We aim to present a rare case of a missing intrauterine contraceptive device (IUCD) that was found in the terminal ileum by laparoscopy and was managed initially by laparoscopy and then proceeded to laparotomy.A 29-year-old female who had a copper IUCD inserted by a senior gynecologist presented to the clinic with pelvic pain and discomfort. She underwent laparoscopy for IUCD removal. Intraoperatively, the IUCD was discovered to be embedded in the terminal ileum, and therefore, laparoscopy was converted to an open laparotomy. The patient was readmitted multiple times because of abnormal fluid collection in the pelvic region, which was resolved finally by pigtail insertion.This case sheds a light on the possibility of complications occurring in the medical field even if the practitioner is a senior gynecologist. Furthermore, missed IUCDs require thorough investigation and imaging to make an appropriate management plan to avoid serious complications.
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