An intrauterine device (IUD) is a highly effective, long-acting form of reversible contraception placed within the uterus. Standard IUDs feature retrieval strings that extend into the vaginal canal, allowing for a routine check of the device’s position and its eventual easy removal. When these strings are not visible during a routine exam or when removal is desired, it can cause immediate concern for the patient. However, the absence of visible strings does not automatically indicate a serious problem, and a structured medical approach is used to locate and safely retrieve the device.
Why IUD Strings May Not Be Visible
The most common reasons for missing strings do not suggest the IUD has malfunctioned or moved significantly. Often, the strings simply retract or coil up against the cervix or into the endocervical canal. This curling can happen naturally due to changes in the cervix throughout the menstrual cycle or when a patient is pregnant.
Another frequent cause is that the strings were initially trimmed too short during the insertion procedure, making them difficult to reach or see. In a small percentage of cases, the strings may have broken off, or the IUD itself may have rotated slightly, tucking the strings out of sight within the uterus. The missing strings may also be a sign of partial or complete expulsion of the IUD from the uterus, which sometimes goes unnoticed by the patient.
Locating the Missing IUD
When the strings are not immediately visible, the healthcare provider first attempts a manual retrieval by gently probing the cervical canal. They may use a specialized tool, such as a cytobrush or narrow alligator forceps, to sweep the endocervical canal in an effort to snag the strings and pull them into view. If this initial office-based attempt is unsuccessful, the next step is to determine the device’s location.
The primary diagnostic tool used in this situation is a transvaginal ultrasound (TVS). Ultrasound provides a clear image of the uterus, confirming if the IUD is still correctly positioned within the uterine cavity. If the ultrasound confirms the IUD is properly in the uterus, the provider can proceed with removal.
If the ultrasound does not show the IUD in the uterus, it may have perforated the uterine wall and migrated into the abdominal cavity. In this scenario, an abdominal X-ray, often called a Kidney, Ureter, and Bladder (KUB) film, is necessary to confirm if the device is outside the uterus.
Specialized Removal Techniques
Once the IUD is definitively located, the technique for removal depends on its position within the body. If the ultrasound confirms the IUD is correctly seated in the uterine cavity but the strings are unavailable, the removal can often still be completed in an outpatient setting. This procedure involves stabilizing the cervix, often with a tenaculum, and then using specialized grasping forceps or an IUD hook to enter the uterine cavity and retrieve the device.
The grasping tool is guided through the cervix and maneuvered inside the uterus to grasp the base of the IUD. This exploration may be done blindly or, increasingly, under real-time ultrasound guidance to ensure precision and safety. While the procedure can cause cramping, it is generally quick and tolerated well by the patient, sometimes with the aid of a paracervical block for local anesthesia.
Hysteroscopic Removal
If the IUD is embedded in the uterine muscle or if the office-based attempts are unsuccessful, a hysteroscopic removal is recommended. Hysteroscopy is a minimally invasive surgical procedure where a thin, lighted telescope with a camera is inserted through the cervix to visualize the inside of the uterus. This allows the surgeon to directly see the IUD, determine the extent of any embedding, and use small instruments passed through the hysteroscope to grasp and remove the device. This approach avoids the need for major surgery.
Laparoscopic Removal
In the rare event that the IUD has perforated the uterine wall and migrated outside the uterus, surgical removal is required. The preferred method for removing an IUD that has translocated into the abdominal or pelvic cavity is laparoscopy. This involves small incisions and the use of a camera and surgical instruments to retrieve the device from the peritoneal cavity, preventing potential complications.
Post-Procedure Expectations and Recovery
Following the removal of an IUD, patients should anticipate some common and temporary side effects. Mild to moderate cramping is normal, as the uterus contracts after the device is removed, and this can be managed with over-the-counter pain relievers. Light vaginal bleeding or spotting may also occur for a few hours up to a few days.
The recovery time largely depends on the removal method utilized. For successful office-based removals, recovery is almost immediate, and most patients can resume normal activities the same day. If the removal required a hysteroscopy, recovery is still rapid, with most women feeling recovered within a few days, though strenuous activity may be restricted for up to a week.
It is important to contact a healthcare provider immediately if symptoms include severe, unrelieved pain, heavy bleeding that saturates more than one pad per hour, or signs of infection such as fever, chills, or foul-smelling discharge. Fertility returns immediately upon removal of the IUD, and patients must use an alternative contraceptive method right away if they wish to avoid pregnancy.