Contraception 88 (2013) 599 – 603

Commentary

Controversies in family planning: how to manage a fractured IUD

Susan Wilson a,⁎, Grace Tan a , Margaret Baylson b , Courtney Schreiber a
a
Division of Family Planning in the Department of Obstetrics and Gynecology at the Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
b
Department of Family Medicine and Community Health at the Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA

Received 30 April 2013; revised 23 July 2013; accepted 24 July 2013

Question: We recently took care of a 34-year-old female
who was referred to us for management of a retained arm
from an intrauterine device (IUD). The Paragard® IUD had
been inserted 5 years prior, approximately 8 weeks postpar-
tum, and the insertion had been uncomplicated per report.
She experienced intermittent episodes of heavy vaginal
bleeding and pelvic pain over the 5 years, with one encounter
in the emergency room at which time a computed
tomographic scan showed the IUD in the uterine body. She
declined removal of the IUD until February 2013. The
provider who removed the IUD reported applying gentle
traction to the IUD strings; however, the provider noted that
one arm was missing from the device following removal.
The patient was asymptomatic on presentation to our office.
She gave her consent for inclusion in this manuscript.
This is the third case of a partially retained Paragard®
IUD we've seen in the past 9 months. In our previous cases, a
paracervical block was given, and the use of a manual
vacuum aspiration device was successful in removing the
retained IUD arm. The patients tolerated the in-office
procedure well. We are curious to know if other individuals
have experienced similar fragmentation of IUDs and their
management strategies.
Respondent 1: I saw a patient in May 2012 who had her
Paragard® IUD removed after 1 year in place and presented
with a retained IUD arm in her cervix. She had an X-ray
following the partial IUD removal. The patient was
asymptomatic. Alligator forceps were unsuccessful in
initially removing the IUD arm. The piece could not be
visualized by office hysteroscopy. She was scheduled for the
operating room (OR); however, on repeat X-ray before
⁎ Corresponding author. Tel.: +1 215 615 5234; fax: + 1 215 615 5319.
E-mail address: susan.wilson@uphs.upenn.edu (S. Wilson).
0010-7824/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.contraception.2013.07.007
proceeding to the OR, no IUD fragment was noted. We
assumed she passed the piece during her menstrual cycle in
the time between the two X-rays.
Respondent 2: A patient with a “stuck” Paragard® IUD
that had been in place for 10 years was referred to me in
September 2012. Following removal, one of the IUD arms
was missing. In-office use of alligator forceps was unsuc-
cessful in removing the missing arm. The patient received a
formal ultrasound prior to being brought to the OR. The IUD
fragment could not be visualized by hysteroscopy. At this
point, no further attempts to remove the fragment were made,
and a Mirena® IUD was placed while in the OR.
Respondent 3: I was referred a patient in January 2013
whose Paragard® IUD had been in place for 5 years and was
fragmented upon removal. One prior in-office attempt at
removal of the IUD piece had been made prior to her referral
to me. No radiologic studies had been done. The patient was
asymptomatic at presentation. In my office, a paracervical
block was given, and using the alligator forceps under
ultrasound guidance, the IUD fragment was successfully
removed from the anterior lower uterine segment.
Respondent 4: I had a patient in October 2012 who had an
embedded Paragard® IUD arm near the internal cervical os.
She had had her IUD in place for 6 years prior to removal.
She denied any symptoms with the retained IUD fragment in
place. In-office attempts using an IUD hook and alligator
forceps under ultrasound guidance were not successful. She
did not receive any formal imaging studies. She was brought
to the OR, at which time the fragment was visualized
hysteroscopically and removed with polyp forceps.
Conclusion to the presented case: Initial in-office attempts
at removal of the IUD arm under ultrasound guidance were
unsuccessful. The patient was offered in-office manual
vacuum aspiration (MVA), but declined. A formal ultra-
sound showed the arm embedded in the anterior endometrial/

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600 Commentary / Contraception 88 (2013) 599–603
myometrial wall. In the OR, we were unable to visualize the
IUD arm via hysteroscopy. Using a combination of operative
hysteroscopy, MVA and sharp curettage, we successfully
removed the retained IUD arm.
1. Literature review
1.1. Background
The IUD is the most widely used method of reversible
contraception in the world today [1]. Use rates vary by
country, with the highest rates at 40% in Korea and Vietnam
[2]. In the United States, the use of IUDs has been influenced
by historical events. The negative repercussions of the
Dalkon® Shield in the 1970s and studies associating IUD use
with tubal infertility in the 1980s are two factors that
contributed to the decline in rates of IUD use from 10% in
the early 1970s to less than 1% by 2003 [3]. Since then, the
use of IUDs by American women has been slowly
increasing. According to national statistics collected by the
Centers for Disease Control and Prevention in 2009, 8% of
women reported using the IUD for contraception [4].
The two Food and Drug Administration (FDA)-approved
IUDs available in the United States today are the copper T-
380A (Paragard™) and the levonorgestrel intrauterine
system (Mirena™). Metal-based IUDs have a long historical
existence dating back to the early 1900s and have undergone
significant shape and size changes over the years [5].
Clinically significant adverse events related to the IUD
are few and uncommon. The most frequently occurring
events include expulsion (2%–10% in the first year) and
perforation (1/1000 insertions) [6]. An even less common
adverse event is the breakage or fracture of an IUD, with a
paucity of reports in the literature. The fracture can occur
spontaneously in utero with expulsion of IUD fragments, or
it can occur iatrogenically in which case a piece of the IUD is
missing following removal. While fracture rates have been
reported to be 1%–2% with the use of past IUDs, the
frequency of such events occurring with modern-day IUDs is
unknown [7]. The finding of a fractured IUD, either by
spontaneous expulsion of an IUD fragment or following IUD
removal, can cause much anxiety for both the patient and the
treating physician. It is logical to assume that, with
increasing IUD use, as is the case in the United States
today, the incidence of all outcomes, both positive and
negative, will increase. Therefore, it is important to be aware
of the less common adverse events that can occur with IUDs
and how to properly manage them.
We report three cases of IUD fracture over a 9-month
period and have heard of 15 other nationwide cases via
personal communication, the majority of which have
occurred in the past year. The purpose of this paper is to
review the literature on fractured IUDs and their manage-
ment, and recommend management strategies based on
historical knowledge and current practices. We hope to
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raise awareness of this uncommon contraceptive complica-
tion in order to facilitate its management, especially as IUD
use increases.
1.2. Historical reports of IUD Fracture
The finding of fractured IUDs has been reported
sporadically in the worldwide literature. We performed a
Pubmed search using combinations of the keywords and
MeSH terms “iud,” “intrauterine device,” “Paragard,”
CuT380A,” Mirena,” “levonorgestrel intrauterine system,”
“break,” “breakage,” “broken,” “fracture,” “fractured,” “frag-
ment,” “fragmented,” “fragmentation,” and “adverse effects.”
Of the 47 articles that matched our search criteria, 30 reported
on cases of IUD fracture. All reports were either case reports
or small case series, many with very limited clinical
information. One of the earliest publications, by the
International Planned Parenthood Federation Medical Bulle-
tin, described a batch of defective IUDs [8]. A “batch” of
malmanufactured IUDs was noted in one other report as well
[9]. Among the initial cases of fragmented IUDs in the 1970s
in which the IUD type was specified, the majority involved
the Lippes Loop — a plastic, multilooped device [10–13].
Most had been in place for approximately 2 years, and
fragments were removed in the OR under general anesthesia.
Other reports referenced the Grafenburg ring, Majzlin spring,
Cu-7 and Cu-T IUDs [14–16]. The majority of cases from the
1980s and 1990s, when specified, reported on the Multiload
Cu250 [17–22]. Of reports that detailed the fractured IUD,
the most common findings were IUD strings that tore off or
missing IUD arms following removal. The utility of
hysteroscopy to successfully remove IUD fragments was
mentioned in several reports [18,23].
We found 10 reports since the year 2000 regarding
fractured IUDs. When specified, the reported devices
comprised several models of copper IUDs [27–30]. One
case reported a fragmented levonorgestrel IUD [31]. The
average duration in utero prior to fracture was 5 years, and
the most common presentation was a retained IUD arm
following removal, with a few cases reporting spontaneous
expulsion of an IUD stem. Most reporting clinicians
obtained a formal ultrasound to visualize the missing IUD
fragment(s) before proceeding to the OR for a procedure
under general anesthesia. While a few case reports employed
laparoscopy or laparotomy, most reported visualizing the
IUD fragment on hysteroscopy and successfully removing it
by operative hysteroscopy [19,32,33]. In a more recent case,
office suction and manual curettage were used to remove the
IUD fragment [31]. Alternative outcomes of retained IUD
fragments included passage during the patient’s menstrual
cycle and leaving a fragment in place [27,29]. The patient in
the latter case was monitored for 12 months without any
adverse events.
In the United States, only three case reports have been
published regarding IUD fractures. These cases ranged from
a broken Majzlin spring noted upon removal in 1972, a
missing fragment of a Lippes Loop noted upon removal in
 Commentary / Contraception 88 (2013) 599–603
1978 and four cases of embedded, broken IUDs in women
with infertility in 1984 [13,25,34].
The occurrence of IUD fractures has led investigators to
question the structural integrity of new and used IUDs. One
of the first published studies found corrosion and decreased
thickness of the bodies of 26 Lippes Loops which had been
in utero for various lengths of time [24]. Pressure tests
showed a positive relationship between time in utero and
IUD rigidity, resulting in decreasing amounts of pressure
required for IUD breakage. Additionally, it was noted that
fractures occurred more frequently at curved portions of the
IUD device. A more recent study done in Italy comparing
four commonly used European copper IUDs found that the
resistance to mechanical fatigue varied among all new as
well as used IUDs, that all IUDs showed an exponential
decrease in resistance with time in utero and that IUD shape
may influence resistance to mechanical fatigue [25]. The
incidence of copper wire breakage, secondary to dissolution
in utero, has also been shown to increase with increasing
duration of use [26]. No studies to date have examined the
two modern-day IUDs used in the United States.
1.3. Recent reports of IUD fracture
After conducting a brief, nationwide inquiry of members
of the Society of Family Planning, we received 15 reports of
IUD fracture (personal correspondence). Almost all were
single case reports, and 13 involved the FDA-approved
copper IUD (two responders did not identify the type of
IUD). Of these reports, we received further information
detailing 11 of the cases, all of which occurred in 2012 or
2013, with the IUD in place for an average of 6 years (range,
1–10 years) prior to the fracture. All cases reported a missing
IUD arm following removal of the IUD, both after “easy”
and “stuck IUD” removals. The most common location for
the fragment to be identified was in the lower uterine
segment or cervix. All patients were asymptomatic with the
retained IUD fragment in place.
Initial in-office management strategies included using an
IUD hook, alligator forceps under ultrasound guidance or an
MVA. One patient requested that no attempts at removal be
made as she no longer desired fertility. Office hysteroscopy
was used in two cases: one with partial removal of an
embedded cervical IUD and the other resulting in difficulty
visualizing the intrauterine IUD fragment (likely due to the
prior instrumental attempts at removing the fragment). Of the
11 attempts at removal, 8 used alligator forceps (1 of which was
successful), and 3 used MVA (2 of which were successful).
Before proceeding to the OR for IUD fragment removal,
five cases underwent formal radiologic imaging (ultra-
sound, X-ray or magnetic resonance imaging). In one case,
the IUD fragment was not visualized on repeat X-ray, and
it was thought that the fragment might have passed during
the patient’s intervening menses. Of two cases lost to
follow-up, one re-presented with a spontaneously expelled
IUD arm.
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601
Five of the 11 detailed cases proceeded to the OR. While
hysteroscopy was performed in all cases, the IUD fragment
could only be visualized in two of the cases, and the
successful removal of the fragment required polyp forceps in
one case and an MVA in the other case. No further attempts
at removal were made in the three cases in which
hysteroscopy was unable to visualize the IUD fragment.
Alternatively, one patient desired that a new IUD be placed
while in the OR, another desired a subsequent sterilization
procedure, and the third is currently attempting to conceive.
The long-term consequences of not removing a retained
intrauterine IUD fragment are unknown, in terms of both the
individual’s health and future pregnancy outcomes. Thor-
ough counseling of the patient and documentation of the
discussion are necessary in these circumstances.
1.4. Management summary
Current-day removal strategies for a retained IUD
fragment(s) include less-invasive techniques than historical
approaches. Initial use of an MVA or IUD hook/narrow tip
forceps under ultrasound guidance are two options readily
available to most clinicians. We would recommend against
using biopsy forceps as their sharp cutting design has been
known to “biopsy” the IUD, making it a less-than-ideal
instrument for intact removal of an IUD or specific piece of
IUD (personal communication). Based on our small sample
of cases, an MVA may provide a higher chance of successful
removal and may have a lower risk of uterine perforation,
especially when office ultrasound is not available. While
some studies advocate the use of hysteroscopy, its utility in
removing IUD fragments is uncertain. If a clinician were
inclined to use hysteroscopy, we recommend its use prior to
any uterine instrumentation in order to maximize visualiza-
tion. Strategies for IUD fragment removal in the OR include
all of the options that are available in-office. In addition,
sharp curettage can be employed either in-office with
adequate sedation or in the OR. Ideally, this latter technique
is done under ultrasound visualization for targeted curettage
and minimal trauma to the uterus. Leaving an IUD fragment
in utero has unknown consequences and should be discussed
with the patient prior to surgical management.
The utility of formal radiological studies before attempt-
ing removal is unclear, especially with the availability of in-
office ultrasound or ultrasound technicians in the OR. When
the location of the IUD is unclear or office ultrasound
imaging fails to locate the IUD, further imaging studies may
be warranted. The use of X-ray offers an inexpensive method
for determining the general location of IUD fragments.
In discussing all management options for a retained IUD
fragment, the necessity of removal is unclear. While the
reported incidence of this adverse event is quite small, there
are even fewer published reports describing the outcomes
of prolonged retention of IUD fragments. Many of the
previously mentioned cases from the literature describing
IUD fragment removal presented with irregular bleeding
602 Commentary / Contraception 88 (2013) 599–603
and cramping, thus suggesting a need for removal
[11,28,33,35]. Alternatively, other women were reported
to be asymptomatic upon presentation [11,29,30,36]. One
case report described no complications from the retention
of an IUD arm in utero during 12 months of follow-up
expectant management [29], and another reported retention
of an IUD arm with a subsequent normal pregnancy [36].
Outcomes of a retained IUD fragment with respect to future
fertility are unknown.
Additional information concerning the need to remove an
IUD fragment may be gained by extrapolating the evidence of
the consequences of prolonged retention of an intact IUD.
Again, however, there are very few such studies in the
literature, and no clinical trials have examined the risks of
prolonged IUD retention. Symptoms of bleeding, abnormal
vaginal discharge and pelvic pain can occur with prolonged
IUD retention [37,38]. Publications relating prolonged
IUD use with pelvic infections are limited to single case
reports or small case series, and as such have not been
associated with prolonged IUD retention [39–41]. While the
risk of an Actinomyces-positive Pap smear has been found to
be increased after several years of IUD use, the clinical
significance of this finding is questionable as Actinomyces
species are normal inhabitants of the female genital tract and
their increased detection on Pap smears has not been
associated with an increased risk of pelvic infections
[42–44]. With respect to fertility, it is the recommendation
by the American Congress of Obstetricians and Gynecologists,
World Health Organization and FDA to remove any IUD prior
to attempting pregnancy or in pregnancy when possible
without an invasive procedure; whether these guidelines are
applicable to fragments of retained IUD is unknown [45]. In
summary, while there is insufficient evidence to date to
confidently recommend or not recommend retained IUD
fragment removal, we encourage clinicians to discuss the
clinical situation with their patient and assess if she has a
preference for removal or not. We would recommend removal
if the patient is symptomatic with pain, bleeding or signs of
infection, or if she desires future fertility.
The management of any malfunctioning medical device,
including fractured IUDs, involves appropriate reporting of
the adverse event. Medical device reporting is a mechanism
by which the FDA can receive and monitor significant
medical device adverse events. Historically, hospitals and
manufacturers have underreported device problems. The Safe
Medical Device Act of 1990 requires all user facilities (e.g.,
hospitals, clinics) to report device-related deaths to the FDA
and the manufacturer if known, and serious device-related
injuries to the manufacturer or the FDA if the manufacturer is
not known. In addition, manufacturers are required to submit
a semiannual report of serious injuries to the FDA. While an
IUD fracture may not constitute a serious adverse event,
defined by the FDA to include events that are life-threatening,
result in permanent impairment or require an intervention to
prevent permanent disability, its occurrence is still unexpected
and typically requires invasive interventions to correct.
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Additionally, as previously described, there are historical
accounts of “batches” of IUDs with higher rates of breakage.
In order to anticipate this possible occurrence, IUDs that have
fractured should be reported to their respective manufacturer.
For the case presented in this editorial, Teva was contacted
and has requested additional information in the form of an
Adverse Drug Event Follow-Up Report.
In summary, IUD fragmentation is a rare and often
unreported event. With increasing IUD use in the United
States, the possibility of uncommon IUD-related adverse
events increases. Current management strategies for the
removal of retained IUD fragments should begin with in-
office techniques, with subsequent attempts in the OR if
necessary. It is also important to report all IUD fractures to
the respective manufacturer in order to maintain a high
quality of IUD devices for the safety of our patients.
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