Removal and expulsion

Facilitating Safe Removal

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

• IUC removal consultation video IUC removal procedure video IUC removal ‘Top tips’ (requires FSRH log-in)
• E-lfh eSRH Module 15, Section 10 “Removal of IUC”.

Clinicians removing IUC 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).
• Up to date with basic life support training.

Timing of LNG-IUS removal or replacement

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

Unexpected findings at IUC removal

On removal of an IUC check the device  is intact and that it is the expected device and therefore 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 FSRH 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 IUCs inserted abroad where the clinician is not familiar with the device refer to FSRH Clinical Guideline: Intrauterine contraception (March 2023)

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

Difficult removals:

Most IUC removals are straightforward. Difficult IUC removals may be due to a number of factors including anatomical variations, IUC malposition (including perforation), clinician experience and/or the level of pain or discomfort experienced. When there is difficulty in removing an IUC, a referral should be made to an experienced provider.

The overall risk of IUC expulsion is approximately 1 in 20 and expulsion appears to be most common in the first year of use, particularly within 3 months of insertion.

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 with IUC
• those who have had a previous expulsion
• when IUC is inserted for gynaecological indications: the risk of expulsion may be higher when IUC is inserted on days 1–8 of the menstrual cycle than later in the cycle.

If the individual wishes to have another IUC this can be inserted once expulsion is confirmed. Users should be advised that the risk of expulsion appears to be higher in those who have had a previous expulsion. 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 IUC expulsions, a pelvic ultrasound to assess the uterine cavity may be helpful prior to insertion of a further IUC.

Post-insertion USS is not predictive of the likelihood of further expulsion but can provide immediate confirmation of correct positioning.

When LNG-IUD is being inserted for gynaecological reasons, clinicians may wish to consider inserting the IUC after day 8 of the menstrual cycle. Alternatively, or in addition, clinicians could offer individuals treatment to suppress menses (e.g. tranexamic acid, oral progestogen or continuation of their usual treatment for menstrual management/contraception) for one to three cycles post-insertion.