Lost Strings

When strings are missing, the IUC is usually in place, but expulsion, perforation, and pregnancy must be excluded.

Causes of missing strings

• Most commonly, the IUC is in the correct location, but the strings are within the endocervical canal or uterine cavity.
• Uterine enlargement secondary to pregnancy can also cause retraction of strings.
• IUC has been expelled.
• IUC has perforated the uterus.

What to do?

• Immediately exclude pregnancy with a urine hCG test.
• If not pregnant, the following steps can be undertaken to visualize strings in office:
  • A cytobrush or alligator forceps can be used to draw string out of the endocervical canal
  • Endocervical speculum or sound may allow string or post to be seen
• Ultrasound can be used to confirm an intrauterine placement.
• If unable to locate IUC on ultrasound, obtain an X-Ray of the abdomen, up to diaphragm.
• If IUC is not identified at X-Ray and the woman is asymptomatic, the IUC has been expelled. Promptly discuss with the woman about contraceptive options, which may include IUC replacement.
• If strings cannot be located and the device is to be removed, a IUD hook or alligator forceps can be used (with or without paracervical block). If unsuccessful, hysteroscopic removal may be necessary.
• If intra-abdominal placement is diagnosed, the woman should be referred to gynaecology on an urgent basis, or booked for laparoscopic removal on a semi-urgent basis (while not an emergency, it should be removed promptly).

Costescu D. and Guilbert E. et al. Preceptorship Program on IUC insertion - Module 4