IUD Removal Procedure
IUD removal is a straightforward office procedure that can be performed at any time during the menstrual cycle by grasping the strings with ring forceps and applying steady, gentle traction to withdraw the device through the cervix. 1, 2
Pre-Removal Assessment
Before attempting removal, verify the following:
- Rule out pregnancy if the patient has been sexually active and removal is requested, as IUD removal during pregnancy requires special consideration 3
- Exclude active pelvic infection as a contraindication to immediate removal 4
- Visualize the IUD strings at the cervical os during speculum examination 2
- Assess for ectopic pregnancy if pregnancy is confirmed before attempting removal 5, 3
Standard Removal Technique
The removal procedure follows these steps:
- Insert a speculum and identify the IUD strings at the external cervical os 2
- Grasp the strings with ring forceps or similar instrument close to the cervix 1, 2
- Apply steady, gentle traction while the patient takes a deep breath or coughs to facilitate removal 1
- Withdraw the device through the cervical canal in a smooth motion 1, 2
The procedure is typically uncomplicated and can be completed in a primary care office setting 1
Special Clinical Scenarios Requiring Immediate Removal
Remove the IUD immediately in these situations:
- Confirmed intrauterine pregnancy with visible strings - removal reduces (but does not eliminate) risks of spontaneous abortion and preterm delivery 3
- IUD located in the cervix rather than uterine cavity - causes reduced efficacy, pain, bleeding, and infection risk 3
- Uterine perforation or myometrial embedding especially if symptomatic with pelvic pain (wait 4-6 weeks before replacing) 3
- Cervical or endometrial cancer requiring treatment 3
- Current breast cancer (the IUD is contraindicated and must be removed) 3
Pelvic Inflammatory Disease Management
Do not remove the IUD immediately when PID is diagnosed:
- Start appropriate antibiotics first and reassess in 24-48 hours 5, 3
- Remove only if no clinical improvement after 48 hours of antibiotics or if the patient desires discontinuation 5, 3
- Removal after antibiotic initiation minimizes bacterial spread from the procedure 5, 3
Post-Removal Considerations
After IUD removal, address these points:
- Offer alternative contraception immediately if ongoing pregnancy prevention is desired 5, 3
- Consider emergency contraception if the patient had recent intercourse and residual sperm may be present 5
- No waiting period is necessary before attempting conception - the CDC explicitly states waiting for the next menstrual period is unnecessary 4
- Prescribe NSAIDs for pain (ibuprofen 600-800 mg every 6-8 hours or naproxen 440-550 mg every 12 hours with food) if needed 5
Common Pitfalls to Avoid
- Do not remove the IUD before evaluating unexplained vaginal bleeding - the device can remain during diagnostic workup 3
- Do not routinely remove for amenorrhea - this affects approximately 50% of levonorgestrel IUD users by 2 years and requires only reassurance unless unacceptable to the patient 3
- Do not delay removal if strings are visible and pregnancy is confirmed, as leaving it in place increases pregnancy complications 3