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Key message points An ultrasound scan may pick up a low-lying or malpositioned intrauterine device/intrauterine system (IUD/IUS) and the clinical significance of this finding is uncertain.
Automatic replacement of the IUD/IUS may be unnecessary and an individualised approach to management is suggested.
If the decision is made to remove a low-lying or malpositioned device, another highly effective method of contraception should be instituted without delay.
Introduction
There are two main types of intrauterine contraception: the copper intrauterine device (IUD) and the levonorgestrel-releasing intrauterine system (LNG IUS). Pregnancy rates are low; 1-2% after 5 years of use. 1 Complications include infection, expulsion and uterine perforation. 2 The optimal position of a T-shaped IUD/IUS is traditionally described as vertically within the uterine cavity, up against the fundus, with the arms projecting horizontally. 3 Occasionally, on ultrasonic examination of the pelvis either incidentally or in a symptomatic woman, it is noted that an IUD/IUS is lying lower down in the uterine cavity, or even partially or completely within the cervical canal.
At present, there is no clear evidence of the clinical implications of a low-lying or malpositioned IUD/IUS and no formal published guidance on the most appropriate management of this situation. Prior to carrying out this literature review, we conducted a questionnaire survey of senior doctors working in sexual and reproductive health to identify trends in current practice. 4 This confirmed the current uncertainty amongst clinicians and lack of consensus on the best way to manage a low-lying IUD/IUS. We then performed a systematic review of the literature to appraise the risks of a low-lying IUD/IUS, with particular regard to risk of failure, whether or not women experience more symptoms, whether the IUD/IUS may move spontaneously to a correct position and, finally, whether postpartum insertion is a time of high risk for low-lying placement.
Methods
A search of the online database PubMed was performed from inception through to March 2013 for peer-reviewed articles concerning a malpositioned IUD or IUS, the risks, symptoms and failure rates. Search terms included were 'intrauterine device', 'intrauterine system', 'malposition', 'migration', 'misplaced' and 'failure'. Reference lists from articles that had been identified from the search were examined for further eligible articles.
Results
The primary literature search identified 1101 results, but only a small number...