Ultrasonography of

IUD Positioning

Problematic Findings & Clinical Implications

Natasha Kumar, MS4

Womens Diagnostic Imaging Elective

Introduction

IUDs

T shaped small devices

Paragard: copper, lasts 10 years

Mirena: levonorgestrel, lasts 5 years

Arms fully echogenic on U/S

Only proximal and distal points of arms echogenic on U/S
Characteristic central/posterior shadowing

>99% effective

Imaging

Pelvic US (transvaginal) used most commonly

Abdominal XR if pelvic US cannot locate IUD (radioopaque)
CT/MRI if IUD associated with perforation/abscess

Sagittal (A) and transverse (B) view of Mirena IUD

Sagittal (C) and transverse (D) view of Paragard IUD
Coronal 3D view of Paragard IUD

Malpositioning

11% of IUDs (Green Journal 2011)

Clinical suspicion: change in string length or absence of strings
Symptoms: excess bleeding, pelvic pain

Expulsion

Most commonly occurs with insertions after vaginal

delivery
Greatest risk within first year of placement
More common with copper IUDs (6%) vs Mirena (3%)
In absence of witnessed expulsion:

U/S to confirm placement

Abdominal XR to exclude perforation/migration

Displacement
Historical definition: >3 mm from
uterine fundus
Clinical note: Paragard IUDs have
decreased efficacy when displaced
and should be removed!
23 year old patient with positive pregnancy
test and hx of IUD
A. Sagittal view of IUD placed in LUS/cervix
B. Transverse view of IUD and gestational
sac at fundus
IUD was removed without issue, resulting in full
term, uncomplicated delivery

Displaced IUDs

33 year old patient with acute abdominal pain and hx of IUD

A. Sagittal view of IUD placed almost completely in cervix with fluid
collection posterior to cervix
B. Transverse view showing complexity of fluid collection
Confirmatory CT + beta HCG of 595 surgery for ruptured ectopic pregnancy

Embedment

A.
B.

Defined as extension into myometrium alone

Occurs at time of insertion
Can be associated with pain or bleeding
Best seen on U/S using 3D coronal image

Sagittal view of extension into posterior myometrium

Transverse view shows IUD arms extending outside serosa

Perforation

Partial penetration through serosa or complete entry into

intraperitoneal cavity
1-2 cases per 1000
Seen with inexperienced practitioners, early postpartum
placement, and in women with few pregnancies/multiple
miscarriages

Takeaways
Radiology
There are four kinds of malposition for IUDs: expulsion,
displacement, embedment, and perforation.
Typically, ultrasound imaging can effectively assess IUD position.
3D coronal imaging is the best way to exclude embedment of IUD
arms in the myometrium.
Abdominal XR can be used to locate perforated IUDs. CT/MRI
may be appropriate if perforation is associated with an abscess.
Clinical Implications
Patients with malpositioned IUDs may have increased bleeding or
pelvic pain.
Paragard IUDs in particular are less effective when displaced and
should be removed.

Works Cited

Boortz, Hillary E., et al. Migration of intrauterine devices:

radiologic findings and implications for patient care.
Radiographics 32(2) (2012): 335-352.
Nowitzki, Kristina M., et al. Ultrasonography of
intrauterine devices. Ultrasonography 34(3) (2015): 183.
Peri, Nagamani, David Graham, and Deborah Levine.
Imaging of intrauterine contraceptive devices. Journal of
Ultrasound in Medicine 26.10 (2007): 1389-1401.