الفهرس 
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Abstract
Intrauterine Contraceptive Device (IUCD) is one of the most commonly used reversible, low cost, long duration of effectiveness, high efficacy method of contraception.
Insertion of an IUD is associated with complications such as abdominal pain, pelvic inflammatory disease, expulsion, re-traction into the cervix or uterus, and uterine perforation. This complication appears to be associated with the type of device, time of insertion, skill of the operator and position of the uterus.
Most perforations occur at the time of insertion, but partial perforation with subsequent delayed complete perforation may also occur. Patients may present with pregnancy or lost threads or may remain asymptomatic for years. A common presentation is abdominal pain. Perforation is most commonly seen through the posterior wall of the uterus. Perforations may be partial, with some portion of the device remaining within the endometrial cavity, or complete, with the device passing wholly into the peritoneal cavity. The migrated IUD can cause fibrosis, perforation and obstruction of the large and small bowel, mesenteric penetration, bowel infarction, rectal strictures, and rectouterine fistula.
The present study was conducted at the department of obstetrics and gynaecology at Minia Maternity University Hospital and other central hospitals through a period from August 2019 to July 2020 to determine the risk factors and management of cases of missed IUCD threads.
A total of 224 patients had participated in the study and were either coming for routine checkup (follow-up/renewal/removal) with any complaints related to IUCD or gynecological complaints or referred from other health center for missing IUCD threads or other IUCD related/gynae complaints and were found to be having missing threads.
All patients were subjected to full detailed history, clinical examination, and investigations. The management plan was selected according to final clinical findings.
The study revealed the followings:
• More than one half of the studied patients were in the age group 26-35 years old (54%) and had parity from two to three (61.6%). Around half of their deliveries were by vaginal delivery (50.4%).
• Majority of patients were complaining of missed threads (81.2%). More than two thirds of them, their complaint was delayed (71.4%) and had inserted IUD during menstrual period (69.2%).
• The most prevalent place and time for IUD insertion was primary health care units and interval time (66.5%) and (49.1%) respectively.
• The largest percent of the studied women, the physician had not evacuated their bladder before insertion (77.7%) and they did not follow up after insertion (73.2%).
• Almost all the studied patients had no previous abdominal surgery (98.7%). The most prevalent IUD type was CU T 380A (82.6%) followed by Nova t (15.2%). More than one half of patients reported previous use of IUD (61.6 %).
• All studied patients had no threads felt by vaginal examination (100%). Almost all patients had no threads seen by speculum examination and had retroverted uterus (97.3%) and (93.3%), respectively.
• Radiological examination for the studied patients with US demonstrated that IUD did not appeared in around one third of patients (30.8%). The most prevalent finding with ultrasonography was displaced IUD (28.1%) followed by in-situ IUD (25.0%).
• Uterine perforation occurred in around one third of the studied patients (29%). The second most prevalent finding was missed threads with displaced IUD (28.1%) followed by missed threads with IUD in-situ (25.0%). while pregnancy occur in only (5.4%) of patients.Expelled IUD occur in only (1.7%).
• The most frequently used procedures for IUD removal were crocodile forceps and laparoscopy in (41.1%) and (24.1%) of patients, respectively.
• The most prevalent site of perforation by IUD was posterior uterine wall (60.3%). Douglas pouch was the most frequent site for extrauterine IUD (58.8%).
• There was statistically significant difference between patients with different clinical outcomes as regards age, time of complaint, time of IUD insertion, time since insertion, difficulties during insertion, bladder evacuation before insertion, follow up after insertion, type of IUD and type of previous contraceptive method used.
• While there was no statistically significant difference between patients with different parity, modes of delivery, surgical history and previous use of IUD as regards clinical findings.
Based on the previous findings the study recommended the followings:
• Adequate training of the service providers is of critical importance to avoid perforation during insertion.
• Appropriate counseling and good selection of women using IUDs as regarding the time of IUD insertions and anatomical findings of the uterus.
• Motivate women to regular follow up after insertion and early reporting whenever they are unable to feel the IUD string.
• The availability of office based 2D and 3D ultrasound systems affords the physician and patient an inexpensive, noninvasive means to monitor IUD placement and uterine compatibility.
• Displaced IUD should be removed to prevent complications such as pain, bleeding, and pregnancy.
• Perforated IUD should be removed to prevent complications such as colonic or mesenteric perforation and infection.
• A need for future research to identify newer devices with lesser complications and better ways of its application to significantly reduce the associated complications.
• Alternatives to the conventional T-shape IUD design, such as the intrauterine ball (IUB) and the frameless intrauterine devices which hold significant clinical advantages and fit any size uterine cavity are highly recommended.