Is it safe to blindly remove an intrauterine device that has been in place for 18 years?

Should You Blindly Pull Out an IUD That Has Been in Place for 18 Years?

No, you should not blindly remove an IUD that has been in place for 18 years without first attempting to visualize the strings and assessing the clinical situation, but in-office removal without visible strings is safe and effective when performed with appropriate techniques.

Initial Assessment

Before attempting removal, you need to determine string visibility at the external cervical os:

• If strings are visible: Standard removal with ring forceps is appropriate 1
• If strings are not visible: This becomes a "lost" or retained IUD requiring specialized techniques, but can still be safely removed in-office 2, 3

Why "Blind" Removal May Be Problematic After 18 Years

An IUD retained for 18 years (far beyond its approved duration) presents specific concerns:

• String retraction or breakage is common with prolonged retention, occurring in approximately one-third of cases where total IUD and string length measures <7.5 cm 2
• Potential embedding into the uterine wall increases with duration of use 3
• Uncertain intrauterine location must be confirmed, as the device could have perforated or been expelled 4

Recommended Approach for In-Office Removal

Step 1: Confirm Intrauterine Location

• Perform transvaginal ultrasound to verify the IUD is within the uterine cavity before attempting removal 3
• This prevents unnecessary manipulation if the device has perforated or been expelled 4

Step 2: Attempt Specialized Removal Techniques

If the IUD is confirmed intrauterine but strings are not visible, use one of these proven methods:

• IUD hook technique: A specialized hook-type instrument can successfully retrieve IUDs without visible strings with 100% success when the device is intrauterine 4
• Cylindrical brush method: Rotating a cylindrical brush in the cervical canal can extract the device in 89% of cases (24/27 patients) 5
• Ultrasound-guided removal: Using transabdominal ultrasound guidance with either a crochet-type IUD hook or alligator forceps achieves 83% success rate (19/23 patients) 3

Step 3: Escalate if Office Removal Fails

• Hysteroscopic removal should be reserved for failed office-based attempts, occurring in approximately 11-17% of cases 5, 3
• This is significantly more expensive ($3,562 vs $465 for ultrasound-guided office removal) 3

Key Clinical Pitfalls to Avoid

• Do not attempt forceful blind extraction without confirming intrauterine location, as this risks uterine perforation if the device is embedded or partially perforated 3
• Do not immediately refer to operating room without attempting office-based removal techniques first, as this is unnecessarily costly and invasive 3
• Do not use standard ring forceps blindly if strings are not visible—this has low success rates and led to referrals in the studies reviewed 5

Patient Counseling

According to current CDC guidelines, if the patient desires removal at any time, remove the method and offer counseling on alternative contraceptive methods 1. After 18 years, the device is certainly expired and should be removed regardless of the patient's contraceptive needs.

Success Rates Summary

The evidence demonstrates high success rates for in-office removal of retained IUDs:

• All 29 IUD removals were successfully performed as outpatient procedures in one series 2
• 83-89% success with specialized office techniques before requiring hysteroscopy 5, 3
• No complications reported with hook or brush techniques 5, 4