Rahul Manchanda –  Rinoy Sreedharan – Nivedita Singh
Department: Minimally Invasive Gynaecology Department
Institution’s name: Manchanda’sEndoscopic Centrea

With the advent of multiple options, safer practices and easily available facilities, termination of pregnancy in India is slowly on the rise. Pregnancy termination is associated with associated with complications like haemorrhage and uterine perforation which are immediate[2] and delayed complications like Asherman’s syndrome, menstrual disturbances and quite commonly secondary infertility. We describe a case of secondary infertility due to the retention of fetal bone pieces in the uterine cavity. There have been many case reports of prolonged retention of fetal bones post abortion causing secondary infertility[3]. The patient may be asymptomatic (as in our case) or may be symptomatic with complaints like dysmenorrhoea, vaginal discharge or abnormal uterine bleeding[4]. The diagnosis and treatment of such a case can be done effectively hysteroscopically[5]

A 28 year old woman presented with secondary infertility of 2 years and history of termination of a pregnancy at three and a half months 2 years back. She had no other presenting complaints. She had had regular periods with average flow over the last two years not associated with any pain or discharge. Infertility investigations of both the partners was carried out. The husband was normospermic. The lady’s hormonal profile did not show any abnormality. However, her ultrasonography showed the presence of hyperechoic areas in the uterine cavity which was suspected to be a intrauterine contraceptive device or retained products of conception from the last pregnancy.

Image 1

The patient was posted for a diagnostic hysteroscopy. Specimen was obtained hysteroscopically from the uterus which was sent for microscopic examination. The patient followed up after 6 months of the procedure with complaints of history of amenorrhoea of 2 months,nausea and vomiting in morning. She was advised an urine pregnancy test and ultrasonogram.

The findings on hysteroscopy are shown in Video 1.

screenshot 1 screenshot2

The specimen retrieved on hysteroscopy was sent for microscopic examination.

Image 2

The slide shows the presence of bone trabeculae along with endometrium, thus confirming the presence of bone tissue inside the uterus. The ultrasonographic picture after 4 months shows the presence of fetal pole.

Image 3

The number of pregnancy terminations being done for various reasons are on the rise. Even though the safety quotient has risen over the years, complications still do occur. As in our case, they may remain asymptomatic making it difficult to diagnose. It acts like an intrauterine contraceptive device and prevents conception which is proven by the fact that the lady conceived within four months of removal of the bone pieces. Cases of secondary infertility should be dealt with suspicion and the hysteroscopy should be performed for accurate diagnosis and treatment in the same sitting[5].

The entity of retention of fetal bones post abortion should be borne in mind while investigating a case of secondary infertility. Hysteroscopy is effective for both diagnosing and treating infertility arising due to retained bone fragments in the uterus.

Conflict of Interest
The authors stated no conflict of interest. [The images can be opened using windows photo viewer. Videos have been created with windows live movie maker and can be easily viewed in windows media player]


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