoperative exploration. This robust inflammatory process directly correlated with her clinical presentation, manifesting as progressive left-sided abdominal pain and contributing to localized abdominal wall swelling overlying her paraumbilical hernia.

Migrated IUDs have been reported in multiple anatomical locations, including the bowel, bladder, appendix, adnexa, peritoneal cavity, and abdominal wall. Bladder involvement is clinically significant due to the risk of calculus formation^[7–9^]. Although spontaneous migration is uncommon, early partial penetration at insertion appears to play a key role in subsequent displacement. Clinical presentation is variable. Patients may present with abdominal pain, abnormal uterine bleeding, missing strings, or unintended pregnancy; however, up to 30% of patients remain asymptomatic^[8,10^]. Symptoms depend on the site of migration. Bowel involvement may present with abdominal pain, fever, diarrhea, or hematochezia^[11,12^], whereas urinary tract involvement may manifest as dysuria, frequency, hematuria, or recurrent urinary tract infection^[13^]. Ovarian involvement may present with pelvic pain and dyspareunia^[14^]. In our patient, the migrated copper IUD elicited a localized inflammatory response, leading to omental and anterior abdominal wall adhesions. This manifested clinically as progressive left-sided abdominal pain.

Diagnosis requires a structured, stepwise approach. Initial evaluation includes pelvic examination and ultrasonography; however, non-visualized strings should prompt further imaging with abdominal radiography. Cross-sectional imaging with CT or magnetic resonance imaging (MRI) is essential for accurate localization and assessment of organ involvement prior to intervention^[15,16^]. In our case, the patient initially presented to a spine clinic for back pain, which, fortunately, led to the incidental radiographic detection^[16^] of the extrauterine IUD. Subsequent CT imaging was crucial, as it not only confirmed the presence of dual IUDs but also precisely localized the migrated device to the left lower abdomen – confirming the absence of visceral perforation and allowing for safe surgical planning.

Management is guided by the location and extent of migration. The World Health Organization recommends the removal of all extrauterine IUDs once identified, even in asymptomatic patients, due to the risk of severe complications such as abscess formation, fistulae, obstruction, and hydronephrosis^[17,18^]. Complications may be severe and organ-specific. Perforation into adjacent organs can result in significant morbidity. Bowel involvement – including the small intestine, colon, appendix, and rectum – may lead to obstruction, peritonitis, fistula formation, or intestinal gangrene, occasionally requiring bowel resection^[19^]. Urinary tract perforation, involving the bladder or ureter, may result in stone formation, hydronephrosis, or fistulae such as vesicouterine or colovesical fistulae, with rare presentations including menouria^[19–21^].

While minimally invasive retrieval is often feasible, complex cases may require more extensive surgical intervention^[19^]. Minimally invasive techniques, including hysteroscopy, laparoscopy, cystoscopy, and colonoscopy, are preferred; however, laparotomy may be required in cases of dense adhesions or organ involvement, particularly when the bowel is affected^[18,20,22–24^]. A multidisciplinary approach involving gynecology, general surgery, and urology is often necessary in complex cases^[24,25^]. The likelihood of requiring open surgical intervention for migrated IUDs is strongly influenced by the anatomical location of the device. Table 1 shows “Locations of IUDs at time of extraction and the percentage requiring open surgery”^[25^], with the highest rate of laparotomy observed in cases with both pelvic and abdominal organ involvement (57.1%), compared with abdominal-only migration (40.0%) and isolated pelvic locations, which demonstrate the lowest rate (12.9%)^[17^]. Patients with a history of surgeries, deliveries, or suspected adhesions require particular caution during surgical exploration, as dense adhesions may obscure localization and increase operative complexity. Nevertheless, with meticulous adhesiolysis, successful minimally invasive retrieval can often still be achieved^[6^]. In the present case, despite the device being firmly embedded within the omentum and anterior abdominal wall, careful laparoscopic exploration and adhesiolysis allowed for successful retrieval of the device alongside a concurrent paraumbilical hernia repair, ensuring an uneventful recovery.

Table 1.

Locations of IUCDs at time of extraction and the percentage requiring open surgery^[25^].

Site of IUCD at time of operation	n (%)	Rate of open surgery
All Sites	129	36 (27.9%)
Pelvic location	62 (48.1%)	8 (12.9%)
Free in pelvis	42	–
Attached to uterus	9	–
Tubo-ovarian	2	–
Attached to rectum	3	–
Attached to bladder	1	–
Attached to broad ligament	5	–
Abdominal cavity, not related to pelvic organs	60 (46.5%)	(40.0%)
Embedded in omentum	41	–
Free in peritoneal cavity	6	–
Attached to bowel	13	–
Involving abdominal and pelvic organs	7 (5.4%)	(57.1%)
Mass of bowel and pelvic structures	4	–
Mass of omentum and pelvic structures	3	–

A key clinical pitfall in IUD management is misinterpreting missing IUD strings as spontaneous expulsion, leading to reinsertion without confirmation of device location. This may result in the presence of dual IUDs – one intrauterine and one extrauterine – causing delayed diagnosis and increased morbidity^[19^]. Our case exemplifies this scenario: the patient assumed her initial copper IUD had been spontaneously expelled upon becoming pregnant, and a second device was placed postpartum without prior radiological confirmation of the first device’s absence. This oversight directly resulted in dual IUD retention and a significantly delayed diagnosis of intraperitoneal migration.

As summarized in Table 2, reported cases of dual IUD retention consistently highlight this preventable pitfall. Reinsertion without prior imaging leads to undetected dual-device presence, with one IUD remaining intrauterine and the other migrating to adjacent structures such as the bladder, abdomen, or rectum. Clinical consequences range from incidental findings during pregnancy to significant morbidity, including urinary symptoms, abdominal pain, rectal involvement, uterovesical fistula, adhesion formation, bowel perforation, peritonitis, and hemorrhage. Management varies from minimally invasive retrieval to open surgical intervention and, in severe cases, hysterectomy. These findings, heavily reinforced by our patient’s clinical course, emphasize that failure to confirm IUD location prior to reinsertion is a key preventable error, and that early imaging and timely removal are essential to minimize complications.

Table 2.

Reported cases of dual IUCD (intrauterine and extrauterine migrated IUCD) highlighting diagnostic pitfalls, clinical consequences, and management outcomes.

Case No.	Study	Patient presentation	Etiology of dual IUCD	Diagnostic pitfalls/delay	Imaging	Location of both IUCDs	Consequences	Management
1	Schwartzwald et al[26]	Cyclic menstrual hematuria	IUCD reinsertion after presumed expulsion	No early imaging after missing strings	Imaging + intraoperative findings	IUCD 1: Bladder (uterovesical fistula tract); IUCD 2: Intrauterine	Uterovesical fistula, severe urinary morbidity	Hysterectomy with fistula repair
2	Liu et al[27]	Urinary frequency, urgency, pregnancy with IUCD in situ	IUCD reinsertion after presumed expulsion	Failure to confirm absence of the first IUCD	CT, cystoscopy	IUCD 1: Bladder/ureteric region; IUCD 2: Uterine cavity	Bladder calculus formation	Cystotomy for IUCD removal
3	Pathan H et al[28]	Pregnancy, incidental finding	IUCD reinsertion after presumed expulsion	No radiologic confirmation before reinsertion	CT, ultrasound	IUCD 1: Intrauterine; IUCD 2: Intraperitoneal (omentum/abdominal wall)	Intraperitoneal migration, risk of omental adhesions and organ injury	Laparoscopic adhesiolysis and IUCD removal
4	Abasiattai et al[29]	IUCD protruding per rectum	Missing strings; unrecognized perforation followed by reinsertion	Delayed recognition of migrated IUCD	X-ray	IUCD 1: Rectum; IUCD 2: Uterus	Rectal perforation	Transrectal extraction
5	Our case	Asymptomatic, missing strings	Reinsertion after presumed expulsion without imaging confirmation	Dual failure: no imaging before reinsertion and asymptomatic migration	X-ray, CT, MRI	IUCD 1: Intrauterine; IUCD 2: Intraperitoneal with adhesions	Dense pelvic adhesions	Laparoscopic adhesiolysis and IUCD removal

Conclusion

Dual IUD retention is a rare but clinically significant and preventable complication, most commonly arising from the assumption that missing IUD strings indicate spontaneous expulsion without objective confirmation. Failure to verify device location prior to reinsertion can result in dual IUD placement, delayed diagnosis, and potentially serious intra-abdominal complications, including visceral perforation and fistula formation. This case highlights the importance of strict adherence to imaging confirmation – particularly radiography – before reinsertion in all patients with “missing” IUD strings. A high index of suspicion and early imaging are essential, especially in patients presenting with pelvic or urinary symptoms, to ensure timely diagnosis and prevention of avoidable complications. From a surgical perspective, this case demonstrates that laparoscopic retrieval remains a safe and effective management option, even in the presence of adhesions, when performed with meticulous technique.

Ethical approval

Dr Sulaiman Al Habib Medical Group waived the need for IRB approval due to the absence of patient identification in the study’s enrolled participant.

Consent

Written informed consent was obtained from the patients for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

This study did not receive any funding.

Author contributions

A.M.A.: Principal investigator and writing; A.S.A.-D.: Designs, writing and review; M.K.S.: Literature review, and data collection; S.A.H.: Overall supervision.

Conflicts of interest disclosure

The authors declare no competing interests.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Dr Ahlam M. Alfaraj.

Data availability statement

Not applicable.

Provenance and peer review

Not commissioned; externally peer-review.