IUD Removal Procedure

Remove an IUD by visualizing the cervix with a speculum, identifying the strings, and pulling gently on them to extract the device. 1

Standard Removal Technique

Visualize the cervix using a speculum and identify the IUD strings as the first step. 1
Remove the IUD by pulling gently on the strings once the cervix has been prepared. 2, 1
Cleanse the cervix and sterilize any instruments prior to and during the removal procedure. 3
The procedure is uncomplicated and can be performed in an office setting by primary care providers. 4

Advise the patient to return promptly if she develops heavy bleeding, cramping, pain, abnormal vaginal discharge, or fever. 2, 1
Consider emergency contraceptive pills if appropriate after removal. 2
Counsel on alternative contraceptive methods and offer another method if desired. 2, 5

Perform or refer for ultrasound examination to determine the IUD location, as the device may still be in the uterus, may have been expelled, or may have perforated the uterine wall. 2, 5, 6
If the IUD is properly positioned and the patient is asymptomatic, the device can remain in place. 5

Remove a malpositioned IUD as soon as possible if it is low-lying, extending into the cervix, or embedded in the myometrium, especially when associated with pelvic pain. 5, 6
An IUD that has perforated the uterus must be removed as soon as possible. 5
The CDC recommends removal of a malpositioned IUD without requiring updated ultrasound if previous imaging confirmed malposition and the patient has persistent symptoms. 5

If ultrasound-guided removal fails, hysteroscopic-guided removal is the superior next option, avoiding unnecessary major operations and complications. 7
Hysteroscopic removal has been shown effective with low risk of complications and no major readmissions in clinical experience. 7

Evaluate for possible ectopic pregnancy immediately. 2
If strings are visible or can be retrieved safely from the cervical canal, remove the IUD as soon as possible by pulling gently on the strings. 2
Advise the woman that leaving the IUD in place increases risk for spontaneous abortion (including life-threatening septic abortion) and preterm delivery; removal reduces but does not eliminate these risks. 2
Systematic review evidence shows that 8 out of 10 pregnancies with retained LNG-IUDs ended in spontaneous abortion. 2

Initiate appropriate antibiotic treatment first before removing the IUD to avoid potential bacterial spread from the removal procedure. 1, 3
In mild to moderate PID, it is not necessary to remove the IUD during treatment unless the patient requests removal or there is no clinical improvement after 72 hours of appropriate antibiotic treatment. 3
In severe PID, consider removing the IUD after an appropriate antibiotic regimen has been started. 3
Evidence shows that treatment outcomes do not generally differ between women who retain the IUD versus those who have it removed, though one trial showed higher recovery rates for clinical signs and symptoms with removal. 2

Do not delay removal in pregnancy when strings are visible—this substantially increases risks of septic abortion, preterm delivery, and infection. 2
Do not remove an IUD in cases of active PID before starting antibiotics, as this may spread bacteria. 1, 3
Do not assume an IUD with non-visible strings has been expelled—always perform ultrasound to locate the device and rule out perforation. 2, 5
Do not perform major surgery for perforated IUDs in asymptomatic patients without careful consideration, as conservative management may be appropriate in select cases. 8