Management of Missing IUD Strings

Differential Diagnosis

  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

Work up of Missing Strings

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)

Management and Prevention

 

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

 

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:

        • 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

 

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

 

5. Translocation

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

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

 

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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