How Is an IUD Removed If the Strings Are Not Visible?

When IUD strings cannot be seen at the cervical opening, removal follows a stepwise approach that begins with simple office-based techniques and escalates only if needed. In most cases, a clinician can retrieve the device during a regular office visit using a small brush or specialized forceps, with one study reporting success in over 96% of attempts.¹ The situation is common enough that providers have well-established protocols, yet it understandably causes anxiety because the usual reassurance of feeling those strings is gone. What happens next depends on where the IUD actually is, and the first job is figuring that out.

Why IUD Strings Disappear

Missing strings are reported in roughly 5% of IUD users overall, though the figure climbs to somewhere between 4.5% and 18% among people specifically presenting for a checkup or removal.² That wide range reflects differences in how and when clinicians look for the strings, but the point is that this is not a rare scenario.

The most common reason is mundane: the strings have simply curled up into the cervical canal or the uterine cavity, pulled out of sight by normal uterine activity. Less often, the strings may have broken off, or the IUD itself may have partially or fully expelled. In rare cases, the device has perforated the uterine wall and migrated outside the uterus entirely.¹ Each of these possibilities leads to a different removal strategy, which is why the next step is always imaging rather than immediately trying to fish the IUD out.

Locating the Device With Imaging

Before anyone attempts removal, a pelvic ultrasound is the standard first move. Ultrasound can confirm the IUD is still inside the uterus, show whether it has shifted position, and reveal if it is embedded in the uterine wall. When ultrasound results are inconclusive, or when the IUD simply cannot be seen in the uterus at all, a plain abdominal X-ray comes next. The X-ray’s job is straightforward: if the IUD shows up on the X-ray but was absent on ultrasound, the device has perforated the uterus and is sitting somewhere in the abdominal cavity.³ If neither ultrasound nor X-ray shows the IUD, it likely fell out without being noticed.

This imaging sequence matters because it determines whether the removal can happen in a standard office visit or whether a more involved procedure is needed. An IUD sitting normally in the uterus with retracted strings is a very different situation from one embedded in bowel tissue. The vast majority of cases fall into the simpler category.

In-Office Retrieval With Simple Instruments

When imaging confirms the IUD is still in the uterus, the provider typically starts with the least invasive office-based method. A cytobrush, a small, thin brush normally used for cervical sampling, is rotated inside the cervical canal to catch the curled-up strings and pull them into view. In a study of 112 women with missing IUD strings, the cytobrush alone successfully retrieved the device in about 63% of cases. When the brush did not work, clinicians switched to instruments like toothed forceps or specialized clamps, bringing the overall in-office success rate to 96.4%.¹

These office procedures are generally done without sedation. Various instruments, including artery forceps and small hooks, can be used to grasp the strings or the IUD itself once it is located within the canal or lower uterine cavity.⁴ For most people, the discomfort is similar to what they felt during insertion: cramping that can range from mild to sharp but resolves quickly. Over-the-counter pain relief taken beforehand is usually sufficient.

Ultrasound-Guided Removal

If the blind office approach fails, real-time ultrasound guidance is the next tier. The provider uses a live ultrasound image to visualize the IUD’s exact position while maneuvering instruments to grasp it. This is still typically done in an office or outpatient setting rather than an operating room.

One study of 23 patients whose IUDs were retained found that ultrasound-guided removal succeeded in about 83% of cases, with the remaining patients going on to hysteroscopic removal.² The advantage of having real-time imaging is obvious: the provider can see exactly where the IUD sits relative to the uterine walls and adjust the approach accordingly, rather than working by feel alone. This makes the procedure especially useful when an IUD has shifted into an unusual position or is partially embedded.

Hysteroscopic Removal

When neither blind office techniques nor ultrasound-guided removal can get the IUD out, hysteroscopy is the standard next step. A hysteroscope is a thin, lighted camera that is passed through the cervix into the uterine cavity, giving the provider a direct view of the IUD and surrounding tissue. Small instruments passed through the scope can then grasp and extract the device under direct visualization.

Hysteroscopy can often be performed in an office setting rather than a full operating room. Research at an academic hospital found that hysteroscopic removal of retained IUDs was effective after failed ultrasound-guided attempts, with no major complications or hospital readmissions reported over a three-year period.⁵ The procedure avoids the need for a larger surgery, which is its main appeal. It is particularly useful when the IUD is embedded in the uterine lining or when the strings have broken off entirely, leaving nothing to grasp from the cervical canal.

About a third of office hysteroscopies do end up requiring a follow-up procedure in the operating room, though. Reasons include cervical stenosis (a narrowed cervix that the scope cannot easily pass through), pain during the procedure, or unexpected findings like large polyps or fibroids.⁶ When that happens, the patient is rescheduled for an operating-room hysteroscopy with sedation or anesthesia.

When the IUD Has Perforated the Uterus

Uterine perforation is the scenario people worry about most, and for good reason: if the IUD has passed through the uterine wall, it requires surgical retrieval rather than a simple office visit. Perforation can be complete, with the IUD entirely outside the uterus in the abdominal cavity, or partial, with the device lodged to varying degrees within the muscle of the uterine wall.⁷ In either case, the IUD is no longer accessible through the cervix.

Laparoscopy, a minimally invasive surgery using small abdominal incisions and a camera, is the most common approach for removing a perforated IUD. When the device has not involved surrounding structures, laparoscopic retrieval is straightforward. One case report described a patient whose IUD was removed from the perirectal fat, where it had been sitting undetected for over 20 years after being mistakenly considered expelled.⁸ In that case and many like it, laparoscopic removal is the recommended treatment unless there is bowel perforation or severe infection.

In rarer situations, a perforated IUD embeds itself in surrounding organs, most commonly the bowel. When the device has penetrated the intestinal wall, the surgery becomes more complex. One surgical team described carefully dissecting an IUD free from the sigmoid colon, closing the bowel defect with sutures, and discharging the patient the next day without complications.⁹ Another team used a wound protector device to perform a bowel repair laparoscopically that would historically have required a larger open surgery, noting that many previous cases had been converted from laparoscopy to open abdominal surgery mid-procedure.¹⁰ Surgical technique in this area continues to improve, and the trend is toward keeping these procedures minimally invasive whenever possible.

What Causes Perforation in the First Place

Perforation is rare overall but worth understanding because it is the main reason an IUD removal might turn into an actual surgery. It can happen at the time of insertion, known as primary perforation, or gradually afterward as the uterus contracts and pushes the device through its wall over time. Primary perforation is more likely when the tip of the inserter is narrow, the cervix is difficult to pass through, or the insertion procedure is otherwise complicated.¹¹ Secondary perforation, the gradual kind, may result from a mismatch between the size of the IUD and the size of the uterine cavity, which generates uneven forces on the device.

Certain risk factors stand out. A study comparing patients with and without perforation found that younger age, higher parity, lack of ultrasound before and after insertion, less experienced providers, and missed follow-up visits were all associated with increased risk.¹² Some research has also noted an association between breastfeeding at the time of insertion and perforation, though whether breastfeeding itself causes perforation or is simply correlated with other risk factors like recent delivery remains unclear.⁷ Abdominal pain was the most common complaint that led to a perforation diagnosis.

Cervical Preparation for Difficult Removals

Sometimes the IUD is confirmed to be in the uterus, but the cervix is too tight for instruments to pass through easily. This is common in postmenopausal people, whose cervical tissue tends to narrow and stiffen over time, but it can happen to anyone. When a provider anticipates a difficult removal, they may prescribe a medication to soften and dilate the cervix before the procedure.

A systematic review found that several medications were effective for this purpose. Misoprostol and mifepristone in particular were shown to widen the cervical canal and reduce procedure time, cutting down on the need for mechanical dilation during the removal itself.¹³ These medications are typically taken several hours before the appointment. The result is a cervix that is easier to work with, which makes the procedure faster and less painful. If you are postmenopausal or have a history of cervical procedures, it is reasonable to ask your provider whether cervical preparation might help.

The Cost Gap Between Office and Operating Room

One practical dimension that rarely comes up in the anxiety of the moment is how dramatically the cost changes depending on where the removal happens. Ultrasound-guided removal in an office setting averaged around $465, compared to roughly $3,562 for removal in an operating room.² That is nearly an eightfold difference. Another study found that operating-room removal was significantly more expensive than either office-based hysteroscopy or ultrasound-guided removal, while those two office-based options were comparable to each other in cost.¹⁴

Time is also a factor. Patients who had their hysteroscopy done in an office spent an average of about two and a half hours in the clinic, compared to nearly six hours for those whose procedure was in the operating room.⁶ The office group also required fewer pre-procedure tests and studies. None of this means the operating room is unnecessary; some removals genuinely need sedation, general anesthesia, or the surgical capacity of an OR. But when an office-based approach is feasible, the savings in money and time are substantial, which is why providers generally try simpler methods first and escalate only when needed.

Copper Versus Hormonal IUDs and Retention

Not all IUDs behave the same when it comes to getting stuck. An international survey of hysteroscopic IUD removals found that the copper T device accounted for about 74% of retained IUDs found in the uterine cavity and roughly 60% of fragmented devices, despite the fact that hormonal IUDs are now the more widely sold type.¹⁵ The rigid frame of the copper T may make it more prone to embedding or fragmenting, particularly in smaller uterine cavities. Fragmentation itself adds a layer of complexity to removal because providers need to confirm that all pieces have been extracted.

This does not mean copper IUDs are inherently more dangerous. They have been used for decades with an excellent safety record, and the copper T remains the most widely used IUD type globally. But if you have a copper device and your strings go missing, the possibility of fragmentation is something your provider will keep in mind during the retrieval process, and it is one more reason why imaging before removal attempts is standard practice.

What to Expect If It Happens to You

If you reach for your IUD strings and cannot find them, or your provider cannot see them during a routine visit, the sequence of events is fairly predictable. You will get an ultrasound to confirm the device is where it should be. If it is, your provider will likely attempt retrieval in the office that same visit or at a follow-up appointment, starting with a cytobrush and moving to forceps if needed. Most people walk out of that appointment with the IUD removed and without having needed anything more than ibuprofen.

If the office attempt does not work, ultrasound-guided removal or hysteroscopy comes next, still typically in an outpatient setting. The jump to an operating room or to laparoscopic surgery only happens in the small fraction of cases where the IUD has perforated the uterus or cannot be reached by other means. Even then, complications from these procedures are low, and recovery from laparoscopic retrieval is usually quick, often a day or two.

One thing worth knowing: you should continue using backup contraception from the moment missing strings are discovered until the IUD is confirmed to be properly positioned or has been removed and replaced. A displaced IUD may not be providing reliable protection, and there is no way to know for certain until imaging confirms its location. If you are planning to have the IUD removed for a desired pregnancy, the removal method itself does not affect future fertility, though the timeline to conception will depend on other individual factors unrelated to the retrieval technique.

1
Contraception. In-office retrieval of intrauterine contraceptive devices with missing strings
2
Contraception. Safe and cost-effective ultrasound guided removal of retained intrauterine device: our experience
3
Journal of Clinical and Diagnostic Research. Missing IUCD Strings: Role of Imaging in Locating the Misplaced Device
4
PubMed. The effectiveness and safety of ultrasound-guided removal of a Mirena intrauterine system when the strings are not visible and conventional office procedures have failed
5
PubMed Central. Hysteroscopic-guided Removal of Retained Intrauterine Device: Experience at an Academic Tertiary Hospital
6
Obstetrics & Gynecology. Office versus Operating Room Hysteroscopy: A Comparison of Outcomes and Resource Utilization
7
PubMed Central. Intrauterine devices and risk of uterine perforation: current perspectives
8
PubMed Central. Laparoscopic removal of a perforated intrauterine device from the perirectal fat
9
PubMed Central. Laparoscopic Retrieval of Intrauterine Device Perforating the Sigmoid Colon
10
PubMed Central. Laparoscopic removal of migrated intrauterine device embedded in intestine
11
PubMed Central. Role of uterine forces in intrauterine device embedment, perforation, and expulsion
12
PubMed Central. Risk factors of uterine perforation when using contraceptive intrauterine devices
13
PubMed. Medical methods for cervical ripening before the removal of intrauterine devices in postmenopausal women: a systematic review
14
Obstetrics & Gynecology. Difficult IUD Removals: Outcomes and Cost Comparison
15
PubMed Central. In-office hysteroscopic removal of retained or fragmented intrauterine device without anesthesia: a cross-sectional analysis of an international survey