Results

The questionnaire responses were collated. Almost all the respondents (90%) stated that they would replace an IUD that was lying either totally or partially in the cervical canal, but fewer would do so if the IUD was low-lying but intrauterine (Figure 1). A similar trend was seen for the IUS, although all numbers were lower, with only one respondent stating they would remove an IUS that was 1–2 cm from the fundus (Figure 2). This may suggest that the majority of respondents were concerned that a malpositioned IUD or IUS would not provide acceptable contraceptive function and that the further away it was from its optimum position, the more concerning this was. Fewer respondents were concerned when the device was an IUS, presumably because amenorrhoea is reported in some cases even when the IUS is located outside the uterus in the pelvis.1 Interestingly, 10% of respondents would not replace an IUD/IUS that was lying within the cervix. There has been a study demonstrating no difference in efficacy of a LNG-releasing intracervical device when it was placed within the cervix compared to intrauterine placement,2 and presumably respondents were reassured by this. However, the cautious approach of most respondents in wishing to replace an imperfectly sited IUD or IUS reflected the importance of effective contraception and a general ‘better safe than sorry’ attitude.

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Figure 1

Clinicians’ responses to the question: “Would you replace a low-lying intrauterine device found incidentally on ultrasound scan if it was …?”

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Figure 2

Clinicians’ responses to the question: “Would you replace a low-lying intrauterine system found incidentally on ultrasound scan if it was …?”

When it came to considering symptoms of abnormal bleeding or pain, there was mixed opinion amongst the respondents as to whether a low-lying device was likely to be responsible. Almost all the respondents would look for other causes. Opinion was divided on whether removal would help to improve symptoms (Figure 3). The responses to this question reflect the general uncertainty as to the extent to which IUDs cause symptoms. Irregular bleeding and pelvic pain are not uncommon symptoms and may have many different causes. In general, the respondents were reluctant to blame the IUD or IUS without exploring all other options.

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Figure 3

Clinicians’ responses to the question: “If a woman has some abnormal bleeding and/or pain and a scan identifies a low-lying intrauterine device (IUD) or intrauterine system (IUS), would you in respect of the (A) IUD and (B) IUS…?”.

Opinion was also divided when respondents were asked if they agreed if bleeding and pain were more common in women with a low-lying IUD or IUS (Figure 4).

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Figure 4

Clinicians’ responses to the question: “Do you agree with the following statements?”

Almost half (45%) of the respondents expressed uncertainty as to whether copper IUD failure was more common with low-lying IUDs, whilst 40% felt that this statement was true, and 15% that it was not true (Figure 4). This wide spread of opinion on the efficacy of a low-lying IUD reflects the paucity of published literature on this subject. Replacement of an IUD is associated with small risks of complications such as perforation or infection and can be inconvenient or uncomfortable for the patient, so ideally should not be done without good reason. Evidence-based guidance on this issue would clearly be useful.

Some 47% of respondents agreed that a low-lying T-shaped device could migrate upwards in the uterine cavity to a normal position, whilst 16% did not agree with this and 37% were uncertain. One respondent did not answer this question (Figure 4).

Finally, most respondents did not feel that postpartum insertion was a specific risk for low-lying positioning of an IUD (Figure 4). Risk of pregnancy in the postpartum period is significant, so it is important to provide effective and convenient contraception at that time. While the majority of clinicians had overall concerns regarding the efficacy of low-lying devices, they did not feel that postpartum insertion increased the risk for devices to be low-lying and would presumably not limit their use at this time.