title: The Challenging Intrauterine Contraceptive: In-office Hysteroscopic Approach.
abstract: To describe 3 cases of misplaced or retained Intrauterine Contraceptive (IUC) that were successfully resolved by hysteroscopy performed in an ambulatory setting using miniaturized electrosurgical and mechanical operative instruments.
  
  
  
  Step-by-step description of the technique using slides, pictures, and video (educative video) (Canadian Task Force classification III).
  
  
  
  Misplaced or retained IUC may be related to several causes; incorrect insertion is the leading cause. In these cases, patients may complain of abnormal bleeding, pelvic pain, or pregnancy or they may remain asymptomatic. When a displaced IUC is suspected, transvaginal ultrasonography is the primary investigation followed by radiography in cases in which the IUC is not seen within the uterus. Additional imaging such as computed tomographic scanning or magnetic resonance imaging may be needed. Hysteroscopy represents the gold standard for diagnostic clarification and management of a dislocated or embedded IUC.
  
  
  
  The hysteroscopic approach of the 3 cases was the following: removal of a partially perforating IUD in the cesarean scar pouch, repositioning of a dislocated IUS in the isthmocele, and removal of an embedded IUS in the cornual area. The procedures were performed in an ambulatory setting using a 5-mm continuous flow hysteroscope and vaginoscopic approach without any analgesia and/or anesthesia. The alternate use of mechanical and electrosurgical 5F instruments allowed us to separate the IUC from the myometrial uterine wall, respecting the healthy myometrium and without causing significant patient discomfort or complications.
  
  
  
  The possibility of using miniaturized electrosurgical and mechanical instruments with small-diameter hysteroscopes offers the possibility of an effective, safe, cost-efficient, and well-tolerated removal or repositioning of a misplaced or retained IUC. This minimally invasive approach can be performed in an office setting to avoid more invasive and traumatic approaches.
authors.affiliation: Department of Public Health, University of Naples 'Federico II', Naples, Italy. Electronic address: cdispie@tin.it.
authors.forename: Attilio
authors.initials: A
authors.lastname: Di Spiezio Sardo
authors.affiliation: Department of Gynecology and Obstetrics, ABC Foundation School of Medicine, São Paulo, Brazil.
authors.forename: Mariana
authors.initials: M
authors.lastname: da Cunha Vieira
authors.affiliation: Department of Public Health, University of Naples 'Federico II', Naples, Italy.
authors.forename: Marianna
authors.initials: M
authors.lastname: Scognamiglio
authors.affiliation: Department of Public Health, University of Naples 'Federico II', Naples, Italy.
authors.forename: Brunella
authors.initials: B
authors.lastname: Zizolfi
authors.affiliation: Department of Public Health, University of Naples 'Federico II', Naples, Italy.
authors.forename: Carmine
authors.initials: C
authors.lastname: Nappi
authors.affiliation: Department of Gynecological Sciences and Perinatology, Policlinico Umberto I 'La Sapienza' University of Roma, Rome, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: de Angelis
mesh_terms: D000328:Adult; D000556:Ambulatory Surgical Procedures / Q000379:methods; D000758:Anesthesia; D002170:Canada; D002921:Cicatrix / Q000601:surgery; D003271:Contraceptive Agents, Female / Q000008:administration & dosage*; D020878:Device Removal / Q000379:methods*; D004598:Electrosurgery / Q000379:methods; D005260:Female; D005547:Foreign Bodies / Q000601:surgery*; D006801:Humans; D020702:Hysteroscopes; D015907:Hysteroscopy / Q000295:instrumentation / Q000379:methods; D058736:Intrauterine Device Migration; D007434:Intrauterine Devices / Q000009:adverse effects*; D008866:Microsurgery / Q000379:methods; D009215:Myometrium / Q000601:surgery; D017699:Pelvic Pain / Q000209:etiology; D011247:Pregnancy; D014057:Tomography, X-Ray Computed
chemical_list: D003271:Contraceptive Agents, Female
keywords: Hysteroscopy; Intrauterine contraceptive device; Misplaced intrauterine contraceptive; Office hysteroscopy; Retained intrauterine contraceptive