"Lost" IUD/IUS threads guidance for Primary Care

NHS Tayside RefGuide
NHS Tayside

This guidance is written for health care providers in Primary Care to help them to deal with patients using an intrauterine device (IUD) or intrauterine system (IUS) and presenting with “lost threads”.

General advice

Please assume that IUS/IUD with “lost threads” is not in situ and consider the need of a pregnancy test (PT), emergency contraception and a bridging contraceptive method.

The “lost threads” flow charts are aimed at clinicians at different levels of competency and experience in dealing with this clinical presentation. Which pathway to take depends on whether the patients want to keep their IUC or wants it replaced/removed.

For those wanting to keep their IUC, please request a pelvic USS (Radiology Department).

Device retrieval in patients with “lost threads” who want the device removed or replaced can be attempted by practitioners within their competency and experience and with appropriate analgesia. The cervical canal could be explored without a pelvic USS confirming the presence of the device. However, it’s not recommended to explore the uterine cavity if not sure that the device is in place.

Please refer the patient electronically to Tayside Sexual & Reproductive Health Service (TSRHS) via SCI Gateway either directly, or if attempt to remove the IUD/IUS was not successful.

Some important points to remember:-

  • Most “lost threads” reported by a patient can be found on VE or speculum exam.
  • Reasons for lost IUS/IUD threads on speculum examination (in descending order of frequency):
    • they are curled up in the cervix or endometrial cavity,
    • the IUD/IUS was inserted lower than the uterine fundus and has moved up, pulling the threads on the way (“fundal-seeking”),
    • the threads were cut short (accidentally or on purpose) or broke off,
    • the threads are very short for one of the reasons above and only are visible part of the cycle,
    • the IUD/IUS has expelled (more likely the six months after insertion and in patients with heavy menstrual bleeding (HMB) but can happen at any time),
    • the patient is pregnant and the IUS/IUD has been pulled up by the growing uterus.
    • the IUD/IUS perforated and is lying abdominally.
  • Nonetheless: please assume that IUS/IUD with “lost threads” is not in situ as default and consider the need of a pregnancy test (PT), emergency contraception and a bridging contraceptive method.
  • Please arrange a pelvic USS (Radiology Department) for patients who have lost threads but want to keep their IUD/IUS. Patients who are referred to TSRHS for an IUD/IUS removal or replacement will get their TV USS scan at their appointment.
  • Please do not try to bring down “lost threads” in patients who want to keep their device as this can displace the device and reduce its effectiveness.
  • Please do not explore the uterine cavity to remove an IUD/IUS with “lost threads” unless the patient had a recent USS¹ showing the device being in situ.
  • If removing an IUD/IUS within 7 days of unprotected sexual intercourse (UPSI) on the request of a patient who accepts the risk of an iatrogenic pregnancy: please discuss emergency hormonal contraception (EHC) and recommend a follow-up pregnancy test (PT) three weeks after the last UPSI.
  • Emergency contraception: (if indicated) do not give ulipristal acetate (EllaOne®) emergency contraception to patients with (possibly) an IUS in situ as any systemic hormone level might reduce its effectiveness. Give levonorgestrel (Upostelle®, Levonelle®, Emerres Una®) emergency contraception instead.
  • Due to the uterine contractions a very short intracervical thread might reappear spontaneously around menstruation. The retrieval +/- reinsertion procedure might also be easier.
  • Please remember that a patient who is pregnant with an IUS/IUD in situ has an up to 50% risk of having an ectopic pregnancy. There is also an increased miscarriage risk. Do not attempt to remove the IUD/IUS in Primary Care. Please refer any pregnant woman with (possibly) an IUD/IUS in situ to the Early Pregnancy Assessment Clinic (EPAC) at Ninewells (632 069) or, if she is in pain, to the Gynaecology Assessment Unit (GAU) (632 761) for an urgent USS to locate the pregnancy +/- the IUD/IUS.

"Lost" IUD/IUS threads pathway (part 1): patients not requesting removal or replacement

Lost IUD/IUS threads pathway part 1

"Lost" IUD/IUS threads pathway (part 2): patients requesting or needing removal or replacement

Lost IUD/IUS threads pathway part 2

Analgesia

  • Ideally the patient takes oral analgesia half an hour before the procedure (type according to the patient’s preference) +/-
  • Inject local anaesthesia to tenaculum/ vulsellum site (if requested by patient) +/-
  • Apply cervical block (type according to clinician’s preference) (if requested by patient)

Procedures

Before a pelvic USS confirms presence of device in uterus

  1. Routine pre-assessment for IUD/IUS removal or replacement: consider the timing of last unprotected sexual intercourse, the need for a PT and NAAT CT/GC screening.
  2. Consent patient and discuss possible pain, bleeding, perforation and vasovagal reaction and failure to retrieve the device (completely)
  3. Explore only the cervix (max depth approx. 2.5 cm). There is usually no need for a tenaculum at this stage.
  4. An endocervical brush (for example “Cervibrush”) could be inserted into the cervical canal to try to bring down the threads with a rotating (twirling) movement.
  5. An Emmett thread retriever* could be inserted in the cervical canal and gently rotated to trap the threads, snag then and bring them down.
  6. The cervical canal could be explored with narrow long artery forceps or Hartman’s IUD retrieving (crocodile) forceps*. Gently open, turn and close the jaws and withdraw.
  7. If attempt unsuccessful and not competent to explore intrauterine cavity: please refer electronically to TSRHS via SCI Gateway.

After recent1 USS confirmed an intrauterine IUD/IUS2

  1. Consent patient and discuss possible pain, bleeding, perforation and vasovagal reaction and failure to retrieve the device (completely)
  2. Repeat steps 1- 4 above.
  3. A flexible plastic uterine sound* could be used to “feel” the device within the uterine cavity.
  4. Use a tenaculum to straighten the canal.
  5. Gentle dilatation of the internal cervical os with a (tapered/ graded) plastic dilator* might be needed.
  6. An Emmett thread retriever could be inserted up to the uterine fundus and gently rotated to trap the threads and bring them +/- the IUD/IUS down. Begin at the fundus and twirl along anterior then posterior uterine wall, from fundus to canal.
  7. A Hartman’s IUD retrieving (crocodile or alligator) forceps* could be inserted into the uterine cavity to feel for the device, catch the threads or device and remove it. Gently open, turn 90 degrees and close the jaws at progressive depths and withdraw until “purchase” of the IUC threads, stem or arm.
  8. If attempt unsuccessful or poorly tolerated: please refer electronically to TSRHS via SCI Gateway.

* Instruments can be purchased from Durbin Sexual Health Supplies.

References

  1. An USS done within the three months prior to the appointment would usually be regarded as “recent” but the final decision how “recent” a scan is lies with the clinician.
  2. The IUS/IUD reported as lying in uterine cavity, without being embedded or partially perforated.

Abbreviations

CT/GC     chlamydia and gonorrhea
EHC        emergency hormonal contraception
FU          follow-up
GAU        Gynaecological Assessment Unit
HMB       heavy menstrual bleeding
IUD        intrauterine device (“copper coil”)
IUS         intrauterine system (“hormone coil”)
NAAT       nucleic acid amplification test (for chlamdyia and gonorrhea)
PT           pregnancy test
SRH        Sexual & Reproductive Health
STI         sexually transmitted infection
TSRHS    Tayside Sexual & Reproductive Health Service
UPSI       unprotected sexual intercourse
USS        ultrasound scan
VE          vaginal examination

Editorial Information

Last reviewed: 02/08/2025

Next review date: 02/08/2027

Author(s): Gleser H.