# An asymptomatic postmenopausal uterine perforation with bilateral embedment by a V-shaped intrauterine device: a case report

## TL;DR

A postmenopausal woman had a rare IUD perforation case requiring laparoscopic intervention, highlighting the risks of asymptomatic retained IUDs.

## Contribution

Demonstrates a novel combined hysteroscopic-laparoscopic approach for safely retrieving a deeply embedded IUD with multi-organ involvement.

## Key findings

- Postmenopausal IUD retention can lead to severe, asymptomatic perforation with extrauterine embedment.
- Ultrasound may underestimate the extent of IUD perforation, necessitating laparoscopic confirmation.
- Extreme traction resistance during hysteroscopy should prompt immediate conversion to laparoscopy for safety.

## Abstract

Retained intrauterine devices (IUDs) after menopause are common in China, yet their complications may be clinically silent. Uterine atrophy and rigid open-frame designs can permit gradual transmural erosion, leading to seemingly routine removal requests that conceal high-risk extrauterine involvement.

A 54-year-old asymptomatic postmenopausal woman presented for elective IUD removal. Transvaginal ultrasound suggested deep myometrial embedment with suspected serosal extension. During hysteroscopy, the device could be grasped but exhibited extreme traction resistance, raising concern for transmural perforation; the procedure was immediately converted to laparoscopy. Laparoscopy revealed a rare dual-site extrauterine embedment: one arm perforated the posterior uterine wall and was embedded in the pelvic peritoneum adjacent to the left ureter, while the contralateral arm traversed the fundus and was completely impacted within the right tubal isthmus. Right therapeutic salpingectomy and opportunistic contralateral salpingectomy were performed. Under laparoscopic visualization, the IUD was then safely retrieved through the uterine cavity with hysteroscopic guidance. The postoperative course was uneventful.

This case illustrates that postmenopausal IUD retention can culminate in severe, multi-organ-adjacent perforation without symptoms, and that ultrasound may underestimate the extent of extrauterine involvement. In hysteroscopic IUD removal, “extreme traction resistance” should be treated as an intraoperative red-flag prompting immediate cessation and conversion to laparoscopy. A combined hysteroscopic-laparoscopic strategy enables controlled dissection, organ protection, particularly the ureter and tube, and complete retrieval with minimal uterine trauma.