Israeli Woman Pregnant With IUD In Place: Are There Risks?

Question:

Hello, Sorry for my poor English. I live in Israel, so English is not my mother-tongue :) I had a Mirena placed at late November 2011. Ultrasounds showed that it was placed well. To make thing short: I've got pregnant in February. My ginecologist didn't succeed to get Mirena out. After doing more ultrasound tests with two different specialists: no one is sure if it is in or out.

I was checked by professor (who has very high reputation and I know him for several years and trust his opinion). He says that it might happen that Mirena has gone out of womb but not completely. He suspects that it is half-out (all this is very surreal for me). No one can tell what end of Mirena is out (I mean no one knows if it still secrete Progesteron into the womb) . We planned to have more children, so I'm not against the idea of pregnancy. Hence no one wants to perform laporascopy test to discover what is going on.

Now, suppose the Mirena is still in (half or complete) and it secretes the Progesterone into the womb. I know there is a risk of miscarriage and there is nothing I can do about. The question is: can these dose of Progesteron harm the embryo? Are there statistics or researches on that?

And say the embryo will be boy, can Progesterone influence him and his hormone levels as to even change the "orientation"? Sorry for that last question, but I can't help thinking of that.

Please make some order in my situation. Of course I'm observed by ginecologists and he is checking relevant information for me right now. Thanks in advance. LT from Israel

Answer:

Hello LT from Israel,

I'm sure that your gynecologist is doing the same research that I had to do to answer this question. It is a good question, but I don't think there is any real clear answer. This is what I found out and it is from the following website: http://www.drugs.com/pro/mirena.html

Based on the information from the above site, if an IUD is in place when pregnancy occurs, you have the following risks:

1. There is a two fold increased risk of miscarriage.
2. There is a four fold increased risk of preterm labor, delivery and loss.
3. There is an increased risk of 2nd trimester infection (chorioamnionitis) and maternal death.
4. Few congenital anomalies have been noted (there is no statistic).
5. Regarding your last question: There has been some reports of and there could be an increased risk of masculinization of a female fetus.

In your case, it would be very important to know if the IUD is in place. If it can't be seen easily by ultrasound, then a pelvic x-ray would probably be indicated, not a laparoscopy. The IUD should be seen and the amount of radiation is very small and won't affect the fetus or pregnancy.

I hope all goes well and good luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A

Comment: My question required some serious research and was answered very clearly Thank you very much!

Previous Ectopic, Left Salpingectomy, Painful HSG: Can I Still Get Pregnant?

Question:

Dear Dr. Ramirez,

Approximately 8 years ago, after the birth of my first child, I had an IUD (copper T) inserted. About 6 months later, I lost the thread,and went back to the medical practice for it to be removed and replaced, but was told that losing the thread wasn't a threat. Anyway, 2 more months later, I had an ectopic pregnancy which ruptured my left fallopian tube and resulted in an emergency salpingectomy...... the entire tube was removed (about 7 cm).

Fast forward 8 years, I am ready to have another child, however an HSG (hysterosalpingogram) revealed proximal blockage to my right tube. I was in an immense amount of pain during this procedure.....that I cried. I am not convinced that the results of the HSG are accurate because of the pain (similar to labor pains)that I felt. Also because the ectopic was due to a foreign object, I don't feel that there should be anything wrong with my right tube. Anyway, my questions are as follows and I really appreciate your time:

1. Since the IUD was the cause of my ectopic pregnancy, would I be considered a high risk for another ectopic (assuming my right tube is not blocked#?

2. Based on the pain that I was in, could the proximal blockage be a result of a tubal spasm? What are the stats on false hsg readings for proximal blockage?

3. Is it possible that a left salpingectomy could result in scar tissue blocking the remaining right tube?

4. And finally, my uterus and ovaries (I still have both) are healthy per the scan. There is evidence of scarring from my previous c-section. How feasible is it for my right tube to pick up an egg from my left ovary as I usually feel ovulation cramping on my left?

Thank you very much in anticipation. E. (age 35),USA

Answer:

Hello E. from the U.S.,

You cannot be sure that the IUD was the cause of the ectopic. That would be a false assumption. Certainly having an IUD in place can increase the risk of an ectopic but intrauterine pregnancies also occur with IUD's in place. The IUD does not block the tube, it creates a hostile bed for implantation of the embryo. Ectopic pregnancies mostly occur because of fine adhesions within the tube which prevent the embryo from migrating into the uterus. As a result, the embryo implants there. The most common reason for these adhesions are from some form of inflammatory event in the past, often a sub-clinical (no symptoms) infection by a bacteria. Chlamydia is the most common form but some studies also point to multiple different bacteria. In any case, this infection gets into the tube, causes the tubal lining to become inflamed thereby resulting in scar tissue formation. It is possible that this inflammation is was led to the blockage of the right tube, whereas the left tube was only partially blocked, hence the ectopic.

In terms of the pain with the HSG, yes, it could mean that you had tubal spasm but the more likely source was that because the tube is blocked, the increased pressure or pushing by the doc caused increased stretching of the uterus and hence increased pain. I would have to look up the statistics for false readings on HSG, but it is low and so HSG is the gold standard for the diagnosis of tubal blockage. I am sure there is some false positive or false negative readings, however.

If the surgery was performed without incident, a salpingectomy on the left should not cause blockage of the right tube at its entrance. Any pelvic surgery could lead to scar tissue formation within the pelvis and lead to blockage at the end of the tube, however (your previous c-section).

If the right tube is normal at the fimbriated end, and there are no adhesions within the pelvis, then there is a good chance of egg pickup even if ovulation is from the opposite side. The reason is that the egg from one side of the ovary does not necessarily go directly to the tube on that side. The opening to the tube is not that close to the ovary. In fact, the egg falls into a pool of fluid within the culdesac, a space behind the uterus, where the tube lies and through fluid motion, gets to the tube. So pregnancy can and have occurred in patients with a functioning ovary on one side and a normal tube, without an ovary, on the opposite side.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.montereybayivf.com/
Monterey, California, U.S.A.

Comment: Dear Dr. Ramirez, Thank you very much for your response. You are very knowledgeable and I feel very enlightened. Again, many thanks, E.