Objective. Indications for IUDs. IUDs 3 types. ParaGard IUD. Mirena IUD. Sonographic Evaluation of Intrauterine Devices (IUDs) Inert

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1 Sonographic Evaluation of Intrauterine Devices (IUDs) Anna S. Lev-Toaff, MD FACR Department of Radiology Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Leading Edge in Diagnostic Ultrasound Atlantic City, 2010 Worldwide, IUDs are most commonly used reversible contraceptive method. Use of IUDs in US is also increasing for contraception and local progestational effect. Sonography has important role in evaluation of IUDs, to confirm correct position and assess for complications. Therefore, imagers need to know normal and abnormal appearances of IUDs Objective To review the types of IUDs and normal and abnormal sonographic appearances Discuss the role of 2D and 3D ultrasound Artifacts related to IUDs Complications Indications for IUDs Reversible contraception in women w at least 1 full term pregnancy Treatment of endometrial hyperplasia HRT- local progestin comb w estrogen Treatment of excessive uterine bleeding idiopathic, adenomyosis,, small fibroids ParaGard IUD Mirena IUD Inert IUDs 3 types Copper-bearing Hormone-containing 1

2 IUDs Inert Plastic polyethylene w Ba sulfate Lippes Loope Stainless Steel Ring IUD Adjacent to Gestational Sac Saf-T-Coil Dalkon Shield (problematic) Stainless Steel Ring (China) QuickTime and a Sorenson Video decompressor are needed to see this picture. Lippes Loop Sagittal: 5 echogenic foci aligned in cavity with shadowing IUDs Copper bearing* Copper-7, Nova-T T (1970 s) ParaGard (T T Cu380A) available in US, effective for 10 years Have highly echogenic straight shaft and crossbars that form the shape of a 7 or a T 2DUS 3DUS *Local increase in copper levels leads to decreased sperm motility and irritation of endometrium,, possibly ovicidal. IUDs hormone containing* Progestasert - natural progesterone in reservoir, effective 1 year Mirena - synthetic progestogen, levonorgestrel,, highly effective for 5 yrs IUDs Mirena T-shaped plastic polyethylene w barium sulfate (for radiopacity), 32-mm vertical stem, 32-mm horizontal portion w arms tips angled down. Stem has reservoir containing levonorgestrel and silicone covered by a silicone membrane. * contraception, endometrial hyperplasia, part of HRT, menorrhagia/anemia 2

3 IUDs Mirena Characteristic appearance, portions highly echogenic,, unlike copper IUDs, which are more completely echogenic. Early versions of the Mirena IUD difficult to visualize sonographically; ; string could be very echogenic. More recent versions - more easily identifiable vertical shaft and slightly less echogenic but still readily identifiable string IUDs Mirena Contraceptive effect of Mirena mainly due to its local effect, ovulatory cycles w follicular rupture usually occur in women of fertile age using Mirena. Atresia of follicle may be delayed, follicle may continue to grow. Enlarged follicles in about 12% of the subjects using Mirena. Reasons for referral for US Thread no longer visible/palpable expulsion, broken thread, retraction into uterus; thread length --? displacement Increased menstrual flow (esp( after period of expected diminished flow) may be clue to expulsion Pain concern for embedment Signs/symptoms of infection Amenorrhea or other signs concerning for pregnancy Complications/Findings of IUDs Myometrial penetration or Embedment may decrease contraceptive effectiveness, result in pregnancy, embedded IUD usually removed (may be difficult), surgical removal may be necessary. Expulsion (partial/complete) Abnormal position Fragmentation Pelvic infection Pregnancy intrauterine and ectopic Complications Uterine Perforation Most serious complication of IUD. Multiplanar and Rendered Display of T-Shaped T ParaGard IUD Frequency of uterine perforation 0.05 and 13 per 1,000 insertions, varying w factors related to patient, operator and IUD. Approximately 15% of IUD-related uterine penetrations lead to complications in adjacent visceral organs, primarily intestines: obstruction, penetration, infarction, mesenteric injury, rectal strictures, rectouterine fistulas. 3

4 Multislice Display of T-shaped IUDs ParaGard IUD in Normal Position Copper-T T IUD in Arcuate uterus IUD in Uterus Appearing in Normal Position or Slightly Low on 2DUS Where is the IUD on 3D? IUD is penetrating the Myometrium 4

5 Where is the IUD? 2D images. Mirena IUD in Uterine Cavity: On 2D String Simulating IUD in Cervix 3DUS Mirena IUD T-shaped IUD, short arm minimal myometrial penetration Echogenic string 34 yo woman presents abd/pelvic pain Copper T IUD Copper T IUD in LUS/cervical canal- short arms in myometrium Artifacts mimicking fragmentation (yellow arrows) 5

6 Copper T IUD in cervical canal Artifacts mimicking fragmentation References 1. Intrauterine devices and intrauterine systems, Crosignani PG, Human Reproduction Update, 2008;14, Imaging of Intrauterine Contraceptive Devices, Peri N et al, J Ultrasound Med 2007; 26: Sonographic determination of the position of a levonorgestrel intrauterine device, Van Schoubroeck D et al, Ultrasound Obstet Gynecol 2009; 33: Clinical effects of the levonorgestrel-releasing intrauterine device in patients with adenomyosis. Cho S et al, Am J Obstet Gynecol. 2008; 198(4):373 What next? If an IUD is known/thought to be present but not visualized sonographically Further evaluation may include Plain film document presence of extrauterine IUD but not exact location CT will show location of IUD and associated complications. MRI can show IUD as signal void (safety of all metal-containing IUDs at 3 T has not yet been proven). Conclusions IUDs increasingly being used for reversible contraception, HRT, Rx excessive uterine bleeding and endometrial hyperplasia; reduce need for endometrial ablation and hysterectomy. Sonography plays a crucial role in the evaluation of patients with IUDs. Familiarity with appearances of IUDs and pitfalls in imaging important. 3DUS may add significant information that affects clinical management. 6

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