• intrauterine systems

I read with interest Dr Agarwal's case report on incomplete intrauterine system (IUS) removal1 in the July 2014 issue of this Journal. Having just read the article yesterday, I had an advice call from a clinician who suspected she had removed an IUS and left the horizontal arms in the uterine cavity.

I had a similar case a few years ago where it was noted that when the IUS was removed the levonorgestrel sleeve had moved upwards along the IUS stem, trapping the horizontal arms in a vertical position inside the sleeve. When I moved the sleeve down towards its usual position the horizontal arms were present. When the aforementioned clinician checked the removed IUS today it transpired that this was the case here too.

I am not convinced that the horizontal arms are missing in Figure 1 in Dr Agarwal's case report.1 The levonorgestrel sleeve appears to sit too high from the end of the IUS compared to normal placement. A measurement against the IUS would have made this easier to determine. It would be unusual not to identify the arms at hysteroscopy and yet see them on ultrasound scan. However, transvaginal ultrasonography can be difficult when trying to identify an IUS, and I wonder if in fact this was artefact and that the hysteroscopy was correct. If Dr Agarwal still has the IUS it might be worth going back to check if the arms are within the sleeve.