Puerperal insertion of a copper-releasing and a levonorgestrel-releasing intrauterine contraceptive device

A copper-releasing IUD and levonorgestrel-releasing IUDs releasing 30 μg and 10 μg levonorgestrel per day were inserted six weeks after delivery in 110 volunteers. During the treatment, events and patterns of bleeding were recorded and plasma levonorgestrel concentrations were measured. The number of events in one year of follow-up was very low, four removals out of 40 in the copper-releasing IUD group and five removals out of 70 in the levonorgestrel-releasing IUD group. Bleeding and spotting was significantly more common after insertion of a levonorgestrel-releasing IUD than a copper-releasing IUD, but it was scanty and well-tolerated. After three months, levonorgestrel-releasing IUD patients had less bleeding and spotting than the copper-releasing IUD patients. No pregnancies occurred during the study period. There were two uterine perforations with a uterine sound at the insertion. In the 30-μg per day levonorgestrel-releasing IUD group, initially high plasma levonorgestrel concentrations reached a plateau four weeks after the insertion. In the 10-μg per day levonorgestrel-releasing IUD group, the plasma concentrations of levonorgestrel stabilized after the initial two weeks.     

Vaginal flora changes on Pap smears after insertion of levonorgestrel-releasing intrauterine device

Background

The levonorgestrel intrauterine system (LNG-IUS) combines a uterine foreign body and the continuous release of low-dose levonorgestrel for contraception. Its influence on the rate of vulvovaginal infections and flora disturbance is insufficiently known, but important for contraceptive advice in women, especially those who develop recurrent vaginosis or Candida vulvovaginitis.

Study Design

Slides of 286 women who had a Pap smear taken before and 1 to 2 years after placement of a LNG-IUS were blindly reviewed for the presence of abnormal vaginal flora (AVF), bacterial vaginosis (BV), aerobic vaginitis (AV) and Candida vaginitis (CV).

Results

Prior to insertion, there were no differences in vaginal flora abnormalities between women using different kinds of contraception. LNG-IUS users did not have different rates of AVF, BV, AV or CV, but the general risk to develop any infection was increased. Uterine bleeding after insertion did not seem to predict a different flora type.

Conclusion

We found that Pap smears suggested more vaginal infections after 1 year of LNG-IUS use than prior to insertion of the device.     

Pain reduction during and after insertion of an intrauterine contraceptive device

The intrauterine contraceptive device (IUD) is an establshed method of fertility regulation despite certain problems. The major problems relating to IUD use are unwanted pregnancy, excessive bleeding, genital infection, occasional uterine perforation, device translocation, and pelvic pain. All fertility regulation personnel are aware that a very large number of potential IUD acceptors are concerned about the possibility of pain before, during and after device insertion.Pain is recognized as one of the major reasons for termination of the use of the IUD. Despite this, and unlike other IUD problems, IUD-related pain has been very poorly studied. At a recent workshop on intrauterine contraception there was not one presentation on this topic [1]. The reason for this is that IUD-related pain is difficult to study, requiring careful analysis of subjective rather than objective data. Nevertheless a thorough understanding of the mechanisms, causes, prevention and treatment of IUD-related pain is important for fertility regulators in both developed and developing countries.

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Resumen Pese a ciertos problemas, el dispositivo anticonceptivo intrauterino (DIU) es un método reconocido para la regulación de la fertilidad. Los mayores problemas relacionados con el uso de DIU son: embarazo no deseado, sangrado excesivo, infección genital, perforación uterina ocasional, dispositivo cambiado de sitio y dolor pelviano. El personal que regula la fertilidad tiene conciencia que a un gran número de potenciales aceptantes de DIU les preocupa la posibilidad de dolor antes, durante y después de la inserción del dispositivo.El dolor está reconocido como una de las mayores razones para la terminación del uso de DIU. Pese a esto, y a diferencia con otros problemas conectados con los DIU, el dolor relacionado con ellos ha sido muy poco estudiado. En una reciente reunión de trabajo sobre anticoncepción intrauterina, no hubo ninguna presentación sobre este tópico [1]. La razón de esto es que el dolor relacionado con los DIU es difícil de estudiar y requiere un cuidadoso análisis de datos subjetivos más que objetivos. Sin embargo, la comprensión absoluta del mecanismo, las causas, la prevención y el tratamiento del dolor relacionado con los DIU es importante para la regulación de la fertilidad, tanto en los países desarrollados como en aquellos en desarrollo.

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Resumé Malgré certains problèmes, la pose d'un dispositif contraceptif inter-utérin (DIU) est une méthode établie de régulation de la fertilité. Les principaux problèmes liés à l'utilisation des DIU sont les suivants: grossesses involontaires, saignements excessifs, infections génitales, parfois perforations utérines, déplacement du dispositif et douleurs pelviennes. Les responsables de la régulation de la fertilité sont tous conscients du fait qu'un très grand nombre de femmes qui accepterainent éventuellement d'utiliser un DIU sont préoccupées par la possibilité de douleurs avant, pendant et après la mise en place d'un dispositif.Il est admis que l'abandon d'un DIU est déterminé dans la plupart des cas par les doulers qu'il occasionne. Pourtant, au contraire d'autres problèmes liés aux DIU, les douleurs qu'ils peuvent causer ont été fort peu étudiées. A des journées de travail sur la contraception interutérine tenues récemment, aucune communication à ce sujet n'a été présentée [1]. Cette lacune provient de ce qu'il est difficile de mener une étude sur les douleurs liées à l'utilisation des DIU, celle-ci nécessitant une analyse de données subjectives plutôt qu'objectives. Il est néanmoins essentiel, pour les responsables de la régulation de la fertilité, aussi bien dans les pays développés que dans les pays en développement, de compre à fond les mécanismes, les causes, la prévention et le traitement des douleurs liées à l'utilisation des DIU.

     

Postplacental or delayed levonorgestrel intrauterine device insertion and breast-feeding duration

Background

The objective of this study was to assess the effect of timing of postpartum levonorgestrel-releasing intrauterine device (IUD) insertion on breast-feeding continuation.

Study Design

Women interested in using a levonorgestrel IUD postpartum were randomized to immediate postplacental insertion (postplacental group) or insertion 6–8 weeks after vaginal delivery (delayed group). Duration and exclusivity of breast-feeding were assessed at 6–8 weeks, 3 months, and 6 months postpartum. Only women who received an IUD were included in this analysis.

Results

Breast-feeding was initiated by 32 (64%) of 50 of women receiving a postplacental IUD and 27 (58.7%) of 46 of women receiving a delayed IUD (p=.59). More women in the delayed group compared with the postplacental group continued to breast-feed at 6–8 weeks (16/46 vs. 15/50, p=.62), 3 months (13/46 vs. 7/50, p=.13), and 6 months postpartum (11/46 vs. 3/50, p=.02). The results did not differ when only women who initiated breast-feeding or only primiparous women with no prior breast-feeding experience were analyzed.

Conclusions

Immediate postplacental insertion of the levonorgestrel IUD is associated with shorter duration of breast-feeding and less exclusive breast-feeding. Further studies on the effects of early initiation of progestin-only methods on women's lactation experience are needed.     

Ease of insertion, contraceptive efficacy and safety of new T-shaped levonorgestrel-releasing intrauterine systems

OBJECTIVE: The objective of the study was to evaluate ease of insertion, contraceptive performance and safety, in parous and nulliparous women, of two new T-shaped levonorgestrel (LNG)-releasing intrauterine systems (LNG-IUS), Femilistrade mark (parous women) and Femilis Slim (nulliparous women), releasing 20 mug of LNG per day. An ancillary objective was to evaluate expulsion and user continuation. DESIGN AND METHODS: An open, prospective, noncomparative study (interim analysis). Two hundred thirty-five insertions were performed in fertile women seeking contraception. Of these, 143 (60.8%) parous women were fitted with Femilis and 92 (39.2%) nulliparous women were fitted with Femilis Slim. The LNG-IUS was inserted using a simplified push-in technique (without folding the cross-arms in the insertion tube). RESULTS: This paper is the first report with the Femilis LNG-IUS. The push-in technique of insertion was considered simple and safe. Insertion was reported "easy" in virtually all women (97.9%). Pain at insertion was absent in 24.7% and "mild" in 67.7% of women. With respect to pain, there were no statistical differences between the parous and nulliparous group. At the time of study analysis, the total number of women-months of use was 1769.7. Seventy-six women had the Femilis IUS in place for periods in excess of 1 year. The study was well followed up with lost to follow-up of only two women. No pregnancies were observed. There was one expulsion in the nulliparous and one in the parous group. Ten removals were performed for medical reasons (mainly bleeding and pain). One pelvic infection occurred in a nulliparous woman caused by Chlamydia trachomatis, which was resolved without removing the IUS. There were no other serious adverse events reported. Both Femilis and Femilis Slim were well tolerated, which resulted in a high continuation rate (94.04%). CONCLUSION: The Femilis LNG-IUS is an effective contraceptive and is easily inserted. The simple and safe insertion procedure could be an advantage for use by nonspecialist providers such as nurses, midwives, general practitioners, and for those not inserting intrauterine devices regularly. Femilis Slim could be an attractive long-term contraceptive option in young and adolescent women.     

Return to fertility after removal of a levonorgestrel-releasing intrauterine device and Nova-T

In a European randomized multicenter study, the efficacy and safety of an intrauterine contraceptive device releasing 20 microgram levonorgestrel/24 hours (LNG-IUD) have been evaluated and compared to the Nova-T. Because the LNG-IUD has a strongly suppressive effect on the endometrium and in some women affects ovarian function, the return to fertility after removal of the IUD was studied. Two-hundred-nine women (71 in the Nova-T and 138 in the LNG-IUD group), who had their IUDs removed because of planning pregnancy, were followed at least 24 months or until termination of pregnancy. For the Nova-T, the cumulative conception gross rate was 71.2/100 women after 12 months (79.7 after 24 months) and for the LNG-IUD 79.1 (86.6 after 24 months). The difference between the devices is not statistically significant, and in spite of the endometrial suppression during use of LNG-IUD, there is no delay of return to fertility and in both groups 96% of the pregnancies occurred during the first year after removal of the device. Eighty-four % of the pregnancies in the Nova-T group and eighty-six % in the LNG-IUD group ended in live births. The results suggest that the endometrium recovers quickly, normal ovulations are established and the fertility seems to be unaffected after use of an LNG-IUD.     

Body iron stores and patterns of bleeding after insertion of a levonorgestrel- or a copper-releasing intrauterine contraceptive device

The effects of the use of a copper-releasing IUD (Nova-T) and a levonorgestrel-releasing IUD on iron stores were studied over the first year after postmenstrual insertion and during lactation after childbirth. The pattern of bleeding was evaluated daily over the first year. Conventional hematological evaluations and serum ferritin concentrations were measured in 15 women in each group at the time of insertion, and six and twelve months later. After postmenstrual insertion, there was a significant increase at one year in the number of red blood cells in the levonorgestrelreleasing IUD group and an increase in the mean serum ferritin concentration that was not significant. In the copper-releasing IUD group, a significant (p< 0.025) decrease was found in serum ferritin concentrations after six and twelve months and a statistically significant difference existed between serum ferritin concentrations of the copper-releasing IUD group and the levonorgestrel-releasing IUD group at one year (p< 0.02). When the IUDs were inserted puerperally, there was a significant rise in the number of red blood cells and decreases in the mean corpuscular volume and mean corpuscular hemoglobin at one year in both groups. The mean serum ferritin concentration decreased during the first six months in both groups but, in the levonorgestrel-releasing IUD group it reached a plateau and in the copper-releasing IUD group it continued to decrease. At one year there was a significant difference in the mean serum ferritin concentrations between the IUD groups (p< 0.005). The different effects of these two IUDs on body iron balance are based on differences in the patterns of bleeding in the women using the IUDs. Over the first three months of postmenstrual insertion, the number of days of bleeding and spotting was higher in the levonorgestrel-releasing IUD group than in the copper-releasing IUD group, but during the latter half of the year there were fewer days of bleeding and spotting in women using the levonorgestrel-IUD than in women using the copper-releasing IUD. The insertion of a levonorgestrel-releasing IUD during lactational amenorrhea was associated with more days of bleeding and spotting during the three first months than the insertion of a copper-releasing IUD. Most of this was scanty spotting and after the first month, the women using levonorgestrel-IUD had fewer days of menses-like bleeding than the women using a copper-releasing IUD. The results of the study show that the long-term effects of the IUDs on iron stores may be precisely evaluated by using serum ferritin determinations. The copper-releasing IUD, which results in a minimal increase in the amount of bleeding over the first year, still affects the serum ferritin concentration whereas the levonorgestrel-releasing IUD is associated with a decreased amount of bleeding and prevents consumption of the body iron stores.     

Immediate postplacental insertion of an intrauterine contraceptive device during cesarean section

Background

An intrauterine device (IUD) is an effective reversible form of contraception. We determined the efficacy and safety of immediate postplacental IUD insertion during cesarean section.

Study Design

Two hundred forty-five women with term pregnancies delivering by cesarean section between September 2006 and December 2007 were included in the study. A copper IUD (TCu 380A) was inserted using a ring forceps within 10 min of removing the placenta. The participants were examined before hospital discharge and at 6 weeks, 6 months and 12 months postpartum.

Results

None of the patients were lost to follow-up. There was one case of an unplanned pregnancy (0.4%). There were no serious complications associated with immediate IUD insertion during cesarean section. The cumulative rates of expulsion, removal for bleeding/pain and other medical reasons were 17.6, 8.2 and 2.4 per 100 women per year, respectively. The continuation rates were 81.6% and 62% at 6 and 12 months, respectively.

Conclusion

Immediate postplacental IUD insertion during cesarean section provides adequate protection against pregnancy. However, greater than one fourth of the participants discontinued IUD use due to spontaneous expulsion or other medical reasons.     

Pharmacokinetic and pharmacodynamic studies of levonorgestrel-releasing intrauterine device

Intrauterine devices releasing 20 micrograms/day levonorgestrel were inserted in 10 women (ages 25-34). Bleeding and spotting patterns were recorded on a menstrual card during one year of follow-up. Blood samples were collected for radioimmunoassays of LH, estradiol (E2), progesterone (P) and levonorgestrel (LNG) and for sex hormone binding globulin (SHBG) 3 times a week during the 1st month of use, and twice a week during the 6th and 12th treatment months. Among the 10 women, two experienced irregular cycles with prolonged intermenstrual spotting, four had amenorrhea in the latter part of treatment months, while the other four had regular cycles. According to the serum levels of E2 and P, the hormone profiles were divided into four types of reaction: A) anovulatory, B) anovulatory but with high follicular activity, C) ovulatory but with luteal insufficiency, and D) ovulatory. Among the 29 treatment cycles, there were 10 D-type, 3 C-type, 13 B-type and 3 A-type of ovarian reactions: 44.8% of the cycles were ovulatory (C + D) and 55.2% were anovulatory (A + B). In general, serum levels of levonorgestrel were low in ovulatory cycles and were high in anovulatory cycles. The difference was statistically significant. There were marked individual differences. The decline of serum LNG from the 1st (492 pmol/l) to the 6th (320 pmol/l) treatment months was 34.9% on average. The amenorrheic cycles coincided mostly with the hormonal profile of ovulatory types, which indicated that the cause of amenorrhea is due to the local effect of levonorgestrel on the endometrium. The levonorgestrel levels were significantly correlated with serum SHBG, r = 0.8856, p less than 0.001, and with E2, r = 0.4661, p less than 0.05.     

Immediate versus delayed insertion of the levonorgestrel-releasing intrauterine device following dilation and evacuation: a randomized controlled trial

BackgroundThe study was conducted to compare 6-month usage of the levonorgestrel-releasing intrauterine device (LNG-IUD) when placed immediately or 3 to 6 weeks after dilation and evacuation (D&;E) procedure.Study DesignWe enrolled women undergoing D&;E at 15 to 23 weeks of gestation. After completion of the D&;E, subjects without contraindications to immediate IUD insertion were randomized to immediate or delayed (3 to 6 weeks later) LNG-IUD insertion. Subjects in the immediate group had the LNG-IUD placed using ultrasound guidance. All subjects returned at 3 to 6 weeks and 8 to 10 weeks after D&;E and were contacted by phone at 6 months.ResultsOf the 93 subjects enrolled, 88 were randomized. All 44 subjects (100%) randomized to immediate insertion had successful IUD placement, while only 20 (45.5%) of the 44 subjects randomized to delayed insertion returned for IUD placement, all of which were successful [difference 54.5%, 95% confidence interval (CI) 39.8%–69.3%]. Seventeen (38.6%) participants in each group were lost to follow-up. Of subjects contacted at the 6-month follow-up phone call, 23 of 27 women (85.2%) and 17 of 27 women (62.9%) were utilizing the LNG-IUD in the immediate and delayed groups, respectively (difference 22.2%, 95% CI ?0.4% to 44.8%). Intrauterine device expulsion occurred in three subjects (6.8%) and one subject (5.0%) in whom the IUD was placed in the immediate and delayed groups, respectively (p=1.0). No significant adverse events occurred.ConclusionSignificantly more participants had the LNG-IUD placed in the immediate insertion group compared with the delayed insertion group. Given the low risk of complications, immediate post-D&;E insertion of the LNG-IUD should be offered, especially for populations that may have difficulty returning for follow-up.     

Patterns of ovulation and bleeding with a low levonorgestrel-releasing intrauterine device

Patterns of bleeding and plasma concentrations of levonorgestrel, progesterone, estradiol, LH and FSH were studied in ten volunteers who had a levonorgestrel-releasing IUD inserted postmenstrually. The IUD was designed to release 12 microgram/day. All but two of the volunteers ovulated during treatment. The ovulatory cycles differed from the control cycles by being longer and by having depressed plasma progesterone levels during the luteal phases. Intermenstrual spottings occurred frequently during the first sixty days of treatment. No pregnancies occurred during the course of the study.     

A comparative study of the levonorgestrel-releasing intrauterine system Mirena versus the Copper T380A intrauterine device during lactation: breast-feeding performance, infant growth and infant development

BACKGROUND: Mirena is a levonorgestrel-releasing intrauterine system (LNG-IUS) that provides highly effective and long-acting progestogen-only contraception. OBJECTIVE: The objective of this study was to analyze the possible effects of using LNG-20 microg IUS on breast-feeding performance, infant growth and infant development during the first postpartum year as compared with the Copper T380A intrauterine device (Cu T380A IUD). DESIGN: This study is a prospective, controlled and randomized trial. SETTING: The study was conducted at the Department of Obstetrics and Gynecology, Assiut University Hospital, Egypt. METHODS: Three hundred twenty lactating women asking for initiation of contraception during the early postpartum stage were assigned randomly into two groups, the LNG-20 microg IUS group (n=163) and the Cu T380A group (n=157). The insertions were done 6-8 weeks postpartum. Each participant was followed up at three monthly intervals after insertion and until the first birthday of her baby. During these visits, the breast-feeding pattern was assessed, certain infant physical growth parameters were measured and a set of infant development tests was performed. RESULTS: No pregnancy occurred in both groups. There were no significant differences in the net continuation rates between the two groups (89.3 for LNG-IUS vs. 90.9 for Cu T380A). The LNG-20 microg IUS group had comparable rates of breast-feeding continuation, complete weaning, full breast-feeding and partial breast-feeding, with the Cu-IUD group. No statistically significant differences were found between groups with regard to all infant physical growth parameters and various infant development tests. CONCLUSION: The findings of the current study confirm that the use of LNG-20 microg IUS during the first postpartum year in lactating women provides highly effective and acceptable contraception and does not negatively influence breast-feeding or the growth and development of breast-fed infants.     

Pregnancy and the intrauterine contraceptive device

The incidence and outcome of 30 pregnancies occurring in 300 women wearing the Lippes loop C were analyzed. The patients were all Caucasians born in the United Kingdom who were fitted with the IUD between October 1965 and December 1966. The age of the patient and the duration of her loop use were found to be significant factors influencing the incidence of pregnancy, and duration of loop use and its retention in the uterus were significant factors affecting the incidence of abortion. The incidence of accidental pregnancy fell dramatically after the first year of use. Patients under 30 years of age conceived more readily with the device than those in the older age group. Of the 30 patients who conceived, 3 obtained a termination of pregnancy. Of the 27 remaining patients, 5 conceived following expulsion, 1 conceived either before or after expulsion, and 21 conceived with the device in situ. In those who retained the loop there were 12 abortions. 10 of the 12 abortions were in the first trimester.     

The non-contraceptive effects of the levonorgestrel-releasing intrauterine device

Clinical trials have consistently shown that the IUD that releases 20 g levonorgestrel daily (LNG-IUD-20) has a contraceptive efficacy comparable to, if not surpassing, the Copper T380 and the Multiload Copper-375 IUDs.The focus of this review is the device's non-contraceptive effects — the beneficial ones, such as reduction of menorrhagia, a therapeutic effect on dysmenorrhea, and prevention of ectopic pregnancy, as well as the deleterious ones, such as amenorrhea, spotting and irregular bleeding, hormonal side-effects, and functional ovarian cysts. Also discussed are the possibility of a preventive effect on pelvic inflammatory disease, the effects of the IUD on postpartum/lactating women, fertility return after removal and other safety issues.In general, the LNG-IUD-20's non-contraceptive benefits are substantive, carry important medical and public health implications, and far outweigh the device's deleterious effects, which are either medically mild or transient in nature, and can usually be managed satisfactorily by counseling.A better understanding of these effects, both beneficial and deleterious, of this hormone-releasing IUD should lead to more effective patient counseling, which, in turn, should improve user quality of life, minimize unnecessary removals, and maximize continuation of use.

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Resumen Los ensayos clínicos realizados señalaron sistemáticamente que el DIU que descarga 20 g de levonorgestrel diariamente (LNG-DIU-20) tiene una eficacia anticonceptiva similar o incluso superior a la de los DIU CuT380 y Multiload Cu375.Este examen se centra en los efectos no anticonceptivos del dispositivo, los benéficos, tales como la reducción de la menorragia, el efecto terapéutico sobre la dismenorrea y la prevención del embarazo ectópico, así como los perjudiciales, por ejemplo, la amenorrea, las pérdidas y el sangrado irregular, los efectos secundarios hormonales y los quistes ováricos funcionales. También se examina la posibilidad de un efecto preventivo de la enfermedad inflamatoria pélvica (PID), los efectos del DIU sobre mujeres de posparto/lactantes, el retorno de la fecundidad después del retiro y otras cuestiones de seguridad.En general, los beneficios no anticonceptivos de los LNG-DIU-20 son significativos, tienen importantes repercusiones médicas y de salud pública, y compensan con creces los efectos perjudiciales del dispositivo, que son médicamente ligeros o bien de naturaleza pasajera, y pueden ser manejados satisfactoriamente, en términos generales, mediante un asesoramiento adecuado.Una mejor comprensión de los efectos, tanto benéficos como perjudiciales, de estos DIU de descarga hormonal habrá de llevar a un mayor asesoramiento de pacientes, lo cual, a su vez, mejorará la calidad de vida de las usuarias, reducirá al mínimo los retiros innecesarios y aumentará al máximo la continuación del uso.

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Resumé Les essais cliniques ont invariablement montré que le DIU libérant chaque jour 20 g de lévonorgestrel (LNG-IUD-20) a une utilité contraceptive comparable, sinon supérieure, à celle des dispositifs Copper T380 et Multiload Copper-375.Le présent article est axé non seulement sur les effets non contraceptifs du dispositif, ceux qui sont bénéfiques, tels qu'une réduction de la ménorragie, un effet thérapeutique sur la dysménorrhée, la prévention des grossesses ectopiques, mais aussi sur les effets délétères tels que l'aménorrhée, les microrragies et les pertes sanguines irrégulières, les effets hormonaux secondaires et les kystes fonctionnels ovariens. Y est examinée aussi la possibilité d'un effet préventif des maladies pelviennes inflammatories, les effets du DIU chez les femmes lors du post-partum et de la lactation, le retour à la fécondité après le retrait et d'autres aspects de sécurité.En général, les avantages non contraceptifs du LNG-IUD-20 sont considérables, ont d'importantes incidences médicales et en matière de santé publique, et compensent très largement les effets délétères du dispositif, lesquels sont soit bénins du point de vue médical soit passagers et peuvent en général être convenablement surmontés en demandant conseil.Une meilleure connaissance des effets, bénéfiques et délétères, de ce DIU libérant des hormones devrait permettre de mieux conseiller les patientes, ce qui devrait du même coup améliorer la qualité de la vie des utilisatrices, réduire au minimum les retraits inutiles du dispositif et maximaliser la poursuite de son utilisation.

     

The 'tail' of a missing intrauterine contraceptive device

This case presents a cautionary tale demonstrating the importance of skilled ultrasonography for the correct location of an intrauterine device (IUD) lying within the uterine cavity where the threads are 'lost'. Accurate ultrasound examination can ensure the avoidance of unnecessary x-rays or surgery. The case also acts as a reminder that a missing thread of an IUD does not imply that the device is misplaced.