Remove the IUD Before Proceeding with Medication Abortion
The best next step is to remove the copper IUD before initiating medication abortion. The IUD is visualized within the uterine cavity with visible strings, making removal straightforward and essential for reducing serious complications 1.
Rationale for IUD Removal
The CDC's U.S. Selected Practice Recommendations explicitly state that when an IUD user is found to be pregnant and does not wish to continue the pregnancy, the provider should:
- Counsel her about options (which she has already decided)
- Remove the IUD as soon as possible if strings are visible or can be retrieved safely 1
Leaving the IUD in place significantly increases risks for:
- Spontaneous abortion (including life-threatening septic abortion)
- Preterm delivery
- Chorioamnionitis
- Other infectious complications 1
Recent research confirms these risks: a 2023 retrospective study of 233 pregnancies with copper IUDs showed pregnancy loss rates of 61.4% when the IUD was retained versus 33.3% when removed (p < 0.001) 2. Even among pregnancies that continued beyond early loss, adverse outcomes occurred in 53.1% of IUD-retained cases versus 27.8% of IUD-removed cases (p = 0.03) 2.
Step-by-Step Management Algorithm
1. Remove the IUD immediately
- Since the IUD is visualized on ultrasound and within the uterine cavity, strings should be accessible
- Remove by gently pulling on the strings 1
- This can be done in the office setting
2. Proceed with medication abortion
- Once the IUD is removed, standard medication abortion protocols can be followed
- The presence of copper does not affect fetal development, so there are no teratogenic concerns if she were to continue the pregnancy 3
- However, removal is still indicated to reduce pregnancy complications
3. Provide appropriate counseling
- Advise her to return promptly for heavy bleeding, cramping, pain, abnormal discharge, or fever 1
- Discuss future contraception options after the abortion is complete
Critical Pitfalls to Avoid
Do NOT proceed with medication abortion while the IUD remains in place. While the guidelines address IUD management in the context of continuing pregnancy, the same principles apply to elective termination—the IUD should be removed to minimize infection risk and ensure optimal outcomes.
Do NOT delay removal. The guideline states the IUD "should be removed as soon as possible" when strings are visible 1. At 5 weeks gestation with an intrauterine pregnancy confirmed, this is the ideal time for safe removal before proceeding with termination.
Do NOT attempt complex retrieval procedures. Since the IUD is visualized and presumably has accessible strings, simple office removal is appropriate. Ultrasound-guided retrieval is only necessary when strings are not visible 4.
Evidence Quality
The recommendations are based on CDC guidelines (2013) 1 supported by systematic reviews showing clear benefit to IUD removal. While most evidence is Level II-2 to II-3, the consistency across multiple studies and the magnitude of risk reduction (doubling of spontaneous abortion rates with retained IUD) 2, 3 make this a strong recommendation despite the moderate evidence level.
The 2023 study provides the most contemporary evidence specifically for copper IUDs, demonstrating that removal improves outcomes for both early pregnancy loss and later adverse events 2.