Title: Migrated Intra-Uterine Device to Infra-umbilical skin: A rare Case Report
Version: 4 Date: 25 Nov 2024
Reviewer:  Antonio Bandala-Jacques
Reviewer's report:
Dear authors:
Thank you for submitting your re-reviewed manuscript
Overall, I say the manuscript has drastically improved and only minor alterations are needed,
for the most part.
ABSTRACT
A) You start with ": IUDs are most effective, reversible and safe methods of contraception. "
I think this is missing an article. Please rephrase to "IUDs are *an* effective, reversible, and
safe method of contraception"
B) your sentence "Of these; Chance of having pregnancy and IUD misplacement are the least
common complications occurring only in 1-2 from 1000IUD users.
Could be rephrased to
"Pregnancies are IUD misplacement are uncommon complications, ocurring in 1-2 per 1,000
users"
C) In "It can be asymptomatic and incidentally found while imaging for any other diagnosis or
may present with various acute clinical presentations.  "
I suggest you change "It" to "Migration"
D) "Self-examination of the strings and vigilant evaluation at regular checkup is recommended
for early detection of misplaced IUDs. "
You don't mention self-examination in the body of your manuscript
INTRODUCTION
E) The use of the word "the" in your first sentence throws me off. You write:
Intrauterine devices (IUDs) are the most effective, relatively safe and long acting reversible
contraceptives (LARCs)
But the use of "the" before the list implies that it should be read as
Intrauterine devices (IUDs) are the most effective, (the) relatively safe and (the) long acting
reversible contraceptives (LARCs)
I would either remove the word "the" or split into two sentences
F) As mentioned in a prior version, Levonorgestrel is not a trademark. do not capitalize
Levonorgestrel-releasing in the first paragraph. It is fine in the second, as it is the beginning
of a sentence
G) Similar to my comment "E", when you write:
"Levonorgestrel-containing IUDs act by thickening of the cervical mucus thereby preventing
sperm permeability, endometrial decidualization followed by atrophy, altering the motility of
the tube; oocyte and blastocyst apoptosis due to induced inflammatory response by the presence
of an intrauterine foreign body"
As "preventing" is the first verb used, it makes the sentence grammatically incorrect. May I
suggest adding verbs in each instance, such as:
Levonorgestrel-containing IUDs act by thickening the cervical mucus (thereby preventing
sperm permeability), promoting endometrial decidualization followed by atrophy, and altering
the motility of the tube. This results in oocyte and blastocyst apoptosis due to the induced
inflammatory response by the presence of an intrauterine foreign body
H) In "Chance of conception and Migration with misplacement of IUD are very rare
complications occurring in 1-2 per 1,000users reported"
DO not capitalize migration. Also, I would remove "Chance of". Please also note the lack os
space between 1,000 and users
I) "Migrated IUDs may be misplaced, and found in any pelvic or abdominal organs following
uterine perforation. "
I would say migrated IUDs are, by definition, misplaced? I would omit that part of the sentence
J) "Risk factors for possible uterine perforation and trans-mural migration are insertion by less
experienced clinician, "
Either add the definite article "a less experienced clinician" or (preferred) pluralize to "insertion
by less experienced clinicians"
K) Lack of space in "within 6months following delivery". Also, I would spell out numbers <10.
But that's a personal decision
L)  Same comment as 'J'. Add an article or pluralize in :
- "Patients with migrated IUDs have varied clinical picture"
- "The clinical presentation of misplaced device"
- "Misplaced device may be first incidentally detected "
- "Ectopic rest of IUDs may cause urolithiasis"
CASE PRESENTATION
M) In "She had six deliveries all were vaginally, and uncomplicated.". This is an improvements,
but I would revise to "She had a reproductive history of six vaginal deliveries, all uncomplicated"
N) Lack of space in "Over the past 18months"
O) Please pluralize "she had regular menstrual cycle "
P) Please switch "lasts for 3 to 5days " to the past tense, and mind the missing space. Missing
space in "After 7weeks ", "2years back ", "2months.", etc. This occurs many more times
throughout the manuscript
Q) In "She never had follow-up visits onwards neither tried to palpate IUD strings. " I would
switch "neither" to "nor"
R) There is a missing verb in "The abdomen was soft and no area of tenderness, organomegaly
or palpable mass. "
S) "There was no active bleeding or drainage of puss from the extraction site during" I believe
you meant 'pus'
T) "In addition, there was no fistulous tract which can be seen by the naked eye. " Please revise
to "In addition, there was no fistulous tract which could be seen by the naked eye. "
U) In "This mother was also advised to visit our hospital early in case of pain, fever, bowel, and
bladder complaint or any other symptoms."
You have not referred to the patients as "mother" until this point of the manuscript. I would be
consistent and use "patient"
V) Please revise "After IUD removal she didn’t appear to follow up clinics, but reported no
symptom or complication on phone call interview." to "After IUD removal she did not appear
to follow-up clinics, but reported no symptom or complication on phone call interview."
DISCUSSION
W) "IUDs are reversible, safe, and most effective contraceptive methods currently available"
Please revise. Maybe:
"IUDs are a reversible, safe, and effective contraceptive methods"
CONCCLUSION
X) In your first paragraph:
"We present likely the first reported case of IUD migration to infra-umbilical skin which bestows
a new finding to the existing literatures."
please revise to "We present what is likely the first...."
Later in that paragraph, I would forego of the word "luckily"
Z) In "It is better if women have regular checkups and vigilant examination even though they
remain asymptomatic and comfortable after IUD insertion. "
Better than what ? I would say this as a fact. "It is recommended that" or "Women should..."
AA) in "For the scientific community, we recommend to perform systematic review and meta-
analysis on migrated and misplaced IUDs to better understand the clinical pattern, "
I don't think a meta-analysis would work here? what metric exactly? and regarding systematic
reviews, you have already cited one. i don't think this sentence fits your conclusion well