INTRODUCTION: There are no guidelines for management of an intrauterine device (IUD) during surgery in which a uterine manipulator is used, with practices varying from preemptive removal and replacement versus replacement only if dislodged. OBJECTIVE: We aimed to determine the prevalence of IUD displacement with manipulator use and compare demographic and clinical characteristics among individuals who had a dislodged IUD during endometriosis surgery contrasted with those who did not. METHODS: We conducted a retrospective chart review of patients who had a laparoscopic excision of endometriosis surgery between 2019 and 2024 by a minimally invasive gynecologic surgery (MIGS) division in an academic hospital. Demographic and clinical information were gleaned from the electronic health record. The outcome was a documented dislodged IUD at the time of surgery or signs, symptoms, and/or imaging of a malpositioned IUD within 6 months after surgery, which was presumed to be related to the surgery. We used chi-square statistics and t-tests to compare the distribution of demographic and clinical variables among those who had a dislodged IUD compared to those without. Statistical significance was set to p<0.05, and statistical analysis was performed using Stata version 19 (College Station, TX: StataCorp LLC). RESULTS: Seven-hundred and fifty-five patients with a uterus had a laparoscopic excision of endometriosis without a concurrent hysterectomy or hysteroscopy. Of the 755 patients, 77 (10.2%) planned on same IUD continuation after surgery. In total, 16/77 (20.8%) had their IUD dislodged, with 12/16 (75.0%) noted intraoperatively, and 4/16 (25.0%) diagnosed within 6 months postoperatively. Of the 4 diagnosed postoperatively, 2 (50%) required removal in the OR. The RUMI ® was the most common brand of manipulator used (35/77, 45.5%). When compared to all other manipulators used (V-care®, Zumi®, and sponge stick), RUMI® was significantly less likely to be associated with IUD dislodgement at any time than the other grouped manipulators (3/35 versus 13/42, p=0.023). No significant difference was noted in dislodgement by IUD type, gravidity, or parity. Of 755 patients, 6 planned IUD removal, 26 planned IUD replacement, and 114 planned IUD placement. CONCLUSIONS: Approximately a fifth of patients who underwent endometriosis surgery with a uterine manipulator experienced a dislodged IUD. Dislodged IUDs were more likely to be discovered during surgery than postoperatively. However, 25% of the time, there was a delay in diagnosis of displacement, which was presumed to be due to the uterine manipulator. The RUMI ® was less likely to be associated with IUD dislodgement than other manipulators. There was no evidence of association between demographic or other clinical factors that could help predict who might experience a dislodgement. Patients suffering from endometriosis may be hesitant to accept the risk of a delay in diagnosis of dislodgement, particularly if they find a speculum exam and/or IUD replacement in clinic painful. Surgeons should consider counseling patients about the risk of dislodgement during surgery with possible need for subsequent removal and may want to offer IUD replacement preemptively as an option.
Sullender et al. (Fri,) studied this question.