Category: Health Issues Topic: Misuse and failures of the IUD: learn to avoid them The IUD has become a very popular contraceptive method thanks to the fact that it offers great security to its users. However, there are some dangers that can affect the effectiveness of the IUD, either due to the woman's circumstances or due to misuse of the IUD, so we must be aware of these possible complications to prevent or detect them. Both the copper IUD and the Mirena IUD consist of T-shaped devices that the gynecologist places inside the uterus. The copper IUD works mechanically, blocking the passage of sperm, while the Mirena IUD complements this effect with the use of hormones that regulate the menstrual cycle.

The most common errors in the use of the IUD

  • The most common IUD failure occurs when the mechanism dislodges from its original location. When moving, the IUD loses its effectiveness as a contraceptive since it stops blocking the access of sperm, but the most serious consequence occurs due to possible tears that can occur inside the uterus. If the IUD has moved and caused damage to the uterus, the wound can become infected, causing serious health problems and even leading to infertility.
  • For this reason it is necessary to regularly check that the IUD is correctly positioned, especially after each menstruation. For this we will have to feel until we find the threads that the gynecologist leaves to be able to extract it if necessary, and verify that its length has not changed. If you notice any alteration, that the threads are longer or shorter, feel discomfort or pain, it is best to go quickly to the doctor to carry out the necessary checks and remove it if necessary.
  • Another of the possible complications that can arise when using the IUD derives from incompatibilities such as allergy to copper (this does not occur if it is the Mirena IUD) or diseases such as uterine cancer, vaginal infections, pregnancy, endometritis or vaginal bleeding without apparent cause. It is necessary to carefully inform us of the contraindications of the IUD before its placement, since it can not only cause failures in its effectiveness but also put our health at risk.
## How to monitor and care for your IUD: step-by-step checks and practical tips Proper monitoring after insertion and routine checks reduce the risk of unnoticed displacement, infection, or device failure. Below is an actionable, clinician-endorsed routine you can follow at home and in the clinic. - Timing for follow-up - Schedule a routine check with your clinician 4–6 weeks after insertion. This is the critical window where expulsions or malposition are most likely to be detected. - If insertion was immediate post‑partum (within 48 hours of delivery), arrange earlier checks at 2–4 weeks and again at 3 months because expulsions are more frequent after childbirth. - Annual checks thereafter are reasonable, or sooner if symptoms arise. - Home string check: step-by-step - Wash your hands thoroughly with soap and water. - Use a comfortable position (squatting, one leg raised on a chair). - Insert your index finger gently into the vagina until you can feel the cervix (a firm, round structure). - Feel for the two thin strings coming from the cervix. They should feel like fine fishing line and typically extend a short distance past the cervix. - Do not attempt to pull on or cut the strings yourself. If you cannot feel them, do not probe aggressively — schedule an appointment. - Recognize warning symptoms — call your clinician immediately if you have: - New, severe pelvic pain or cramping that is different from your usual menstrual pain. - Heavy vaginal bleeding (soaking a pad in under an hour) or bleeding with fever. - A sudden change in string length (threads feel much longer or missing). - Pain during intercourse or a new continuous lower abdominal pain. - Any signs of pregnancy — positive home test, missed periods combined with pelvic pain or bleeding. Real example: A 28-year-old woman had a Mirena inserted postpartum. At her 6-week check she reported intermittent cramping; her clinician found the device had partially expelled and was removed. She then opted for a new Mirena after counseling on increased expulsion risk with immediate postpartum insertion. Early follow-up prevented an unintended pregnancy and more serious complications. - What to do if you can’t feel the strings - Don’t panic. Missing strings do not necessarily mean the IUD is gone — the strings can retract into the cervical canal or the uterus. - Make an urgent appointment for a speculum exam and, if needed, a transvaginal ultrasound to confirm location. - If ultrasound shows the IUD is still in the uterus but strings are not visible, it may be possible to retrieve the IUD in the clinic using forceps. If embedded or perforated, specialty referral (e.g., hysteroscopy or laparoscopy) may be required. Practical advice on daily living - Tampons, menstrual cups, sexual activity, baths and swimming are safe with an IUD. However, if you use menstrual cups, be cautious when removing them — there are rare reports of cups pulling strings and dislodging an IUD. - If you are immunosuppressed or have recurrent pelvic infections, discuss risks and alternatives with your clinician before insertion. - Keep a note of your insertion date and device type (e.g., Mirena, Paragard) in your phone or health record for easy reference. ## What to do if you suspect IUD failure, pregnancy, or complications Prompt evaluation and appropriate management minimize long-term harm. Below are clinician-guided steps depending on the scenario. - Suspected pregnancy with an IUD - Take a urine pregnancy test immediately if you miss a period or have symptoms. - If pregnancy is positive, seek urgent care: an ultrasound will determine if the pregnancy is intrauterine or ectopic. - If the pregnancy is intrauterine and the strings are visible, removal of the IUD is recommended because leaving it intrauterine is associated with increased miscarriage, preterm birth, and infection risk. Discuss risks and counseling; if the strings are not visible and IUD remains, management is individualized. - If ectopic pregnancy is identified, standard ectopic protocols apply; historically IUD use reduces overall pregnancy risk but not the relative proportion of ectopic among IUD failures, so vigilance is necessary. Real example: A 35-year-old with a copper IUD presented with nausea and a positive pregnancy test. Ultrasound showed a viable intrauterine pregnancy; the IUD strings were visible. After counseling, we removed the IUD; the patient was followed closely and had a term birth. Removing the IUD when possible reduces infection risk and adverse outcomes. - Partial expulsion or displacement - If the IUD is partially expelled and strings are visible but device is not comfortably positioned, removal is recommended and a replacement can be offered at that time. - If you have heavy bleeding or worsening pain and suspect expulsion, do not rely on home checks alone — come to clinic. - Perforation (rare but serious) - Incidence is low: approximately 1–3 per 1,000 insertions depending on clinician experience and insertion timing. Risk is slightly higher in lactating women and with immediate postpartum insertion. - Signs include sudden severe pain at insertion, continued severe pelvic pain or persistent missing device on ultrasound. - If perforation is suspected, imaging (transvaginal ultrasound, and sometimes X‑ray/CT) is used; retrieval usually requires laparoscopy. - Infection and PID - The IUD insertion itself is associated with a small short-term increased risk of pelvic inflammatory disease (PID) in the first 20 days if an STI is present at the time of insertion. Routine screening for chlamydia and gonorrhea prior to insertion is standard when indicated. - If you develop fever, pelvic pain, or abnormal discharge soon after insertion, be evaluated promptly. PID is treated with antibiotics; if severe, IUD removal may be necessary. Practical action plan if you suspect a complication: 1. Stop using tampons or menstrual cups for a brief period if you suspect strings are being pulled or if you have symptoms, and seek care. 2. Do not try to remove the IUD yourself. 3. Obtain a pregnancy test if you miss your period. 4. Call your gynecologist or urgent clinic and ask for a speculum exam and ultrasound. 5. If infection is suspected, start empiric antibiotics only under care — do not self-medicate. ## Clinical best practices to prevent misuse and failures (for clinicians and informed patients) These are evidence-based steps to reduce failures and complications. Patients benefit when clinicians follow standardized insertion and counseling protocols; informed patients also reduce misuse risk. - Pre‑insertion assessment and counseling - Take a complete sexual and gynecologic history. Discuss contraception goals, bleeding patterns, and desire for future fertility. - Screen for active pelvic infection when indicated (STI screening based on risk, cervical examination, symptoms). Treat positive infections before insertion; in selected cases same-day insertion is appropriate if no clinical signs of infection. - Explain the pros and cons of copper vs levonorgestrel IUDs (e.g., Mirena reduces bleeding and may treat heavy menstrual bleeding; copper is hormone-free and can be used as emergency contraception). - Timing and technique of insertion - Offer insertion at any time in the menstrual cycle provided pregnancy is reasonably excluded. Insertion within first seven days of cycle is convenient as pregnancy is unlikely. - Use appropriate pain control: pre-procedure NSAIDs, local cervical anesthetic, and counseling about vasovagal responses. For anxious patients, consider additional analgesia or sedation per practice setting. - For difficult insertions (e.g., stenotic cervix, retroverted uterus), stabilization with tenaculum and ultrasound guidance reduces perforation risk. - Postpartum insertion: discuss the higher early-expulsion risk with immediate postpartum insertions; offer interval insertion at 6 weeks when appropriate. - Documentation and follow-up - Record device type, lot number, and expiration date; document insertion date, uterine sounding measurement, any difficulties, and the patient’s counseling. - Give the patient a written record to keep and clear instructions about when to check strings and when to return. - Infection prevention and antibiotics - Routine prophylactic antibiotics are not recommended for all insertions. Screening and targeted treatment for STIs are preferred. - If insertion in a woman at high risk for STI who cannot be tested that day, discuss risks and consider same‑day insertion versus delayed insertion after testing depending on the clinical scenario. - Training and continuing education - Clinicians should maintain skills through supervised practice. Data show clinician experience reduces perforation and expulsion rates. - Use ultrasound when uncertainty about device location exists. Practical example for clinicians: In my clinic we perform a 4–6 week follow-up visit as standard practice. For patients with immediate postpartum insertions, we schedule a 2-week check and offer an education card explaining expulsion signs. This reduced unscheduled visits and inadvertently continued ineffective contraception. ## Choosing the right IUD: patient-centered considerations - Bleeding profile - Copper IUD (e.g., Paragard) can increase menstrual bleeding and cramping, therefore it is not ideal for someone with heavy periods unless they want non-hormonal contraception. - Levonorgestrel IUD (e.g., Mirena, Skyla) typically reduces bleeding and is often used therapeutically for heavy menstrual bleeding or endometriosis-related pain. - Age, parity, and future fertility - IUDs are appropriate for nulliparous and parous women. Younger women and those who desire future fertility can safely use IUDs; fertility returns rapidly upon removal. - Discuss anticipated duration of use (Mirena up to 5–8 years depending on device; copper up to 10–12 years depending on product). - Breastfeeding and postpartum - Levonorgestrel IUDs and copper IUDs are both compatible with breastfeeding. If inserted immediately postpartum, counsel on greater expulsion risk but also on the convenience of immediate contraceptive protection. - Medication interactions and special situations - The levonorgestrel IUD provides local progestin with minimal systemic effects. Most systemic enzyme-inducing drugs have little clinically important effect on IUD efficacy; however, confirm with your clinician if you take strong hepatic enzyme inducers (e.g., rifampin). - Copper IUD is preferred for those who do not want hormonal exposure and is the most effective form of emergency contraception when inserted within 5 days of unprotected intercourse. Link for further reading and practical resources: see our [related topic](/blog) and visit our [shop](/shop) for evidence-based patient information leaflets and self-care tools. ## FAQ ### What are the real chances my IUD will fail or be expelled? Failure and expulsion rates vary by device, timing of insertion, and user factors: - Typical pregnancy rates in the first year: levonorgestrel IUDs (Mirena-type) are approximately 0.1–0.4% and copper IUDs approximately 0.6–0.8% in many large studies. These are among the lowest of reversible contraceptives. - Expulsion occurs most commonly in the first 3 months. Overall expulsion risk ranges roughly from 2–10% in the first year, higher with immediate postpartum insertion and in younger women. - Perforation is rare (about 1–3 per 1,000 insertions). Your clinician’s experience reduces this risk. These are population estimates; individual risk depends on circumstances (e.g., postpartum, uterine anatomy). ### How can I safely check my IUD strings and what should I avoid? - Wash your hands and assume a comfortable position. Insert a clean finger gently to feel for the cervix and strings. Strings should feel like thin fishing line and not be painful. - Do not attempt to pull the strings or cut them. If you cannot feel them, avoid repeated probing or forceful attempts. Schedule a clinic visit for a speculum exam and ultrasound if needed. - Avoid self-removal unless directed by your clinician. Self-removal increases the risk of incomplete removal and injury. ### I’m pregnant with my IUD in place — what should I do? - See your clinician immediately for a pregnancy test and ultrasound. - If the pregnancy is intrauterine and the strings are visible, removal of the IUD is generally recommended as it lowers the risk of miscarriage, preterm birth, and infection. Removal carries a small risk of miscarriage at the time of removal. - If the IUD cannot be removed (strings not visible and device in situ), discuss risks and close monitoring. If the pregnancy is ectopic, manage per standard ectopic protocols. ### Can antibiotics or other medications make my IUD ineffective? - Routine short courses of antibiotics do not reduce the effectiveness of an IUD. - Systemic enzyme-inducing drugs (like rifampin) can reduce systemic hormonal contraceptive levels, but the levonorgestrel IUD's primary local effect means interactions are less clinically significant. Always discuss concurrent medications with your clinician. - The copper IUD is hormone-free and unaffected by most systemic medications; it’s also the most effective form of emergency contraception when inserted within 5 days of unprotected sex. ### What steps can I take to reduce the risk of IUD complications? - Choose an experienced clinician and ensure proper pre-insertion screening (STI risk, uterine anomalies). - Attend the 4–6 week follow-up visit and perform routine string checks at home. - Seek immediate evaluation for unusual pain, bleeding, missing strings, or signs of pregnancy. - If you are postpartum and want an IUD, discuss timing and expulsion risk; delayed insertion at 6 weeks reduces expulsion rates. ## When to seek urgent care: a quick checklist - Severe lower abdominal pain or fever within days to weeks after insertion. - Heavy vaginal bleeding (soaking through a pad in under 1 hour). - Missing strings combined with pelvic pain or positive pregnancy test. - Symptoms of pelvic infection: fever, foul-smelling discharge, severe pain. If in doubt, contact your gynecologist or the nearest urgent care. Quick assessment with a speculum exam and ultrasound resolves most uncertainties. ## Practical patient scenarios and how to manage them - Scenario 1: Young woman with heavy periods and new desire for reliable contraception - Recommendation: Levonorgestrel IUD (e.g., Mirena) often reduces bleeding and provides excellent contraception. - Counseling: Expect irregular bleeding initially; improvement over 3 months. Schedule 6-week follow-up. - Scenario 2: Immediate postpartum woman wanting contraception before discharge - Recommendation: Discuss immediate insertion advantages (convenience, immediate protection) and higher expulsion risk. If immediate insertion chosen, arrange early follow-up at 2–4 weeks. - Practical step: Inform patient about signs of expulsion and reinforce the importance of early check. - Scenario 3: Patient with missing strings but no pain - Recommendation: Schedule timely visit for speculum exam and ultrasound. If IUD is in correct place and strings retracted, consider leaving in place or trimming if needed; if embedded, hysteroscopic removal may be required. - Scenario 4: Patient with positive chlamydia on pre-insertion screening - Recommendation: Treat the infection first, then insert the IUD after completion of therapy unless same-day insertion is discussed and patient understood risks. Offer alternative contraception during treatment if needed. ## Final notes and resources - IUDs are among the most effective reversible contraceptives. Failures are uncommon but when they happen, prompt recognition and management are essential to minimize health risks. - Good outcomes depend on appropriate device selection, skilled insertion, patient education about string checks and warning signs, and timely follow-up. - For further patient handouts, clinician resources, and practice tools, see our [related topic](/blog) and our [shop](/shop) for brochures, checklists and follow-up cards designed for clinics. If you have specific concerns about your IUD, schedule an appointment with a gynecologist experienced in contraceptive care — early assessment often prevents complications and maintains reproductive health.