Elsevier

Contraception

Volume 86, Issue 4, October 2012, Pages 354-358
Contraception

Original research article
Management of missing strings in users of intrauterine contraceptives

https://doi.org/10.1016/j.contraception.2012.01.018Get rights and content

Abstract

Background

A common question among health care professionals is how to manage nonvisible strings in users of intrauterine contraceptives (IUCs) at repeat follow-up visits. This study assessed the position of the IUCs in women who consulted repeatedly with nonvisible IUC strings.

Study Design

The medical records of the clinic were reviewed to identify new acceptors and switchers who had an IUC inserted between 1990 and 2009. All women were identified whose IUC string could not be visualized at the external os of the cervix by the health care professional at any given follow-up visit, even after attempting a standard maneuver of sweeping the strings from the cervical canal using a cervical brush or trying to visualize the strings in the cervical canal using colposcopy. Data were also retrieved on the use of ultrasonography and/or pelvic X-ray to assess IUC position, as well as data from any subsequent visits at which the IUC strings were nonvisible.

Results

The medical charts of 14,935 patients using an IUC were reviewed, and 750 women (5.0%) presenting for the first time with missing IUC strings at any follow-up visit were identified. Ultrasound scans showed the IUC to be in situ in 735 cases (98.0%), while 9 women (1.2%) had expelled the device and, in 5 cases (0.7%), the device was found in the pelvis following uterine perforation. IUC strings were missing on a second occasion in 297 cases. The device was found to be in situ in 295 cases (99.3%) and had been expelled in 2 (0.7%). At subsequent consultations, (between 1 and 18 years after the first consultation), strings were missing in 113, 55, 19 and 5 cases. In 111 (98.2%), 54 (98.2%), 18 (94.7%) and 5 (100%) of these cases, respectively, the IUC was found to be in situ, while in the remaining cases, the device had been expelled.

Conclusions

Missing IUC strings are an uncommon finding, and ultrasonography confirmed that the device was in situ in the majority of these cases. For women with persistent missing IUC strings after one ultrasound scan that has verified appropriate intrauterine position, given the 2.4% likelihood that expulsion may have occurred at the time of subsequent visits, repeating the ultrasound (if available) should be considered for at least one (and possibly two) additional women's visit.

Introduction

Intrauterine contraceptives (IUCs) including the copper-releasing intrauterine device (IUD) and the levonorgestrel-releasing intrauterine system (LNG-IUS) are used by millions of women worldwide and constitute one of the most effective forms of contraception [1]. IUDs, LNG-IUS and implants are long-acting reversible contraceptive methods or “forgettable contraceptives” [2] in that they provide effective contraception for at least 3 years following one single intervention. In fact, the TCu380A IUD is approved for up to 10 years of use, with reports of the device having been used for as long as 20 years [3], [4]. The LNG-IUS is approved for up to 5 years of use [5], [6].

IUC users normally return for the first follow-up consultation at 6–12 weeks and after every year or every 2 years, and since the devices may potentially be used for many years, women commonly attend many routine follow-up consultations at which gynecological and breast examinations are performed and cervical smears are taken for cancer screening whenever appropriate. At that time, visualization of the IUC strings in the cervical os is an indication that the IUC is in situ [7]. However, it has been reported that in 4.5% to 18.0% of IUC users [8], [9], [10], [11], the strings cannot be visualized at the external cervical os. The most common reason for missing IUC strings is string retraction into the cervical canal or uterine cavity, which may be a consequence of short strings, uterine enlargement or pregnancy. Additionally, missing strings could be an indication of unnoticed IUC expulsion or uterine perforation.

If the woman whose IUC strings cannot be visualized wishes to have her device removed, this will require a simple procedure generally performed on an outpatient basis using any of the various devices that have been described for this purpose [8], [9], [10], [11]. However, before attempting removal, an ultrasound scan should be performed to ensure that the IUC is in situ [12]. In nonpregnant women, strings can sometimes be successfully retrieved with a simple procedure such as sweeping the strings from the cervical canal using a cervical brush, a maneuver that may be performed irrespective of whether the woman wishes to keep the device [13]. In addition, colposcopy may be useful in helping to locate the strings [14].

Nevertheless, a problem arises if the woman wishes to retain the IUC. In LNG-IUS users who are amenorrheic, inadvertent expulsion can be suspected if normal menses return; however, in copper IUD users, the only indication of expulsion may be pregnancy, although pregnancy is not necessarily synonymous with expulsion. Two previous publications presented flowcharts [12], [15] for the management of women with missing IUC strings. Those investigators recommended that after an attempt to remove the strings from the cervical canal, ultrasonography should be performed to investigate whether the IUC is in situ. If the device is not in situ, a pelvic X-ray should be performed to evaluate the possibility of uterine perforation. This flowchart has been in use in our clinic for more than 30 years.

However, one of the above-mentioned manuscripts [12] stated that “When an appropriately located IUC is confirmed on ultrasound examination and the patient wishes to maintain the IUC, no further follow-up is required until the IUC is to be removed.” Nevertheless, when the IUC strings are repeatedly missing at follow-up consultations but an ultrasound scan has already confirmed that the IUC is indeed in situ, it is still difficult to convince women that the IUC is in situ and counsel them that “no further follow-up is necessary” until the woman asks for it to be removed, particularly when the device is a copper IUD [12]. One common question among the professionals in our clinic is how to manage women who repeatedly present with missing IUC strings at follow-up visits. The objective of this study was to assess the position of the IUC in women who consulted more than once with missing IUC strings in order to improve management during the follow-up of these contraceptive users.

Section snippets

Subjects and methods

This was a retrospective study performed at the Human Reproduction Unit, Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil. After Institutional Review Board approval, all the medical records from the years 1990 to 2009 were reviewed, and data were retrieved on all the women who had had an IUC inserted, whose IUC strings could not be visualized at a medical follow-up consultation, whose strings remained nonvisible after an

Results

The medical charts of 14,935 patients using an IUC were reviewed. Of these, 750 women (5.0%) were identified who presented for the first time at any of the routine medical follow-up visits [mean±standard deviation (SD) 25.4±30.6; range 1–203 months after insertion] with IUC strings that could not be visualized and that continued to be missing even after attempts had been made to remove the strings from the cervical canal using a cervical brush or after the use of a small forceps or even after

Discussion

A large number of medical records referring to new acceptors of two of the most common IUCs in use worldwide, the TCu380A and the LNG-IUS, were reviewed for this study; however, only 750 of these women (5%) had consulted at least once when the strings of the IUC were not visible at the external os of the cervix even after a common maneuver had been performed to try to retrieve the strings from the cervical canal. The present finding that IUC strings are missing at 5% of follow-up consultations

Acknowledgments

This study was partially funded (grant 573747/2008-3) by the Brazilian National Research Council (CNPq).

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