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-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.

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

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.

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 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

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%.

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