Vaginoscopic technique combined with bypass intrauterine device removal: a novel method using in difficult intrauterine device removal

Introduction

Background

China accounts for two-thirds of the global population with intrauterine devices (IUDs) (1). The success rate of IUD removal is influenced by factors such as IUD type, duration of placement, history of cesarean section or cervical surgery, menopausal status, operator proficiency, and intrauterine adhesions (IUA) (2-4). Traditional ultrasound-guided IUD removal necessitates cervical pretreatment, speculum insertion, cervical clamping and dilation, and assessment of uterine cavity depth and IUD position. However, this method fails to confirm the IUD type or uterine cavity conditions, often causing significant patient discomfort. Challenges such as uterine flexion or IUD incarceration (particularly with metal coil devices) further increase procedural difficulty, elevating risks of uterine perforation, intestinal injury, and postoperative infection (5). In postmenopausal patients, vaginal and cervical atrophy render cervical clamping or traction unfeasible. Cervical stenosis and adhesions obstruct safe instrument passage, while blind exploration of uterine cavity depth significantly raises perforation risks.

Rationale

The vaginoscopic technique, combined with bypass IUD removal, is performed without cervical pretreatment, anesthesia, or dilation (6). Under direct vaginaoscopic visualization, the procedure enables atraumatic access through the vagina into the cervical canal and uterine cavity. For cases involving cervical stenosis, adhesions, or IUD embedment, 5-Fr scissors may be utilized for adhesiolysis. The IUD retrieval hook demonstrates superior strength and durability compared to 5-Fr instruments, alongside enhanced cost-effectiveness (priced at only $5 per unit). A slender, straight IUD retrieval hook is essential. The hook is secured at the irrigation port of the inner sheath without requiring passage through a 5-Fr working channel. The hysteroscope and retrieval hook are advanced simultaneously into the uterine cavity, minimizing patient discomfort. The IUD is extracted under continuous visualization, ensuring precise and safe removal.

Objective

The vaginoscopic technique combined with the bypass IUD removal method enables direct visualization for difficult IUD removals, reduces 5-Fr instrument damage, and enhances cost-effectiveness. This approach is particularly suited for postmenopausal patients and resource-limited settings, improving procedural safety, increasing success rates, and minimizing device-related complications. We present this article in accordance with the SUPER reporting checklist (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-48/rc).

Preoperative preparations and requirements

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images and videos. A copy of the written consent is available for review by the editorial office of this journal.

Instrument requirements: Shenda ZG-3A 30° hysteroscope; 5-Fr working channel; 13-Fr × 220 mm inner sheath; 16-Fr × 210 mm outer sheath; Soder 5-Fr × 380 mm pointed tip, single joint scissors; Soder 5-Fr × 380 mm rotatable foreign body forceps, Xinhua IUD retrieval hook ZG002C 280 mm.

Preoperative preparation: no cervical pretreatment, no speculum, no cervical clamping and dilation, no uterine exploration, and no B-ultrasound guidance.

Procedure location: outpatient gynecology operating room; anesthesia-free; no hospitalization required. This case involves a 70-year-old patient with a history of IUD placement for 40 years and 20 years post menopause.

Step-by-step description

Remove the outer sheath of the hysteroscope, keep the inner sheath (Figure 1).

Figure 1 Remove the outer sheath of the hysteroscope and keep only the inner sheath.

Video 1: evaluate vaginal and cervical pathologies to rule out contraindications. Identify the cervical internal os for subsequent instrument navigation. Dissect adhesions or stenotic tissue using 5-Fr scissors to access the uterine cavity. True canal: loose tissue texture, absence of patient discomfort, and clear fluid efflux. False canal: dense tissue resistance, patient-reported pain, and active hemorrhage. Advance the distal end of the hysteroscope slowly through the cervical isthmus, employing intermittent advancement or withdrawal to minimize mucosal trauma. Perform continuous saline irrigation to clear intrauterine effusion and optimize visualization. Identify the ostium of at least one fallopian tube to confirm anatomical orientation. Conduct a comprehensive survey of the endometrial cavity, documenting adhesions, polyps, or other pathologies.

Video 2: resolve adhesions in the central uterine cavity to optimize visualization and instrument maneuverability. Maintain optimal working distance between instruments and the endometrium. Minimize rotational or lateral movements to reduce patient discomfort and enhance procedural efficiency. If bleeding occurs, pause and reassess under direct visualization before proceeding. Dilate the uterine isthmus with 5-Fr scissors to expand hysteroscopic maneuvering space, particularly critical for IUD incarceration cases. Position the hysteroscope parallel to the uterine cavity axis. Align instruments with the midline of adhesions and dissect along the IUD’s longitudinal plane. Elevate the IUD using the distal tip of the hysteroscope rather than dissecting from above. Keep 5-Fr scissors strictly along the medial edge of the IUD; do not extend beyond the lateral edge to prevent uterine perforation. Utilize ultrasound guidance if anatomical uncertainty persists. Ensure full separation of embedded IUD segments prior to removal. The endometrial polyp will be treated later.

Video 3: the bypass IUD removal technique is employed for the following reasons (Figure 2).

Figure 2 IUD removal resistance diagram. IUD, intrauterine device.

Remove the outer sheath, retaining only the inner sheath (Figure 1). Select a slender, straight IUD retrieval hook (Figure 3) and secure it at the irrigation port of the inner sheath (Figure 4), aligning it with the sheath’s lateral groove. The retrieval hook operates externally to the 5-Fr working channel, ensuring unobstructed maneuverability. The combined diameter of the hysteroscope and retrieval hook remains ≤6 mm, minimizing cervical trauma.

Figure 3 Comparison of two IUD removal hooks. IUD, intrauterine device.

Figure 4 Hysteroscope, IUD removal hook, and operating gestures. IUD, intrauterine device.

Secure the retrieval hook with the index finger of the right hand, maintaining continuous tension to prevent disengagement during retrieval (Figure 4).

Position the light guide bundles at the 3 o’clock direction to optimize intrauterine illumination. Advance the hysteroscope and IUD retrieval hook simultaneously into the uterine cavity without speculum placement. Extend the IUD retrieval hook 1.5 cm beyond the distal end of the hysteroscope. Engage the inferior edge of the IUD under direct visualization (Figure 5). Maintain a 1 cm working distance between the hysteroscope lens and the IUD to ensure clear visualization. Withdraw the hysteroscope, IUD, and retrieval hook together in a controlled manner (Figure 5).

Figure 5 Distance of working and field of view.

Video 4: the vaginoscopic technique enables simultaneous diagnosis and treatment of uterine cavity pathologies in postmenopausal patients through a single-step procedure. For endometrial polyps, the use of 5-Fr scissors allows atraumatic dissection by peeling rather than aggressive resection, minimizing tissue trauma while prolonging instrument longevity.

Postoperative considerations and tasks

Postoperative care should prioritize monitoring patient pain levels, implementing infection prevention measures, and scheduling a follow-up ultrasound (B-ultrasound) within 3 to 6 months to rule out complications such as intrauterine fluid accumulation or pyometra.

Tips and pearls

• Use a ≤4.5 mm vaginoscope with a 5-Fr working channel, eliminating the need for a speculum.
• No cervical pretreatment is needed.
• The IUD retrieval hook is cost-effective, mechanically robust, and resistant to damage, making it a reliable tool for complex removals.
• The IUD retrieval hook does not require passage through the vaginoscope’s 5-Fr working channel, simplifying the procedure and reducing instrument wear. Use a straight retrieval hook secured at the inner sheath’s irrigation port. The 6 mm combined diameter ensures atraumatic passage through the cervical isthmus, reducing patient pain.
• The hysteroscope, IUD retrieval hook, and IUD must be withdrawn simultaneously under direct visualization to ensure safe and complete removal.
• Enables instant diagnosis and treatment of intrauterine diseases, ensuring speed and efficiency.

Discussion

Traditional IUD removal under ultrasound guidance poses significant challenges, particularly in postmenopausal patients. Difficulties include speculum placement, cervical clamping, and accurate assessment of uterine cavity depth, often resulting in the inability to confirm the correct cervical canal, IUD type, or intrauterine position of the IUD. Blind exploration of the uterine cavity increases the risk of complications such as uterine perforation, cervical laceration, massive hemorrhage, intestinal injury, and bladder trauma.

In patients with a history of cesarean section or IUD embedment (especially with metal coil IUDs) (7-16), blind removal may lead to uterine artery rupture, cervical laceration with bleeding, or IUD entrapment in the cervical canal, significantly increasing procedural risks, complexity, and patient discomfort.

Surgical highlights

The vaginoscopic technique combined with bypass IUD removal eliminates the need for speculum use, cervical clamping, or cervical dilation, significantly reducing patient discomfort. This approach allows direct access to the cervix and uterine cavity without requiring blind exploration of uterine depth or IUD position. 5-Fr scissors are used to dissect stenosis and adhesions, enabling precise visualization of the IUD type and position and facilitating simultaneous diagnosis and treatment of intrauterine pathologies.

The IUD retrieval hook does not require passage through the 5-Fr working channel; instead, it is secured at the irrigation port of the inner sheath, aligned with its lateral groove. The hysteroscope and retrieval hook are advanced simultaneously into the uterine cavity, and the hysteroscope, IUD, and hook are withdrawn together under direct visualization, enhancing procedural safety and success rates.

The retrieval hook provides sufficient mechanical strength to extract the IUD, particularly in cases of IUD embedment or postmenopausal patients with metal coil IUDs.

Strengths and limitations

Strengths

Use a miniaturized vaginoscope with an outer diameter ≤4.5 mm to minimize patient discomfort and accurately locate the IUD. The bypass IUD removal technique eliminates the need for the IUD retrieval hook to pass through the 5-Fr working channel. Instead, the hysteroscope, IUD, and retrieval hook are withdrawn together under direct visualization, ensuring safe and complete removal. This entire process is performed without the need for ultrasound guidance, relying solely on hysteroscopic visualization for precision and safety.

Limitations

This surgical approach cannot be performed without a miniaturized vaginoscope (outer diameter ≤4.5 mm) and a slender, straight IUD retrieval hook. These instruments are essential, particularly for postmenopausal patients, as they enable atraumatic access and precise manipulation in cases of cervical stenosis, adhesions, or IUD embedment. To qualify for performing this advanced procedure, surgeons must independently complete at least 500 conventional hysteroscopic surgeries and perform 100 vaginoscopic procedures under the guidance of senior physicians, demonstrating proficiency in the use of 5-Fr cold knife instrumentation and mastery of standard IUD retrieval techniques, including adhesion dissection and atraumatic device extraction, to ensure safe and effective implementation of this minimally invasive approach.

Comparison with other surgical techniques and researches

Traditional hysteroscopic IUD removal requires anesthesia, speculum placement, and cervical clamping and dilation, making the procedure particularly challenging for postmenopausal patients due to cervical atrophy and stenosis. Additionally, the IUD retrieval hook cannot be advanced through the hysteroscopic working channel, and the use of 5-Fr forceps often results in instrument damage or slippage during IUD extraction, further complicating the procedure.

Implications and actions recommended

This procedure was completed in 15 minutes, whereas traditional hysteroscopic requires at least 60 minutes. Traditional IUD removal may take over an hour and even result in failure when encountering IUD embedment. It is recommended that vaginoscopic technique combined with bypass IUD removal should be adopted for postmenopausal patients who need to remove IUDs, especially metal coil IUD.

Conclusions

The vaginoscopic technique combined with bypass IUD removal is performed without ultrasound guidance, relying solely on direct visualization throughout the entire procedure. This approach eliminates the need for speculum use, cervical clamping, cervical dilation, or blind exploration of uterine cavity depth and IUD position. The IUD retrieval hook is cost-effective, mechanically robust, and resistant to damage.

In the bypass IUD removal method, the IUD retrieval hook does not require passage through the hysteroscope’s 5-Fr working channel. Instead, it is secured at the irrigation port of the inner sheath, allowing the hysteroscope and retrieval hook to enter the uterine cavity simultaneously. Under direct visualization, the hysteroscope, IUD, and retrieval hook are withdrawn together, ensuring a safe and efficient procedure that minimizes patient discomfort and instrument damage.

This technique is particularly suitable for postmenopausal patients, as the retrieval hook provides sufficient mechanical strength to extract the IUD, even in cases of IUD embedment or metal coil IUDs. Its clinical efficacy and safety make it a valuable approach worthy of widespread adoption and application.

Acknowledgments

The videos were awarded the first prize in the ANX Cup Hysteroscopic-Vaginoscopy Technical Skill Competition [2024].

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-48/rc

Peer Review File: Available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-48/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.com/article/view/10.21037/gpm-24-48/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images and videos. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Li ZR, Qin MY, Qian X, et al. A review on removal of intrauterine device in postmenopausal women in China. Chinese Journal of Reproduction and Contraception 2022;42:652-7.
2. Chinese Medical Association Family Planning Branch. Guideline for the removal of intrauterine device after menopause. Zhonghua Fu Chan Ke Za Zhi 2019;54:649-53. [PubMed]
3. Jing X, Yang JG, Zhang L, et al. Multiple logistic analysis on correlation factors of removal intrauterine contraceptive device in difficulty in postmenopausal women. Chinese Journal Of Family Planning & Gynecotokology 2010;2:6-9.
4. Yin C, Bai WP. Analysis on the influencing factors,and the prevention and treatment of difficult intrauterine device removal of menopausal women. Chinese Journal of Family Planning 1814;2021:1808-10.
5. Kang JZ, Xiao ZQ, Huang YM, et al. Situation on the Removal of Intrauterine Device in Shanghai. Journal of Practical Obstetrics and Gynecology 2011;27:127-30.
6. Bettocchi S, Selvaggi L. A vaginoscopic approach to reduce the pain of office hysteroscopy. J Am Assoc Gynecol Laparosc 1997;4:255-8. [Crossref] [PubMed]
7. Wang Y, Li Y, Lai Y. Office hysteroscopy to guide intrauterine device hook use for the removal of a deeply embedded intrauterine device. Contraception 2024;132:110366. [Crossref] [PubMed]
8. Patacchiola F, Altobelli E, Di Febbo G, et al. Chinese IUD removal techniques in a Chinese population in central Italy. Clin Exp Obstet Gynecol 2015;42:480-4. [Crossref] [PubMed]
9. Chang EJ, Sokol DC, Phung KG. Use of an In-Office, Handheld Hysteroscopy System (ENDOSEE) for Difficult Intrauterine Device (IUD) Removal. J Minim Invasive Gynecol 2018;25:S121-2. [Crossref]
10. Miles S, Chan D, Guido R. 56: use of resectoscope to remove fractured intrauterine device (IUD). American Journal of Obstetrics & Gynecology 2020;222:S852-3. [Crossref]
11. Cheung VY. A 10-year experience in removing Chinese intrauterine devices. Int J Gynaecol Obstet 2010;109:219-22. [Crossref] [PubMed]
12. Xia E, Duan H, Huang X, et al. Hysteroscopic removal of foreign bodies and its method of monitoring. Chin Med J (Engl) 2003;116:125-8. [PubMed]
13. Zhao Y, Wang Y. Ultrasound Combined With Single-Use Cervical Dilation Sticks And Lidocaine Achieved Good Clinical Outcomes In Hysteroscopic Removal Of The Intrauterine Device: A Pilot Study. Altern Ther Health Med 2023;29:48-51. [PubMed]
14. Vitale SG, Di Spiezio Sardo A, Riemma G, et al. In-office hysteroscopic removal of retained or fragmented intrauterine device without anesthesia: a cross-sectional analysis of an international survey. Updates Surg 2022;74:1079-85. [Crossref] [PubMed]
15. Liu L, Chi Y, Wang Y, et al. A novel hysteroscopic hook for extracting retained contraceptive intrauterine devices under direct vision. Eur J Contracept Reprod Health Care 2015;20:136-40. [Crossref] [PubMed]
16. Cohen SB, Bouaziz J, Bar-On A, et al. In-office Hysteroscopic Extraction of Intrauterine Devices in Pregnant Patients Who Underwent Prior Ultrasound-guided Extraction Failure. J Minim Invasive Gynecol 2017;24:833-6. [Crossref] [PubMed]