Contraception 85 (2012) 131 – 139

Review article

Pregnancy outcomes with an IUD in situ: a systematic review☆,☆☆

Dalia Brahmia,⁎, Maria W. Steenlandb , Regina-Maria Rennerc ,
Mary E. Gaffielda , Kathryn M. Curtisb
a
Department of Reproductive Health and Research, World Health Organization, CH-1211 Geneva 27, Switzerland
b
Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
c
Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR 97239, USA
Received 12 April 2011; revised 16 June 2011; accepted 23 June 2011

Abstract

Background: While intrauterine devices (IUDs) provide highly effective contraception, pregnancies among IUD users do rarely occur. The
objective of this systematic review is to assess the evidence about risks for adverse pregnancy outcomes among women who conceive with an
IUD in situ.
Methods: We searched MEDLINE, POPLINE, EMBASE and LILACS databases from inception through April 2011 for peer-reviewed
articles containing evidence related to pregnancy outcomes among women who conceived while using copper (Cu) and levonorgestrel-
releasing (LNG) IUDs.
Results: Nine articles met our inclusion criteria. Women with retained IUDs were at the greatest risk of adverse pregnancy outcomes, including
spontaneous abortion, preterm delivery, septic abortion and chorioamnionitis. Cu-IUD removal decreased risks but not to the baseline risk of
pregnancies without an IUD. One case series examined the LNG-IUD; when left in situ, 8 in 10 ended in spontaneous abortions.
Conclusion: Pregnancies complicated by a remaining IUD in situ were at greater risk of adverse pregnancy outcomes. Early IUD removal
appeared to improve outcomes but did not entirely eliminate risks.
© 2012 Published by Elsevier Inc.

Keywords: IUD; Copper IUD; Levonorgestrel IUD; Pregnancy; Complication; Systematic review

1. Introduction place during the pregnancy. This systematic review

appraises the published evidence on the safety of extracting
Pregnancy with an intrauterine device (IUD) in situ is a or leaving a Cu-IUD or LNG-IUD in place when a woman
risk factor for adverse pregnancy outcomes including becomes pregnant and desires to continue her pregnancy.
miscarriage and preterm labor. However, pregnancy among
IUD users is a an uncommon event; the typical first-year
failure rates for the copper IUD (Cu-IUD) and the 2. Methods
levonorgestrel-releasing IUD (LNG-IUD) are 0.8% and
0.2%, respectively [1]. Among women who do become We searched MEDLINE, POPLINE, EMBASE and
pregnant with an IUD in situ, there are risks associated with LILACS databases from inception through April 2011 for
both removal of the IUD as well as with leaving the IUD in peer-reviewed articles (in all languages) containing evi-
dence related to pregnancy outcomes among women who
☆
The findings and conclusions in this report are those of the authors conceived while using Cu-IUDs and LNG-IUDs. We used
and do not necessarily represent the official position of the World Health the following search strategies: MEDLINE (pregnancy
Organization or the Centers for Disease Control and Prevention. outcome OR pregnancy complication) AND (IUD(s) OR
☆☆
This review was supported by resources from the Department of IUCD(s) OR intrauterine devices OR intrauterine device);
Reproductive Health and Research at the World Health Organization, the
POPLINE Pregnancy outcomes[kw] & IUD[kw]; LILACS
Centers for Disease Control and Prevention, an Anonymous Foundation,
and the National Institute of Child Health and Human Development, USA. intrauterine devices or dispositivos intrauterinos or dis-
⁎ Corresponding author. Tel.: +41 22 791 1523, fax: +41 22 791 4171. positivos [Words] and pregnancy [Words]; EMBASE
E-mail address: [email protected] (D. Brahmi). (pregnancy outcome OR pregnancy complication) AND
0010-7824/$ – see front matter © 2012 Published by Elsevier Inc.
doi:10.1016/j.contraception.2011.06.010
132 D. Brahmi et al. / Contraception 85 (2012) 131–139

(IUD(s) OR IUCD(s) OR intrauterine devices OR intrauter- one was a case series describing pregnancy outcomes in
ine device). Reference lists from articles identified by the LNG-IUD users [5].
search, as well as key review articles, were hand searched to
identify additional articles. In some cases, study authors 3.1. Cu-IUD
were contacted directly for clarification. Seven cohort studies compared pregnancy outcomes of
women whose IUDs were left in place with either women
2.1. Study selection
whose IUDs were removed [8,11,13], or with a group of
We included studies that described intrauterine pregnancy women who became pregnant without an IUD [9] or both
outcomes in women who had a Cu- or LNG-IUD in situ at [7,10,12]. One cohort study compared pregnancies without
the time of conception as well as the impact of removing or an IUD at conception to women whose IUD was removed [6]
retaining the IUD. Pregnancy outcomes of primary interest (Table 1).
included spontaneous abortion, septic abortion, chorioam-
3.1.1. IUD retained versus removed
nionitis, preterm delivery and intrauterine fetal demise.
Tatum et al. [11] described the outcomes of 275 women
Secondary outcomes of interest included vaginal bleeding,
who conceived with a Cu-IUD and elected to continue their
premature rupture of membranes, congenital malformations
pregnancy. Of these, 118 women (43%) had their IUD
and birth weight. We excluded studies that investigated other
removed (80% in the first trimester) or the IUD was expelled
types of IUDs (e.g., Lippes loop or coil), did not specify IUD
type or focused exclusively on ectopic pregnancies. Case (111 removed and 7 expelled), and 157 (57%) left their IUD
series were included for the LNG-IUD due to the lack of in place. The authors combined the expelled and removed
cohort studies but excluded for the Cu-IUD as sufficient IUD groups in the analysis due to similar outcomes. More
than three quarters of women whose IUDs were removed or
comparative evidence from larger cohort studies is available.
expelled delivered a live birth (79%) compared with less than
2.2. Assessment of study quality half (44%) of women whose IUDs were left in place.
Spontaneous abortion occurred significantly more often in
All authors participated in summarizing and systemati- the retained IUD group compared to women whose IUDs
cally assessing the evidence through the use of standard were removed or expelled (54% vs. 20%; RR, 2.7; 95% CI,
abstraction forms [2]. The quality of each individual piece of 1.8–3.9). Twenty-nine (26%) of 113 spontaneous abortions
evidence was assessed by two independent reviewers using occurred in the second trimester; in only 3 of them, the IUD
the United States Preventive Task Force grading system [3], had been removed. While not statistically significant, the
and results are presented in the evidence tables. proportion of preterm delivery was greater in the IUD
retention group than in the IUD removal group (17% vs. 4%;
2.3. Data synthesis
RR, 2.3; 95% CI, 0.8–6.8). Stillbirth occurred in 2% of the
We did not compute summary measures of association IUD retention group and 1% of the IUD removal group.
because of the heterogeneity of study designs, study During a 6-year period, Inal et al. [8] recruited copper
populations and interventions. Although a meta-analysis T380 IUD users seeking reproductive health services in
was not possible, we report our findings according to the Turkey. Although the primary aim of the study was to
Meta-analysis of Observational Studies in Epidemiology compare rates of device dislocation among 318 women who
guidelines [4]. For studies where sample size and proportion became pregnant while using the IUD with 300 nonpregnant
in each group were available, we computed point estimates IUD users, the study reports the pregnancy outcomes of 89
as relative risks (RRs) and confidence intervals (CIs) (28%) women who decided to continue their pregnancy.
comparing the risk in the IUD retained versus removed Among these, 56 women had their IUD removed and 26 left
groups for our primary outcomes, using the retained group as it in place. The authors do not account for the 7 remaining
a reference. Where RR is reported, these are from our cases. Significantly more spontaneous abortions occurred in
calculations; however, we present the adjusted odds ratios the retained IUD group (77%) compared to the removed IUD
(ORs) from the logistic regression models reported in the group (27%) (RR, 2.9; 95% CI, 1.8–4.7). The authors
studies as these models could not be duplicated. The reported in personal communication that among women with
statistical analysis was performed using SAS software a retained IUD, 33% experienced preterm delivery compared
version 9.1 (SAS Institute Inc., Cary, NC, USA). with 9% in the removal group (RR, 3.2; 95% CI, 1.0–10.5), a
trend that almost reached significance.
Deveer et al. [13] conducted a prospective cohort study
3. Results among women with pregnancies of at least 12 weeks to
compare outcomes with retained IUDs (n=30) versus those
Our search identified 2209 studies, and 9 met all inclusion after IUD removal (n=18) during an 11-month period in
criteria [5–13]. Seven of the nine included studies were Turkey. There was a significantly increased risk of
retrospective cohort studies of Cu-IUD users [6–12], one spontaneous abortion among women in the retained IUD
was a prospective cohort study of Cu-IUD users [13], and group (53%) compared with the early IUD removal group
 D. Brahmi et al. / Contraception 85 (2012) 131–139 133

(17%) (RR, 3.2; 95% CI, 1.1–9.5). Similarly, preterm conducted further adjusted analyses using logistic regression
delivery occurred in 23% of women whose IUDs were models for the outcomes of chorioamnionitis and preterm
retained compared to 6% in the removed IUD group. While delivery. Adjusting for age and parity, retained IUD and IUD
the authors reported a p value of .000, the RR did not reach removal, compared to no IUD, were significantly associated
statistical significance in our calculation (RR, 4.2; 95% CI, with preterm delivery [OR, 2.6 (95% CI, 1.6–4.3), and OR,
0.6–31.4). 2.2 (95% CI, 1.5–3.3), respectively]. Adjusting for prema-
ture rupture of membranes and gestational age, both IUD
3.1.2. IUD retained versus removed versus pregnancy groups were associated with chorioamnionitis [OR, 6.3 (95%
conceived without IUD CI, 2.6–14.9) retained IUD; OR, 3.1 (95% CI, 1.3–7.8)
Mermet et al. [10] followed 67 French women who removed IUD].
conceived while using a copper-bearing IUD and continued von Theobald et al. [12] compared outcomes of live births
their pregnancy. Thirty-eight of them had their IUD after pregnancies with retained Cu-IUDs (n=12) with
removed, and 29 elected to keep it in place. A group of 34 outcomes from pregnancies after first-trimester IUD removal
women who conceived without an IUD, matched for age, (n=41) and pregnancies without an IUD (n=14,442). Over a
parity and time of delivery, were also included for 4-year period at a maternity hospital in France, combined
comparison. The authors reported a significantly increased risk of adverse pregnancy outcomes (bleeding, preterm
risk of spontaneous abortion of 48% among women with a labor, premature rupture of membranes, preterm delivery,
retained IUD compared with 8% among women who had hypertension and congenital malformations) were higher in
their IUDs removed (RR, 6.1; 95% CI, 1.9–19.3). Ninety the retained IUD group (83%) compared with the IUD
percent of pregnancies with a retained IUD had complica- removal group (44%). Preterm delivery occurred more
tions including vaginal bleeding, spontaneous abortion, frequently with a retained IUD (25%) or a removed IUD
premature rupture of membranes and preterm delivery (17%) than among women who conceived without an IUD
compared with 34% of the IUD removal group. Seven of (7%) (reported pb.05). However, our calculated RR was not
the 52 infants born in all the IUD pregnancies had congenital statistically significant (RR, 1.5; 95% CI, 0.5–4.8). There
anomalies. Two septic abortions were reported at 16 and 23 was no statistically significant difference in congenital
weeks among women who kept their IUD in place; none malformations between the retained IUD (0.08%) and
occurred among women whose IUDs were removed. removed IUD (0.02%) groups (RR, 3.4; 95% CI, 0.2–50.6).
Comparison with the 34 women who conceived without an
IUD was limited; overall pregnancy-related complications in 3.1.3. IUD retained versus pregnancy conceived without IUD
this group were 29% but only included vaginal bleeding. Kim et al. [9] retrospectively evaluated the outcomes of
Ganer et al. [7] conducted a retrospective cohort study 12,297 pregnancies among which 196 had a Cu-IUD in situ.
among women with pregnancies of at least 22 weeks to The study included parous women with singleton pregnan-
compare outcomes of pregnancies with retained Cu-IUDs cies during a 10-year period presenting to a maternity
(n=98) versus those with first-trimester IUD removal hospital in Santiago, Chile, but excluded women (n=12) who
(n=194) and those who conceived without an IUD had their IUD removed in early pregnancy. The authors used
(n=141,191) over a 19-year period in Israel. They used a logistic regression to model the pregnancy outcomes
linear-by-linear p value to express an ordinal measure of adjusting for age, parity, history of preterm birth, underlying
significance across all three groups. The percentage of medical condition, smoking and prepregnancy body mass
pregnancies ending in preterm delivery differed significantly index. Pregnancies with a retained IUD were compared with
in their analysis (18% retained IUD, 14% removed IUD and pregnancies without an IUD and found to be associated with
7% no IUD; linear-by-linear pb.001). However, in compar- increased odds of spontaneous abortion occurring after 12
ing the IUD retained group with the IUD removed group in weeks (16% vs. 1%; adjusted OR, 16.8; 95% CI, 10.6–26.7),
our analysis, the RR of preterm delivery did not reach preterm birth (56% vs. 21%; adjusted OR, 5.8; 95% CI, 4.3–
statistical significance (RR, 1.2; 95% CI, 0.7–2.1). Similarly, 8.0), vaginal bleeding (19% vs. 5%; adjusted OR, 3.1; 95%
Ganer et al. reported an increased risk of chorioamnionitis CI, 2.1–4.7) and clinical chorioamnionitis (8% vs. 2%;
among women in the retained IUD group (7%) compared adjusted OR, 4.1; 95% CI, 2.3–7.2). There was no
with the early IUD removal group (4%) and the no IUD significant difference in the rate of congenital malformations
group (1%) (linear-by-linear pb.001), but the RR was not between the IUD and no IUD groups (8% vs. 7%; adjusted
significant when comparing the IUD retained group with the OR, 1.4; 95% CI, 0.8–2.4) after adjusting for age, parity,
IUD removed group (RR, 0.2; 95% CI, 0.1–0.4). Congenital gestational age, underlying medical condition, smoking and
malformations occurred in 10% of the retained IUD group, prepregnancy body mass index.
6% of the early IUD removal group and 5% of the no IUD
pregnancies (linear-by-linear p=.041); however, in our 3.1.4. IUD removed versus pregnancy conceived
analysis, the RR of congenital malformations did not reach without IUD
statistical significance between the IUD retained and IUD Chaim and Mazor [6] conducted a small cohort study
removed groups (RR, 1.8; 95% CI, 0.8–4.1). The authors comparing rates of preterm delivery among women in Israel
 134
Table 1
Comparative studies of pregnancy outcomes following exposure to copper IUD
Retained vs. removed IUD
Reference, source Study design Population Outcomes measured Results reported in original papers Results calculated Strengths and weaknesses Quality
of support by review authors
IUD retained vs.
removed
Tatum et al. [11], Retrospective 918 pregnancies with Spontaneous IUD retained Adequate sample of IUD Level II-2,
NIH, cohort; a Cu-IUD in situ at abortion (SAB) vs. removed pregnancies fair, direct
Population 1970–1976; conception Preterm delivery (PTD) Comparison of outcomes
Council Canada, 275 continued Live birth between IUDs left in place
Puerto Rico, pregnancies Stillbirth IUD retained (n=157) n (%) p value* RR 95% CI and IUDs removed
USA 157 retained IUD SAB 85 (54) b.005 2.7 (1.8–3.9) Moderate loss to follow-up
118 removed or expelled PTD 12 (17) b.02 2.3 (0.8–6.8) (13%)
(80 %) in first trimester Live birth 69 (44) 0.6 (0.5–0.7) Contacted patients directly
Still birth/ 3 (2) 2.3 (0.2–21.4) regarding outcomes

D. Brahmi et al. / Contraception 85 (2012) 131–139

neonatal death Timing of IUD removal/
⁎p value compared to IUD removed expulsion not matched
with outcomes
IUD removed/expelled (n=118) No adjustment for
n (%) potential confounders
SAB 24 (20)
PTD 4 (4)
Live birth 93 (79)
Still birth/ 1 (1)
neonatal death
Inal et al. [8], Retrospective 618 women using SAB IUD retained Comparison of outcomes Level II-2,
not stated cohort, 1994– copper T380A IUD Septic abortion vs. removed between IUDs left in place poor, direct
1999, Turkey 318 pregnancies with PTD IUD in place and retained (n=26) n (%) RR 95% CI and IUDs removed
Cu-IUD SAB 20 (77) 2.9 (1.8–4.7) Relied upon medical charts
89 continued Septic abortion 0 (0) – for information
pregnancies PTD 6 (23) 3.2 (1.0–10.5) IUD removal procedure
26 retained IUD not specified
56 removed IUD IUD removed due to dislocation (n=56)
300 Cu-IUD controls n (%)
not pregnant SAB 15 (27)
Septic abortion 0 (0)
PTD 4 (7)
Deveer et al. Prospective 48 women using a SAB IUD retained Comparison of outcomes Level II-2,
[13], not stated cohort, June Cu-T 380A IUD Vaginal bleeding vs. removed between IUDs left in place fair, direct
2009–April 30 women who Placental abruption IUD retained (n=30) n (%) p value⁎ RR 95% CI and IUDs removed
2010, Turkey retained the IUD Premature rupture of SAB (first 16 (53) .005 3.2 (1.1–9.5) Prospective study likely
18 women whose IUDs membranes (PROM) and second improved reporting
were removed in early PTD trimesters) of outcomes
pregnancy Small for gestational Vaginal bleeding 12 (40) .391 1.4 (0.6–3.4) Small sample size
Included all singleton age (SGA) Placental abruption 2 (7) .263 – IUD removal procedure
pregnancies ≥12 weeks PROM 12 (40) .002 – not specified
PTD 7 (23) .000 4.2 (0.6–31.4) No adjustment for
SGA 2 (7) .590 0.6 (0.1–3.9) potential confounders
⁎p value compared to IUD removed
 IUD removed (n=18) n (%)
SAB 3 (17)
Vaginal bleeding 5 (28)
Placental 0 (0)
abruption
PROM 0 (0)
PTD 1 (6)
SGA 2 (11)
Retained vs. removed vs. no IUD
Mermet et al. Retrospective 157 women with IUD in SAB IUD retained Comparison of outcomes Level II-2,
[10], not stated cohort, 1979– situ at conception Septic abortions vs. removed between IUDs left in poor, direct
1985, France 67 (36%) continued Vaginal bleeding IUD retained (n=29) n (%) RR 95% CI place and IUDs removed
pregnancies PROM SAB 14 (48) 6.1 (1.9–19.3) Limited information
29 retained IUD PTD Septic abortion 2 (7) about complications
38 removed IUD Congenital PROM and PTD 2 (7) Poorly defined outcomes
in 1st trimester malformations Combined 26 (90) and not all reported
34 pregnancies complications Small sample size
without IUD (SAB, vaginal IUD removed under

D. Brahmi et al. / Contraception 85 (2012) 131–139

bleeding, PROM ultrasound guidance and
and PTD) with 2-mm grasper if
located above pregnancy
IUD removed (n=38)
n (%)
SAB 3 (8)
Septic abortion 0 (0)
Combined 13 (34)
complications

7/52 congenital malformations

in combined IUD group

No IUD (n=34) n (%)

Vaginal bleeding 10 (30)
von Theobald Retrospective 12 pregnancies Vaginal bleeding IUD retained Comparison of outcomes Level II-2,
et al. [12], cohort, with retained Cu-IUDs PROM vs. removed between IUDs left in place poor, direct
not stated January 1985– 41 removed IUDs PTD Reported RR 95% CI and IUDs removed
December in first trimester Congenital IUD retained (n=12) n (%) p value Results of some
1988, France 14,442 pregnancies malformations Vaginal bleeding 2 (16) b.02 2.3 (0.4–12.1) outcomes not reported
without IUD compared to or unclear
Included only “viable IUD removed Small sample size
fetus,” i.e., excluded PROM 1 (9) 0.7 (0.1-5.3) IUD removal procedure
ectopic pregnancy PTD 3 (25) b.05 compared 1.5 (0.5-4.8) not specified
and SAB but does not to no IUD No adjustment for
define gestational age Malformations 1 (0.08) 3.4 (0.2-50.6) potential confounders
Overall pathology (83) .03 compared –
to IUD removed

IUD removed (n=41)

n (%) Reported p value
Vaginal bleeding 3 (8) .05 compared
to no IUD
PROM 5 (12)
PTD 7 (17) b.05 compared
to no IUD

135
(continued on next page)
 136
Table 1 (continued)
Table 1 vs.
Retained (continued)
removed IUD
Reference, source Study design Population Outcomes measured Results reported in original papers Results calculated Strengths and weaknesses Quality
of support by review authors
IUD retained vs.
removed
Malformations 1 (0.02)

Overall pathology (44)

No IUD (n=14,442)
(%)

D. Brahmi et al. / Contraception 85 (2012) 131–139

VB (10)
PROM (3)
PTD (7)
Malformations (7)
Ganer et al. [7], Retrospective 98 pregnancies with Placenta previa IUD retained (n=98) % Linear-by- IUD retained Comparison of outcomes Level II-2,
not stated cohort, 1988– retained Cu-IUD Placental abruption linear⁎ vs. removed between IUDs left in place good, direct
2007, Israel 194 removed IUDs in Chorioamnionitis p value RR 95% CI and IUDs removed
early pregnancy PROM Placental previa 4 b.001 0.8 (0.3–2.5) Adjustment for potential
141,191 pregnancies PTD Placental abruption 4 b.001 2.0 (0.5–7.8) confounders
without IUD Low birth weight Chorioamnionitis 7 b.001 0.2 (0.1–0.4) Limited discussion
Included all singleton (b2.5 kg) PROM 10 .021 1.3 (0.6–2.8) of methods
pregnancies N22 weeks Congenital PTD 18 b.001 1.2 (0.7–2.1) Outcomes not clearly
malformations Birthweight b2.5 kg 11 b.001 0.8 (0.4–1.6) defined
Malformations 10 .041 1.8 (0.8–4.1) Unknown timing of
IUD removal
IUD removed (n=194) IUD extraction procedure
% not specified
Placental previa 4
Placental abruption 2
Chorioamnionitis 4
PROM 8
PTD 14
Birthweight b2.5 kg 13
Malformations 6

No IUD (n=141,191)
%
Placental previa 4
Placental abruption 1
Chorioamnionitis 1
PROM 6
PTD 7
Birthweight b2.5 kg 7
Malformations 5
⁎linear p value comparing IUD retained to IUD
removed to no IUD
Removed vs. no IUD
Chaim and Mazor Retrospective 16 pregnancies with PTD Removed IUD (n=16) n (%) Outcome clearly defined Level II-2,
[6], not stated cohort, Israel Cu-IUD at conception, PTD 3 (19) Small sample size poor, direct
then removed p=.045 compared to no IUD IUD removal timing not
48 pregnancies without OR, 10.8 (95% CI, 0.8–78.1) specified
IUD matched for age, IUD removal
parity and gravidity No IUD (n=48) n (%) procedure not specified
PTD 1 (2) No adjustment for potential
confounders
Retained vs. no IUD
Kim et al. [9], Retrospective 196 pregnancies with SAB N12 weeks IUD retained (n=196) n OR* (95% CI) Outcomes clearly Level II-2,
not stated cohort, retained Cu-IUD Placental previa SAB N12 weeks 31 16.8 (10.6–26.7) defined good, direct
December 121,101 pregnant Placental abruption Placental previa 4 0.7 (0.2–2.9) Adjustment for
1997–June women no IUD Chorioamnionitis Placental abruption 16 3.4 (2.0–5.9) potential
2007, Chile Singleton pregnancies PROM Chorioamnionitis 16 4.1 (2.3–7.2) confounders
and parous women PTD (PTD) PROM 68 9.4 (6.8–13.0) No comparison
Excluded women SGA PTD 110 5.8 (4.3–8.0) group of women

D. Brahmi et al. / Contraception 85 (2012) 131–139

post-IUD removal Congenital SGA 10 0.7 (0.4–1.4) who removed IUD
in early pregnancy malformations Malformations 15 1.4 (0.8–2.4) in early pregnancy
⁎Adjusted OR of IUD retained vs. no IUD

No IUD (n=121,101) n
SAB N12 weeks 146
Placental previa 186
PROM 714
Placental abruption 249
Chorioamnionitis 209
PTD 2503
SGA 1141
Malformations 828

NIH, National Institutes of Health.

137
138 D. Brahmi et al. / Contraception 85 (2012) 131–139

Level II-3, poor, direct

who conceived with a Cu-IUD in situ, but had the IUD
removed after pregnancy was diagnosed (n=16), with a
comparison group (n=48) who conceived without an IUD.
The prevalence of preterm delivery was increased in the IUD

Quality
exposed group compared with the group who conceived
without an IUD: 19% versus 2%; p=.045 (OR, 10.8; 95% CI,
0.8–78.1). The cohorts were matched for maternal age,

follow-up of medical records,

Population-based sample of
LNG-IUD users in Finland,

18% loss to follow- up, recall

parity and gravidity, but no other potential confounders

pregnancy to identify cases,

bias for 63% who reported

Strengths and weaknesses
were evaluated.

Pregnancy but was not a

Relied on self-reported

LNG-IUD pregnancy
3.2. Levonorgestrel IUD

We identified one case series that described the pregnancy

large sample
outcomes of LNG-IUD users (Table 2). Forty pregnancies
conceived with an LNG-IUD in situ were identified on a self-
administered questionnaire of 17,360 LNG-IUD users in
Finland (58,600 woman-years) and verified with hospital

25 (63)
n (%)
records from 1990 through 1996. Of these pregnancies, 63%

15
5
8
2
were ectopic. Ten of the 15 intrauterine pregnancies were
continued, and five women had induced abortions. Of the 10

Intrauterine pregnancy

Healthy-term delivery
Retained IUD (n=40)
women who continued their pregnancy with the LNG-IUD,

Ectopic pregnancy

Induced abortion
eight spontaneously aborted, and two had an otherwise
uncomplicated term delivery of healthy infants [5].
Results

SAB
4. Discussion

The evidence from the nine studies of overall fair quality

included in this review consistently demonstrated that Spontaneous abortion (SAB)
Intrauterine pregnancy

pregnancies conceived with an IUD in place are associated Healthy-term delivery

Outcomes measured

Ectopic pregnancy

with adverse pregnancy outcomes, with the greatest risk

Induced abortion

among those pregnancies in which the IUD was not

removed. Compared with women who conceived without
an IUD, women with a retained IUD had a greater risk for
Observational study of pregnancy outcomes following exposure to levonorgestrel IUD

spontaneous abortion, preterm delivery and chorioamnionitis

[9]. Compared with women whose IUDs were removed in
68 not LNG-IUD pregnancies

early pregnancy [7,8,10–13], women who retained the IUD

132 pregnancies reported by

were at increased risk of adverse outcomes including

40 confirmed LNG-IUD
17,630 LNG-IUD users,

spontaneous abortion [8,10,11,13], preterm delivery [7,10]

records verified for

and septic abortion [10]. Even after IUD removal, women

108 pregnancies

who conceived with an IUD remained at higher risk for

pregnancies

preterm delivery compared to pregnancies conceived

Population

without an IUD [6,7,10,12]. While some studies report on

fetal malformations, data are insufficient to draw conclusions
on any association between conceiving with an IUD in situ
questionnaire, 1996,

and risk of malformations [7, 9–12].

The authors of only one study included in this review [10]
Cross-sectional
Study design

specified the procedure of the IUD extraction, and we

assume that the others only removed IUDs with visible
Finland

strings, but we do not know for certain. Several case series

have reported ultrasound-guided IUD removal when the
strings have retracted into the uterus [14–16]. This practice is
Reference, source of

Backman et al. [5],

more controversial as the potential to disrupt a wanted

Schering Oy

pregnancy is hypothesized to be greater. Schiesser et al. [15]

described successful ultrasound-guided removal of “lost
Table 2

support

IUDs” in 80 of 81 pregnancies (75 in the first trimester and 6

in the second trimester) and report a preterm delivery rate of
 D. Brahmi et al. / Contraception 85 (2012) 131–139 139

13.5% and a spontaneous abortion rate of 22.1% (no References

difference between the trimesters). This rate is comparable
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