Infertility caused by an unnoticed intrauterine contraception device: Case series.

This is a 32-year-old para 4 mother who presented with a 4-year history of inability to conceive. She stated that the last delivery was 4 years prior to the current visit, and it was an early neonatal death. She stated that after the last delivery she had PPH (postpartum haemorrhage), for which manual exploration and manipulation of the uterus were performed. She claims that she has never used any type of contraception since her last delivery. However, upon speculum examination, the thread of IUCD was visible, and it was confirmed with ultrasound that there was IUCD inside the uterus. During the speculum examination, the thread was grasped and removed. Despite the IUCD presence in her uterus, she denied receiving any counselling about the provision of contraception during pregnancy, delivery, or postpartum. After the removal of the IUCD, she never came back.

Infertility is defined as the inability of the couple to conceive despite unprotected sexual contact of 1-year duration. It affects about 10%–15% of couples all over the world and their socioeconomic status in addition to the reproductive health. Also, it is one of the reasons for divorce, especially in low-income countries. 1 – 3 Causes of infertility can be classified as female, male, or unexplained factors. Female factor infertility is further subdivided into ovulatory, tubal, uterine, cervical, and vaginal factors. While male factor infertility is subdivided into pre-testicular, testicular, and post-testicular. 4 , 5 Among uterine factors are anatomical abnormalities of the uterus, either congenital or acquired, such as uterine didelphys, septate uterus, arcuate uterus, uterine myoma, Asherman syndrome, adenomyosis, and others can cause infertility. 6 , 7 Unnoticed intrauterine contraceptive device (IUCD) causing infertility is an extremely rare event, with only a few case reports of women who forgot that they had IUCD inside their uterus. In this report, I will discuss three women who came to the clinic for an infertility work-up and were found to have unnoticed IUCD in their uterus. 8 – 11

Infertility is described as the inability of a couple to conceive after 12 or more months of unprotected sexual activity as the result of either male or female reproductive issues. It can be classified as primary or secondary. Primary infertility is when a person has never been able to conceive, while secondary infertility is when at least one past pregnancy has happened. Worldwide, infertility affects millions of people of reproductive age (10%–15% of couples), which has an effect on their families and communities. Worldwide, it is estimated that 48 million couples and 186 million individuals struggle with infertility. Approximately 85% of infertile couples have an identifiable cause. The three most common causes of infertility are ovulatory dysfunction, male factor infertility, and tubal disease. The remaining 15% of infertile couples have unexplained infertility. 1 , 2 , 12 , 13 IUCDs are one of the long-acting reversible contraception (LARC) methods in which fertility returns immediately after removal. Although there are rumours and myths about IUCD causing infertility in nulliparous women, multiple studies have found that IUCD does not cause infertility. Counselling, on the other hand, is an important part of family planning and one of the sexual and reproductive health rights. The woman should receive proper counselling regarding the benefits and drawbacks of various contraceptive techniques prior to receiving any sort of contraception, and only after having a complete understanding should she make a voluntary, informed decision. Women who are thinking about using LARC methods should get thorough information, both verbally and in writing, to help them choose and employ a method. In order to rule out infection, perforation, or expulsion, patients should also receive a follow-up appointment following their first menstrual cycle or 3 to 6 weeks after the device was implanted. Three of the above patients received no contraception counselling and were not informed about their IUCD inside their uterus. 8 – 11 , 14 – 18 Although uncommon, a forgotten IUCD is a potential cause of unexplained infertility and a differential diagnosis for gynaecologic symptoms. A diagnostic examination should be performed in a methodical, speedy, and cost-effective manner during the infertility work-up to identify all relevant factors, with an initial emphasis on the least invasive procedures for discovering the most prevalent causes of infertility. Pelvic examination is one of the required physical examinations, and pelvic ultrasonography, either transabdominal or transvaginal, is one of the first lines of investigation for all infertile women. All three women didn’t know that there was IUCD inside them, and during the initial work-up of the infertility, if a pelvic examination and ultrasound had been conducted, the IUCD might have been easily recognised, removed, and unnecessary costs prevented. 7 , 8 , 19

Infertility caused by an unnoticed IUCD is a rare event; however, in this report, three women had IUCD insertions at different health institutions without their knowledge, which violates their reproductive rights. So, before providing any type of contraception to any woman, the health provider should provide counselling, ensuring that she understands the type of contraception and that choices are made based on voluntary, informed decision-making.