Can an Intrauterine Device (IUD) be left in place if the strings are lost but the device is appropriately positioned?

Can an IUD Be Left in Place if Strings Are Lost but Device is Appropriately Positioned?

Yes, an IUD can be left in place if the strings are not visible but ultrasound confirms appropriate intrauterine positioning, provided the patient is not pregnant and has no concerning symptoms. 1

Clinical Context Matters

The management of missing IUD strings depends critically on whether the patient is pregnant:

In Non-Pregnant Patients

The IUD may remain in place if properly positioned on ultrasound. 1

• When strings are not visible, perform or refer for transvaginal ultrasound to confirm the IUD location within the uterine cavity 1
• If ultrasound confirms appropriate intrauterine positioning, the device can continue to provide effective contraception 2
• The patient should be counseled to return promptly for heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever 1
• Consider that the IUD may have been expelled or perforated the uterine wall if it cannot be located on imaging 1, 3, 4

Key caveat: If the IUD cannot be located on ultrasound, obtain an abdominal X-ray to rule out uterine perforation, as this is a relatively inexpensive and non-invasive way to detect an extrauterine device 4

In Pregnant Patients

The management is entirely different and removal should be attempted if possible. 1

• First, evaluate for ectopic pregnancy 1
• If strings are visible or can be retrieved safely from the cervical canal, the IUD should be removed as soon as possible by gently pulling on the strings 1
• Removal reduces (but does not eliminate) the substantial risks of spontaneous abortion, septic abortion, preterm delivery, and infection 1
• If strings are not visible and cannot be retrieved safely, ultrasound-guided extraction can be performed with a high success rate (77% live birth rate) and acceptable complication profile 5, 6
• Ultrasound-guided removal using alligator forceps has been successfully performed with pregnancies progressing to term 5
• The miscarriage rate after ultrasound-guided extraction (22%) is comparable to removal of IUDs with visible strings 6

Stepwise Approach for Missing Strings (Non-Pregnant)

1. Attempt to visualize strings: Use a cytobrush or cotton swab to sweep the cervical canal and attempt to retrieve strings 2

2. Obtain imaging: Perform transvaginal ultrasound to confirm intrauterine location 1, 2

3. If IUD is intrauterine and appropriately positioned: The device can remain in place with patient counseling about warning signs 1

4. If IUD cannot be located on ultrasound: Obtain abdominal X-ray to rule out perforation or confirm expulsion 3, 4

5. If perforation is confirmed: The IUD should be removed as soon as possible, typically requiring laparoscopic removal 7, 4

Common Pitfalls

• Assuming expulsion without imaging: Always confirm location with ultrasound when strings are missing, as uterine perforation can present with minimal or atypical symptoms 3, 4
• Failing to obtain X-ray when ultrasound is negative: An empty uterine cavity on ultrasound does not definitively mean expulsion; perforation must be ruled out 4
• Attempting removal in pregnancy without proper technique: If strings are not visible in pregnancy, ultrasound-guided extraction by an experienced provider is preferred over blind instrumentation 5, 6