Management of Missing IUD Strings

Differential Diagnosis

IUD in-situ in correct position
- String coiled in endocervical canal or endometrial cavity
- String short or broken
Unnoticed expulsion
Intrauterine pregnancy brings strings into the uterus as it grows
Malpositioning of the device following perforation
- Embedment in the myometrium
- Translocation into the abdominal or pelvic cavity

Work up of Missing Strings

Assess pregnancy status

Pregnancy test positive: locate and date pregnancy; manage accordingly
Pregnancy test negative:
- Attempt to sweep strings from canal:
  - Twirl an endocervical brush in the cervical canal
  - Try using a thread retriever to snag the strings
  - If available use a colposcope to aid visualization of the strings with magnification. This is ideally done with an endocervical speculum to peer into the endocervical canal to visualize threads. If visible – do not attempt to pull them down unless patient desires removal.
- If not able to visualize strings – (pregnancy test negative) do ultrasound (or if x-ray is more available may start with KUB)
Starting with Ultrasound:
- Ultrasound shows IUD in situ: go to #1 below
- Ultrasound shows no IUD in situ: order KUB and if no IUD seen it has been expelled: if IUD seen on KUB and not seen in uterus on ultrasound: IUD is translocated.
- Ultrasound shows possible embedment: order 3D ultrasound or CT
Starting with KUB
- No IUD is seen it has been expelled
- IUD seen: must ALSO do ultrasound to determine location unless it is clearly translocated (seen not near uterus)

Management and Prevention

1. IUD determined to be in situ:

Desires retention
- May leave in place for remainder of IUD lifespan
- Option: annual pelvic ultrasound in lieu of string check
Desires removal
- Consent for uterine instrumentation procedure
- Bimanual exam
- Probe for strings in cervical canal
- Administer cervical block
- Apply tenaculum
- Real-time ultrasound guidance may help, if available
- Choose extraction device
  - Patterson alligator forceps to search within the uterine cavity, using a tenaculum to stabilize the uterus before intrauterine manipulation:
    - No cervical dilation necessary
    - Within the uterine cavity gently open/close forceps completely at quarter turns and progressive depths until “purchase” of the IUD stem or string (or arm).
  - Thread Retriever or thread retriever with hook:begin at fundus and twirl along anterior, then posterior, uterine wall from fundus to canal
  - If ring-shaped IUD: use crochet hook or 3-5 mm suction curette

2. Additional measures, for removal as indicated

3. Expulsion

Occurs in 2-10% placements
Unnoticed expulsion may present with pregnancy
Risk of expulsion related to
- Provider’s skill at fundal placement
- Higher parity
- Uterine configuration and anomalies
- Prior history of expulsion
- Time since placement (↑ within 6 mos but can occur any time)
- Timing of placement (post placental delivery, post second trimester abortion)
- Adherence to manufacturer’s instructions to prevent expulsion:
  - - Re-advance the tube after releasing arms
    - Remove the rod and tube separately
  - LNG IUDs:
    - Ensure device is at fundus before pulling the slider(s) all the way down
    - Ensure the sliders are completely down with no space between the bottom of the slider(s) and the handle before removing the insertion tube
Partial expulsion may present with
- Pelvic pain, cramps, intermenstrual bleeding
- IUD string longer than previously

4. Embedment

If embedment suspected evaluate with 3-D ultrasound or pelvic CT with contrast:To decide whether to start the extraction with laparoscopy or hysteroscopy
Extract via operative hysteroscopy or laparoscopy

5. Translocation

Copper IUDs can cause more adhesions, must extract promptly via operative laparoscopy
LNG-IUS is less reactive, but recommend laparoscopic removal

6. IUD Removal in Menopausal Women

Strings seen: remove
No strings visible…weigh risks
- Hazards of continuation (post-menopausal bleeding, ? pelvic actinomycosis)
- Hazards of removal (pain, perforation)

Tail-less IUD (e.g., Chinese stainless-steel coil ring) should not be removed unless requested by the patient

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