oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
Intrauterine contraceptive device (IUCD) users should be shown how to check for the presence of threads following each menstruation cycle. If the threads are missing, the patient should be advised to consult a doctor.
An IUCD should be removed:
- When the user requests
- When the device's expiry date arrives
- If the user develops any contra-indication
- If adverse effects fail to resolve
IUCD-related complications are significantly reduced if inserted by an experienced professional. Current National Institute for Health and Clinical Excellence (NICE) guidance states that they should only be fitted by trained personnel who fit at least one per month. Studies to date assessing the risk factors are few and are further limited by the rarity of such complications.
IUCD-related problems tend to be random although nulliparous women have a statistically greater risk of developing problems compared with parous women users. The decreased risk may be due to the stretching and weakening of the cervical canal during vaginal delivery, which more readily accommodates the IUCD or sound. The same research also found that more nulliparous women require cervical dilation compared with breast-feeding parous women.
IUCD threads occasionally get lost. There are three reasons why this may occur:
- An unrecognised spontaneous expulsion has occurred.
- The thread has coiled up within the endocervix.
- The IUCD has perforated the uterine wall and migrated through the abdominal cavity.
Always consider the woman with lost threads either to be already pregnant, or at risk of being so.
- Explore the cervix with narrow artery forceps, under direct vision. Gently open and close the jaws and withdraw. Threads that have been drawn up into the cervical canal or uterus will be found with this procedure. This occurs in the majority of cases.
- If unsuccessful after giving appropriate analgesia, eg mefenamic acid 500 mg, proceed to exploration of the uterine cavity with a retriever hook.
- If still unsuccessful, refer for ultrasound scan by an experienced sonographer. Abdominal X-ray may be considered if this is unsuccessful, as copper devices have flexible side arms made from barium sulphate, which is detectable by X-ray examination.
- Hysteroscopy or laparoscopy/laparotomy may be required if perforation and transmigration are diagnosed.
Pregnancy with IUCD in situ
If the patient is pregnant with IUCD in situ and wishing to proceed to full-term, gentle removal in the first trimester has been found to halve the miscarriage rate. If the patient elects for termination of pregnancy, the IUCD can be removed at the time of surgery.
The estimated incidence of insertion failure is 0.23-0.83%. Pain experienced during insertion is associated with increased failure rate. Parous women have a lower risk of insertion failure. The other factor relates to the experience of the doctor.
These occur most frequently in the first 3 months of use and usually during menstruation. They are associated with:
- Young age in the users
- Immediate postpartum insertion
- Skill of the clinician
Problems relating to the cervix
These can include problems passing the sound or the IUCD through the cervix and immediate expulsion. Age increases the risk of problems, especially in nulliparous women:
- Women have a decreased risk if they have had a previous vaginal delivery compared with nulliparous women.
- Syncope may also be experienced secondary to vagal stimulation from the cervix, with an estimated incidence on insertion being 2.1%. Bradycardia, for the same reason as above, is more commonly found in nulliparous women compared with parous women.
- Convulsions are rare; incidence is 0.05%.
Further reading & references
- Family Planning Association
- Robinson R, China S, Bunkheila A, et al; Mirena intrauterine system in the treatment of menstrual disorders: a survey of UK patients' experience, acceptability and satisfaction. J Obstet Gynaecol. 2008 Oct;28(7):728-31.
- Long-acting reversible contraception, NICE Clinical guideline (October 2005)
- Farmer M, Webb A; Intrauterine device insertion-related complications: can they be predicted? J Fam Plann Reprod Health Care. 2003 Oct;29(4):227-31.
- Ismail H, Mansour D; The 'tail' of a missing intrauterine contraceptive device. J Fam Plann Reprod Health Care. 2002 Apr;28(2):96-7.
- Hepburn S; IUDs: current perspectives. Curr Ther (Seaforth). 1994 Oct;35(10):49-55.
- John Guillebaud. Your Questions Answered: Contraception, 4th Edition
- Mishell Dr Jr, Sulak PJ; The IUD: dispelling the myths and assessing the potential. Dialogues Contracept. 1997 Spring;5(2):1-4.
- Penney G, Brechin S, de Souza A, et al; FFPRHC Guidance (January 2004). The copper intrauterine device as long-term contraception. J Fam Plann Reprod Health Care. 2004 Jan;30(1):29-41; quiz 42.
- Barsaul M, Sharma N, Sangwan K; 324 cases of misplaced IUCD--a 5-year study. Trop Doct. 2003 Jan;33(1):11-2.
- Masters T, Everett S, May M, et al; Outcomes at 1 year for the first 200 patients fitted with GyneFix at Margaret Pyke Centre. Eur J Contracept Reprod Health Care. 2002 Jun;7(2):65-70.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
|Original Author: Dr Hayley Willacy||Current Version: Dr Hayley Willacy|
|Last Checked: 20/04/2011||Document ID: 2347 Version: 23||© EMIS|