The intrauterine contraceptive device (IUCD) is a commonly used, highly effective method of contraception, inserted vaginally into the uterine cavity to prevent unintended pregnancy. Copper-containing IUCDs have a reported failure rate as low as 0.08% [1]. Although generally safe, IUCDs can occasionally perforate the uterus and migrate into the intra-abdominal cavity, leading to a range of complications. The incidence of uterine perforation with copper IUCDs is estimated at 1.1 per 1,000 insertions (95% confidence interval (CI), 0.7–1.7) [2]. Reported complications include intra-abdominal adhesions, bowel perforation, urinary bladder involvement, and, in rare instances, appendicitis or even appendiceal perforation.

Migration of an IUCD to the appendix is exceptionally uncommon, with only a limited number of cases reported in the literature to date (see below for review of literature). Cases presenting specifically as IUCD-associated appendicitis are even rarer, making such presentations clinically significant and diagnostically challenging. This report describes a rare case of migrated copper IUCD associated with appendicitis, highlighting the importance of considering this unusual etiology in patients with a history of IUCD insertion presenting with acute abdominal symptoms.

A 27-year-old woman, para 4, living 4, presented to the Surgical Outpatient Department with a complaint of vague lower abdominal pain for 1 year, aggravated for 15 days. The pain was non-radiating and mild-to-moderate in intensity. It was not associated with other gastrointestinal problems (like nausea, vomiting, diarrhea, constipation, hematochezia, dyschezia), urinary complaints, or fever. The patient had a history of IUCD insertion 2 years ago. She got pregnant 1.5 years ago with the contraceptive device in situ and had a full-term normal delivery 6 months ago with an IUCD in situ. On examination, the abdomen was soft and non-tender.

She was admitted under the General Surgery Department; radiological investigations were carried out, and an X-ray of the abdomen revealed an IUCD in the right iliac fossa, with the possibility of foreign body granuloma formation (Fig. 1). Ultrasonography of the abdomen and pelvis was suggestive of a linear hypoechoic structure of 34 × 31 mm with surrounding hypoechoic areas and increased vascularity noted in the anterior abdominal wall in the right iliac fossa region. The hemogram was suggestive of a hemoglobin level of 11.7, and the total white blood cell (WBC) count was 7,200/mm³.

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Figure 1. Erect abdominal X-ray. The black arrow shows IUCD in the right iliac fossa region. IUCD: intrauterine contraceptive device.

The patient underwent a diagnostic laparoscopy. Intraoperatively, upon creation of a pneumoperitoneum, adhesions were found on the anterior abdominal wall in the right iliac fossa. A whitish structure was visible within the adhesions (Fig. 2). On carrying out the dissection, the misplaced IUCD was found within the adhesions. On dissecting further, another tubular structure was found within the adhesions, and upon tracing the lower end of the structure, the base of the cecum was found, with the convergence of three taeniae coli present, confirming the presence of the appendix within the adhesions. The appendix was inflamed, and the horizontal limb of a copper T device was adherent to it (Fig. 3). The copper T device was initially removed from the adhesions and out of the abdominal cavity, and then a laparoscopic appendectomy was carried out by cauterizing the mesoappendix and ligating the base of the appendix with Vicryl 2-0.

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Figure 2. Intraoperative findings. The black arrow shows the vertical limb of the IUCD embedded with the omentum into the tip of the appendix. IUCD: intrauterine contraceptive device.

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Figure 3. Intraoperative findings while performing the dissection. The black arrow shows the horizontal limb of the IUCD embedded in the appendix with the anterior abdominal wall. The grey arrow shows the inflamed appendix attached to the anterior abdominal wall. IUCD: intrauterine contraceptive device.

The contraceptive device was a Copper-T 380A, which is long-acting, effective for 10 years, and reversible as well.

The patient was vitally stable in the postoperative period and passed urine and stool normally and was discharged on the third postoperative day. The patient came for follow-up and had no complaints. The histopathological examination of the appendicular specimen retrieved revealed the presence of acute appendicitis.

A foreign body, such as a copper T intrauterine device, can initiate bacterial proliferation, which may lead to appendicitis. This bacterial proliferation may be aerobic or anaerobic, and no single organism is solely responsible. An unusual intraoperative finding of the migrated IUCD adhering closely to the inflamed appendix helps to identify an important anatomical relationship and raises the possibility of a contribution by the IUCD.

The risk of a copper T device perforating the uterus and contributing to appendicitis is notable due to the close anatomical proximity of the uterus and appendix. Intrauterine devices are commonly used for long-term contraception. Uterine perforation can occur either due to technical difficulties during insertion or as a result of chronic inflammation that slowly weakens and penetrates the uterine wall [3]. This process may be further influenced by natural uterine contractions and pressure gradients between the intrauterine and intraperitoneal spaces [4]. A smaller uterine cavity and increased cervical resistance to dilation may be responsible for an increased risk of uterine perforation in nulliparous women, although supporting evidence is limited [5].

Nevertheless, the exact pathogenesis connecting the migrating IUCD with appendicitis is unknown. Two possibilities exist for the mechanism: (1) The migrating IUCD caused an inflammatory response and adhesions around the appendix; and (2) Primary appendicitis could cause periappendiceal inflammation and adhesions, incorporating the migrating IUCD at a later date. Since the order of events cannot be known from past history, a causal relationship cannot be proven.

There are two main types of IUCDs used these days: non-hormonal, copper-releasing IUCDs and hormonal, levonorgestrel-releasing IUCDs (LNG-IUCDs) [4]. However, in earlier days, another IUCD called Lippes Loop was also in use. Copper-containing IUCDs are associated with greater irritation [4]. Acute appendicitis due to a foreign body occurs in approximately 0.005% of appendectomy specimens [6]. Common foreign bodies include stones, teeth, nails, metal, needles, bones and coins, while IUCDs have rarely been reported in the literature [7].

Few cases have documented IUCD migration associated with acute appendicitis [8, 9], with patients presenting with symptoms such as nausea, vomiting, fever, and abdominal pain. These symptoms may be accompanied by right lower quadrant abdominal tenderness and laboratory findings such as leukocytosis or C-reactive protein levels [10]. Surgical intervention remains the standard approach for a migrated IUCD [4]. Both laparoscopy and laparotomy can be used, but laparoscopy tends to have the edge, with less tissue trauma, quicker procedures, faster recovery, and a lower risk of adhesions [11].

Table 1 [8–10, 12–18] presents a concise review of previously reported cases of IUCD migration involving the appendix, outlining their presentation, operative findings, management approaches, and outcomes in comparison to the current case.

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Table 1. Appendiceal Migration of Intrauterine Contraceptive Devices: A Review of Reported Cases

The majority of the patients with IUCD-associated appendicitis were from the middle age group of 20–45 years (90%). Almost all of the females were multiparous (81%) and had previous pregnancies. The device found to have been associated with appendicitis was a copper-containing IUCD in most of the cases, and the duration between copper-T insertion and the appearance of symptoms ranged from 3 months to 18 years. The most common presenting symptoms were lower abdominal pain, with asymptomatic cases being rare. An IUCD with omentum found adherent to the inflamed appendix in the right iliac fossa region of the abdomen explained why lower abdominal pain was the most common presenting symptom. After the surgical intervention, the recovery was uneventful in all the cases.

Uterine perforation and migration outside the uterine cavity are rare complications in the context of the usage of the IUCD. In this particular case, the copper T was found to have migrated into the vicinity of the inflamed appendix. Although the results of the surgical procedure indicate a potential causal relationship between the migration and the inflammation of the appendix, the available data do not prove the cause-and-effect relationship between these two conditions. Thus, this case presents an unusual case of appendicitis in association with the migration of the IUCD.

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