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Home > Professional Reference > IUCD - Lost Threads and Other Problems

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IUCD - Lost Threads and Other Problems

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

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 problems

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.

Lost threads

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

First perform a speculum examination to locate the threads, which may have been expelled into the vagina/posterior fornix. Determine whether the patient is pregnant before proceeding further.

  • 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, e.g. 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.3 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.4If the patient elects for termination of pregnancy, the IUCD can be removed at the time of surgery.

Insertion failure

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.

Expulsion

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

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%.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%.

Perforation

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

Document references

  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]

Internet and further reading

Acknowledgements

EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2011.
Document ID: 2347
Document Version: 23
Document Reference: bgp24663
Last Updated: 3 Feb 2010
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