Ms. R, a 28-year-old G1P1 presents at four weeks postpartum requesting long-acting contraception via an IUD. She requests Mirena (levonorgestrel IUD) because she has heard “good things” about it and understands that it might help decrease her menstrual flow and, hopefully, she could skip having periods altogether.

Ms. R has a history of postpartum depression. Her infant was recently released from the hospital for an infection requiring in-patient treatment for two weeks. She had attempted to breast-feed while the baby was in the NICU, but using a breast pump to supplement feedings proved painful and produced little breast milk. Ms. R is currently taking Zoloft (sertraline) 50mg daily and is feeling less depressed. The baby is doing well, and after a thorough discussion in the clinic, she makes the decision to abandon the idea of breast feeding.

Ms. R reads and signs the consent form prior to the IUD insertion procedure. A bimanual exam reveals an anteverted uterus. The speculum is placed, the cervix visualized and cleansed with betadine. A tenaculum is applied and the uterus is sounded to 7cm (6–10cm is required for placement).  The IUD is loaded in the insertion tube and inserted to the depth of 7cm. The strings are cut to 1” length and the patient is given the opportunity to feel the strings that have been cut to get an idea of how to check them on her own to validate that the IUD is in place. Ms. R is counseled to perform string checks after periods and occasionally throughout use.

Approximately three weeks later, Ms. R presents complaining of dyspareunia. She describes it as a sharp pain on her right side with deep penetration. A speculum is inserted and no IUD strings are visible. A transvaginal ultrasound is ordered, and no IUD is seen in the uterus. A pelvic X-ray reveals the IUD “somewhere in the pelvis, most likely behind the uterus.” A laparoscopy is performed, and the IUD is seen in the pelvis behind and outside of the uterus. It is removed laparoscopically.

Despite the fact that the WHO recommends IUD insertion after 4 weeks postpartum, study data demonstrates an increased risk of uterine perforation in lactating women.1 Because Ms. R had made the decision to discontinue breast feeding on the same day as the IUD insertion, she remained at a greater risk for complications due to her lactational status. It is recommended that particular care be exercised when inserting IUD’s in postpartum women. An ultrasound to confirm proper insertion is recommended, though it is not standard practice.

1. Kaislasuo J, Suhonen S, Gissler M, et al. Intrauterine contraception: incidence and factors associated with uterine perforation—a population-based study. Human Reproduction. 2012;27(9):2658–2663.