One successful intrauterine device into a uterus didelphys: a case report and literature review

¹University of Goma, Faculty of Medicine, Department of Obstetrics and Gynaecology, Goma, Democratic Republic of Congo, ²Regional Hospital of North-Kivu Province, Department of Obstetrics and Gynaecology, Goma, Democratic Republic of Congo, ³Global Medicine Centre and Laboratory, Goma, Democratic Republic of Congo, ⁴Nursing college of Kalemie, Kalemie, Democratic Republic of Congo

^&Corresponding author
Kasereka Muteke John, University of Goma, Faculty of Medicine, Department of Obstetrics and Gynaecology, Goma, Democratic Republic of Congo

Introduction    

Anatomical uterine disorder is a category 4 WHO medical eligibility for IUDs use, meaning a condition which represents an unacceptable health risk if the contraceptive method is used [1]. It is contraindicated because of its association with a high risk of malposition into the uterus, uterine perforation and its migration into the abdominal cavity and viscera [1]. However, women with such conditions also have the right to use effective contraceptive methods and an IUD use has been suggested in known and individualized women [2]. The purpose of this case report is to demonstrate that only one LNG-IUD contraception can be sufficient and effective method in known and selective women with uterus didelphys. However, a case-series study is needed for more evidence. We report the case of a 35-year-old woman known with uterus didelphys successfully using a LNG-IUD contraception for 15 months so far.

Patient and observation     

History: this is a 35 year-old, female, married, Para 4 and 6 abortions (P4 +6), living in Goma, Democratic Republic of the Congo, who came in our outpatient clinic “Global Medicine Centre and Laboratory” for family planning on 16^th April 2020. In her menstrual history, she had her menarche at 14 year-old, since then she experiences dysmenorrhea. She has a regular menstrual cycle. Her period lasts 4 to 5 days with normal flow. Her last menstrual period was on 10^th April 2020, used 3 to 4 vaginal pads per day. In her obstetric history: she is P4+6, with 4 living children, all born by cesarean section. She had recurrent pregnancy loss. She conceived once with a copper T 380-IUD in situ when then her condition of uterus didelphys was revealed to her at her Gravida 2, the pregnancy ended up in abortion at its 12 weeks of amenorrhea Table 1. In her past medical history, she has no chronic medical condition, no diabetes mellitus, she was tested negative for HIV. She has nor hypertension or hepatitis. In her past surgical history, she delivered her 4 children by cesarean section (Table 1), she had an ovarian cystectomy in 2019. She had six abortions with 2 dilatation and curettages and 2 manual vacuum aspiration procedures.

Drug use: no history of smoking and drug use.

Contraceptive history: she had to use combined oral contraceptive (COC) pills, period awareness, and IUD. We noticed that she conceived while using a copper IUD contraception.

Sexual activity: she had her first intercourse at her 19-year-old, since then she experiences chronic dyspareunia and pelvic pain. There is no history of sexual transmitted infection.

Physical examination and evaluation: on general examination, she is in fair general condition, her Body Mass Index (BMI) is 25.2, BP 128/82 mmHg, PR 88 bpm. The rest of the exam noted nothing special. On gynaecologic examination, vulva and vagina were normal, the uterus and its adnexa were not palpable due to abdominal obesity. On the speculum examination, there were two cervices. There was no vaginal septum. A pelvic ultrasound scan was made and revealed a uterus didelphys Figure 1.

Diagnosis and management: this is a P4 +6 with a uterus didelphys searching for family planning services. She was counselled about available contraceptive methods and selected an LNG-IUD that was inserted on that very day into her left uterus Figure 2.

Patient perspective: six months later, she had a three months secondary amenorrhea which was associated with endometrial atrophy revealed on ultrasound scan. At her last review (15 months later), she really appreciated her contraceptive method: there is no pregnancy, no more dysmenorrhea and her pelvic chronic pain is relieved.

Patient consent: informed consent was obtained from the patient prior to insert the LNG-IUD.

Ethics statement: publishing a case report does not require a permission from the university ethic committee.

Discussion     

Up to the fifth and sixth week of embryonic life, the genital system remains indifferent [3]. Two pairs of genital ducts are present at this time: the Wolffian duct (mesophrenic) and the Mullerian duct (paramesophrenic). In females, the absence of Mullerian inhibiting factor secreted by the Sertoli cells of the testis and SRY gene expressed on Y chromosome leads to the regression of Wolffian duct and to further development of Mullerian duct [3,4]. During the 7^th week, paired Mullerian ducts arise from focal invagination of the coelomic epithelium found on the upper pole of each mesonephros, then the Mullerian ducts grow caudally and laterally to the urogenital ridges [3]. In the eighth week, a vertical fusion of Mullerian ducts occurs. The upper third of the vagina, the cervix, both fallopian tubes and the uterus derive from the Mullerian ducts. When fusion does not occur it leads to a uterus didelphys [3]. At this stage, a midline septum is present but resorbs around 20 weeks. When resorption does not occur it leads to septate uterus [3]. Mullerian duct abnormalities have a part in subfertility of women with such conditions. Having a uterine anomalies is generally associated with poor pregnancy outcomes such as increased risk of spontaneous abortions, premature labour (only 45% have term delivery rate in uterus didelphys) and cesarean delivery due to breech presentation, and decreased live birth [5-9]. Our patient had a total of 10 pregnancies but 6 of them ended up in spontaneous abortion. The remaining 4 were all delivered by cesarean section. Little is known about the pathogenesis of recurrent pregnancy loss in Mullerian duct abnormalities [7].

Anatomical uterine disorder is a category 4 WHO medical eligibility for IUDs use, meaning a condition which represents an unacceptable health risk if the contraceptive method is used [1]. This is to prevent or to avoid complications due to their insertion into the uterus including IUDs expulsion, IUDs malposition in the uterus, uterine perforation and migration of IUDs into the abdominal cavity and viscera [10]. Actually IUDs should not be used in uterus didelphys. However this contraindication has been controversial for some authors suggesting that IUDs can still be inserted in selective and known patients with such a condition; and have successfully inserted them into the uterus didelphys [11]. However, in all literature we read through, all authors were using two IUDs into didelphys uterus. Our patient was known with uterus didelphys conditions and we successfully placed only one LNG-IUD into her left uterus. Since then she does not experience anymore dysmenorrhea and not getting pregnant. LNG-IUD is a long acting high effective and reversible form of contraception.

It works by thickening the cervical mucus, thinning the endometrium lining and stromal decidualization without affecting ovulation [12]. According to Attia et al. released LNG in the pelvis by the IUD leads to endometrial concentrations that are 200 to 800 times superior to those found after daily oral use [12]. This explains its use in management of other gynaecological conditions such as endometriosis, adenomyosis, heavy menstrual bleeding, dysmenorrhea, endometrial hyperplasia [10,12,13]. The LNG-IUD has proven its effectiveness in relieving pelvic pain symptoms caused by peritoneal and rectovaginal endometriosis. Intrauterine administration of LNG with direct distribution to pelvic tissues would imply a local concentration resulting in endometrial glandular atrophy and extensive transformation of the stroma, endometrial cell proliferation down regulation, increasing of apoptotic activity [14]. Considering this mechanism and high LNG concentration in the pelvis, we thought using only one LNG-IUD might be sufficient to achieve an effective contraception for two uteri, inversely to other authors we read through using a LNG-device in each uterus [2].

We couldn´t choose Copper IUD because of its mechanism: the presence of copper IUD makes the uterus a toxic environment for sperm and ova, impairing implantation. Specifically, cytotoxic peptides formed from a sterile inflammatory reaction inhibit sperm mobility, reduce sperm capacitation and survival and enhance sperm phagocytosis [10]. Abdala Moussa et al. described in their case report an untended pregnancy with Cu T 380 in situ in the other horn of the uterus [15]. This happened to our patient at her gravida 2: in her obstetrical history we noticed that she conceived while using a Cu T 380 IUD contraception and the pregnancy ended up in spontaneous abortion. Considering its mechanism, we think only one Cu T 380 can´t be enough to protect against pregnancy in two uteri unless two Cu T 380 IUDs are inserted at once, one in each uterus. Most women with a didelphys uterus are asymptomatic, but may present with dyspareunia or dysmenorrhea in the presence of a vaginal septum and/or an endometriosis [5]. We think our patient might have peritoneal endometriosis in regard to dyspareunia, dysmenorrhea and her chronic pelvic pain which all were relieved with LNG-IUD use.

Conclusion     

This is a case report of a 35 year-old woman, P4 +6, with uterus didelphys using successfully one LNG-IUD contraceptive. After one year and three months she is satisfied with the method and we think only one LNG-IUD might be an effective contraception instead of an IUD in each uterus. However, case-series study is needed for more evidence.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

We all managed the case, followed up and wrote-up the manuscript. All the authors have read and agreed to the final manuscript.

Table and figures     

Table 1: obstetric history

Figure 1: uterus didelphys before LNG-IUD insertion

Figure 2: LNG -IUD in situ, into the left uterus

References