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Differential

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1. IUD in-situ in correct position

   • String coiled in endocervical canal or endometrial cavity

   • String short or broken

2. Unnoticed expulsion

3. Intrauterine pregnancy brings strings into the uterus as it grows

4. Malpositioning of the device following perforation

   • Embedment in the myometrium

   • Translocation into the abdominal or pelvic cavity

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Work up of Missing Strings

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1. Assess pregnancy status

   • Pregnancy test positive: locate and date pregnancy; manage accordingly

   • Pregnancy test negative:

     • Attempt to sweep strings from canal:

       • Twirl an endocervical brush in the cervical canal

       • Try using a thread retriever to snag the strings

       • If available use a colposcope to aid visualization of the strings with magnification. This is ideally done with an endocervical speculum to peer into the endocervical canal to visualize threads. If visible – do not attempt to pull them down unless patient desires removal.

     • If not able to visualize strings – (pregnancy test negative) do ultrasound (or if x-ray is more available may start with KUB)

   • Starting with Ultrasound:

     • Ultrasound shows IUD in situ: go to #1 below

     • Ultrasound shows no IUD in situ: order KUB and if no IUD seen it has been expelled.

       • If IUD seen on KUB and not seen in uterus on ultrasound: IUD is translocated.

     • Ultrasound shows possible embedment: order 3D ultrasound or CT

   • Starting with KUB

     • No IUD is seen it has been expelled

     • IUD seen: must ALSO do ultrasound to determine location unless it is clearly translocated (seen not near uterus)

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Management and Prevention

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1. IUD determined to be in situ:

• Desires retention

  • ​May leave in place for remainder of IUD lifespan

  • Option: annual pelvic ultrasound in lieu of string check

• Desires removal

  • Consent for uterine instrumentation procedure

  • Bimanual exam

  • Probe for strings in cervical canal

  • Administer cervical block

  • Apply tenaculum

  • Real-time ultrasound guidance may help, if available

  • Choose extraction device

    • Patterson alligator forceps to search within the uterine cavity, using a tenaculum to stabilize the uterus before intrauterine manipulation:

      • No cervical dilation necessary

      • Within the uterine cavity gently open/close forceps completely at quarter turns and progressive depths until “purchase” of the IUD stem or string (or arm).

    • Thread Retriever or thread retriever with hook

      • Begin at fundus and twirl along anterior, then posterior, uterine wall from fundus to canal

    • If ring-shaped IUD: use crochet hook or 3-5 mm suction curette

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2. Additional measures, for removal as indicated

• Pain management

• Cervical block + oral NSAIDs for pain

• Conscious sedation

• Cervical dilation

• Osmotic dilator

• Rigid dilators

• Misoprostol may facilitate IUD extraction(not placement however)

 

3.Expulsion

• Occurs in 2-10% placements

• Unnoticed expulsion may present with pregnancy

• Risk of expulsion related to

  • Provider’s skill at fundal placement

  • Higher parity

  • Uterine configuration and anomalies

  • Prior history of expulsion

  • Time since placement (↑ within 6 mos but can occur any time)

  • Timing of placement (post placental delivery, post second trimester abortion)

  • Adherence to manufacturer’s instructions to prevent expulsion:

    • Paragard:

      • Re-advance the tube after releasing arms

      • Remove the rod and tube separately

    • LNG IUDs:

      • Ensure device is at fundus before pulling the slider(s) all the way down

      • Ensure the sliders are completely down with no space between the bottom of the slider(s) and the handle before removing the insertion tube

• Partial expulsion may present with

  • Pelvic pain, cramps, intermenstrual bleeding

  • IUD string longer than previously

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4. Embedment

• If embedment suspected evaluate with 3-D ultrasound or pelvic CT with contrast

  • To decide whether to start the extraction with laparoscopy or hysteroscopy

• Extract via operative hysteroscopy or laparoscopy

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5. Translocation

• Copper IUDs can cause more adhesions, must extract promptly via operative laparoscopy

• LNG-IUS is less reactive, but recommend laparoscopic removal

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6. IUD Removal in Menopausal Women

• Strings seen: remove

• No strings visible…weigh risks

  • Hazards of continuation (post-menopausal bleeding, ? pelvic actinomycosis)

  • Hazards of removal (pain, perforation)

• Tail-less IUD (e.g., Chinese stainless-steel coil ring) should not be removed unless requested by the patient

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