By Rebecca H. Allen, MD, MPH
Assistant Professor,
Department of Obstetrics and Gynecology,
Warren Alpert Medical School of Brown University,
Women and Infants Hospital,
Providence, RI

Dr. Allen reports she is a consultant for Actavis and Bayer and receives grant/research support from Bayer.

It is not uncommon that we receive reports from radiology regarding the location of an intrauterine device (IUD) in a patient that we have sent for a pelvic ultrasound examination for an entirely different reason (e.g., an adnexal mass). These incidental findings of low-lying or malpositioned IUDs are a conundrum for the practitioner. Many questions arise when attempting to counsel the patient:

  • Will the IUD be effective for contraception?

  • Will the IUD be effective for abnormal uterine bleeding if it is the 52 mg levonorgestrel IUD?

  • Is the IUD responsible for any symptoms due to its position, such as abnormal uterine bleeding or pelvic cramping?

  • Does it matter if it is in the lower uterine segment or cervix?

  • Should the IUD be removed and replaced?

If you are not sure what do to do about low-lying IUDs, you are not alone. A survey of providers in the United Kingdom and Australia revealed that there is some level of uncertainty about what to do.1 Approximately 90% of providers stated they would remove and replace a copper IUD that was totally or partially in the cervical canal, but only 45% would replace a copper IUD that was more than 2 cm below the fundus and only 10% if it was 1 to 2 cm below the fundus. The numbers were similar for levonorgestrel IUDs. Respondents also had divided opinions as to whether low-lying IUDs cause bleeding and pain symptoms more often than normally situated IUDs.

Whether malpositioned IUDs have decreased contraceptive efficacy is unclear. Studies concluding that low-lying IUDs are associated with contraceptive failure typically examine cases of pregnant women with an IUD in situ compared to non-pregnant women. One study reported that IUDs were displaced into the cervix in 13/25 (52%) pregnant women and 7/97 (7%) non-pregnant women.2 However, it is unknown if the growing pregnancy pushed the IUD into a low-lying position. In other words, which came first, the low-lying IUD or the pregnancy? Studies examining risk factors for IUD failure are few and none have examined IUD location in relation to failure prior to pregnancy being diagnosed.3 The best evidence evaluating IUD location and failure involves only the levonorgestrel IUD. In a randomized, controlled trial, 151 women had a 20 mcg/day-releasing levonorgestrel IUD placed intracervically and 147 at the uterine fundus.4 There were no differences between the two groups after 5 years of follow-up in terms of pregnancy rates. This seems to indicate that the levonorgestrel IUD is effective no matter where it is placed in the uterine cavity. This makes sense given that the main mechanism of action is thickening cervical mucus. However, no such data are available for the copper IUD.

Assuming an incidentally found malpositioned IUD in an asymptomatic patient, the risks and benefits of removal must also take into account the subsequent contraceptive option chosen by the patient. One retrospective study of 182 women with malpositioned IUDs (73% in the lower uterine segment or cervix, 11.5% embedded and/or rotated, 7% expelled, 7% intraperitoneal, and 19% with more than one type of malpositioning) found that 121 women had their IUDs removed. Of these women, only 37% received another long-acting reversible contraceptive or sterilization.5 The remaining relied on less-effective methods. Because studies have shown that the IUD can migrate up and down in the uterine cavity with the menstrual cycle, it may be that the device left in place would resume its proper position at a later point.6,7 Therefore, removing the device in an asymptomatic patient may be premature.

If the patient has symptoms such as pain and/or bleeding and a malpositioned IUD, providers have debated whether the IUD is responsible for the symptoms. One case-control study evaluated 236 women with an IUD and symptoms of pain and/or bleeding compared to 245 asymptomatic women with an IUD. They found no relationship between IUD location in the cavity based on ultrasound measurements (IUD-endometrium, IUD-myometrium, and IUD-fundus) and symptoms.8 In contrast, a study published by Benaceraff et al on three-dimensional ultrasound and IUD location among 167 women found that 21/28 (75%) women with malpositioned IUDs complained of pain and/or bleeding compared to 38/139 (34%) women with normal located IUDs.9 Certainly as a practical matter, clinicians must individualize their treatment of patients and, if other causes of pain and/or bleeding have been ruled out, it is prudent to remove the IUD to see if the symptoms improve. This may hold true to a greater extent for rotated and embedded IUDs compared to IUDs in the lower uterine segment.

A review of the literature on this topic summarized the data into four recommendations10:

  1. Wait and see if the device moves itself with backup contraception, and review using ultrasound at a later date.
  2. Consider attempting to move the device with alligator forceps back up into the cavity, although this depends on operator skill and patient tolerance.
  3. Replace the IUD with ultrasound review at 6 weeks. The patient should be advised that the replacement IUD may also become displaced.
  4. Remove and choose an alternative contraceptive method.

My own bias for asymptomatic women relying on the device for contraception is to leave low-lying levonorgestrel IUDs in place with appropriate counseling and to remove and replace low-lying copper IUDs. I have not attempted pushing a low-lying IUD back up into the cavity with alligator forceps, although one study demonstrated in a small case series that this was technically possible.11 Due to the lack of definitive evidence, many of these decisions will involve a frank discussion with the patient regarding the clinical unknowns and their personal preferences.

References

  1. Golightly E, Gebbie AE. Clinicians’ views on low-lying intrauterine devices or systems. J Fam Plann Reprod Health Care 2014;40:113-116.
  2. Anteby E, et al. Intrauterine device failure: Relation to its location within the uterine cavity. Obstet Gynecol 1993;81:112-114.
  3. Thonneau P, et al. Risk factors for intrauterine device failure: A review. Contraception 2001;64:33-37.
  4. Pakarinen P, Luukkainen T. Five years’ experience with a small intracervical/intrauterine levonorgestrel-releasing device. Contraception 2005;72:342-345.
  5. Braaten KP, et al. Malpositioned intrauterine contraceptive devices: Risk factors, outcomes, and future pregnancies. Obstet Gynecol 2011;118:1014-1020.
  6. Faundes D, et al. T-shaped IUD move vertically with endometrial growth and involution during the menstrual cycle. Contraception 1998;57:413-415.
  7. Morales-Rosello J. Spontaneous upward movement of lowly placed T-shaped IUDs. Contraception 2005;72:430-431.
  8. Faundes D, et al. No relationship between the IUD position evaluated by ultrasound and complaints of bleeding and pain. Contraception 1997;56:43-47.
  9. Benacerraf BR, et al. Three-dimensional ultrasound detection of abnormally located intrauterine contraceptive devices which are a source of pelvic pain and abnormal bleeding. Ultrasound Obstet Gynecol 2009;34:110-115.
  10. Golightly E, Gebbie AE. Low-lying or malpositioned intrauterine devices and systems. J Fam Plann Reprod Health Care 2014;40:108-112.
  11. Ber A, Seidman DS. Management of the malpositioned levonorgestrel-releasing intrauterine system. Contraception 2012;85:369-373.