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8/13/2023

Management of Malpositioned Intrauterine Devices

As the rate of intrauterine device (IUD) insertion increases, IUD malposition has become more common, with some studies citing an incidence as high as 10.4%. Most nonfundal IUDs are located in the lower uterine segment or cervix, which can be typically identified via ultrasonography. Some malpositioned IUDs appear to be embedded in the myometrium on imaging. Common symptoms of a malpositioned IUD include pain and bleeding, although some patients may be asymptomatic. Effectiveness of a malpositioned IUD is dependent on location and type. An IUD found in the cervical canal on imaging or pelvic exam is considered partially expelled. Regardless of symptoms, IUDs in this location are at increased risk for complete expulsion. Pregnancy should be ruled out and the device should be removed. The IUD may be replaced if the patient desires.

Asymptomatic low-lying IUDs (those above the internal cervical os) present a particular challenge for gynecologic providers, as there is no clear evidence for their contraceptive effectiveness. A copper IUD is most effective when located in the fundal portion of the uterus. Thus, it should be removed when malposition is identified because of the increased risk of contraceptive failure. In comparison, levonorgestrel-releasing IUDs may be left in place if located in the lower uterine segment, as the local effect of the levonorgestrel likely serves as adequate contraception even when malpositioned. Rather than being expelled, most low-lying IUDs actually move to a fundal position due to uterine contractility.

Many IUDs, even those that appear embedded, can be removed in the office by grasping the strings with a clamp and applying traction. If removal is unsuccessful with moderate traction or if the strings are not visible, the next step is hysteroscopic removal. This can be done either in the office setting or in the operating room. Once a malpositioned IUD is removed, it may be immediately replaced according to the patient’s wishes. A history of IUD malposition or IUD expulsion is not a contraindication for subsequent IUD insertion. The recurrence rate of malposition is unknown.

IUD removal has several potential consequences. Most malpositioned devices are not promptly replaced with a highly effective contraceptive after removal. Accordingly, the risk of unintended pregnancy following removal is greater than the theoretical risk of decreased pregnancy prevention with a nonfundal IUD. Unnecessary device removal and replacement can also result in patient discomfort. Lastly, there are significant costs associated with long active reversable contraceptive usage. While IUDs may be discounted or have no associated out-of-pocket costs for some patients, IUDs are expensive at retail value.

When a malpositioned IUD is identified, it is important to identify device location, type, and patient contraceptive goals to provide appropriate counseling and engage in shared decision-making.

Further Reading:

American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice; Long-Acting Reversible Contraceptive Expert Work Group. Committee Opinion No 672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods. Obstet Gynecol. 2016 Sep;128(3):e69-77. doi: 10.1097/AOG.0000000000001644. PMID: 27548557.

Braaten KP, Benson CB, Maurer R, Goldberg AB. Malpositioned intrauterine contraceptive devices: risk factors, outcomes, and future pregnancies. Obstet Gynecol. 2011 Nov;118(5):1014-1020. doi: 10.1097/AOG.0b013e3182316308. PMID: 22015868.

Initial publication August 2023

Final editing of initial publication performed by The Medical Pen, LLC.

 

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