During the study period, we recorded 10 cases of pregnancy among the 1783 women who were on the Cu-IUD at the centre, i.e. a frequency of 0.6%.

The average age of the patients was 30.1 years, with extremes of 19 and 39 years. Six patients were older than 30 years. The average parity was 3 with extremes of 0 and 6. Half of the patients were multiparous. Seven patients were married and three were single.

The Cu-IUD was inserted between day 4 and day 10 of the menstrual cycle in nine patients. In only one case was the Cu-IUD inserted post-placental. The average time from insertion to diagnosis of pregnancy was 25.1 months, with extremes of 3 months and 72 months.

All of the insertions were performed by midwives in different health facilities.

The pregnancy was intrauterine in 9 cases and extrauterine in 1 case. The Cu-IUD was found in the uterus on ultrasound in 8 cases and was not found in two cases. The Cu-IUD was in the cervical-isthmic region in 2 cases, intramyometrical in 2 cases, and in the uterine fundus in 4 cases. The term of the pregnancy at diagnosis varied from 6 weeks of amenorrhoea to 18 weeks of amenorrhoea (Table 1).

The causes of pregnancy would be poor insertion of the IUDcu in 20% of cases (insertion in the uterine muscle); migration in 20% of cases (IUD at the isthmus); unnoticed expulsion in 20% of cases; an anti-nesting effect by its mechanism of action in 10% of cases and a probable decrease in the effectiveness of the Cu-IUD in 30% of cases.

The occurrence of pregnancy among the patients was perceived in different ways. Thirty percent blamed the ineffectiveness of the method, 20% thought that the provider was incompetent. In 20% of the cases, the occurrence of a pregnancy under the method was a divine will. In 30% of the cases, the occurrence of the pregnancy under the method was a bad spell.

The experience of this situation varied from patient to patient. Forty percent of the patients were surprised with tears when the pregnancy was announced. Thirty percent were worried about the unborn baby and 30% were disappointed with contraceptive services.

The Cu-IUD was removed in two patients (Cu-IUD in the cervical-isthmic situation and in the myometrium). Those in the uterine fundus were not removed after unsuccessful attempts to remove them. Prenatal follow-up was scheduled for the patients. A laparotomy salpingectomy was performed in the patient who had an ectopic pregnancy.

The main complications were spontaneous abortion in two patients in whom the Cu-IUD was removed. Two patients delivered prematurely at 32 weeks’ and 34 weeks’ amenorrhoea. Two patients had resorted to clandestine induced abortion. Three patients had completed their pregnancies and delivered vaginally. Examination of the delivery revealed the Cu-IUD attached to the placental cake in five cases.

The contraceptive method adopted after pregnancy was jadelle implants in 8 cases and spousal vasectomy in 2 cases.

During the study period, the frequency of pregnancy with the Cu-IUD was 0.6%. Expressed by the PEARL index, the failure rate of this contraceptive method varies between 0.2% and 1.6% depending on the performance of the device, without distinction of the place of implantation of the egg [2] [3]. In our study, there were two unnoticed expulsions responsible for the occurrence of pregnancy. Pregnancy was the reason for the unnoticed expulsion of the IUDcu®. To minimize the occurrence of IUD pregnancies, it is imperative before any IUD insertion to ensure that there is no incipient pregnancy, to respect the precautions for IUD insertion, and to institute periodic monitoring.

The mechanism of action of the Cu-IUD is thought to proceed from several phenomena [1] [5]: in the cervical mucus: alteration of the mobility, capacitation and therefore the fertilizing power of the spermatozoa; in the uterine cavity: cytotoxic effect and alteration of spermatozoid transport. The copper surface area required for satisfactory effectiveness must be greater than or equal to 250 mm² [6]. For this method to be effective, insertion must be done at any time with reasonable assurance that the woman is not pregnant. The Cu-IUD should be placed deep in the uterine cavity and its vertical stem should not descend into the cervical canal below the isthmus. In our study, the intrauterine device used was the T 380 A copper device with a copper surface area of 380 mm². The main reasons for the occurrence of pregnancy would be poor insertion (insertion into the uterine muscle), secondary migration of the IUD into the uterine cavity, unnoticed expulsion, an anti-nesting effect due to its mechanism of action and a probable decrease in the effectiveness of the Cu-IUD. In our study, the Cu-IUD was found in the myometrium in 20% of cases. This complication would result from the provider’s failure to master the insertion technique. Inserted in the myometrium, this IUD will not be able to prevent fertilisation and implantation. It is important to master the technique of Cu-IUD insertion and to perform a systematic ultrasound after insertion to ensure the proper placement of the Cu-IUD. Routine ultrasound after IUD insertion is not a recommended practice in the country but is essential if insertion is complicated.

Secondary migration of the Cu-IUD was found to be associated with pregnancy. This is probably due to the amount of menstrual flow. It should be noted that menstrual flow varies from one woman to another and, for the same woman, varies from one moment to another in relation to certain gynaecological pathologies and even in relation to the Cu-IUD since some studies have reported an increase in menstrual flow due to the Cu-IUD [1] [5]. Four to 15% of women are reported to discontinue the Cu-IUD within one year of insertion because of menorrhagia [7]. It is important to institute regular follow-up in women on the Cu-IUD and always check the correct placement of the Cu-IUD to ensure the effectiveness of the method.

Another situation in our study would be related to the anti-nesting effect of the Cu-IUD. It is now clearly demonstrated that Cu-IUD does not increase the risk of ectopic pregnancy. The risk of ectopic pregnancy is even reduced in women with a Cu-IUD (0.25% per year) compared with 0.5% in women without contraception [7] [8]. Nevertheless, when a woman with a Cu-IUD is pregnant, this diagnosis must be eliminated because 1 in 20 pregnancies is extra uterine [9] [10].

We have found cases of pregnancy even though the Cu-IUD is still in the uterus. This situation has led us to think that the effectiveness of the Cu-IUD has probably decreased.

The occurrence of pregnancy among patients was perceived as ineffectiveness of the method, incompetence of the provider, and divine will.

The Cu-IUD is a very effective method when properly inserted, as most studies have pointed out [2] [3]. The failure in our study is partly due to poor insertion, which would be related to provider incompetence. To remedy this situation, it is important to strengthen the skills of midwives in charge of contraceptive services and to check the correct position of the Cu-IUD with pelvic ultrasound. If the Cu-IUD is not correctly inserted, it is important to remove it and repeat the procedure correctly.

The experience of this situation varied from patient to patient. Forty percent of the patients were surprised with tears when the pregnancy was announced. Thirty percent were worried about the unborn baby and 30% were disappointed with the contraceptive services. The occurrence of pregnancy under intrauterine contraception is rare, being estimated at less than 1% per woman-year, but it is still not a good experience, with various fears such as the risks for the unborn baby, as we found in our study [11] [12]. This is the “real” failure of the method. To improve this experience, it is important to specify the possibility of pregnancy despite the use of a modern contraceptive method, since contraceptive methods are not 100% effective. If the woman is aware of this, she will be able to accept the occurrence of pregnancy better, even if her objective was to avoid a pregnancy temporarily or permanently.

The main complications were spontaneous abortion in two patients in whom the Cu-IUD was removed. Two patients delivered prematurely at 32 and 34 weeks’ gestation. Two patients had resorted to clandestine induced abortion. Three patients had completed their pregnancies and delivered vaginally. Examination of the delivery revealed the Cu-IUD attached to the placental cake.

Our results corroborate those in the literature. Indeed, the finding of a pregnancy invites the removal of the Cu-IUD if the threads are still accessible [1] [5]. The theoretical risk of the presence of a foreign body is represented by late septic abortion, which would occur a little more than one in two times [9]. However, no risk of congenital malformations or genetic abnormalities [7] has been demonstrated. Nevertheless, the risk of early spontaneous miscarriage after removal of the Cu-IUD is estimated at about 30% [13].

In fact, a pregnancy occurring under the Cu-IUD whether the Cu-IUD has been removed or not, is at risk of premature delivery, premature rupture of the membranes and chorioamniotitis, this risk appearing to be increased when the Cu-IUD is left in place [2].