An unusual case of infertility: Retention of fetal bone

The challenge and issues of women procuring abortion had been documented for centuries. Most of these acts had been illegitimate, obtained from unlicensed health centres and had resulted in too many complications and death of some of the women. These post-abortal complications are mostly under-reported since they are done in secrecy and the victims themselves do not want to face the public stigmatization that goes with public knowledge that one did an abortion. These abortion clinics are illegal, not meant to offer such services, manned by improperly trained personnels. The environment may not be conducive, the instruments used may not be appropriate and also may not be properly sterilized. But they are highly patronized by desperate women and girls who got pregnant unintentionally and must terminate such pregnancies at all cost and any means. They cannot go to public hospitals or to most privately owned hospitals because abortion is a criminal act that may attract criminal prosecution and a jail term. So, the numerous undocumented abortions are done in these unsanitary centres. Some do well, but some end up with complications. Our report is one of such cases that ended with a peculiar complication that only manifested years afterwards. It was a unique case of a bony part of the aborted foetus that was retained in the Teenager’s uterus and caused infertility even after the she got married.


Introduction
Abortion is illegal in many nations of the world and may attract a jail term for both the patients and the provider. It may be allowed in special situations when the life and wellbeing of the pregnant mother is in danger and even then an approval must be given by certified specialist gynecologist.
In all abortions, every attempt must be made to ensure that the products of conception is completely evacuated and appropriate antibiotics given afterward.
But in some cases, some products of the conception is inadvertently retained inside the uterus and these may lead to some adverse effects. Such products may include mostly parts of the implanted placentae tissue which may remain attached to the wall of the uterus. If not detected and removed, such retained products of conception may lead to hemorrhage and infection.
But our index report was that of an actual case of Secondary infertility years after an abortion of a five month old pregnancy was done for her. She was then a 14 year old teenager but got married years later and was unable to achieve pregnancy. Routine investigations done for Secondary infertility revealed Retained bone particle in the uterine endometrium has probably been responsible for the infertility. Where did the bone come from?

Index Case
Was a married young woman who was not able to achieve pregnancy despite numerous unprotected sex that she had with her equally young husband. She was a vibrant 14 years old teenager when she got pregnant and out of fear kept it for five months before she sought for advice from her friends. They of course advised her to go for an abortion, from the same place that they usually go to for such procedures.
Apparently, the procedure went well, with no complications reported and she progressed in life and got married but she was not getting pregnant and her doctor ordered for a pelvic ultrasound that revealed an intrauterine shadow of nature?
Her doctor, a family physician suggested that a dilatation and curettage be done so as to remove whatsoever was present in her uterus. She agreed and the procedure was done under general anesthesia with ultrasound guidance.
The result was astonishing, as the removed particles was a bone tissue, where did this bone come from. Further questioning by the doctor revealed that she was once pregnant and terminated it at five (5) months gestational age.
That was the only viable explanation for the origin of the bone in her wombs, most probably a retained foetal part following the abortion that she did several year ago.

Discussion
Abortion is illegal in most countries and carries a jail term for both the patient and provider if they are caught (1) Thought illegal, it is still done and poor rural and single unmarried girls who cannot access contraceptives services and therefore get pregnant when they do not want to/it still seek for help [1].
They therefore resort to unsafe abortions from unqualified personal and in unsanitary, unhygienic places.
According to the World Health Organization (WHO), six out of every ten unintended pregnancies end up been aborted, and that 45% of these terminations are done in unsafe and unhygienic places [2].
Again about 97% of these unsafe abortions are done in the undeveloped nations [2].
Abortion can only be said to be safe if done by trained and qualified person with the skills and using recommended techniques [2].
Some women may even die and there are over 250,000 deaths reported worldwide from complications due to illegal abortions, with well over 220 women out of every 100,000 women deaths from abortions in the developing world [4].
The prolonged retention of fetal bone is an uncommon condition after a previous abortion [5,6,7,8]. In documented cases, hyperechogenic areas were found through transvaginal ultrasound scan and the bones were removed by hysteroscopy. Since foetal bones are formed after eleven(11) weeks of pregnancy, any history of abortion that has progressed beyond this time and associated finding of hyperechogenic areas on ultrasound scan should be evaluated for any foetal bone. Hysteroscopy should be performed under abdominal ultrasonography guide to ensure foetal bone is entirely removed during a single surgery. [5] And tens of thousand of women are hospitalized and treated from issues arising from such illegal abortions [1].
Our index case aborted a five months old pregnancy and a bony fragment from the foetus was retained in her womb over several years. This retained bone prevented her from getting pregnant, but surprisingly did not lead to excessive bleeding nor sepsis as reported in some cases. [6] But it inadvertently served as a barrier to her getting pregnant just as an IUCD would have and it was only after the foreign body was removal that she achieved pregnancy in her marital home.

Conclusion
In conclusion, we have reported a rare complication of illegal abortion and an unusual cause of Secondary infertility. Physicians should therefore have a high index of suspicion when managing similar cases of infertility when they encounter hyperechogenic shadow on ultrasound scan of the uterus.