From the Guidelines
Difficult intrauterine device (IUD) removal can lead to serious complications, including uterine perforation, expulsion, and infection, and therefore, it is crucial to seek care from a healthcare provider experienced in IUD management. When attempting removal, it is essential to consider the potential complications, such as heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever, as noted in the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1.
Potential Complications
- Uterine perforation: If the IUD cannot be located, it might have perforated the uterine wall, as suggested by the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1.
- Expulsion: The IUD might have been expelled, and therefore, it is essential to determine its location using ultrasonography, if available 1.
- Infection: Abnormal vaginal discharge or fever can indicate an infection, and prompt medical attention is necessary to prevent further complications.
Management
- Ultrasonography: If available, consider performing or referring for ultrasound examination to determine the location of the IUD, as recommended by the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1.
- Prompt medical attention: Advise the woman to seek care promptly if she experiences heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever, as noted in the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1.
Key Considerations
- It is crucial to seek care from a healthcare provider experienced in IUD management to minimize the risk of complications and ensure safe removal of the device.
- The use of ultrasonography and prompt medical attention can help prevent and manage potential complications associated with difficult IUD removal, as suggested by the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 1.
From the Research
Complications of Difficult Intrauterine Device (IUD) Removal
- Difficult IUD removals are associated with increased pain, with users experiencing more intense pain (>4) during the procedure 2
- The risk of difficult removals is higher for users of IUDs for ≥3 years and for those with previous cesarean deliveries, with a 3 times higher risk and 1.5 times increased risk, respectively 2
- In some cases, IUD removal may require medical methods for cervical ripening, such as oestrogens, mifepristone, misoprostol, and methyl carboprost, to facilitate the procedure and reduce the need for forced cervical dilatation 3
- These medical methods can also alleviate pain during IUD removal and reduce the risk of uterine injury, but may be associated with gastrointestinal side-effects such as nausea and diarrhoea 3
- The use of prophylactic antibiotics prior to IUD insertion has been studied, but the evidence is limited, and the reduction in IUD removal rate for medical reasons was not statistically significant in one pilot study 4
Factors Associated with Difficult IUD Removal
- Duration of IUD use: ≥3 years 2
- Previous cesarean deliveries 2
- Nonvisible or "lost" IUD threads, which can hinder the extraction process 5
- Stenotic cervix in postmenopausal women, which may require medical methods for cervical ripening prior to IUD removal 3