Should a low-positioned Paragard (intrauterine device, IUD) be replaced?

Management of a Low-Positioned Paragard IUD

A low-positioned Paragard IUD should be replaced to ensure optimal contraceptive efficacy and reduce the risk of complications such as dyspareunia and expulsion. 1

Assessment of a Low-Positioned IUD

When a Paragard IUD is found to be low in position, the following assessment should be performed:

• Bimanual and cervical examination to verify the exact position of the IUD and rule out any associated infection 1
• Ultrasound evaluation to confirm the position of the IUD relative to the fundus
• STI testing if there are risk factors or symptoms suggesting infection 1

Why Replacement is Necessary

A low-positioned IUD is considered malpositioned and requires intervention for several reasons:

1. Reduced contraceptive efficacy: The copper IUD works best when properly positioned at the fundus of the uterus
2. Increased risk of expulsion: Studies show that proper fundal placement decreases expulsion rates 2
3. Potential for symptoms: Malpositioned IUDs can cause dyspareunia, abnormal bleeding, and pain 1

Replacement Procedure

The Society for Maternal-Fetal Medicine and CDC guidelines support the following approach:

1. Remove the malpositioned IUD
2. Immediately replace with a new Paragard IUD using proper technique for high fundal placement
3. Consider using transabdominal ultrasound guidance during insertion to ensure proper placement 2

Insertion Technique for Optimal Placement

When replacing the IUD, proper technique is essential:

• Cleanse the cervix with antiseptic solution
• Use ring forceps to grasp the anterior lip of the cervix
• Ensure high fundal placement of the device (critical for reducing expulsion rates) 2
• Consider trimming strings to 10-12 cm if immediately post-partum, or standard length otherwise
• Confirm fundal placement through bimanual examination or ultrasound guidance 2

Follow-up Recommendations

After replacement:

• Schedule follow-up in 4-6 weeks to verify proper positioning
• Advise the patient to use backup contraception (condoms) for at least one week after replacement
• Instruct the patient on warning signs that require immediate attention (severe pain, fever, abnormal discharge)

Important Considerations

• The Paragard (Copper T380-A) IUD is approved for 10 years of use 1
• Expulsion rates are higher with improper placement, particularly when the IUD is not at the fundus 2
• A properly positioned IUD has a failure rate of less than 1%, making it highly effective 3

Common Pitfalls to Avoid

1. Delaying replacement: This increases the risk of unintended pregnancy
2. Removing without replacing: Many women who have an IUD removed with plans for delayed reinsertion never return for placement 2
3. Ignoring anatomical variations: Consider that uterine cavity size varies among women, particularly between nulliparous and parous women 4, 5
4. Failing to verify proper placement: Always confirm fundal placement after insertion

By ensuring proper placement of the Paragard IUD at the fundus, you maximize its contraceptive efficacy while minimizing the risk of complications and early discontinuation.