What are the signs that an Intrauterine Device (IUD) is correctly implanted in a woman?

Signs of IUD Malposition or Complications

If you suspect an IUD may be malpositioned, the key warning signs include persistent pelvic pain, heavy or prolonged bleeding, cramping, abnormal vaginal discharge, fever, or inability to palpate the IUD strings on examination. 1, 2

Clinical Assessment of IUD Position

String Visibility and Palpation

• The primary method to assess proper IUD placement is checking for the presence of visible strings at the cervical os. 1
• At routine visits, healthcare providers should consider performing an examination to check for the presence of the IUD strings. 1
• If strings are not visible and cannot be retrieved safely, this suggests possible expulsion, perforation of the uterine wall, or the device being positioned too high in the uterus. 1

Warning Signs Requiring Immediate Evaluation

Women should be advised to seek care promptly if they experience any of the following symptoms after IUD placement: 1, 2

• Heavy bleeding - particularly if new onset after the initial 3-6 month adjustment period
• Persistent or severe cramping and pelvic pain - especially pain that worsens rather than improves over time
• Abnormal vaginal discharge - which may indicate infection
• Fever - suggesting possible infection or perforation

Pregnancy Symptoms with IUD in Place

• If a woman with an IUD develops nausea, vomiting, or other pregnancy symptoms, pregnancy must be ruled out immediately, as IUD-related pregnancies carry significantly elevated risks of spontaneous abortion, preterm delivery, septic abortion, and chorioamnionitis. 3
• The risk of ectopic pregnancy increases greatly when pregnancy occurs with an IUD in place. 3
• Perform a pregnancy test immediately when any woman with an IUD presents with these symptoms. 3

Ultrasound Evaluation for Suspected Malposition

When to Consider Imaging

• If ultrasonography is available, consider performing or referring for ultrasound examination to determine the location of the IUD when strings are not visible. 1
• Ultrasound serves as first-line imaging for evaluation of IUD position in patients with pelvic pain, abnormal bleeding, or absent retrieval strings. 4
• Three-dimensional ultrasonography has proven more sensitive in evaluating subtle findings of malposition, particularly side-arm embedment. 4

Types of Malposition Detected by Ultrasound

Problems associated with malpositioned IUDs include: 4

• Expulsion - partial or complete displacement from the uterine cavity
• Displacement - IUD positioned in the lower uterine segment or cervical canal
• Embedment - IUD embedded in the myometrium
• Perforation - IUD penetrating through the uterine wall

Management Based on Findings

If Strings Are Visible or Device in Cervical Canal

• A malpositioned IUD that is low-lying and potentially extending into the cervix should be removed without requiring an updated ultrasound, especially when associated with persistent pelvic pain. 2
• If the IUD is in the cervical canal, advise the woman that it should be removed as soon as possible by pulling on the strings gently. 1

If Pregnancy Is Confirmed

• If pregnancy is confirmed, the IUD should be removed as soon as possible if strings are visible or can be safely retrieved to reduce the risk of serious complications. 3, 5
• Removing the IUD improves pregnancy outcomes, though risks for spontaneous abortion, preterm delivery, and infection remain substantial even after removal. 1

If Strings Not Visible

• If the IUD cannot be located by ultrasound, it might have been expelled or perforated the uterine wall. 1
• If strings are not visible and the IUD cannot be safely retrieved, referral for ultrasound-guided removal is appropriate. 2

Common Pitfalls to Avoid

• Do not assume normal IUD position based solely on absence of symptoms - routine string checks are important even in asymptomatic patients. 1
• Do not delay pregnancy testing in women with IUDs who have pregnancy symptoms - the stakes are dramatically higher than typical early pregnancy. 3
• Do not confuse expected bleeding irregularities (common in first 3-6 months) with pathologic bleeding from malposition - new onset heavy bleeding after the adjustment period warrants evaluation for displacement or other gynecological problems. 1
• Do not attempt to manage confirmed pregnancy with IUD in situ without specialist consultation given the high complication rates. 3