Figure.3
Hysteroscopy and diagnostic laparoscopy with dye test done in 2021.
Cervix was noted to be pin-hole and very difficult to dilate, foreign
body was seen and removed from the endometrial cavity, the endometrial
cavity otherwise looks normal. Laparoscopy revealed left sided
physiological adhesion of bowel to the pelvic side wall, left tube looks
inflamed but both tubes are positive for dye test and both ovaries look
normal. Histology of the foreign body showed fragments of dead bone.
Discussion
This case highlights the difficulty in diagnosing the cause of her
secondary infertility and abdominal discomfort because the first
ultrasound scan as well as the MRI scan did not show any foreign body
inside the endometrium. Potential differential diagnosis may include
osseous metaplasia driven by chronic inflammation causing destrophic
calcification (3) and endometrial ossification driven by chronic
inflammation as well as tissue destruction in mature endometrial stroma.
(4) The fact that the segment retrieved from hysteroscopy looks like a
fetal long bone and the histology showed dead bone fragment and no
active tissue goes against these two differential diagnosis.
Fetal bone fragment residing in the endometrium can act as a foreign
body causing chronic inflammation to the endometrial environment,
inhibiting implantation of the embryos and therefore cause secondary
infertility. The effect is similar to having an IUCD in situ. It is also
suggested that the fetal bone may have a direct toxic effect to the
developing embryo therefore causing infertility. (4)
Currently, hysteroscopy is used in most of the case reports as the
treatment of choice to retrieve foreign body to either treat the
infertility (1-4) or menstrual complaints, including chronic pelvic
pain. (5) However, there is lack of guidance nationally as to the gold
standard investigations or treatment. In fact, there is lack of evidence
in follow up in abortion care in general. The NICE guideline (6) as well
as the best practice in abortion care provided by the college (7) did
not provide specific guidance regarding symptoms and signs for
incomplete abortion especially post mid-trimester abortion. There is
also lack of guidance on how to investigate suspected incomplete
abortion. With the current situation where more than 70% of abortion is
done in the private sectors, (6) it is understandably difficult to
follow such patients up and to communicate with the primary and
secondary care providers regarding the treatments they have gone
through. However, as retained fetal tissue and bones can cause a number
of menstrual as well as fertility problems in ladies, it is important to
obtain a detailed obstetric history including abortion and bear in mind
such differential diagnosis. There is also a need to review the current
guideline to provide guidance in terms of early recognition,
investigation and appropriate treatment and follow up to these women,
especially when abortion rate is on the rise with current pandemic. (8)
References
- Winkelman WD, Frates MC, Fox JH, Ginsburg ES, Srouji S. Secondary
infertility and retained fetal bone fragments. Obstet Gynecol. 2013
Aug;122(2 Pt 2):458-461. doi: 10.1097/AOG.0b013e3182917c9c. PMID:
23884259.
- Gainder S, Arora P, Dhaliwal LK. Retained Intrauterine Bony Fragments
as a Cause of Secondary Infertility in a Tertiary Level Indian
Hospital. J Hum Reprod Sci. 2018 Jul-Sep;11(3):286-290. doi:
10.4103/jhrs.JHRS_33_18. PMID: 30568360; PMCID: PMC6262664.
- Gulec UK, Parlakgumus HA, Kiliçdag EB, Bolat F, Bagis T. Osseous
metaplasia of the endometrium. BMJ Case Rep. 2010 Aug
19;2010:bcr0420102931. doi: 10.1136/bcr.04.2010.2931. PMID: 22766572;
PMCID: PMC3029676.
- Mishra N, Bharti R, Mittal P, Suri J, Pandey D. Retained Intra-uterine
Foetal Bones Resulting in Secondary Infertility: A Case Report.
Cureus. 2018 May 3;10(5):e2575. doi: 10.7759/cureus.2575. PMID:
31489270; PMCID: PMC6710494.
- Verma U, Chong D, Perez I, Medina C. Fetal bones retained in the
uterine cavity as a rare cause of chronic pelvic pain: a case report.
J Reprod Med. 2004 Oct;49(10):853-5. PMID: 15568412.
- NICE guideline on abortion care
- Best practice in abortion care RCOG
- Abortion
statistics for England and Wales during the COVID-19 pandemic - GOV.UK
(www.gov.uk)