Contraception 89 (2014) 426 – 430

Original research article

Outcome of intrauterine pregnancies with intrauterine device in place and

effects of device location on prognosis☆
A. Seval Ozgu-Erdinc a,⁎, Ufuk Goker Tasdemir b , Dilek Uygur a ,
Ayla Aktulay a , Nicel Tasdemir c , H. Cavidan Gulerman a
a
Zekai Tahir Burak Women Health Care, Education and Research Hospital, Ankara, Turkey
b
Hayrabolu State Hospital, Tekirdag, Turkey
c
Namik Kemal University, Faculty of Medicine, Tekirdag, Turkey
Received 4 May 2013; revised 26 November 2013; accepted 4 January 2014

Abstract

Objectives: This study aimed to compare the outcome of pregnancies with retained or removed intrauterine devices (IUDs) and the effect of
IUD location on pregnancy outcome.
Study design: In a retrospective cohort study, we searched 27,578 records of women who had CuT380 IUD inserted, and 144 pregnancies
with IUD were analyzed. IUDs were removed from 114 patients and retained for 30 patients.
Results: The combined risk of adverse pregnancy outcomes (miscarriage, intrauterine fetal death, intrauterine growth retardation, preterm
birth and preterm premature rupture of membranes) was 36.8% in the IUD-removed group and 63.3% in the IUD-retained group [pb.01;
relative risk (RR)=2.0; 95% confidence interval (CI) 1.3–3.3]. Newborns of the IUD-retained women had significantly lower Apgar scores
and significantly higher admission rate to the neonatal intensive care unit (p=.01; RR=10.8; 95% CI 1.04–111.6 and pb.01; RR=4.5; 95% CI
1.5–12.9, respectively). There were more miscarriages and adverse pregnancy outcome when the IUD was retained (16.9% vs. 66.7%) in
patients with an IUD in low-lying position (pb.01; RR=3.9; 95% CI 1.8–8.6).
Conclusion: Women who conceived with an IUD in place and chose to continue the pregnancy without removing the IUD need close follow-
up, as there appears to be higher risk of adverse pregnancy and neonatal outcome. Furthermore, when the IUD is retained in the low-lying
position, there is increased risk of miscarriage and adverse pregnancy outcome compared to removal of the IUD. Future randomized
controlled studies are needed to determine the outcome of pregnancies with retained or removed IUD.
Implications: In this study, we have evaluated the IUD location and its effect on pregnancy outcome in women with a retained or removed
IUD. This study is the first to investigate the relationship between IUD location and pregnancy outcome in women who conceived with an
IUD. We need evidence from a collaborative multicenter randomized trial to answer the question of whether the IUD should be removed in
case of pregnancy.
© 2014 Elsevier Inc. All rights reserved.

Keywords: Pregnancy; Intrauterine device; Adverse pregnancy outcome; Location

1. Introduction
Intrauterine devices (IUDs) are widely used, safe and
effective contraceptives. IUDs are the fifth most used
modern contraception method in the United States [1] and
the second most used method worldwide, while IUDs are the
☆
Financial disclosure: The authors report no conflict of interest.
⁎ Corresponding author. Zekai Tahir Burak Women Health Care,
Training and Research Hospital, Talatpasa Bulvari, 06230, Ankara, Turkey.
Tel.: + 90 312 306 50 00.
E-mail address: sevalerdinc@gmail.com (A.S. Ozgu-Erdinc).
0010-7824/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.contraception.2014.01.002
first most used modern method (17%) after the traditional
withdrawal method (26%) in Turkey [2]. Pregnancy can
occur rarely, despite the presence of an IUD. The failure rate
of this contraceptive method ranges from 0.8% to 2.3%
[3–6]. Studies investigating why pregnancies occur despite
the presence of an IUD suggested composition of IUD
(copper surface area), duration of use, IUD position, age of
women, history of expulsion and failure of the IUD as risk
factors for the efficacy of IUD [7–9]. Some authors have
suggested removing the IUD during the first trimester of
pregnancy to prevent septic complications and miscarriages
[10,11]. A retrospective study has shown that ongoing
 A.S. Ozgu-Erdinc et al. / Contraception 89 (2014) 426–430
pregnancies with a retained IUD have risks, such as preterm
delivery and chorioamnionitis [12]. However, randomized
controlled studies comparing different management strate-
gies of pregnancies with an IUD in place are needed.
The World Health Organization (WHO) has made a
recommendation for pregnancies in the presence of an IUD
which is mostly based on studies from the 1970s and 1980s [13].
WHO concluded that removing the IUD improves
pregnancy outcome if the IUD strings are visible or can
be retrieved safely from the cervical canal and that the risks
of miscarriage, preterm delivery and infection are sub-
stantial if the IUD is left in place [3]. As there are no
randomized controlled studies about pregnancies with
IUD; studies with large case series are useful to estimate
the outcome of such pregnancies.
This study aimed to evaluate the pregnancy outcomes of
women who conceived despite the presence of CuT380A
IUD and decided to continue the pregnancy. We have
evaluated the IUD location and its effect on pregnancy
outcome in both IUD-retained and -removed women. A
detailed search of literature showed that there are no studies
investigating the relationship between IUD location and
pregnancy outcome in women who conceived with an IUD.
2. Materials and methods
A retrospective cohort study was conducted between 01
January 2005 and 01 January 2012 in the Family Planning
Unit of Zekai Tahir Burak Women Health Care, Education
and Research Hospital, Ankara, Turkey. The study was
approved by the institutional review board. In our clinical
practice, patients found to be pregnant during the
examination are offered to remove the IUD if the strings
are visible. Routine ultrasound examination is performed
for IUD location. The IUD is removed by gently pulling
the thread (in accordance with WHO recommendations)
from the patients in whom the IUD tail is still visible [3].
If the thread is inaccessible, no attempt is made to remove
the IUD. Clinical records of family planning unit during
the study period have been searched. All of the IUDs were
CuT380A. Clinical patient characteristics, such as maternal
age, obstetric history, gestational age and medical history
were evaluated. Early pregnancy losses were recorded, and
the ongoing pregnancy outcomes were evaluated for mode
of delivery, birth weight, 5-min Apgar scores, admission
to neonatal intensive care unit (NICU) and obstetric
complications. We also analyzed the maternal serum C-
reactive protein (CRP) level, white blood cell count
(WBC) and fibrinogen level as markers of the inflamma-
tory response.
The statistical software package SPSS (SPSS Inc.,
Chicago, IL, USA) was used for the statistical analyses.
Whether the distributions of continuous and discrete vari-
ables were normal or not was determined by using the
Kolmogorov–Smirnov test. Differences between the groups
427
were evaluated by using the Kruskal–Wallis test. For
categorical comparisons, two-tailed Pearson χ 2 tests were
used. Statistical significance was calculated using the t test
for differences in continuous variables. A p value less than
.01 was considered to be statistically significant.
3. Results
During the study period, 27,578 patients were seen in the
family planning unit for examination of an IUD. The cohort
consisted of 174 patients who had an IUD at the time of
pregnancy diagnosis and did not want the termination of the
pregnancy. Fourteen patients were excluded after the
diagnosis of an ectopic pregnancy. Patients with IUD
expulsion before the diagnosis of pregnancy were not
included in the study. Except for 16 patients, all the remaining
patients were routinely followed up at our hospital. The
outcomes for these 16 patients could not be retrieved. Thus,
the cohort consisted of the remaining 144 patients. All of the
pregnancies were singleton. Moreover, 114 patients had
chosen the IUD to be removed during the first trimester, and
the IUD was retained in the remaining 30 patients. The
clinical characteristics are summarized in Table 1. There was
no significant difference between the groups in terms of age
and parity. The mean gestational age at the time of diagnosis
was 7.4±2.6 weeks for the IUD-removed group and 8.7±3.8
weeks for IUD-retained group (p=.1).
Table 1 shows 73 patients (64%) in the IUD-removed
group and 11 (36.7%) patients in the IUD-retained group
delivered at term. The difference between the groups for
term pregnancies (deliveries of gestational week ≥ 37
weeks) was significant (pb.01) [relative risk (RR): 0.6,
95% confidence interval (CI): 0.4–0.9]. The combined risk
of adverse pregnancy outcomes (miscarriage, intrauterine
fetal death, intrauterine growth retardation, preterm birth
and preterm premature rupture of membranes) was 36.8%
(n= 42) in the IUD-removed group and 63.3% (n= 19) in the
IUD-retained group (pb.01) (RR: 2.0, 95% CI: 1.3–3.3).
There were fewer miscarriages in the IUD-removed group
than the IUD-retained group (pb.01) (RR: 2.0, 95% CI:
1.3–3.3) (Table 1). Eighteen (15.8%) pregnancies in the
IUD-removed group and 8 (26.7%) pregnancies in the IUD-
retained group were complicated by vaginal bleeding
during the first trimester (p=.2) (RR: 1.7, 95% CI: 0.8–
3.5). The outcome of patients experienced first trimester
bleeding is presented in Table 1. There was no statistically
significant difference in terms of intrauterine growth
retardation (IUGR), oligohydramnios and preterm prema-
ture rupture of membranes (PPROM) between the two
groups (Table 1). There were no women with clinically
diagnosed chorioamnionitis.
The median gestational week at birth for the IUD-
removed group was 39 weeks and was 37.5 weeks for the
IUD-retained group (pb.01). There was no statistically
significant difference between the groups in terms of mode
428 A.S. Ozgu-Erdinc et al. / Contraception 89 (2014) 426–430

Table 1
Comparison of clinical and laboratory characteristics and obstetric outcome of patients with regard to removal of IUD
IUD-removed group IUD-retained group p value RR(95% CI) for
n= 114 (79.2%) n=30 (20.8%) removed IUD
Age (mean, year) 27.5±4.9 29±5.4 .2
Parity (median) 2 (1–6) 2 (1–5) .6
Gestational week at diagnosis (mean) 7.4±2.6 8.7±3.8 .1
Gestational week at birth (median) 39 (24–41) 37.5 (22–40) b.01
Birth weight (median, g) 3400 (730–5140) 3360 (500–4000) .7
Laboratory findings
Median CRP (mg/L), n=32 6.3 (0.9–40) 16.1 (2.2–27.5) .9
Mean WBC, n= 144 10,916±3109 11,193±4190 .7
Mean fibrinogen (mg/dL) n=46 446.3±144.9 485.9±90.3 .3
Term birth, n (%) 73 (64.0%) 11 (36.7%) b.01 0,6 (0.4–0.9)
Preterm birth, n (%) 13 (11.4%) 5 (16.7%) .4 1.5 (0.6–3.8)
Miscarriage, n (%) 28 (24.6%) 15 (50%) b.01 2.0 (1.3–3.3)
First-trimester bleeding, n (%) 18 (15.8%) 8 (26.7%) .2 1.7 (0.8–3.5)
First-trimester bleeding outcome, n
Miscarriage 7 4
Preterm birth 4 0
Term birth 7 4
Oligohydramnios, n (%) 2 (2.3%) 1 (6.3%) .4 2.7 (0.3–27.9)
Intrauterine growth retardation, n (%) 2 (2.3%) 0 .5 1.0 (0.9–1.1)
Preterm premature rupture of membranes, n (%) 2 (2.3%) 2 (12.5%) .05 5.4 (0.8–35.4)
Adverse pregnancy outcome, n (%) 42 (36.8%) 19 (63.3%) b.01 2.0 (1.3–3.3)
Cesarean section, n (%) 38 (44.2%) 8 (50%) .7 1.1 (0.7–1.9)
Birth weight under 2500 g, n (%) 8 (9.3%) 4 (25.0%) .1 2.7 (0.9–7.9)
NICU, n (%) 6 (7.0%) 5 (31.3%) b.01 4.5 (1.5–12.9)
Apgar at 5 min b7, n (%) 1 (1.2%) 2 (12.5%) .01 10.8 (1.04–111.6)
Statistical significance (pb0.01) is stated as bold and underlined.

of delivery, median birth weight and delivery of a baby less
than 2500 g (Table 1). Two babies had an Apgar score below
7 at 5 min after delivery in the IUD-retained group, while one
baby had a low Apgar score in the IUD-removed group (p=
0.01) (RR: 10.8, 95% CI: 1.04–111.6). Six (7%) babies born
from IUD-removed women and 5 (31.3%) babies born from
IUD-retained women were admitted to the NICU (pb.01)
(RR: 4.5, 95% CI: 1.5–12.9). There was no newborn with
congenital anomalies in either group. There were no obstetric
or postpartum complications noted in the records.
The comparison of obstetric outcomes between removed
and retained IUDs with regard to IUD position is presented
in Table 2. When the IUD was located in the uterine cavity,
there were no statistically significant differences in any of the
outcome measures between the removed and retained IUD
groups. When the IUD was in low-lying position, there were
no statistically significant differences between the removed
and retained IUD groups in terms of gestational week at
birth, birth weight, mode of delivery, number of patients with
oligohydramnios, IUGR, first-trimester vaginal bleeding and
preterm births (Table 2). In women with a low-lying IUD,
there were more miscarriages in the IUD-retained women
(66.7%) than IUD-removed women (16.9%) (pb.01, RR:
3.9, 95% CI: 1.8–8.6). In the low-lying IUD group, the
number of patients delivered at term was more in the IUD-
removed women (p=.01, RR: 0.2, 95% CI: 0.0–1.5) than
IUD-retained women. In the low-lying IUD group, the
number of patients with PPROM and adverse perinatal
outcome was more in the IUD-retained women compared to
the IUD-removed women (pb.01, RR=13.5, 95% CI: 1.9–
94.1 and p=0.01, RR=2.6, 95% CI: 1.6–4.3, respectively).
The mean WBC, mean fibrinogen levels and median of
CRP levels were statistically insignificant between the IUD-
retained and -removed groups (Table 1). Although WBC data
were available for all of the patients, CRP and fibrinogen
levels were available only for some of the women as it is not
our routine practice to measure CRP or fibrinogen. Thus, the
results of the statistical analysis have limitations.
4. Discussion
Pregnancies in the presence of an IUD have a greater risk
of adverse obstetric outcomes than pregnancies in the
absence of an IUD [12,14,15]. Spontaneous miscarriage,
preterm delivery and chorioamnionitis are the described
adverse outcomes for these patients. In the present study, the
overall incidence of adverse pregnancy outcomes was higher
in the IUD-retained group than the IUD-removed group. The
two groups were similar in terms of age and parity, which
would be important confounding factors for many pregnancy
outcomes. This finding and the incidences were similar to the
results presented by other authors [16,17].
We found a statistically significant increased risk of
miscarriages in women with a retained IUD compared to
those with a removed IUD. Most of the observational studies
 A.S. Ozgu-Erdinc et al. / Contraception 89 (2014) 426–430 429

Table 2
Impact of IUD removal on obstetric outcome with regard to IUD position
Uterine cavity Low lying
Removed Retained p value RR (95% CI) Removed Retained p value RR (95% CI)
IUD n= 49 IUD n= 24 IUD n= 65 IUD n= 6
Gestational week at birth (median) 40 (31–41) 37.5 (22–40) 0.1 39 (24–41) 35.5 (32–39) .9
Birth weight (median, g) 3495 3360 0.2 3330 2995 1
(1210–4650) (500–4000) (730–5140) (2090–3900)
Preterm birth, n (%) 4 (8.2%) 4 (16.7%) 0.3 2.0 (0.6–7.5) 9 (13.8%) 1 (16.7%) .9 1.2 (0.2–8.0)
Term birth, n (%) 28 (57.1%) 10 (41.7%) 0.2 0.7 (0.4–1.2) 45 (69.2%) 1 (16.7%) .01 0.2 (0.0–1.5)
Miscarriage, n (%) 17 (34.7%) 11 (45.8%) 0.4 1.3 (0.7–2.4) 11 (16.9%) 4 (66.7%) b .01 3.9 (1.8–8.6)
First-trimester bleeding, n (%) 11 (22.4%) 7 (29.2%) 0.5 1.3 (0.6–2.9) 7 (10.8%) 1 (16.7%)
Birth weight under 2500 g, n (%) 2 (6.3%) 3 (21.4%) 0.1 3.4 (0.6–18.3) 6 (11.1%) 1 (50%) .1 4.5 (0.9–21.8)
Apgar at 5 min b 7, n (%) 0 2 (14.3%) 0.03 1 (1.9%) 0 .9
Cesarean section, n (%) 16 (50%) 6 (42.9) 0.7 0.9 (0.4–1.7) 22 (40.7) 0 .3
Oligohydramnios, n (%) 0 1 (7.1%) 0.1 2 (3.7%) 0 .8
IUGR, n (%) 0 0 – – 2 (3.7%) 0 .8
PPROM, n (%) 0 1 (7.1%) 0.1 2 (3.7%) 1 (50%) b .01 13.5 (1.9–94.1)
Adverse pregnancy outcome, n (%) 21 (42.9%) 14 (58.3%) 0.2 1.4 (0.9–2.2) 21 (32.3%) 5 (83.3%) .01 2.6 (1.6–4.3)
Statistical significance (pb0.01) is stated as bold and underlined.

and one prospective study have supported this finding
[15,18,19].
The IUD-retained women delivered babies with a lower
gestational week compared to the IUD-removed women.
Although not statistically significant, pregnancies in the
presence of an IUD have a higher incidence of preterm
delivery and PPROM compared to IUD-removed women.
Studies have postulated a high incidence of preterm delivery
in the IUD-retained group with statistical significance
[12,13,18]. However, the difference between the groups in
these studies, in terms of preterm delivery, was not
confirmed with statistical analysis in a systematic review
by Brahmi et al. [20]. Also, a study by Kim et al. reported a
higher PPROM incidence in pregnancies with an IUD in situ
[14]. Prospective controlled studies are needed to clarify this
question. In contrast to previous studies [20], there were
more newborns with a low Apgar score in the IUD-retained
women in the present study. The need for the NICU was also
significantly greater for the IUD-retained women.
Pregnancy among IUD users is not uncommon. However,
debates over management of such pregnancies continue due
to absence of randomized controlled trials about the
prognosis of pregnancies conceived in the presence of an
IUD [21]. Therefore, we believe that retrospective cohort
studies investigating the results of pregnancies in the
presence of an IUD are still important. No previous study
has investigated the effect of IUD removal with regard to
location of the IUD at the time of diagnosis and its effect on
pregnancy outcome. The only study evaluating the location of
IUD in the presence of pregnancy reported by Moschos et al.
[22] concluded that an intrauterine pregnancy was three times
as likely with a malpositioned or missing IUD, but they did not
investigate the effect of IUD location on pregnancy outcome.
In the present study, when the IUD was in the uterine cavity,
IUD removal did not make any difference on pregnancy
outcome. Importantly, we observed a higher miscarriage and
adverse perinatal outcome risk when we did not remove a low-
lying-positioned IUD. These findings may suggest that IUD
removal during pregnancy should be considered especially
when the IUD is low lying. However, as the number of women
with retained IUD in low-lying position was small, larger-
population-sized prospective studies are needed to clarify the
question of whether the IUD should be removed or not if it is
low lying.
We found higher WBC and CRP and fibrinogen levels in
the IUD-retained group, but the difference did not reach
statistical significance. In their small-sample-size prospective
study, Deveer et al. found a higher CRP level in IUD-retained
women and explained this finding as chronic inflammation
with a low level of bacteremia [19]. We could only have a
small portion of the women’s CRP results, and that might
decrease the power of these statistical results. As our study is
retrospective, a histological evaluation of inflammation was
not possible. An evaluation of inflammation with histological
and microbiological findings would be more valuable [23].
In conclusion, our study confirms that pregnant women
with an IUD in situ have a higher risk of an adverse
pregnancy outcome, lower gestational week, lower Apgar
scores and greater need for the NICU at birth. Moreover,
when the IUDs in low-lying position were not removed, the
women had more miscarriages and adverse perinatal
outcome. Prospective controlled studies evaluating the
pregnancy outcome of women with an IUD in place are
needed for counseling and management of such pregnancies.
We recommend that when the IUD is removed from the
uterine cavity or retained in situ during pregnancy, close
maternal and fetal surveillance is needed.
Acknowledgment
The authors wish to thank Michael Jones and Sibel Gunal
Jones for revising the article as native speaker.
430 A.S. Ozgu-Erdinc et al. / Contraception 89 (2014) 426–430
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