What is the procedure for removing an Intrauterine Device (IUD) in a woman of reproductive age with a previously inserted IUD?

IUD Removal Procedure

IUD removal is a straightforward office procedure performed by gently pulling on the visible strings during speculum examination, with the device removed at any point in the menstrual cycle when the woman desires discontinuation or when clinically indicated.

Standard Removal Technique

When Strings Are Visible

• Locate the IUD strings during speculum examination and remove the device by pulling gently on the strings 1
• The procedure can be performed at any time during the menstrual cycle 2
• No anesthesia or special preparation is typically required for routine removal 3
• The removal is an uncomplicated office procedure that primary care providers can perform 3

Post-Removal Counseling

• Advise the woman to return promptly if she experiences heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever after removal 1
• If the IUD is removed and the woman desires continued contraception, counsel her on alternative contraceptive methods and offer another method immediately 1
• Consider emergency contraceptive pills (ECPs) if appropriate, particularly if the woman had recent unprotected intercourse 1

Management When Strings Are Not Visible

Initial Assessment

• If strings are not visible and cannot be retrieved safely from the cervical canal, perform or refer for ultrasound examination to determine the IUD location 1
• Ultrasound can determine if the IUD has been expelled, remains in the uterus, or has perforated the uterine wall 1

Advanced Removal Techniques

• If ultrasound-guided removal fails, hysteroscopic-guided removal is the superior next option 4
• Hysteroscopic removal has been shown to be effective with low risk of complications and avoids unnecessary major surgery 4
• For embedded IUDs or those reaching the serosal surface, hysteroscopic exploration should be attempted first before considering laparoscopic or open surgery 5
• Preoperative imaging helps assess uterine myometrial thickness and distance to the serosal surface when planning difficult removals 5

Special Clinical Scenarios

IUD Removal in Pregnancy

If a woman with an IUD is found to be pregnant and the strings are visible, the IUD should be removed as soon as possible by pulling gently on the strings 1

• First, evaluate for possible ectopic pregnancy 1
• Counsel that leaving the IUD in place increases risks of spontaneous abortion (including life-threatening septic abortion) and preterm delivery 1
• Removal reduces these risks but may not decrease risk to baseline levels of pregnancy without an IUD 1
• If strings are not visible and cannot be retrieved safely, do not attempt aggressive removal; instead, provide close monitoring 1

IUD Removal with Pelvic Inflammatory Disease (PID)

• The IUD does not need to be removed immediately if the woman has PID and needs ongoing contraception 1
• Initiate appropriate antibiotic treatment according to CDC STD Treatment Guidelines 1
• Reassess in 24-48 hours; if no clinical improvement occurs, continue antibiotics and consider IUD removal 1
• If removal is desired, remove the IUD sometime after antibiotics have been started to avoid potential bacterial spread from the removal procedure 1
• Treatment outcomes generally do not differ between women who retain versus remove the IUD, though appropriate antibiotics and close follow-up are essential 1

Common Pitfalls and Caveats

• Never attempt forceful removal if strings are not visible, as this risks uterine perforation 1
• For postmenopausal women with embedded IUDs, expect potential uterine adhesions that may obscure visualization during hysteroscopy 5
• When removing an IUD in the setting of PID, timing the removal after antibiotic initiation minimizes risk of bacterial dissemination 1
• If pregnancy is desired after removal, fertility returns immediately, so counsel about alternative contraception if pregnancy is not desired 3, 2