Self-removal of IUDs appears to be popular among many people and may empower women, but research indicates successful self-removal is not guaranteed.1-3
“What we know is there are thousands of people who are on a message board talking about self-removal or are interested in learning more about self-removal of IUDs,” says Jennifer Amico, MD, MPH, study co-author and associate professor in the department of family medicine and community health at Rutgers Robert Wood Johnson Medical School in New Brunswick, NJ.1,3
Amico and colleagues found that patients who successfully self-removed their IUDs reported positive experiences and no pain. Those who unsuccessfully attempted to remove their IUDs reported pain or inability to hold the string well enough to pull it out.1
A high interest in IUD self-removal does not mean that most women are successful. For example, a 2014 study revealed that of people who attempted to self-remove their IUD in a clinic, only 20% were successful.2
Researchers continue to study the efficacy of self-removal and how to help people improve, Amico says. “I would push back on the thought that self-removal is less than ideal,” she says. “If someone prefers to self-remove and can do it, I have no qualms or concerns about that at all.”
Women may choose to self-remove an IUD to avoid the cost and inconvenience of a clinic visit. During the pandemic, some people could not visit a clinic for an IUD removal, so Amico heard of some providers talking patients through an IUD self-removal via phone.
“The data we collected was pre-pandemic,” Amico says. “Colleagues talk about self-removal more and implement more self-removal counseling.”
IUD self-removal is an important option to women’s reproductive health autonomy, Amico notes. Earlier research showed that more than half of people surveyed said they would be more likely to recommend an IUD to a friend after learning they could remove their own.4
“I think some providers have concerns about IUD removal in general because they know how effective it is and how difficult it is to access one,” she says. “But they have to keep in mind that barriers to IUD removal are also really threatening in reproductive autonomy.”
For example, Amico found in an earlier study that providers had mixed feelings about removing IUDs when patients requested it. “In self-removal, the provider doesn’t have the option of figuring out a plan other than IUD removal, and also doesn’t have the opportunity to prescribe another option because the physician is not with the patient when the IUD is removed,” she explains.
Doctors worry that patients will remove the IUD themselves without access to another contraceptive method if they still want to prevent pregnancy. “I remind providers that patients stop taking their other methods — like the pill, patch, ring, and injection — without coming to tell their provider first,” Amico says. “Think about self-discontinuation of an IUD in the context of someone stopping to use another method.”
Once reproductive health providers accept IUD self-removal as an option for patients, they may desire to give patients accurate information on performing this safely and successfully. For instance, there are YouTube videos on how to self-remove an IUD.5
Researchers found that provider counseling for self-removal can take place at the time of IUD insertion, which will minimize health risks and affirm patient reproductive autonomy.5
In addition to YouTube videos, the Reproductive Health Access Project offers a downloadable, one-page illustrated guide to IUD self-removal.6
“Someone who is internet-savvy will find out how to do it,” Amico says. “The important part is they want to hear from their providers that it is a safe thing to do.”
A provider can tell patients that they will not hurt themselves by attempting to self-remove their IUDs. For most people, removing an IUD causes a slight cramp and is less uncomfortable than IUD insertion.
“When IUD self-removal was successful, it was quick, easy, painless,” Amico says. “What people wanted to hear about self-removal was that this would be OK and they wouldn’t hurt themselves. If the patient is going to try to find and pull the strings, they can stop if it hurts, but they can’t hurt themselves. If it hurts more than a cramp, stop.” There is not a risk of perforation, but if the IUD will not move and it hurts, then they should stop, she adds.
Research shows that most of the time when people fail to self-remove the IUD, it is because they either could not feel the strings or could not grip the strings.1,4
“They said the strings were slippery, or they could feel it with one finger but couldn’t get two fingers around it to pull it,” Amico says. “Only four out of 1,742 posts said something about pain, bleeding, or resistance.”1 People also wanted to know what to expect after the IUD removal and what they should do about birth control or how quickly to expect pregnancy, she adds.
Amico and colleagues wanted to know what the experience was like for people who tried to remove their own IUDs. “We were interested in finding out if it hurt,” Amico says. “If they couldn’t do it, why couldn’t they do it?”
Literature on IUDs and self-removal point to the barriers for women in accessing removal of long-acting reversible contraception (LARC) methods. “We think about IUDs and implants as great methods,” Amico says. “There’s evidence that it’s great if they want to keep it in [long term], but it’s going to be difficult to access discontinuation.”
For example, in another recent study, in-depth interviews with 51 providers revealed that while they described embracing patient-centered care, they uniformly resisted early LARC removal by withholding information about self-removal of IUDs, negotiating with patients to keep their device longer, and engaging in other delay tactics.7
“If someone wants an IUD, and they decide to have it taken out right away, that’s always going to be OK with me,” Amico says. “People can hear about spotting, but once they’ve had it for six weeks, that’s something else. It’s usually the people who are at the extreme in side effects who want to take it out.”
For instance, one patient described being bent over in pain for nine days straight. “Just because she knows there’s going to be cramping doesn’t mean she’s OK with it when it happens,” Amico says. “If this is a problem with a birth control pill, then we wouldn’t blink an eye and the patient would stop taking it.”
But with LARC, reproductive health providers hold much more power over a patient’s autonomy and decisions. “There’s such a power dynamic and socioeconomic difference between providers and patients, and the IUD user is the one who knows whether it works for them or not,” she says.
In the context of the post-Roe era, when abortions will be difficult or impossible for many women, enforcing more LARC can be seen as another form of reproductive coercion. “The knee-jerk reaction is to have more contraception if there’s no access to abortion, but both of those things are problematic and additive,” Amico notes.
Wanting to prevent pregnancy is not the same as a disease where there are evidence-based cures that work and other things do not work, and it is doctors who know which work and which does not, she says.
Providers can be supportive of IUDs as an effective method of contraception and be in favor of IUD removal. “When it comes to contraception, the outcomes are different, and it’s actually the person who knows the right answer, and it’s not the doctor in this case,” Amico explains. “If someone wants their IUD out, my first response is, ‘Yes, I’ll do that for you today,’ and my second response is, ‘Can we talk more about it?’”
REFERENCES
- Stimmel S, Hudson SV, Gold M, Amico JR. Exploring the experience of IUD self-removal in the United States through posts on internet forums. Contraception 2022;106:34-38.
- Raifman S, Barar R, Foster D. Effect of knowledge of self-removability of intrauterine contraceptives on uptake, continuation, and satisfaction. Women’s Health Issues 2018;28:68-74.
- Amico JR, Stimmel S, Hudson S, Gold M. “$231 … to pull a string!!!” American IUD users’ reasons for IUD self-removal: An analysis of internet forums. Contraception 2020;101:393-398.
- Foster DG, Grossman D, Turok DK, et al. Interest in and experience with IUD self-removal. Contraception 2014;90:54-59.
- Broussard K, Becker A. Self-removal of long-acting reversible contraception: A content analysis of YouTube videos. Contraception 2021;104:654-658.
- Reproductive Health Access Project. Fact sheet: IUD self removal. March 2021.
- Manzer JL, Bell AV. The limitations of patient-centered care: The case for early long-acting reversible contraception (LARC) removal. Soc Sci Med 2022;292:114632.
Self-removal of IUDs appears to be popular among many people and may empower women, but research indicates successful self-removal is not guaranteed.
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