Approach Considerations
Routine removal
The patient is placed in dorsal lithotomy position, and the speculum is used to visualize the cervix. The IUD strings are usually readily visualized. If this is not the case, refer to the "Difficult Removal" section below. Grasp the IUD strings with the ring forceps and apply steady gentle outward traction, and the IUD should easily appear in the vagina. Remove the speculum. Patients should be counseled that immediate return of fertility is probable and if they do not desire conception they should immediately initiate an alternative form of contraception. [12] For patients desiring continued IUD use, a new device can be placed at the same visit.
Difficult removal
Uncommonly, IUD removal may be challenging. The primary indicator of a problem is the inability to visualize IUD strings extending from the cervical os. This may be an incidental finding at the patient’s follow up appointment 4-6 weeks following IUD insertion for routine "string check" to assure correct placement. Alternatively, the lack of visible strings may be a finding on pelvic examination indicated secondary to pain or irregular bleeding. It may also be an incidental finding during a routine pelvic examination.
If IUD strings are not visualized and patient desires removal, a cytobrush (see image below) may be inserted into the endocervical canal, twisted and then withdrawn in an attempt to pull retracted strings into view in the vagina.
If the strings are not found with the cytobrush, an IUD hook may be used to locate the strings in the cervical canal or uterus. With a speculum in place and the cervix clearly visualized, a tenaculum is placed, the IUD hook is inserted into the cervical canal, and an effort is made to hook the strings and pull them into the vagina, where they can be grasped with ring forceps.
This may take several passes to accomplish. If the strings are not recovered from the cervical canal, the hook may be used to attempt the removal from the uterus. Generally, the hook is advanced to the fundus, and 4 systematic passes are attempted, first with the hook directed anteriorly, then posteriorly, then left and right. Although uncomfortable, it is generally tolerable if performed quickly. If not tolerated by the patient, the procedure should be stopped.
If these techniques are unsuccessful, the recommendation is for transvaginal ultrasonography to aid in localization of the IUD. [24] If transvaginal ultrasound confirms intrauterine placement of the IUD without concern for myometrial embedding, additional efforts can be made for outpatient removal. Several techniques have been described, including use of alligator forceps or uterine packing forceps inserted though the cervical canal and used to blindly grasp the IUD and remove it. Alternatively, a similar technique has been performed using ultrasound or hysteroscopic guidance.
Verma et al reported their experience with ultrasound-guided removal of retained IUDs, with or without strings, as safe and cost-effective, and it could be performed in an office setting. [25] Over a 14-month period, the investigators noted that 19 of 23 patients underwent successful ultrasound-guided IUD extraction; the remaining 4 women underwent hysteroscopic-guided IUD removal. The cost of the procedures was $425 and $3562 US dollars [USD], respectively (difference: USD $3137). [25] Similarly, Swenson et al reported successful outpatient extraction of levonorgestrel IUDs in all 29 women in their case series who did not have visible IUD strings at the external cervical os. [26]
When using these more invasive techniques, a paracervical block should be considered for analgesia. In particularly challenging cases or when prior attempts have been limited by patient discomfort, the patient can be taken to the operating room, where an examination under anesthesia, hysteroscopy, and IUD removal may be performed. The later procedure is commonly performed if myometrial embedding is a concern, so that the hysteroscope can be used to evaluate any myometrial defect following removal.
In the instance that no IUD strings are visualized and the IUD is not visualized in the uterus on ultrasound, a radiograph (anteroposterior and lateral upright plain radiograph) is indicated to aid in further localization. The most common reason for these findings is an unrecognized spontaneous expulsion. Unless spontaneous expulsion was immediately recognized by the patient, a radiograph is mandatory prior to further intervention.
Alternatively, the IUD may be intra-abdominal, in which case it would be readily visualized on x-ray. Intra-abdominal placement is most commonly secondary to unrecognized perforation at the time of insertion and less likely to IUD migration. If the patient is in severe pain or hemodynamically unstable, immediate laparoscopy or laparotomy should be performed. Otherwise, the patient can be scheduled for a laparoscopic IUD removal on a nonemergent basis or be managed conservatively if the patient is asymptomatic and a poor surgical candidate. [27, 28]
An intra-abdominal Mirena IUD should always be removed if the patient desires pregnancy, as levonorgestrel levels are elevated in these patients, and ovulation may be suppressed despite the extrauterine location of the IUD. [29] At the time of laparoscopy, 2-3 ports are generally used, depending on the anticipated location of the IUD and attachment to adjacent structures. The most common intra-abdominal location for the IUD is the omentum, followed by the broad ligament. [30] Rarely, laparotomy is necessary for safe IUD removal.
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IUD hook
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Cytobrush
