Intrauterine Device Extraction 

Updated: Nov 29, 2018
Author: Sarah Hagood Milton, MD; Chief Editor: Christine Isaacs, MD 

Overview

Background

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.

Indications

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.

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%).[13] 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.[14, 15]

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.[16, 17, 18] The American College of Obstetricians and Gynecologists (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] 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]

Guidelines

Clinical guidelines on intrauterine contraception were released on November 11, 2018, by the Collège national des gynécologues et obstétriciens français (CNGOF)[22]

  • 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.
 

Periprocedural Care

Equipment

The equipment necessary for IUD removal includes a speculum and a pair of ring forceps. Having an IUD hook, polyp forceps, and a single-tooth tenaculum on hand for difficult removals is also helpful.

Patient Preparation

Anesthesia

No anesthesia or analgesia is indicated for routine removal of either the ParaGard or the Mirena IUD. Removal of IUDs is generally less painful than insertion.

Positioning

For both the Mirena IUD and the ParaGard IUD, removal is best accomplished with patient in dorsal lithotomy position.

 

Technique

Approach Considerations

Routine Removal

The patient is placed in dorsal lithotomy position, and the speculum is used to visualize the cervix. The IUD strings are usually readily visualized. If this is not the case, refer to the "Difficult Removal" section below. Grasp the IUD strings with the ring forceps and apply steady gentle outward traction, and the IUD should easily appear in the vagina. Remove the speculum. Patients should be counseled that immediate return of fertility is probable and if they do not desire conception they should immediately initiate an alternative form of contraception.[12] For patients desiring continued IUD use, a new device can be placed at the same visit.

Difficult Removal

Uncommonly, IUD removal may be challenging. The primary indicator of a problem is the inability to visualize IUD strings extending from the cervical os. This may be an incidental finding at the patient’s follow up appointment 4-6weeks following IUD insertion for routine "string check" to assure correct placement. Alternatively, the lack of visible strings may be a finding on pelvic examination indicated secondary to pain or irregular bleeding. It may also be an incidental finding during a routine pelvic examination.

If IUD strings are not visualized and patient desires removal, a cytobrush (see image below) may be inserted into the endocervical canal, twisted and then withdrawn in an attempt to pull retracted strings into view in the vagina.

Cytobrush Cytobrush

If the strings are not found with the cytobrush, an IUD hook may be used to locate the strings in the cervical canal or uterus. With a speculum in place and the cervix clearly visualized, a tenaculum is placed, the IUD hook is inserted into the cervical canal, and an effort is made to hook the strings and pull them into the vagina, where they can be grasped with ring forceps.

IUD hook IUD hook

This may take several passes to accomplish. If the strings are not recovered from the cervical canal, the hook may be used to attempt the removal from the uterus. Generally, the hook is advanced to the fundus, and 4 systematic passes are attempted, first with the hook directed anteriorly, then posteriorly, then left and right. Although uncomfortable, it is generally tolerable if performed quickly. If not tolerated by the patient, the procedure should be stopped.

If these techniques are unsuccessful, the recommendation is for transvaginal ultrasonography to aid in localization of the IUD.[23] If transvaginal ultrasound confirms intrauterine placement of the IUD without concern for myometrial embedding, additional efforts can be made for outpatient removal. Several techniques have been described, including use of alligator forceps or uterine packing forceps inserted though the cervical canal and used to blindly grasp the IUD and remove it. Alternatively, a similar technique has been performed using ultrasound or hysteroscopic guidance.

Verma et al reported their experience with ultrasound-guided removal of retained IUDs, with or without strings, as safe and cost-effective, and it could be performed in an office setting.[24] Over a 14-month period, the investigators noted that 19 of 23 patients underwent successful ultrasound-guided IUD extraction; the remaining 4 women underwent hysteroscopic-guided IUD removal. The cost of the procedures was $425 and $3562 US dollars [USD], respectively (difference: USD $3137).[24] Similarly, Swenson et al reported successful outpatient extraction of levonorgestrel IUDs in all 29 women in their case series who did not have visible IUD strings at the external cervical os.[25]

When using these more invasive techniques, a paracervical block should be considered for analgesia. In particularly challenging cases or when prior attempts have been limited by patient discomfort, the patient can be taken to the operating room, where an examination under anesthesia, hysteroscopy, and IUD removal may be performed. The later procedure is commonly performed if myometrial embedding is a concern, so that the hysteroscope can be used to evaluate any myometrial defect following removal.

In the instance that no IUD strings are visualized and the IUD is not visualized in the uterus on ultrasound, a radiograph (anteroposterior and lateral upright plain radiograph) is indicated to aid in further localization. The most common reason for these findings is an unrecognized spontaneous expulsion. Unless spontaneous expulsion was immediately recognized by the patient, a radiograph is mandatory prior to further intervention.

Alternatively, the IUD may be intra-abdominal, in which case it would be readily visualized on x-ray. Intra-abdominal placement is most commonly secondary to unrecognized perforation at the time of insertion and less likely to IUD migration. If the patient is in severe pain or hemodynamically unstable, immediate laparoscopy or laparotomy should be performed. Otherwise, the patient can be scheduled for a laparoscopic IUD removal on a nonemergent basis or be managed conservatively if the patient is asymptomatic and a poor surgical candidate.[26, 27]

An intra-abdominal Mirena IUD should always be removed if the patient desires pregnancy, as levonorgestrel levels are elevated in these patients, and ovulation may be suppressed despite the extrauterine location of the IUD.[28] At the time of laparoscopy, 2-3 ports are generally used, depending on the anticipated location of the IUD and attachment to adjacent structures. The most common intra-abdominal location for the IUD is the omentum, followed by the broad ligament.[29] Rarely, laparotomy is necessary for safe IUD removal.

 

Medication

Medication Summary

No antibiotic prophylaxis is indicated for IUD removal.

 

Questions & Answers