What is the proper procedure for removing an Intrauterine Device (IUD) using ring forceps?

IUD Removal Using Ring Forceps

For routine IUD removal, grasp the IUD strings with ring forceps and remove the device by pulling gently with steady traction. 1

Standard Removal Procedure

When Strings Are Visible

• Grasp the IUD strings with ring forceps and pull gently to remove the device. 1
• Apply steady, gentle traction without jerking or twisting movements 2
• The removal should be performed as soon as possible if the patient is pregnant, as leaving the IUD in place substantially increases risks of spontaneous abortion (including life-threatening septic abortion) and preterm delivery 1

When Strings Are Not Visible

• Perform ultrasound examination to locate the IUD within the uterine cavity 1
• Use ultrasound-guided removal with alligator forceps or a crochet-type IUD hook under transabdominal ultrasound guidance 3
• This office-based ultrasound-guided approach has an 83% success rate and costs significantly less ($465) than operating room hysteroscopic removal ($3,562) 3
• If ultrasound-guided removal fails, refer for hysteroscopic removal in the operating room 3

Special Clinical Scenarios

IUD Removal During Pregnancy

• Evaluate for ectopic pregnancy immediately before attempting removal. 1
• Remove the IUD as soon as possible if strings are visible or can be retrieved safely from the cervical canal 1
• For IUDs with non-visible strings during pregnancy, use ultrasound-guided removal with small alligator forceps under high-resolution ultrasound guidance 4
• Counsel the patient that IUD removal reduces pregnancy risks but may not decrease them to baseline levels 1

Partially Expelled IUDs

• For partially expelled IUDs (vertical arm extending through the cervical canal), consider ultrasound-guided repositioning using Hartmann alligator forceps with a 92.7% success rate 5
• If repositioning is unsuccessful or the IUD is positioned >1 cm from the fundus, remove the current IUD and insert a new one 6
• Use ring forceps or Kelly placental forceps for reinsertion rather than the manufacturer's inserter for better fundal placement control 7, 6

Post-Removal Patient Instructions

• Advise the patient to return promptly if she experiences heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever 1, 6
• These warning signs apply whether the IUD was removed successfully or if removal was attempted but unsuccessful 1

Common Pitfalls to Avoid

• Never use excessive force during removal, as this can cause cervical trauma or IUD fragmentation 2
• Do not attempt blind removal with instruments when strings are not visible without ultrasound guidance, as this increases perforation risk 3
• Failing to evaluate for ectopic pregnancy before IUD removal in pregnant patients can lead to missed diagnosis of a life-threatening condition 1
• Do not assume an IUD with non-visible strings has been expelled; it may be embedded in the uterine wall or have perforated, requiring imaging confirmation 1, 6