Malpositioned IUDs: When you should intervene (and when you should not)

Our recommendations

The management of malpositioned IUDs can be clinically challenging. Given the available evidence, we suggest the following:

• If patients present with symptoms that may be attributable to the malpositioned device, such as bleeding or pain, the device should be removed and the patient should be offered immediate replacement or immediate initiation of another form of highly effective contraception. Many women will show improvement in their symptoms if the malpositioned device is replaced with one that is correctly placed.
• The asymptomatic patient with a malpositioned LNG-IUS that is still in the uterine cavity can be expectantly managed. She may be offered replacement if she desires.
• An asymptomatic patient with a malpositioned copper IUD should be counseled that she is potentially at higher risk for pregnancy than she would be if her IUD were correctly positioned. This risk cannot be quantified easily, but it is likely lower than the risk of pregnancy associated with most forms of short-acting contraception. She should be counseled for IUD replacement or removal and immediate initiation of another form of highly effective contraception—but you and she also may opt for expectant management if initiating another highly effective form of contraception is not feasible.

CASE Conclusion

The patient is asymptomatic with an LNG-IUS in the lower uterine segment and embedded in the myometrium. She has no obvious risk factors for IUD malpositioning, but given that her menses were heavy prior to placement, she may have adenomyosis.

Given that she is currently asymptomatic with a hormone-containing IUD, she may be managed expectantly. Were she to become symptomatic, she should be offered IUD replacement (versus another form of highly effective contraception such as an implant or sterilization).

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