IUCD - Lost Threads and Other Problems

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.¹ 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.² 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.

Management

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.⁴If 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%.^2,5 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.⁶ They are associated with:

• Young age in the users
• Immediate postpartum insertion⁷
• Nulliparity
• Skill of the clinician

Reported expulsion rates vary according to type and vary between 5-8.4%.^8,9

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%.² 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%.

Estimated incidence on insertion is 0.19-0.36%.^2,7 Risk factors relate to the skill of the inserting doctor.

1. Long-acting reversible contraception, NICE Clinical guideline (October 2005); (the effective and appropriate use of long-acting reversible contraception)
2. 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. [abstract]
3. Ismail H, Mansour D; The 'tail' of a missing intrauterine contraceptive device. J Fam Plann Reprod Health Care. 2002 Apr;28(2):96-7. [abstract]
4. Hepburn S; IUDs: current perspectives. Curr Ther (Seaforth). 1994 Oct;35(10):49-55.
5. John Guillebaud. Your Questions Answered: Contraception, 4th Edition
6. Mishell Dr Jr, Sulak PJ; The IUD: dispelling the myths and assessing the potential. Dialogues Contracept. 1997 Spring;5(2):1-4.
7. 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. [abstract]
8. Barsaul M, Sharma N, Sangwan K; 324 cases of misplaced IUCD--a 5-year study. Trop Doct. 2003 Jan;33(1):11-2. [abstract]
9. 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. [abstract]

• Contraception, Clinical Knowledge Summaries (2008)
• 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. [abstract]