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OG35.18 | IUD Procedural Skill — SDL Guide (Part 2)

IUCD Removal Technique and Troubleshooting

IUCD removal is required when the device has reached its effective lifespan, when the patient requests discontinuation or is planning pregnancy, or in the setting of complications such as confirmed PID not responding to antibiotics, partial or complete expulsion, or confirmed uterine perforation. In the majority of cases, removal is straightforward — the threads are grasped and the device is pulled out with steady traction. However, missing or broken threads create a diagnostic and technical challenge that must be addressed systematically and without blind uterine instrumentation, which risks completing a perforation or introducing infection. A systematic, investigation-guided approach prevents the common error of attempting blind retrieval that causes more harm than the original complication. Systematic investigation-guided retrieval is always safer and more successful than blind manipulation.

Routine removal technique:
1. Insert Cusco speculum and visualise the cervix; clean the cervix
2. Identify the two threads at the external os; grasp both threads with sponge-holding forceps or ring forceps as close to the os as possible
3. Apply steady, continuous traction in the axis of the uterus (inferiorly and posteriorly); the device exits through the cervical os with the arms folding downward as the device passes through the internal os
4. Confirm the device is intact on visual inspection (both arms present, frame complete, no broken wires)
5. Counsel on contraceptive options: a new device can be inserted immediately in the same visit if the patient wishes to continue IUCD use and there is no active infection

Management of missing threads:
Missing threads most commonly indicate: (a) threads retracted into the cervical canal or uterine cavity; (b) unnoticed device expulsion; or (c) uterine perforation (rare — occurs at insertion, not at follow-up). Management sequence:
- Confirm device presence with transvaginal ultrasound first; if device is in the uterine cavity, proceed to thread retrieval
- If device not seen on ultrasound: obtain abdominal and pelvic X-ray to look for the device outside the uterus (perforation)
- If device is in cavity with retracted threads: use a cytobrush, Emmett hook, or thread retriever to draw out threads from the cervical canal; if unsuccessful, hysteroscopic guided retrieval
- Perforation confirmed (device outside uterus): requires laparoscopic or open surgical retrieval — do NOT attempt transcervical removal

Interpreting Post-Insertion Findings and Follow-Up

Post-insertion assessment at 6 weeks is a structured clinical encounter that confirms device placement, identifies complications in their early and more treatable phase, and provides an opportunity to address side effects before the patient discontinues prematurely. The most common reason for early IUCD discontinuation is not complication but rather inadequately addressed patient anxiety about changes in bleeding pattern or thread length — both of which can be managed with reassurance and correct information at the 6-week visit. Several specific clinical findings require systematic interpretation at this follow-up and at any subsequent consultation where an IUCD is known to be in situ.

Thread check at 6 weeks: the patient should have been taught to feel for her threads; the clinician confirms threads on speculum examination. Threads longer than at insertion suggest partial expulsion (device descending towards the cervix). Threads not found require the systematic ultrasound-first approach described above. If the device is correctly positioned, the patient is advised to continue monthly thread self-checks and returns annually or as needed.

Expulsion recognition: partial expulsion presents as a device visible or palpable at the cervical os, increased cramping, or a partner feeling a hard object during intercourse. Complete expulsion means contraceptive protection is immediately lost. The patient should be counselled urgently about emergency contraception if exposure has occurred since expulsion, and offered reinsertion.

IUCD-associated infection (PID): insertion slightly increases PID risk in the first 20 days due to ascending instrumentation. Thereafter, the IUCD does not independently increase PID risk in women at low STI risk. IUCD-associated PID symptoms: pelvic pain, purulent vaginal discharge, cervical motion tenderness, fever. For mild-to-moderate PID, WHO and RCOG guidelines recommend treating with antibiotics while leaving the device in situ — unnecessary removal worsens outcomes. Device removal is indicated only if there is no clinical improvement within 72 hours of adequate antibiotic treatment or if PID is severe.

Ectopic pregnancy with IUCD in situ: the IUCD is highly effective at preventing intrauterine pregnancy, but if it fails, a higher proportion of resulting pregnancies are ectopic than in unprotected women. Any positive pregnancy test in an IUCD user requires urgent transvaginal ultrasound to confirm intrauterine location and exclude ectopic. This is a critical clinical safety point that must be communicated during counselling.

Simulated Practice and National Programme Context

IUCD insertion requires deliberate practice on simulation models before supervised patient procedures, because the uterine cavity is not directly visible during the procedure and the technique must be internalised from tactile feedback rather than visual cues. The sensations to internalise through simulation are subtle but critical: the gentle resistance of the internal os, the characteristic soft fundal resistance when the sound or inserter reaches correct depth, and the precise differential movement of the withdrawal technique (tube back, rod stationary). Attempting to learn this differential movement for the first time on a patient, rather than on a model, leads to the most common insertion error — advancing the rod rather than withdrawing the tube, which pushes the device downward rather than deploying it at the fundus.

Simulation training for IUCD insertion has been evaluated in multiple procedural education studies: simulation-trained trainees achieve fundal placement significantly more often on their first supervised patient insertion and take less time per procedure compared with trainees who rely only on observation. Both high-fidelity pelvic models and lower-cost 'banana peel' uterine models have been validated for the specific skills of sounding, device loading, withdrawal deployment, and thread trimming.

India RMNCH+A national programme context: India's Reproductive, Maternal, Newborn, Child and Adolescent Health strategy identifies PPIUCD as a priority LARC at district hospitals, community health centres, and primary health centres. Antenatal counselling (ideally at 36 weeks) is the key enabler of PPIUCD uptake — women who have been counselled before labour and given consent before admission are much more likely to accept PPIUCD at the time of delivery. The national PPIUCD training module uses a cascade model: medical colleges train district-level master trainers, who train facility staff. As a final-year MBBS student rotating in labour ward, you will encounter PPIUCD insertion and should be familiar with the rationale, technique, and counselling requirements.

Ethical considerations for PPIUCD: consent must be obtained during the antenatal period — not during active labour when pain and anxiety impair autonomous decision-making. Women must understand that declining PPIUCD does not affect the quality of their labour care. The right to refuse at any point, including at the time of delivery, must be explicitly respected.