Intrauterine Device Complications and Their Management

Purpose of Review Individuals are using intrauterine devices (IUDs) increasingly more frequently not only for contraception and emergency contraception, but also, in the case of hormonal IUDs, for the management of heavy menstrual bleeding and endometrial hyperplasia. While IUD complications are rare, their increasing prevalence is inevitably linked to more patients requiring specialized care for these complications. This review summarizes the most common complications, inclusive of perforation, expulsion, concurrent pregnancy, and difficult IUD removal, as well as their management strategies. Recent Findings The two most recent, large-scale, multi-site cohort studies examining IUD complications were conducted in Europe (European Active Surveillance Study for Intrauterine Devices (EURAS-IUD)) and the USA (Association of Perforation and Expulsion of Intrauterine Devices (APEX-IUD)), confirming the rarity of perforations, occurring in less than 0.5% of individuals over 5 years of follow-up and primarily at the time of or soon after insertion. These studies both confirmed the independent and increased risk of perforation among individuals receiving an IUD in the postpartum state, as well as among breastfeeding individuals. In the APEX-IUD study, the risk of perforation was noted to be elevated even up to 52 weeks postpartum, even when controlling for breastfeeding status. The same study also noted that 10.7% of individuals receiving IUDs within 3 days postpartum expelled their IUDs; while this proportion was significantly elevated compared to those waiting several weeks to receive their IUD, it is remarkably lower than rates seen in previous studies of immediate postpartum IUD insertion. Breastfeeding was protective against IUD expulsion. Additional studies note the incidence of IUD fragmentation and possible differences for rates of fragmentation by device type. Summary IUD complications are generally rare but can become serious or burdensome for patients if their reproductive healthcare providers are not aware of the possible risks and presentation. Understanding the potential for IUDs to perforate the uterus, be expelled, fail to prevent pregnancy, or be difficult to remove, along with the various risk factors linked to these complications, can help providers improve their counseling and take appropriate precautions with IUD insertion to better avoid them, as well as manage them when they inevitably occur.