Removal of Levonorgestrel-Releasing Intrauterine Devices

Immediate Removal Indications

The Centers for Disease Control and Prevention recommends removing the IUD immediately if pregnancy is confirmed and strings are visible, and to evaluate for ectopic pregnancy first before attempting removal 1
Leaving the IUD in place during pregnancy increases risks of spontaneous abortion and preterm delivery, and removal reduces these risks, though not to baseline levels of pregnancy without an IUD 1
The American College of Obstetricians and Gynecologists recommends removing the IUD as soon as possible if it is located in the cervix rather than the uterine cavity, as this causes reduced contraceptive efficacy, pain, abnormal bleeding, and infection risk 2
The American College of Obstetricians and Gynecologists also recommends removing the IUD promptly if it has perforated or embedded into the myometrium, especially if symptomatic with pelvic pain, and to wait 4-6 weeks for myometrial healing before replacing the device 3

The Centers for Disease Control and Prevention recommends that the IUD does not need immediate removal when PID is diagnosed, and to initiate appropriate antibiotic treatment and reassess in 24-48 hours 4
The IUD should be removed only if no clinical improvement occurs after 48 hours of antibiotics or if the woman desires discontinuation, and removal should be done after antibiotics have been started to minimize bacterial spread 4

The Centers for Disease Control and Prevention recommends removing the IUD if the patient desires discontinuation for any reason, including unacceptable bleeding patterns or other side effects, and to counsel on alternative contraceptive methods and offer emergency contraception if appropriate 4

The Centers for Disease Control and Prevention recommends removing the IUD before treatment for cervical or endometrial cancer, though the device likely needs removal at time of definitive treatment, and the IUD is contraindicated for current breast cancer and should be removed 5
For past breast cancer with no evidence of disease for 5 years, use of the IUD is Category 3, meaning risks generally outweigh benefits 6

The Centers for Disease Control and Prevention recommends not removing the IUD before evaluation of unexplained vaginal bleeding, as the device can remain while diagnostic workup proceeds 5
The American College of Obstetricians and Gynecologists recommends not routinely removing the IUD for amenorrhea, as this affects approximately 50% of users by 2 years and requires only reassurance unless unacceptable to the patient 4