Sonographic Evaluation of Intrauterine Devices (IUDs) - SD

Introduction

My name is Dr. Anna Lev Toof from the Department of Radiology at the Hospital of the University of Pennsylvania.

This presentation will review the sonographic evaluation of intrauterine devices worldwide.

IUDs are the most commonly used reversible contraceptive method.

The use of IUDs in the United States is also increasing both for contraception and for local progestational effect.

Sonography has an important role in the evaluation of IUDs to confirm the correct position and to assess for complications.

Therefore, imagers need to know normal and abnormal appearances of IUDs.

The objective of this presentation is to review the types of IUDs and normal and abnormal sonographic appearances to discuss the role of 2D and 3D ultrasound review the pitfalls and artifacts related to IUDs as well as the complications.

Indications for the Use of IUDs

The indications for the use of IUDs includes reversible contraception in women with at least one full term pregnancy, the treatment of endometrial hyperplasia as part of a hormone replacement therapy regimen by providing local progestin in combination with estrogen given by another means, as well as more recently the treatment of excessive uterine bleeding, be it idiopathic adenomyosis or small fibroids.

Types of IUDs

These are the two IUDs that one is most likely to encounter in clinical practice.

On the left is the copper bearing paraguard IUD, which has a T shape, and on the right is the plastic morena IUD, which contains progesterone.

Note that the horizontal upper arms of the Mirena are angled inferiorly at their distal tips.

Inert IUDs

There are three types of IUDs, the inert, the copper bearing, and the hormone containing of the inert uds.

There are the plastic polyethylene IUDs that are impregnated with barium for radio opacity.

Some of these are of historic interests such as the lippy loop, which one may still occasionally see in an older woman the safety coil and the old dcon shield, which was very problematic, a widely used inert.

IUD is the stainless stainless steel ring that is very widely used in China.

And this is an image, a multiplanar image of the stainless steel IUD.

This IUD is not as effective as the IUDs that are most commonly used in the United States.

Here we see the ring in the coronal plane.

In this case a pregnancy occurred and we see that the IUD here represented by these two echo densities is adjacent to the gestational sac.

Note, the ring down artifact that traverses the gestational sac from the metallic ring.

Here is, the lippy loop in the coronal plane.

On a 3D image, we see the serpiginous course of the lippy loop and the typical clue to this IUD on 2D sonography are the five echogenic foci aligned in a straight line with shadowing.

Copper Bearing IUDs

Now of the copper bearing IUDs, the most common that you're likely to see is the paraguard T-shaped IUD, which is available widely in the United States and is effective for 10 years.

One may see also the copper seven IUD.

Now these copper IUDs have highly echogenic straight shafts or vertical portions, and they have crossbars that are also highly echogenic and that form the shape of a seven or a t.

The copper bearing IUDs, cause their effect by a local increase in copper levels, which leads to decreased sperm motility, irritation of the endometrium and possible ocid activity.

Hormone Containing IUDs

Finally, the hormone containing IUDs are used for contraception and endometrial hyperplasia treatment as part of hormone replacement therapy and the treatment of menorrhagia and anemia.

Of these most likely one encounters the Mirena, which includes a synthetic progestogen Levo norges, which is highly effective for five years.

Another one is the progess cert.

Now the morena IUD is T-shaped plastic polyethylene with barium sulfate.

For radiopacity.

It measures 32 millimeters in length and 32 millimeters across.

Both of the arms remember that the tips are angled down, at the end, so this should not be confused for fragmentation.

Now the vertical stem of this IUD has a reservoir containing the hormone, and is thicker than the remainder of the IUD.

The characteristic appearance of the Mirena is that only portions of this device are highly echogenic, unlike the copper IUDs.

So the Morena can present a problem with imaging.

The earlier versions of the Morena were very difficult to visualize sono graphically, and I'll show you examples of that.

And the string could actually be more echogenic than the IUD itself.

The more recent versions are more easily identifiable.

The vertical shaft is more echogenic, and the IUD string is slightly less echogenic.

The horizontal arms with their characteristic downturn distally are still difficult to image.

So again, this is what the IUD looks like.

The contraceptive effect is, mostly due to the local effect of progesterone women that are of fertile age still have ovulatory cycles with follicular rupture.

The other thing to note about this IUD is that the atresia of the follicle may be delayed because of the progesterone and the follicle may continue to grow so that enlarged follicles have been found in approximately 12% of women using the morena.

Reasons for Referral for Ultrasound in Women with IUDs

What are the reasons for referral for ultrasound in women with IUDs?

Commonly the thread is no longer visible or palpable and there is concern about expulsion or a broken thread or retraction into the uterus.

Also, there may be a clinically apparent change in the length of the thread, which suggests the possibility that the device has become displaced.

Now, increased menstrual flow, especially after a period of time where the flow has become diminished, which is what one expects may be a clue to expulsion pain raises concern for embedment.

There may be signs and symptoms or of infection or the patient may present with amenorrhea, which could be a sign of, concerning for pregnancy,

Technique for Evaluation

what is the technique that we use, to evaluate these patients?

We routinely do take a quick look transabdominally, but usually this is not sufficient.

Occasionally, because of their highly echogenic nature, one can determine the location of the copper IUDs transabdominally.

Usually though we use transvaginal sonography and when using 2D ultrasound, very careful scanning in multiple planes that are sagittal to the endometrium as well as coronal to the endometrium to try to recreate as it were in our minds.

The configuration of the IUD 3D ultrasound can be especially helpful for women with the difficult to visualize morena.

Finally, recording a cine clip can be helpful for study, after the examination to assess the, position of the IUD,

Complications and Findings of IUDs

what are the complications and findings of IUDs?

Myometrial penetration or embedment may decrease the contraceptive effectiveness of the IUD and may be seen in conjunction with pregnancy.

The embedded IUD is usually removed and it may be removed with some difficulty and it may require the patient to be taken to surgery.

Expulsion can be partial or complete abnormal position, fragmentation, pelvic infection.

And finally, pregnancy.

Intrauterine and ectopic need to be searched for.

Examples of Abnormal Positions and Complications

Now, here's an example of a case where the IUD is located in the cervical canal and when the IUD is in the cervical canal, it is less effective as a contraceptive.

And here we see that there is an early intrauterine gestation.

Here is a 3D image showing that the, long stem of the IUD is embedded, into the cervix.

Here is the short stem of the IUD in the cervical canal, and the other short stem is located in the upper cervical canal.

Here, another example of an IUD, the long stem is in the cervical canal and the short stem is perpendicular to it, coming out at us embedded in the lower uterine segment in the presence of an intrauterine pregnancy, which progressed normally uterine perforation is the most serious complication of IUD and the literature shows that the frequency varies between 0.05 and 13 per thousand insertions.

The frequency varies with the factors related to the patient, the operator, and the type of IUD.

It is important to be aware of the fact that approximately 15% of IUD related uterine penetrations lead to serious complications in adjacent visceral organs, primarily the intestines.

So obstruction penetration, intestinal infarction, mesenteric injury, rectal strictures and rectal uterine fistulas have all been described as complications of uterine penetration by intrauterine devices.

Normal Placement Examples

Now here are some 3D images of a normally placed T-shaped paraguard IUD.

Here are the horizontal stems and the vertical stems here in the coronal plane.

Again, this IUD is an optimal position with 3D ultrasound.

One can also use the multi slice display where we have multiple parallel slices in the same orientation.

And we can see here another T-shaped IUD notice that one of the horizontal arms is located in a slightly different plane, than the other arm.

But by going through the slices, one can determine that the IUD is intact and in fact is in a good location as is this t-shaped IUD,

Another para guard IUD in a normal location.

Here we see the characteristic double echoes of the horizontal arms and with the rendered 3D image, we can actually see the string of the IUD as well.

Here is a copper T-shaped IUD in a patient with an arcuate uterus.

So it is a little bit lower, than ideal, but given the fact that she has an arcuate uterus, this is probably an acceptable location here, a slightly older case an IUD that appeared in the sagittal plane to be either normal or slightly low in position.

When we explore the location of this IUD using 3D sonography, we note that there is the shadow of the long stem here and then when we manipulate the volume further, we can detect that there is embedment of one of the horizontal arms into the myometrium of the lower uterine segment.

Mirena IUD Examples

Here's an example of a Mirena IUD that is in the uterine cavity, but in which the very echogenic string simulated, the IUD being in the cervix.

So these are the initial 2D images and we have a highly echogenic structure in the lower uterine segment and cervical canal.

There were just a few little echoes foci of shadowing in the upper uterine cavity.

And the initial impression was that this was actually an IUD on its way out.

But further evaluation with 3D ultrasound was very helpful because we could use the artifact, the shadowing from the Mirena, which itself is not terribly echogenic, but we could use the shadowing to image it.

And here we see that the Mirena is in fact in a very good position and what we were seeing was the echogenic string.

So sometimes it's not, it's necessary to use the artifact from the IUD to actually confirm its position.

This woman had some abnormal bleeding and a history of polyp and the concern was is the IUD causing the intra menstrual bleeding or is there another polyp?

And here we see in the coronal plane pointed to by the yellow arrow that there is minimal myometrial embedment or penetration by this horizontal arm.

We actually performed a sonohysterogram to assess the cavity because there can be some difficulty assessing the cavity in the presence of the IUD and demonstrated that there was no polyp confirming the myometrial penetration here.

And the clinician was pleased as long as there was no polyp.

The inter menstrual bleeding itself was not clinically significant.

Now here is an example of the morena IUD notice that there is a curvilinear bright echo in the cervical canal.

Then when we get to the uterine cavity, we see multiple parallel echogenic lines and extensive shadowing in the sagittal plane.

And then when we come into the coronal plane, we have some shadowing from the long stem and then these are the horizontal arms in a coronal cut through the upper uterus.

Again, we have the double echo, but the other arm was not in the same plane and somewhat difficult to see and therefore our confidence was not great that in fact we could say that the IUD was in perfect position.

But again, using the shadow of the IUD to image, the IUD on 3D ultrasound, we see that in fact the IUD is intact and is in a normal location.

Here again is the echogenic string here, another example of the string looking very echogenic, some shadowing from the long stem of the IUD in the coronal plane.

Very difficult to see the horizontal arms of this marna.

IUD here is a cine clip which can be helpful.

Again, we see some shadowing from the long stem of the IUD, but hard to be sure about the horizontal arms, although we can see some punctate, echo echogenic fo foci as we go through it.

Again, much easier and more confident identification of this IUD using the 3D ultrasound.

There's no question that this is nicely placed in the endometrial cavity.

And here is the string that had withdrawn, into the uterine cavity and therefore was not clinically palpable.

Other Case Examples

This 3-year-old woman came in, with abdominal pain.

You can see here on the Topo Graham from the CT that she has a Mirena.

IUD.

The CT can tell us that the IUD is in the general vicinity of the uterus here in the lower uterine segment, but does not give us precise information about the location of the IUD with respect to the uterine cavity.

We see in this case that there is some infiltration and streakiness of the pelvic fat and in fact she had an acute early, PID another example of a woman that was referred because of a lost IUD string In this case, the IUD is highly echogenic with shadowing, this is probably a little bit of the string.

The horizontal arms here are seen nicely. Not much question.

In this case with 3D ultrasound though, we can see what happened to the string.

It didn't break off, but it's curled up, in the uterine cavity.

And here a plain film on a woman.

Again, the question was, is the IUD outside of the uterus? 'cause the string could no longer be palpated.

When you look on a plain film, you know the IUD is someplace in her body in the pelvis, but you really can't say where it is because we can't define the location, of the uterus.

Here on ultrasound, we see the echogenic string again, we see the linear, multiple linear parallel lines that represent the vertical stem of the IUD, the Mirena.

The horizontal arms are here, but difficult to see with confidence.

Again, a 3D ultrasound showing that the IUD is in a good position.

Keep in mind, again, one needs to remember that the distal aspects of the horizontal arms of the marna are bent inferiorly and you don't want to call that a, a broken IUD.

Now here is a topograph from a CT and a woman with a copper TIUD.

You see, it's much more radio opaque.

She presented with abdominal and pelvic pain.

Here we see that there's some beam hardening artifact, related to this metal IUD.

Notice again, we can say that the IUD is someplace in the uterus, but very hard to judge on CT exactly where it is because we don't really see the cavity, distinctly.

Unfortunately in her on ultrasound we see that this copper TIUD is located low.

It's in the lower uterine segment and in the cervical canal, the upper cervical canal.

And in this case we demonstrate an artifact which mimics fragmentation of the IUD.

This is the long stem here, the long stem here seen in cross-section with shadowing, and we actually see four echogenic structures radiating around the long stem.

And the first time that one observes this, it can be rather confusing.

Has the IUD become fragmented? What's going on here?

Is there more than one IUD? This is a video clip.

Notice that there, that of these four, Echo densities, two of them are more echogenic and two of them are less echogenic.

In fact, this is an artifact related that one sees with the copper IUDs.

These artifacts can mimic fragmentation and should not be mistaken for an abnormality.

Recent Literature and Applications

There are, quite a number of, articles in the literature, recently in the last couple of years because of the increased, use of IUDs both for contraception as well as for the treatment of abnormal bleeding.

And I encourage you, to become familiar with, these other applications of the IUD because you will be seeing them in perimenopausal and menopausal women and in women being treated for endometrial hyperplasia.

And there the concern is not so much contraception as it is, making sure that the IUD is in place in order to effectively treat the problem.

What If an IUD Is Not Visualized?

What next? What if an IUD is known or thought to be present but not visualized?

Sono graphically?

Further evaluation may include a plain film which will document the presence of an extra uterine IUD, but not the exact location.

Ct, will show the general location of the IUD and of course is very good for identifying associated complications.

Finally, a comment about the M-R-I-M-R.

I can show the IUD as a signal void.

Keep in mind that the safety of all of the metal containing IUDs at, the high field strength of three T has not yet been proven.

Conclusion

So in conclusion, intrauterine devices are increasingly being used for reversible contraception as part of hormonal replacement therapy and as treatment for excessive uterine bleeding and endometrial hyperplasia.

There is a lot of excitement regarding the application of the IUD for the latter indications because we may be able to reduce the need for endometrial ablation and hysterectomy.

Ultrasound plays a critical role in the evaluation of patients with IUDs.

It is incumbent upon imagers to be familiar with the appearance of IUDs and the pitfalls in their imaging.

And finally, 3D ultrasound may add significant information that can affect clinical management.

Thank you.