Intrauterine Device Extraction

Intrauterine devices (IUDs) are highly effective reversible contraceptives. ^[1] Intrauterine contraception is an increasingly popular choice for women seeking long-term pregnancy prevention. ^[2] In addition, IUDs are among the most cost-effective options for reversible contraception, and overall patient satisfaction with this method is high. ^{[3, 4]}

Three intrauterine devices (IUDs) have been approved by the FDA in the United States: the Mirena intrauterine device, the Skyla intrauterine device, and the ParaGard (T380A intrauterine copper contraceptive). Mirena and Skyla contain levonorgestrel (a progestin) that is released up to 3 years (Skyla) or 5 years (Mirena).

The levonorgestrel-releasing intrauterine systems are the most effective IUD available, with a 0.2% pregnancy rate at 1 year of use for Mirena ^[1] and a 0.9% pregnancy rate after 2 years of use for Skyla. ^[5] Each levonorgestrel-releasing intrauterine system consists of a T-shaped polyethylene frame with a hormone reservoir that contains either 52 mg (Mirena) or 13.5 mg (Skyla) of levonorgestrel. Levonorgestrel is initially released at a rate of 20 ug/day and decreases to 11 ug/day after 5 years for Mirena. ^[6] Skyla releases 13.5 mg of levonorgestrel at a rate of 14 ug/day after 24 days following insertion. The release rate declines to 5 ug/day after 3 years. ^[5]

The mechanism of action of the levonorgestrel-releasing intrauterine system is thought to be multifactorial. The levonorgestrel is thought to cause endometrial suppression and changes in cervical mucus that render the intrauterine environment inhospitable for pregnancy. ^{[7, 8]} In addition, the physical presence of the IUD causes alterations in ovum and sperm migration and potential damage to the fertilized embryo prior to implantation. ^[9] The most common complaints voiced by women using the levonorgestrel-releasing intrauterine system are irregular spotting, which commonly occurs in the months following placement, amenorrhea, and pain. ^{[9, 10]}

The copper T380A IUD is also highly efficacious, with a 0.8% pregnancy rate at one year of use. ^[1] It consists of a T-shaped polyethylene frame that is wrapped with a copper wire. It is approved for contraception for a 10-year interval, after which time it should be removed and a new device placed. The mechanism of action is thought to be related to the physical presence of the IUD, which interferes with sperm and ovum transport and potentially damages the ovum or the embryo prior to implantation. ^[9] The most common side effects of Copper T380A IUD use are bleeding and pain. ^[10]

In general, IUD insertion and removal are both outpatient office procedures intended to be performed by trained health care providers. This objective of this review is to outline IUD removal and discuss issues relevant to this procedure.

Ideally, the indication for IUD removal is desire for pregnancy. Alternatively, IUD removal is indicated after 5 years for the levonorgestrel-releasing intrauterine system and after 10 years for the copper T380A IUD. ^{[6, 11]} In this setting, patients should be counseled that return of fertility after removal may be immediate and rates of pregnancy within the first year after removal approximate those in women without contraception. ^[12] In women seeking continued contraception, a new IUD can be placed at the same visit as the removal of an expired device.

According to the American College of Obstetricians and Gynecologists (ACOG), no strong evidence exists to support the removal of an IUD before its expiration date in asymptomatic women who have reached menopause. IUDs are usually well tolerated by menopausal women. ^[13]

IUD removal should be performed at any time secondary to patient request. The most common reasons cited by patients requesting IUD removal are side effects, including bleeding, pain, or infection (45%); this is followed by device-related issues (32%), fears or misconceptions (12.6%), and desire for current pregnancy (9.7%). ^[14] Current literature suggests that many of these requests for removal, particularly those requested secondary to side effects and fears or misconceptions may be prevented by thorough preinsertion counseling regarding expectations with IUD insertion and continued use. ^{[15, 16]}

Mild pain with insertion is common, and some women continue to experience cramping pain for days to weeks following insertion. Severe pain is uncommon and is cause for prompt evaluation and, possibly, IUD removal. Patients who present requesting IUD removal secondary to unscheduled bleeding, amenorrhea, or pain should have a history and physical examination performed. They should be counseled that these effects maybe an expected outcome with IUD use. A urine pregnancy test should also be performed. If the patient feels the side effects are not acceptable to her despite counseling, or laboratory or examination results are concerning for malposition of IUD or pregnancy, then the IUD should be removed.

Notably, presence of newly diagnosed gonorrhea or chlamydia infection is not an indication for IUD removal. ^{[13, 17, 18]}  ACOG recommends a preinsertion physical examination to evaluate for signs of cervicitis and screening tests for gonorrhea or chlamydia in high-risk women. If cervicitis is suspected based on physical examination, IUD insertion should be delayed until after treatment. Otherwise, screening may be performed and the IUD inserted on the same day.

If this screen returns positive for gonorrhea or chlamydia, the patient can be treated with the IUD in place. Concern in this setting is for ascending genital tract infection or pelvic inflammatory disease (PID) and related sequelae. The risk for PID related to IUD insertion is greatest within the first 20 days after insertion, indicating that the likely mechanism of infection is contamination of upper genital tract from infection present at the time of insertion. ^{[19, 20]}

This underscores the need for screening in high-risk women. The risk for PID in women with a sexually transmitted infection at time of insertion is higher than in women without infection at the time of insertion; however, the overall risk is still low, around 5%. ^[21] Although placing an IUD is contraindicated in a patient with PID, if they acquire PID with an IUD in place treating without removing the IUD is safe. ^{[17, 18, 22]} In this situation, patients should be followed closely, and the IUD should be removed if appropriate clinical improvement does not occur. IUDs should be removed in patients with pelvic tuberculosis. ^{[17, 18]}

Clinical guidelines on intrauterine contraception were released on November 11, 2018, by the Collège national des gynécologues et obstétriciens français (CNGOF) ^[23]

• Intrauterine contraception (IUC) is indicated for adolescents, nulliparous, and patients living with HIV.
• Women with IUC should not alter cervical cancer screening.
• A bimanual examination and cervix inspection are mandatory before the device is inserted.
• Systematic screening for sexually transmitted infection (STI) before device insertion is not recommended. STI screening should be completed before insertion but can also take place at the time of device insertion in asymptomatic women.
• Before device insertion routine antibiotic prophylaxis and premedication are not recommended. 
• Following device insertion, routine pelvic ultrasound examination is not recommended.
• Radiological workup to locate the device is recommended in cases of suspected uterine perforation.
• Intrauterine device should be laparoscopically removed from the abdominal cavity.
• Exclude ectopic pregnancy in cases of accidental pregnancy with IUC.
• In cases of STI or pelvic inflammatory disease, immediate removal of the device is not recommended.
• Device removal should be considered in the absence of clinical improvement after 48 to 72 hours of appropriate treatment.