Case report | Volume 6, Article 38, 03 Aug 2021 | 10.11604/pamj-cm.2021.6.38.29179

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

Kasereka Muteke John, Kaboko Mbilika Kevin

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

Received: 04 Apr 2021 - Accepted: 02 Aug 2021 - Published: 03 Aug 2021

Domain: Reproductive Health

Keywords: Uterus didelphys, levonorgestrel-intrauterine device, case report

©Kasereka Muteke John et al PAMJ - Clinical Medicine (ISSN: 2707-2797). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cite this article: Kasereka Muteke John et al . One successful intrauterine device into a uterus didelphys: a case report and literature review. PAMJ - Clinical Medicine. 2021;6:38. [doi: 10.11604/pamj-cm.2021.6.38.29179]

Available online at: https://www.clinical-medicine.panafrican-med-journal.com/content/article/6/38/full

Home | Volume 6 | Article number 38

Case report

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

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

Kasereka Muteke John1,2,3,&, Kaboko Mbilika Kevin4

 

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

 

 

Abstract

Uterus didelphys represents a uterus malformation where the uterus is present as a double organ due to embryonic fusion failure of the mullerian ducts. As a result, there is a double uterus with separated cervices. This congenital malformation used to be a controversial contraindication of an intrauterine device (IUD) insertion. It is a category 4 WHO medical eligibility criteria: not being used because of its association with a high risk of IUD expulsion, malposition into the uterus, uterine perforation and its migration into the abdominal cavity and viscera. We present and discuss the case of a 35-year-old woman, P4+6, known with uterus didelphys who came to our outpatient clinic for family planning. She was counselled about all available methods and opted for a levonorgestrel IUD (LNG-IUD). We inserted the device into one of her double uterus and she is fully satisfied with the method now one year and three months ago. Levonorgestrel IUD is a long acting, highly effective and reversible form of contraception that works mainly by thickening of the cervical mucus and also by thinning the endometrial lining. Considering its effect on the endometrium and the cervical mucus; and its high level of progesterone pelvic release, we think one LNG-IUD contraception into one of the double uterus is enough and effective in individualized and known women with such condition instead of two IUDs, one being into each uterus, such published in all articles we read through. 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.

 

 

Introduction    Down

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 Up    Down

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 16th 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 10th 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    Down

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 7th 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 Up    Down

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 Up    Down

The authors declare no competing interests.

 

 

Authors' contributions Up    Down

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 Up    Down

Table 1: obstetric history

Figure 1: uterus didelphys before LNG-IUD insertion

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

 

 

References Up    Down

  1. Serfaty D. Update on the contraceptive contraindications. Journal of Gynecology Obstetrics and Human Reproduction. 2019;48(5):297-307. PubMed | Google Scholar

  2. Oelschlager AMA, Kate Debiec, Elizabeth Micks, Sarah Prager. Use of the levonorgestrel intrauterine system in adolescents with known uterine didelphys or unicornuate uterus. Journal of Pediatric and Adolescent Gynecology. 2013;26(2):e58. Google Scholar

  3. Moncada-Madrazo M, Cristobal RV. Embryology, uterus. StatPearls. 2020. PubMed | Google Scholar

  4. Patel N, Anoosh ZG. Gondal, Embryology, Mullerian-inhibiting factor. StatPearls. 2020. Google Scholar

  5. Rezai S, Bisram P, Lora Alcantara I, Upadhyay R, Lara C, Elmadjian M. Didelphys uterus: a case report and review of the literature. Case Reports in Obstetrics and Gynecology. 2015;2015;865821. PubMed | Google Scholar

  6. Katke RD, Acharya S, Mourya S. Uterus didelphys with pregnancy and its different maternal and perinatal outcomes. Int J Reprod Contracept Obstet Gynecol. 2017;6(10):4690-3. Google Scholar

  7. Saravelos SH, Cocksedge KA, Li TC. The pattern of pregnancy loss in women with congenital uterine anomalies and recurrent miscarriage. Reproductive Biomedicine Online. 2010;20(3):416-422. PubMed | Google Scholar

  8. Sharmin S, Alam D, Rahman F. Uterine didelphys with pregnancy outcomes: a case report. Chattagram Maa-O-Shishu Hospital Medical College Journal. 2018;17(2):53-55. Google Scholar

  9. Hiersch L, Yeoshoua E, Miremberg H, Krissi H, Aviram A, Yogev Y et al. The association between Mullerian anomalies and short-term pregnancy outcome. The Journal of Maternal-Fetal & Neonatal Medicine. 2016;29(16):2573-2578. PubMed | Google Scholar

  10. Krishnamoorthy K, Verma U, Intrauterine Devices (IUD): clinical aspects, side effects and potential complications. Advances in Medicine and Biology. 2017;120:73-112. Google Scholar

  11. Espey E, Ogburn T, Hall R, Byrn F. Use of intrauterine device in the setting of uterus didelphys. Obstetrics & Gynecology. 2006;108(3):774-776. PubMed | Google Scholar

  12. Attia AM, Ibrahim MM, Abou-Setta AM. Role of the levonorgestrel intrauterine system in effective contraception. Patient preference and Adherence. 2013;7:777. PubMed | Google Scholar

  13. King CP, Kives S. Case report of the successful use of mirena levonorgestrel intrauterine system in a patient with didelphys uterus and obstructed hemivagina. Journal of Pediatric and Adolescent Gynecology. 2019;32(2):182-185. PubMed | Google Scholar

  14. Vercellini P, Vigano P, Somigliana E. The role of the levonorgestrel-releasing intrauterine device in the management of symptomatic endometriosis. Current Opinion in Obstetrics and Gynecology. 2005;17(4):359-365. PubMed | Google Scholar

  15. Mousa A, Islam TE, Eldeen RM. Unintended pregnancy with IUD in situ reveals the IUD placement into one of the uterine horns in a bicornuate uterus. BMJ Case Reports. 2019;12(12). PubMed | Google Scholar

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case report

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

Case report

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

Case report

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

Volume 6 (May - Aug 2021)
This article authors
On Pubmed
On Google Scholar
Citation [Download]
EndNote
Reference Manager
Zotero
BibTex
ProCite

Navigate this article
Key words

Uterus didelphys

Levonorgestrel-intrauterine device

Case report

Article metrics
Countries of access