Management of IUD Migration in Young Females
If an IUD has migrated outside the uterus, it must be surgically removed, even in asymptomatic patients, to prevent severe complications including bowel perforation, bladder injury, and abscess formation. 1, 2, 3
Initial Assessment and Diagnosis
Clinical Presentation
- Approximately 50% of patients with IUD migration present with pelvic pain, while one-third are completely asymptomatic 3
- Other presentations include pregnancy (indicating contraceptive failure), recurrent urinary tract infections, chronic pelvic discomfort, or discovery of missing IUD strings during routine examination 1, 2, 4
Diagnostic Workup
When IUD strings are not visible on examination:
- First, obtain a plain abdominal X-ray with a hysterometer placed in the uterus to determine if the IUD has perforated 1
- Pelvic ultrasound should be performed to assess IUD location, though it may be insufficient for precise localization 2, 5
- CT scan is strongly recommended for definitive localization of a migrated IUD, as it provides superior visualization compared to ultrasound or MRI 2, 5
- Rule out pregnancy with urine pregnancy test, as IUD migration results in contraceptive failure 1
Surgical Management
Removal is Mandatory
The World Health Organization recommends surgical removal of all migrated IUDs, regardless of symptoms, due to risk of severe complications 2, 3
Surgical Approach Based on Location
- Laparoscopy is the preferred method for IUD removal when the device is in the peritoneal cavity 2, 3
- Laparotomy may be necessary for complex cases involving bowel or bladder perforation 1
- Cystoscopy with cystolitholapaxy is required for intravesical migration with stone formation 4
- Colpotomy can be used for select cases where vaginal extraction is feasible 1
Common Migration Sites
The most frequent locations for migrated IUDs are the intestine, bladder, and omentum, with approximately 80% found in the peritoneal cavity after uterine perforation 2, 3
Post-Removal Care and Contraceptive Counseling
Alternative Contraception
After IUD removal, counsel the patient on alternative long-acting reversible contraceptive methods:
- Consider a new IUD placement only after complete healing and if the patient desires, as IUDs remain highly effective with failure rates less than 1% when properly positioned 6
- The contraceptive implant is an excellent alternative with a failure rate of 0.05% and does not carry perforation risk 6
- Discuss combined hormonal contraceptives or DMPA injection as alternatives 6
Follow-Up
- Ensure complete recovery from surgical removal before considering new contraceptive device placement 1, 2
- Patients generally have no lasting injuries after removal of migrated IUDs, though severe complications have occasionally been reported 3
Prevention and Risk Factor Awareness
Healthcare providers should be particularly vigilant about perforation risk during insertion, especially with painful insertion or in the immediate postpartum period 3
- The risk of pelvic infection and perforation is highest in the first 20-21 days after IUD insertion 6
- Routine follow-up should include checking for presence of IUD strings, and patients should be advised to return if strings become non-palpable 6
- Uterine perforation and migration occur in approximately 1-2 per 1000 IUD insertions 3