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IUCDs Lost Threads and Other Problems

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 expiry date arrives
  • If the user develops any contraindication
  • If adverse effects fail to resolve
IUCD problems

IUCD-related complications are significantly reduced if inserted by an experienced professional. Current 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 to 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 to breastfeeding 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 to be either 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 patient is pregnant before proceeding further.

  • Explore cervix with narrow artery forceps, under direct vision. Gently open and close 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 500mg, proceed to exploration of uterine cavity with retriever hook.
  • If still unsuccessful, refer for ultrasound by 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 if perforation and transmigration is 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 patient elects for termination of pregnancy, the IUD can be removed at 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 use6 and usually during menstruation. 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 risk of problems, especially in nulliparous women
Women have decreased risk if they have had a previous vaginal delivery compared to nulliparous women.
Syncope may also be experienced secondary to vagal stimulation from the cervix, with an estimated incidence on insertion is 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 0.05%.

Perforation

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

Document references
  1. Long acting reversible contraception: the effective and appropriate use of long-acting reversible contraception, NICE Clinical guideline, (October 2005)
  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. FFPRHC Guidance; The copper interuterine device as long-term contraception, Faculty of Family Planning and Reproductive Health Care RCOG (January 2004)
  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 2007.
DocID: 2347
Document Version: 21
DocRef: bgp24663
Last Updated: 3 Oct 2007
Review Date: 2 Oct 2009


















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PS - Health and Poverty

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