Clinical Presentation and Management of Retained Intrauterine Devices (IUDs): A Case Series and Literature Review

INTRODUCTION: Intrauterine devices (IUDs) are the most widely used form of long-acting reversible contraception worldwide. While generally safe and effective, challenges can emerge at the time of removal. A retained IUD is a clinical conundrum for patients and providers requiring surgical intervention. Despite the frequency of IUD use, there is a paucity of data on factors that contribute to a retained IUD. OBJECTIVE: To evaluate clinical, demographic, and procedural factors associated with retained IUDs in a large public hospital system. METHODS: A retrospective, multicenter case review was conducted across 11 hospitals within a large urban health system where patients who underwent IUD removal between January 1, 2020, and December 31, 2022, were identified through electronic health record review based on the availability of pathology reports that documented an IUD removal. Cases were selected for review if the IUD was removed at the time of surgery after an unsuccessful outpatient attempt at removal. Data collected included demographics, medical and surgical history, parity, IUD type, clinical data related to IUD insertion and removal, procedural techniques at attempted removal, and final outcomes. Descriptive analysis was performed. RESULTS: A total of 133 patients underwent IUD removal in the operating room for the indication of retained IUD. The average age of IUD insertion and removal was 31 and 37, respectively. The population was racially and ethnically diverse, with 68% identifying as Hispanic/Latina and 23% as Black/African American. The payor mix included medicaid insurance (35%) and commercial insurance (20%). Most patients (44%) were either self-pay or relied on Emergency Medicaid or a health care access program). Nearly all patients had at least 1 term delivery (94%). A history of cesarean section was noted among 47% of patients, with 32% of patients reporting no history of pelvic surgery. Fibroids were the most common structural abnormality (28%). Contraception was the primary indication for IUD insertion (94%). Non-hormonal IUD was used among 58% of patients. The main indications for IUD removal prior to diagnosis of retained IUD were expiration of IUD (43%) or side effects of IUD (38%). About 29% of patients did not undergo any additional outpatient interventions to remove the IUD after strings were deemed not visible. The majority of patients underwent hysteroscopy (86%) to remove the IUD, with 3% of patients undergoing laparoscopy. Complication rate (3%) was limited to uterine perforation, organ injury, conversion to laparoscopy, or failed removal. CONCLUSIONS: This is the largest retrospective case series to date evaluating factors associated with retained IUDs. Potential risk factors such as history of cesarean section, fibroids, and expired IUDs can be further studied through an improved study design. These findings support the need for enhanced counseling during insertion and consideration of alternative contraceptive options for higher-risk patients. Additionally, greater emphasis on training in advanced office-based removal techniques may help reduce unnecessary surgical interventions, improve patient outcomes, and lower healthcare costs.Table 1