The wandering Mirena: laparoscopic retrieval.

Levonorgestrel-containing intrauterine contraceptive devices, marketed as Mirena (Bayer HealthCare Pharmaceuticals, Inc. Australia) are widely used in contemporary gynecology, primarily as an effective method for contraception and for control of menstrual disorders like menorrhagia and dysmenorrhea. In this article, the authors report 2 cases of Mirena migration following intrauterine insertion by general practitioners (family physicians). In the first case, the contraceptive device had moved to the patient's right iliac fossa just anterior to the cecum and, in the second, within the peritoneal cavity close to the left leaf of the diaphragm. Both patients underwent uneventful laparoscopic retrieval of the devices.

SUMMARY OF CLINICAL FEATURES

Patient One

CM is a 44-year-old multiparous lady, with children 19 and 17 years of age. She delivered both of her children by spontaneous vaginal deliveries. About 15 months ago, she was fitted with a Mirena for contraception. Regular vaginal examinations by her family physician confirmed that the threads of Mirena were coming off the uterine cervix. She was totally asymptomatic when she went for a periodic cervical smear, at which point this problem with the Mirena device was detected. Ultrasound scan confirmed that the device was not present within the uterine cavity. A computerized tomography scan showed that the device had attached to the posterior aspect of the patient's right rectus sheath. Laparoscopy was performed by using the “triple port” of entry, and the device was found in the patient's right iliac fossa just above her cecum and was surrounded by omental adhesions. Laparoscopic adhesiolysis was affected to free the device off the omental and cecal adhesions and that was followed by laparoscopic retrieval of the Mirena (. The procedure was uneventful, and there was no sign of uterine perforation. The patient was discharged after the outpatient procedure.

Migrated Mirena® lying within abdominal cavity on top of the cecum, surrounded by omental adhesions.

Laparoscopic retrieval of the migrated Mirena® device, following an adhesiolysis procedure.

Patient Two

NG is a 19-year-old single lady. She underwent an unremarkable vaginal suction termination of her first pregnancy (STOP) at about 8 week's gestation and was fitted with a Mirena, at the same time, by the treating physician. She was admitted to the hospital 10 days after the Mirena insertion with a history of acute severe pelvic pain that required administration of narcotic analgesic injections. Ultrasound scanning showed that the uterus was “empty.” Plain X-ray of the abdomen showed that the Mirena was in the peritoneal cavity close to the pouch of Douglas. Emergency laparoscopy (“triple port” of entry) was performed, and the peritoneal cavity was carefully inspected. The Mirena was spotted within approximately 3cm of the left leaf of the diaphragm (. There was no sign of uterine perforation. Laparoscopic removal of the device was carried out smoothly, and the patient was discharged after the outpatient procedure.

Migrated Mirena® is close to the left leaf of the patient's diaphragm.

Laparoscopic retrieval of the migrated Mirena® device.

DISCUSSION

The levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena) is the most widely used contraceptive method, with prevalence rates ranging among countries from 2% to 80% of contraceptive users.[1] It releases 20μgm of levonorgestrel/day[2] and is used as an effective and reliable method of contraception, to manage menstrual disorders as in menorrhagia[3] and dysmenorrhoea,[4] as an endometrial protective agent in women using hormonal replacement therapy (HRT),[5] and in the management of select cases of endometrial carcinoma[6] and precancerous conditions, such as atypical endometrial hyperplasia.[7]

As a contraceptive, Mirena is probably the most effective reversible method of contraception[8] and without the need to take daily oral medication, as is the case with combined oral contraceptive or progesterone-only pills.[9] It is well tolerated, long acting, reversible, and adequately retained within the uterine cavity. Patient satisfaction is high with acceptance among parous and nulliparous women alike, as in the above 2 patients, and it also provides reassuring results for clinicians and adolescents considering use of Mirena.[10]

In addition, Mirena is usually recommended as a means of contraception in “high risk” patients as in those with a history of deep venous thrombosis,[11] type 1 diabetes mellitus,[12] liver disease,[13] epileptic seizures,[14] and immunocompromised conditions including HIV.[15] Nevertheless, like many therapeutics in contemporary medicine, Mirena has some side effects. Continuing pain and discomfort as well as irregular vaginal bleeding are most likely the main reasons for patients' requests to discontinue the Mirena device therapy.[16] Discontinuation is accompanied by return of fertility.[17] Contrary to old views, the device does not increase the incidence of pelvic inflammatory disease[18] and infertility, nor does it enhance tubal ectopic pregnancies in women with no sexually transmitted infections.[19] In fact, Mirena may be considered protective against infection, especially in nulliparous women.[20]

Uterine perforation related to the insertion of this device is one of the recognized side effects of Mirena. The incidence of such perforations varies from 0 to 2.6 per 1000 insertions and is largely related to the experience of the operating clinician.[21,22] Expulsion of the device, however, can happen in about 8 per 1000 insertions.[23] In case number 1 above, the uterine perforation was thought to have happened more than a year after insertion, because the patient had periodic speculum examinations initially every month for the first 3 months, then followed by 1 speculum exam every 3 months for the subsequent year. The “threads” of the Mirena device were clearly seen coming off the cervix. The patient remained completely asymptomatic until the device was laparoscopically removed after the threads ceased to be visualized through the cervix. Imaging, especially ultrasonography, has a crucial role in the evaluation and management of intrauterine contraceptive devices and associated complications.[24] Although it is difficult to be certain of the exact cause of “migration” of intrauterine contraceptive devices within the peritoneal cavity, a possible mechanism is that the peristalsis of the intestines could well assist this journey within the patient's abdomen after uterine perforation has occurred.

In case number 2, the patient experienced severe, excruciating pelvic pain, a common symptom of uterine perforation. Interestingly, there was no sign of perforation of the uterus on laparoscopic examination during the Mirena procedure. In relation to the management of this case, one may ask the question: Was it a good idea to insert the intrauterine contraceptive device immediately following STOP (Suction Termination of Pregnancy)? In fact, there is no evidence to support the idea that delayed insertion of the device carries fewer complications.[25] Immediate insertion after first- and second-trimester abortions has a high initial continuation and patient satisfaction rate.[26] Moreover, this simultaneous therapeutic approach assures the operating clinician and the patient that an unwanted pregnancy in the future is very unlikely with the Mirena device inserted on the same occasion as the termination of pregnancy is to be carried out.[27]

CONCLUSION

Because Mirena is gaining in popularity among clinicians and enjoys a wide range of candidacy among gynecological patients, it is imperative that health care providers are fully informed of the value as well as the possible side effects of the device, notably uterine perforation. An experienced gynecological endoscopist should be able to safely remove a missed Mirena out of the peritoneal cavity without any complications.