02/09/13

Intrauterine Device Extraction Technique

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Intrauterine Device Extraction Technique

Author: Sarah Hagood Milton, MD; Chief Editor: David Chelmow, MD more...
Updated: Feb 1, 2013

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.[11] 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 patients follow up appointment 46weeks 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the endocervical canal, twisted and then withdrawn in an attempt to pull retracted strings into view in the vagina.

Cytobrush

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.

IUD hook

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.
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Intrauterine Device Extraction Technique

If these techniques are unsuccessful, the recommendation is for transvaginal ultrasonography to aid in localization
of the IUD.[21] 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.
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. Intraabdominal 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.[22,
23]

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.[24] 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.[25] Rarely, laparotomy is necessary for safe IUD removal.

Further Reading
Mirena
ParaGard

Contributor Information and Disclosures

Author
Sarah Hagood Milton, MD Resident Physician, Department of Obstetrics and Gynecology, Virginia
Commonwealth University Health System
Disclosure: Nothing to disclose.
Coauthor(s)
Nicole W Karjane, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia
Commonwealth University Medical Center
Nicole W Karjane, MD is a member of the following medical societies: American College of Obstetricians and
Gynecologists, Association of Professors of Gynecology and Obstetrics, and North American Society for
Pediatric and Adolescent Gynecology
Disclosure: Merck Honoraria Speaking and teaching
Chief Editor
David Chelmow, MD Leo J Dunn Distinguished Professor and Chair, Department of Obstetrics and
Gynecology, Virginia Commonwealth University Medical Center
David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and
Gynecologists, American Medical Association, American Society for Colposcopy and Cervical Pathology,
Association of Professors of Gynecology and Obstetrics, Council of University Chairs of Obstetrics and
Gynecology, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical
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Decision Making
Disclosure: Nothing to disclose.

References
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