Contraceptive Pearl: Difficult IUD Insertion and Removal

By Lori Atkinson, MD and Maya Bass, MD MA FAAFP

With the increased use of long-acting reversible contraception, clinicians are more likely to encounter difficult intrauterine device (IUD) insertions and removals in their practice. Below are a few strategies and techniques to help troubleshoot these procedures.


Difficult IUD Insertions 

IUD insertions are most commonly complicated by pain and anatomical variations. 

To manage pain during the procedure, a paracervical block1 and/or intracervical block2 at the tenaculum site with a local anesthetic can be performed. Oral ketorolac3 and the Valsalva manoeuvre4 One recent randomized control trial found no significant difference between the “cough method” or “slow closure” method for tenaculum placement.5 Further study is needed to compare these techniques to tenaculum placement alone. Use of “verbacaine” or directed deep breathing or imagery techniques can also improve patient discomfort. If a patient has anxiety around the event, the use of anxiolytics may be beneficial. More research is needed in this area to determine best practices.6

Potential anatomic findings that may hinder the procedure include a narrow endocervical canal in a nulliparous patient, a significantly anteflexed or retroflexed uterus, or uterine fibroids. For all insertions, a short speculum is preferred so that the cervix is not pushed away from the clinician. If the IUD inserter does not pass through the cervix, the first step is to apply gentle traction on the tenaculum to straighten out the cervical canal. If the IUD inserter still will not pass with steady pressure, consider using a uterine sound, a cervical os finder or graduated dilators to determine the appropriate pathway through the cervix and uterus. If fibroids are evident, insertion under ultrasound (US) guidance may be beneficial. The routine use of misoprostol has not been shown to be beneficial before IUD insertion.7,8 but may be considered after a failed attempt. Overall, it is important to remember that clinicians should practice ongoing informed consent and explain the steps they take during a difficult insertion.

There are special considerations for IUD insertion in transgender and gender-nonconforming patients. As the procedure itself or the cramping and irregular bleeding afterward may trigger gender dysphoria, it is essential that adequate counseling occurs prior to the procedure, including anticipatory guidance regarding symptoms after insertion. Additionally, if prolonged testosterone has been used and atrophy is expected, vaginal estradiol for 1-2 weeks prior to the procedure may be discussed, although efficacy has not been specifically studied in this population.


Difficult IUD Removals

An IUD removal is often a simple, quick office procedure, but occasionally, the strings are not visualized, most often due to retraction of the strings into the cervix or uterus. Therefore, the first steps are to obtain history to determine the likelihood that the IUD was expelled and to try to retrieve the strings by inserting either a cytobrush into the cervix or a thread retriever into the uterus and twirling to catch the strings and bring them down into view. If this is unsuccessful and expulsion is unlikely, the location of the IUD must be confirmed. Ultrasound can be used to confirm the location of the IUD within the uterus. If the IUD is found to be within the uterus, then retrieval can be performed with the use of alligator forceps or an IUD hook under local anesthesia, and US guidance can be considered.9 Manual vacuum aspiration (MVA) can also be attempted. If the IUD is not seen within the uterus on US, a pregnancy test should be performed, emergency contraception discussed, and an abdominal x-ray ordered to evaluate for perforation.10,11

Resistance while removing an IUD may indicate that it has become embedded in the uterine wall. Gentle twisting will sometimes loosen the IUD. If this fails, MVA or hysteroscopy may be required. If the IUD is removed, but a fragment is missing, it is important to locate the fragment with ultrasound. Once located and confirmed inside the uterus, determine patient goals for IUD removal, such as relief of pain or desire for pregnancy. If the fragment does not interfere with patient goals, it may not need to be removed immediately and in fact, may pass spontaneously with the next few menstrual cycles. If the fragment requires removal, this may be attempted in office with alligator forceps, or the patient may be referred to GYN surgery.10,11


Updated 11/21/2023 at 3:05 pm PT

RHAP resources:

LARC: Advanced

Algorithm for IUD Removal When No Strings are Visible


1. Mody SK, Kiley J, Rademaker A, Gawron L, Stika C, Hammond C. Pain control for intrauterine device insertion: a randomized trial of 1% lidocaine paracervical block. Contraception. 2012 Dec;86(6):704-9.

2. De Nadai MN, Poli-Neto OB, Franceschini SA, Yamaguti EMM, Monteiro IMU, Troncon JK, Juliato CRT, Santana LF, Bahamondes L, Vieira CS. Intracervical block for levonorgestrel-releasing intrauterine system placement among nulligravid women: a randomized double-blind controlled trial. Am J Obstet Gynecol. 2020 Mar;222(3):245.e1-245.e10.

3. Crawford M, Davy S, Book N, Elliott JO, Arora A. Oral Ketorolac for Pain Relief During Intrauterine Device Insertion: A Double-Blinded Randomized Controlled Trial. J Obstet Gynaecol Can. 2017;39(12):1143-1149. doi:10.1016/j.jogc.2017.05.014

4. Cimsir MT, Yildiz MS. Could the Valsalva manoeuvre be an alternative to the tenaculum for intrauterine device insertion?. Eur J Contracept Reprod Health Care. 2021;26(6):503-506. doi:10.1080/13625187.2021.1934442

5. Lambert T, Truong T, Gray B. Pain perception with cervical tenaculum placement during intrauterine device insertion: a randomised controlled trial. BMJ Sex Reprod Health. 2020 Apr;46(2):126-131. doi: 10.1136/bmjsrh-2019-200376. Epub 2019 Oct 30. PMID: 31666302.

6. Nguyen L, Lamarche L, Lennox R, Ramdyal A, Patel T, Black M, Mangin D. Strategies to Mitigate Anxiety and Pain in Intrauterine Device Insertion: A Systematic Review. J Obstet Gynaecol Can. 2020 Sep;42(9):1138-1146.e2. doi: 10.1016/j.jogc.2019.09.014. Epub 2019 Dec 25. PMID: 31882291.

7. Zapata LB, Jatlaoui TC, Marchbanks PA, Curtis KM. Medications to ease intrauterine device insertion: a systematic review. Contraception. 2016;94(6):739-759.

8. Matthews LR, O’Dwyer L, O’Neill E. Intrauterine device insertion failure after misoprostol administration. Obstet Gynecol. 2016;128(5):1084-1091.

9. Verma U, Astudillo-Dávalos FE, Gerkowicz SA. Safe and cost-effective ultrasound guided removal of retained intrauterine device: our experience. Contraception. 2015;92(1):77-80.

10. Marchi NM, Castro S, Hidalgo MM, et al. Management of missing strings in users of intrauterine contraceptives. Contraception. 2012;86(4):354-358.

11. Swenson C, Royer PA, Turok DK, et al. Removal of the LNG IUD when strings are not visible: a case series. Contraception. 2014;90(3):288-290.


The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or contraception. The information in the Contraceptive Pearls is unbiased, based on science alone.

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