What happens if a hormonal intrauterine device (IUD) is more than 1 cm from the uterine fundus?

Management of Hormonal IUD Positioned >1 cm from the Fundus

A hormonal IUD positioned more than 1 cm from the uterine fundus has an increased risk of displacement, partial expulsion, and reduced contraceptive efficacy, requiring repositioning or replacement to ensure optimal function. 1, 2

Risks of Malpositioned IUDs

• Increased risk of displacement and expulsion when the IUD is not properly positioned at the fundus 2
• Reduced contraceptive effectiveness due to suboptimal hormone delivery to the endometrium 3
• Higher likelihood of side effects including abnormal bleeding and pain 4
• Potential for complete expulsion if partial expulsion is not addressed 5

Assessment of Malpositioned IUD

• Transvaginal ultrasound is the preferred method to evaluate IUD position and the distance from the fundus 5
• The position of the IUD is considered correct if the distance between fundus and the cranial end of the IUD does not exceed the thickness of the uterine wall by more than one-third 4
• Women with uterine width less than 41.5 mm have a higher risk of IUD displacement (sensitivity 53.8%, specificity 75%) 5

Management Options

Option 1: Repositioning the IUD

• Ultrasound-guided repositioning can be performed for partially expelled IUDs with a success rate of approximately 92.7% 6
• Technique involves:
  • Using Hartmann alligator forceps or ring forceps under ultrasound guidance 2, 6
  • Ensuring proper visualization of the cervix 2
  • Gently advancing the IUD to achieve fundal placement 3
  • Confirming proper positioning with ultrasound 2, 3

Option 2: Removal and Replacement

• If repositioning is not successful or not attempted, remove the current IUD and insert a new one 3
• For reinsertion:
  • Ensure proper fundal placement using appropriate technique 2, 3
  • Consider using ring forceps or Kelly placental forceps rather than the manufacturer's inserter for better control 2
  • Confirm placement with ultrasound when available 3

Follow-up Recommendations

• Schedule follow-up ultrasound 4-6 weeks after repositioning to confirm proper placement 6
• Advise patients to return promptly if they experience:
  • Heavy bleeding or cramping 1
  • Abnormal vaginal discharge 1
  • Fever or signs of infection 1
• Consider alternative contraceptive methods if repeated displacement occurs 3

Special Considerations

• Even with successful repositioning, be aware that approximately 17.6% of repositioned IUDs may be expelled within 6 months 6
• Patients with a history of dysmenorrhea have a higher risk of IUD displacement 5
• If the IUD cannot be located on ultrasound, it might have been expelled or have perforated the uterine wall (though perforation is rare at 0.87 per 1000 insertions) 1, 7

Common Pitfalls to Avoid

• Failing to confirm fundal placement after insertion or repositioning 2, 3
• Not considering uterine dimensions when assessing risk of displacement 5
• Overlooking patient symptoms that might indicate malposition 4
• Assuming an IUD is fragmented when the hormonal sleeve may have displaced over the arms during removal 8