Removal and expulsion

Facilitating Safe Removal

There is no formal CoSRH training for IUD removal: follow local pathways for developing and maintaining competence. CoSRH resources to support clinicians removing IUC:

CoSRH Bitesize: Intrauterine contraception (IUC) removal | CoSRH

• E-lfh eSRH Module 15, Section 10 “Removal of IUC”.

Clinicians removing Cu-IUDs should be:

• Able to discuss ongoing contraception needs and provide this or signpost to another provider.
• Able to provide preconception counselling or signpost to another provider.
• Able to recognise pregnancy risk and the need for Emergency Contraception
• Competent at speculum examination
• Able to recognise an abnormal cervix and know how to refer for further examination.
• Aware of how to manage non-routine findings (e.g. non-visible threads).

Timing of Cu-IUD removal or replacement

• Those who do not wish to become pregnant should be advised to avoid UPSI for 7 days prior to Cu-IUD removal.
• Avoid UPSI for 7 days prior to Cu-IUD removal and replacement in case it is not possible to insert the new device.

Table5: Cu-IUD removal [from CoSRH Clinical Guideline: Intrauterine contraception (March 2023)]

Unexpected findings at IUC removal

On removal of a Cu-IUD check the device is intact and that it is the expected device and the correct information about duration of use/follow-up/ongoing contraception has been given.

For advice with regards to broken or /incomplete device refer to CoSRH Clinical Guideline: Intrauterine contraception (March 2023)

https://www.fsrh.org/standards-and-guidance/documents/ceuguidanceintrauterinecontraception

Removal of an unusual device

For advice with regards to Cu-IUDs inserted abroad where the clinician is not familiar with the device refer to CoSRH Clinical Guideline: Intrauterine contraception (March 2023)

https://www.fsrh.org/standards-and-guidance/documents/ceuguidanceintrauterinecontraception

Difficult removals:

Difficult Cu-IUD removals may be due factors such as anatomical variations, Cu-IUD malposition (including perforation), clinician experience and/or the level of pain or discomfort experienced. When there is difficulty in removing a Cu-IUD, a referral should be made to an experienced provider.

Expulsion rates are higher  

• in immediate postpartum insertion compared with interval postpartum insertion
• in adolescents
• insertion after late first-trimester or second-trimester surgical abortions,
• in individuals with fibroids and HMB
• with use of a menstrual cup
• those who have had a previous expulsion
• those with a BMI >25

There is no evidence to suggest that switching to a different IUD may reduce the risk of a further expulsion. If there have been ≥2 IUD expulsions, a pelvic ultrasound to assess the uterine cavity may be helpful prior to insertion of a further IUD. Post-insertion USS is not predictive of the likelihood of further expulsion but can provide immediate confirmation of correct positioning.