Design: Stepwise demonstration using narrated video footage

Setting: Academic tertiary care hospital

Patients or Participants: A 47-year-old G1P0101 with an enlarged multifibroid uterus who presented with chronic vaginal discharge thought to be related to a retained embedded intrauterine device following a uterine artery embolization. All prior vaginal cultures and tests were negative and the discharge persisted despite treatment. Pelvic MRI showed a 15 cm uterus with numerous fibroids significantly distorting the uterine parenchyma with the intrauterine device embedded in a submucosal fibroid. Patient declined hysterectomy and opted for conservative surgical management with hysteroscopic removal.

Interventions: Hysteroscopic partial myomectomy of a calcified fibroid and removal of the embedded intrauterine device.

Measurements and Main Results: Entry into the uterine cavity was difficult due to extreme anteversion and calcium deposits in the cervical canal requiring resection. The uterine cavity was difficult to traverse due to distortion from multiple calcified submucosal fibroids without normal endometrium. The embedded intrauterine device was eventually located on the anterior surface of the uterus near the fundus and was removed successfully without complication after partial hysteroscopic myomectomy.

Conclusion: Intrauterine devices embedded in submucosal fibroids can be removed safely, via a hysteroscopic approach with a partial or complete myomectomy, through careful preoperative planning with an MRI to locate the intrauterine device and location of the submucosal fibroids. Our recommendation is to remove all retained intrauterine devices before uterine artery embolization as the fibroid degeneration and calcification process can complicate future removal. Chronic vaginal discharge related to an embedded intrauterine device will likely not resolve or improve without removal.