Case Studies

Case 3: Lost LNG-IUS threads

A 36-year-old woman attends your SRH clinic for a ‘coil check’. She had an LNG-IUS inserted 6 weeks ago and was told to come back for a review appointment. She is happy with the method so far. She has been unable to feel the device threads herself but wonders if they might just be short. She was menstruating when the device was inserted but has not had any further menses since then. She is a para 2+1 (2 SVDs and 1 miscarriage) and is in a relationship with her husband of 15 years.

• 1. With her agreement you perform a speculum examination. You cannot see the threads of the LNG-IUS. What are the possible causes?

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  Correct answer: Expulsion or perforation may have occurred or the device is in the correct location but the threads are short or have been drawn up into the uterus.

• 2. How do you manage this situation?

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  Correct answer: Pregnancy should be excluded and an ultrasound scan arranged to determine the location of the device. If the device is not seen on ultrasound scan a plain abdominal X-ray should be requested to exclude an extra-uterine location.

• 3. You have access to ultrasound in your clinic therefore you perform a transvaginal scan. The LNG-IUS is correctly located in the uterus. Does the device need to be replaced?

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  Correct answer: No. If the LNG-IUS is correctly located there is no need to remove and replace the device. Its efficacy will be unaffected. The woman should be informed that she may need to attend a specialist clinic (e.g. your service) when removal is required (e.g. licence limit or she requests removal). In the interim, the threads may become visible/palpable again.

• 4. If you couldn’t see the device in the uterus on ultrasound scan and the x-ray report confirmed it to be located towards the right side of the pelvis what action would you take?

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  Correct answer: The woman should be referred to gynaecology for removal of the device (usually via laparoscopy). The LNG-IUS may still confer contraceptive properties when in an extra-uterine location due to continued absorption of progestogen, however additional contraception is recommended as the efficacy is uncertain.