Malpositioned IUDs: How Easy Are They to Remove?

By Rebecca H. Allen, MD, MPH, Editor

SYNOPSIS: In this retrospective cohort study of 436 malpositioned intrauterine devices (IUDs), of the 281 that underwent removal, 82% were removed on the first attempt and 73% were removed using only ring forceps. Most embedded and partially perforated IUDs also were removed using only ring forceps (59% and 67%, respectively).

SOURCE: Frisse AC, Louik JB, Kachwala IA, et al. Ease of removal of malpositioned intrauterine devices: A retrospective cohort study. Contraception 2024;137:110504.

As intrauterine devices (IUDs) become more popular, more ultrasounds that will capture IUD malposition, embedment, and partial perforation will be performed. How easy it is to remove malpositioned and embedded IUDs is an important clinical question that these authors sought to answer.This was a retrospective cohort study conducted at one academic medical center in New York City. The study population consisted of patients with IUDs who had an ultrasound performed between July 2014 and July 2017 for any indication in the emergency department, or an outpatient or inpatient setting. All pelvic ultrasounds containing the terms “IUD,” “intrauterine device,” or “intrauterine contraceptive” were identified.

The primary outcome was IUD malposition, which was defined as any suggestion in the ultrasound report that the IUD was not in the correct position, such as low-lying, embedded, displaced, nonfundal, perforated, rotated, or malpositioned. The medical record then was searched to identify subject age, gravidity, parity, and details about any IUD removals, including provider type, number of attempts, instrument used, and location of IUD removal. The removal characteristics of those with malpositioned IUDs were compared to those with non-malpositioned IUDs.

A total of 1,759 patients had ultrasounds mentioning IUDs and 436 (25%) reports had language describing a type of IUD malposition. Of the 436, 150 (34%) were described as embedded and 16 (4%) were described as partially perforated; these categories were not mutually exclusive. Of the 436 subjects with malpositioned IUDs, 281 (64%) had their IUDs removed, and 238 (85%) were removed on the first attempt, with 77% removed in the office.

Of the 1,323 patients with non-malpositioned IUDs, 545 (41%) underwent IUD removal and 449 (82%) were removed on the first attempt, with 89% removed in the office. The majority of IUDs were removed by OB/GYNs (75% malpositioned, 70% normally positioned) using ring forceps (73% malpositioned, 65% normally positioned). Alligator forceps were used for 21 (8%) of malpositioned and 58 (10%) of normally positioned IUDs. Hysteroscopy was used for 14 (4%) of malpositioned and 36 (7%) of normally positioned IUDs. Embedded IUDs also were removed mostly with ring forceps (59%) or alligator forceps (6%). Only 4% were removed with hysteroscopy. There was no statistical difference in how the malpositioned and normally positioned IUDs were removed.

Commentary

The authors’ main conclusion from this study was that the majority of malpositioned and embedded IUDs can be removed in the office with ring forceps on the first attempt. This has been my experience clinically, provided that IUD strings are visible. Even if they are not visible, the IUD usually can be removed with alligator forceps under ultrasound guidance. The authors recommended that malpositioned IUDs do not need special equipment to manage nor a referral to a subspecialist in most cases.

There are some limitations to the study, however. The authors could not determine the indication for the IUD removal in terms of whether the patient was symptomatic. In addition, they did not report whether the IUDs were placed at interval visits, postpartum visits, or postplacentally, which would have been interesting to know. Furthermore, whether the IUD strings were visualized on examination was not reported.

I was surprised by how many normally positioned IUDs were removed using alligator forceps (10%) and hysteroscopy (7%). I can only presume this was the result of absent strings. The study would have been more robust if the authors had been able to compare management of malpositioned and embedded IUDs with strings visible and without strings visible.

We do know that IUDs inserted postplacentally are associated with more expulsions, malpositioning, and absent strings than IUDs placed at the six-week postpartum visit or outside of pregnancy.¹ As postplacental IUDs become more popular, we are seeing more patients with these issues. The rate of expulsion with postplacental IUD ranges from 10% to 20% depending on the study, compared to 2% to 4% on average with interval placement.²

In terms of malposition, with postplacental placement the rate is estimated at 15% compared to much less with interval insertions.³ Absent strings also are seen more often with postplacental IUD placement, approximately 25% after vaginal delivery and even more, up to 50%, after cesarean delivery, depending on the study.¹ Whether malpositioned IUDs need to be removed depends on a few factors. Any IUD in the cervix or causing the patient pain or bleeding symptoms is best removed. However, malpositioned IUDs in the uterine cavity do not necessarily need to be removed if the patient is asymptomatic and comfortable with leaving it in place.⁴ The levonorgestrel IUDs should work no matter their location in the uterus. The copper IUD is believed to work best in a fundal location, so if it is low-lying, it may benefit from removal and replacement.

A shared decision-making discussion should take place with the patient with appropriate counseling. Given that the IUD provides highly effective contraception, removing a malpositioned IUD when the patient is asymptomatic may risk pregnancy if a less effective method of contraception then is chosen. In conclusion, it is worth attempting to remove malpositioned and embedded IUDs in the office, since most attempts will result in a successful removal.

REFERENCES

1. Whitaker AK, Chen BA. Society of Family Planning Guidelines: Postplacental insertion of intrauterine devices. Contraception 2018;97:2-13.
2. Jatlaoui TC, Whiteman MK, Jeng G, et al. Intrauterine device expulsion after postpartum placement: A systematic review and meta-analysis. Obstet Gynecol 2018;132:895-905.
3. Gurney EP, Sonalkar S, McAllister A, et al. Six-month expulsion of postplacental copper intrauterine devices placed after vaginal delivery. Am J Obstet Gynecol 2018;219:183.e1-183.e9.
4. American College of Obstetricians and Gynecologists. Clinical challenges of long-acting reversible contraceptive methods. Committee Opinion Number 672. September 2016. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/09/clinical-challenges-of-long-acting-reversible-contraceptive-methods

Rebecca H. Allen, MD, MPH, is Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI.