IUD Expulsion: Signs Your IUD Has Moved and What to Do

• Expulsion (the IUD slipping partly or fully out of the uterus) happens in roughly 2-10% of users, most often in the first three months after insertion.
• A partly or fully expelled IUD may no longer prevent pregnancy — so use condoms the moment you suspect it has moved.
• The simplest early-warning tool is a monthly self-check of the strings; strings that feel longer, shorter, missing, or the hard plastic poking through the cervix all warrant evaluation.
• Diagnosis is straightforward: a pelvic exam, a pregnancy test, and a transvaginal ultrasound confirm where the device is.
• Expulsion does not damage your fertility or future contraceptive choices — you can have a new IUD inserted or switch methods.
• Postpartum insertion and very heavy, crampy periods raise the risk; correct insertion by a trained provider lowers it.

IUD expulsion is the partial or complete movement of the device out of its intended position high in the uterine cavity.

Complete expulsion means the device has passed entirely out of the uterus, through the cervix and into the vagina — and from there it often falls out without being noticed. Partial expulsion means the device has slipped down from its intended position near the top of the uterus (the fundus), so the lower part protrudes through the cervix into the upper vagina while the upper part remains inside. Malposition — where the device is still in the uterus but rotated or displaced — is a related but distinct issue.

How common is it? Across clinical studies, expulsion rates range from about 2% to 10%, with most clustering around 3-5% in the first year after insertion. The risk is highest in the first three months — roughly half to two-thirds of all expulsions happen in this window. After three months the risk falls sharply, and beyond one year it is low (about 1-2% per year).

Does the device type matter? Expulsion rates are broadly similar for the copper IUD and the hormonal IUS. Some studies suggest a slightly higher rate for copper devices (which provoke more uterine contractility through their inflammatory action) compared with hormonal ones (where the local progestin tends to quiet the uterus), but the difference is modest. The Cu-T 380A, Multiload Cu-375, Mirena, Eloira and Kyleena all have broadly comparable rates. Our guide to choosing between copper and hormonal IUDs in India covers the other trade-offs.

Does timing of insertion matter? Yes. Insertion immediately after childbirth (within 48 hours of delivery) carries the highest expulsion rate — cited figures of 10-25% in the first six months — because the uterus is still large and contracting strongly. Despite this, immediate postpartum insertion is still recommended in many settings: it provides contraception from the moment fertility could return, and many women find it hard to return for the six-week check-up. Thorough counselling about the higher risk and the need for follow-up is essential. See postpartum contraception timing and the specific considerations after a C-section.

Does having given birth before matter? Women who have never given birth (nulliparous) may have a slightly higher expulsion rate in some studies, though the evidence is mixed. The Kyleena IUS was designed with a slightly smaller frame partly to address this, though the proven advantage is modest. Both nulliparous and parous women remain good IUD candidates — the small difference is a reason for good counselling, not for avoiding the method.

Other risk factors include severe period pain (dysmenorrhoea), very heavy menstrual flow, structural variations of the uterus (bicornuate or septate uterus), large fibroids distorting the cavity, and difficult insertions. Insertion technique that fails to seat the device at the fundus also raises risk — which is why a trained provider matters.

The Indian picture. National data from the National Family Health Survey, large facility-based studies and FOGSI-published series are consistent with international figures: expulsion rates of 2-10%, higher for postpartum insertion. The government Cu-T 380A programme at primary health centres (PHCs) routinely includes self-check counselling and a follow-up at four to six weeks.

Expulsion occurs when the uterus's contractions overcome the stability of the device's placement. Several factors contribute.

Uterine contractility. The uterus contracts gently all the time and more strongly during your period — the same contractions behind menstrual cramps. An IUD slightly increases this activity through the body's foreign-body response, with copper devices producing a bit more. If contractions are strong and the device sits low or marginally placed, it can be pushed down through the cervix, particularly during a heavy or crampy period. If your periods are very painful, our guide to managing dysmenorrhoea may help.

Uterine size and shape. The device is designed for a cavity of roughly 6.5-9.5 cm in length (the typical adult range). A smaller cavity may not hold the full device well; a larger one — particularly with Uterine Fibroids in India: Symptoms, Treatment, Cost & Fertility distorting it — may let the device drift from the fundus. The uterine sounding done at insertion measures the cavity to guide placement.

Insertion technique. The device should be deployed right at the fundus. If the provider can't reach the fundus (because of cervical tightness, a sharply flexed uterus, or anxiety-related resistance), it sits lower than intended — closer to the cervix and easier to dislodge.

Postpartum changes. After delivery the uterus shrinks back to its non-pregnant size over four to six weeks, and the strong involutional contractions during this period explain the higher expulsion risk of immediate postpartum insertion.

Individual variability. Even with identical insertions, one woman keeps the device for years while another expels it within months. Differences in uterine contractility and anatomy account for some of this, and there is currently no reliable way to predict in advance who will expel.

Breastfeeding. Some studies suggest a slightly higher rate in breastfeeding women, possibly because the oxytocin released during let-down adds to uterine contractions. The evidence is mixed, and breastfeeding is not a reason to avoid an IUD — see contraception while breastfeeding.

Why the first three months? Early on, the uterus is still adapting to the device, the lining is shifting, and the device hasn't yet "settled." After three months it has usually stabilised. Late expulsion (after the first year) is uncommon and often linked to a specific trigger such as fibroid growth or another change in the uterine environment.

• Strings you can no longer feel, or that feel noticeably longer or shorter than your last check
• The hard tip of the device protruding through the cervix
• A sudden return of heavier bleeding on a hormonal IUS that had settled
• New, sharp, or worsening pelvic pain, or new deep pain during sex
• A missed period or pregnancy symptoms
• Finding the IUD in your underwear or the toilet

Contact your gynaecologist for an IUD-position check if any of the following apply:

• You cannot feel the strings, or they feel significantly longer, shorter, or different.
• You can feel the hard plastic of the device at or through the cervix.
• You have new, unexplained pelvic pain, or new deep pain during sex.
• You have a bleeding change that doesn't fit your usual pattern.
• You miss a period or have pregnancy symptoms.
• You find the device itself outside your body.

A calm, step-by-step response confirms the situation and minimises any pregnancy risk.

1. Use back-up contraception immediately. Assume your cover is unreliable and use condoms or abstain until the device position is confirmed. This is the single most important first step.

2. Contact your gynaecologist. Ask for an urgent position check — most clinics can see you within a few days. If same-day or next-day care isn't available, keep using back-up contraception meanwhile.

3. Gather information. Note when you last confirmed the strings, any recent symptoms (bleeding change, pelvic pain, deep dyspareunia, pregnancy symptoms), and any recent triggers (a heavy period, for example). If you found the device, bring it to the appointment.

4. The evaluation. The gynaecologist does a pelvic exam, checks the strings, runs a pregnancy test, and usually a transvaginal ultrasound to see exactly where the device is — in the uterus and correctly placed, malpositioned, or expelled.

5. Management depends on the findings. If the device is correctly placed and only the strings have retracted, nothing more is needed. If it's malpositioned, your doctor will discuss whether to leave, remove, or replace it. If it has partly expelled, removal is usually recommended because it won't migrate back and its effectiveness is reduced. If it has fully expelled, it's already out — the question becomes what to use next.

6. Manage the pregnancy-risk window. If the timing of the expulsion and any unprotected sex raise a pregnancy concern, the test result is the immediate answer. If negative and the unprotected window was within the past five days, emergency contraception is reasonable — levonorgestrel pills (i-Pill, Unwanted 72) work up to five days, and a copper IUD inserted as emergency contraception within five days is the most effective option and provides ongoing cover. Our emergency pill versus copper IUD comparison explains the difference.

7. Decide on your next method. You can have a new IUD inserted (same or different type) or switch to another method entirely — a decision best made with your gynaecologist based on your circumstances and preferences.

Evaluation of a suspected expulsion follows a standard sequence.

History. Your doctor asks about insertion timing, when symptoms began, your self-check history, associated symptoms, and your reproductive history — all of which help interpret the findings.

Pregnancy test. A urine pregnancy test is done first, because pregnancy changes the management significantly. If positive, it's evaluated further with ultrasound and beta-hCG.

Pelvic examination. A speculum is placed to see the cervix and check the strings for length and position. If the strings aren't visible, the doctor may gently probe the cervical canal to feel for a device that has slipped into it.

Ultrasound. Transvaginal ultrasound is the standard way to confirm position. The device shows as a bright (hyperechoic) structure within the uterine cavity; its position relative to the fundus is assessed, and a malposition (rotated, embedded, or low) is identified if present. If the device isn't seen in the cavity, expulsion is confirmed.

Abdominal X-ray. If the device isn't seen on ultrasound and isn't outside the body, an X-ray checks for perforation (the device having migrated through the uterine wall). Both copper IUDs and the Mirena IUS (which contains barium) are visible on X-ray. If it's on neither ultrasound nor X-ray, it has been completely expelled and is no longer in the body.

Laparoscopy. In the rare case of confirmed perforation, the device may need surgical retrieval by laparoscopy.

The Indian picture. Ultrasound is widely available across Indian gynaecology settings — corporate hospitals (Apollo, Fortis, Manipal, Max, Medanta), private practices in metros and Tier-2 cities, and district hospitals. PHC and CHC facilities refer to district hospitals or private centres for ultrasound when needed. Pregnancy testing and X-ray are universally available, so the pathway for evaluating expulsion is well-established and accessible.

Once expulsion is confirmed and any pregnancy concern is addressed, the question is what to use next: a new IUD, or a different method.

When reinserting an IUD makes sense. If you had a single expulsion and otherwise liked the IUD, reinsertion is reasonable. The chance of a second expulsion is moderately higher than baseline (cited at around 10-15% versus the background 2-10%), but most second devices stay in place. You can choose the same type or switch — for example, from a copper IUD to a hormonal IUS.

When switching is often preferred. After two expulsions, the risk of a third is substantially higher (cited at around 30-50% or more), and most gynaecologists recommend a different category of method. Good alternatives include the contraceptive implant, the DMPA injection, combined or progestin-only pills, and female sterilisation — none of which carry expulsion risk.

Timing of reinsertion. A new IUD can usually go in with your next period (which also confirms you're not pregnant), or at any time once pregnancy is reasonably excluded. There's no need to wait months.

Mind the contraceptive gap. Between confirmed expulsion and your new method becoming effective, use condoms. If your new method has its own start-up rules (such as seven days of back-up for combined pills started outside the first five days of your cycle), follow them.

The emotional side. Some women find expulsion distressing — they trusted the device and the failure feels personal. It isn't a reflection of anything you did wrong; it's a known complication that occurs in a percentage of users regardless of behaviour. Talking it through with your gynaecologist is worthwhile.

Long-term outlook. A single expulsion predicts no long-term reproductive consequences. Your fertility is unaffected, the uterus returns to its pre-IUD state, and your future choices stay wide open.

The Indian picture. Reinsertion of a copper IUD is free at PHCs, CHCs and district hospitals and through ASHA outreach under the National Health Mission. The hormonal IUS and implant are available through private gynaecology and corporate hospitals; the DMPA injection (Antara) is free at government facilities and also available privately; pills are widely available.

A monthly self-check of the IUD strings is one of the most useful habits for catching expulsion early. It isn't strictly required — many women never self-check and never expel — but it offers reassurance and early detection.

When to check. Most gynaecologists suggest once a month, ideally after your period (or at a consistent time each month if you don't bleed because you're on a hormonal IUS or DMPA). After a period is convenient because any expulsion during it would be evident.

How to check. Wash your hands well with soap and water. Squat, or sit on the toilet, or put one foot up on the seat to bring the cervix within reach. Insert one or two clean fingers until you feel the cervix at the top of the vagina — it feels like a small firm round structure, about the size of the tip of your nose, with a small dimple in the centre. The strings hang from that dimple. (If you're new to this, our guide to finding and checking your cervix walks through it.)

What to look for. If you feel the strings at the usual length, the device is in place — nothing to do. Contact your gynaecologist if you can't feel them, if they feel much shorter or longer than usual, or if you feel the hard plastic of the device through the cervix.

Normal variation. Strings can feel slightly different across the cycle because the cervix shifts position — a little higher and softer mid-cycle, lower and firmer around your period. Weight changes, anxiety, and pregnancy can all affect how easily you reach the cervix. These are normal if the strings are present at roughly the usual length.

How often. Monthly is the standard. Checking after every act of intercourse or workout is unnecessary and can fuel anxiety. Checking less than monthly is acceptable but reduces early detection. Self-check matters most in the first three months, after postpartum insertion, and after any unusually heavy or crampy period.

Important: feel for the strings, don't pull on them — pulling could theoretically displace the device.

The Indian picture. ASHA workers and ANM staff at PHC and CHC level are trained to teach self-check, and it's a standard part of the National Health Mission family-planning programme and of private insertions. A partner can help with the check if you prefer, but it isn't necessary.

Expulsion can't be entirely prevented, but several practices lower the risk.

Correct insertion by a trained provider is the most important factor — properly stabilising the cervix, sounding the cavity to confirm depth and direction, deploying the device at the fundus, and trimming the strings appropriately. Insertion by an experienced gynaecologist or trained ANM minimises technical risk.

Appropriate device choice for your anatomy — standard devices suit adult cavities of about 6.5-9.5 cm; smaller-framed devices such as Kyleena may suit smaller cavities. Routine pre-insertion ultrasound isn't needed but can help where anatomy is uncertain.

Timing. Insertion during or shortly after a period in a non-postpartum woman has the lowest expulsion rate. Immediate postpartum insertion carries higher risk but is appropriate in many situations when weighed against the benefit of immediate cover.

Good counselling so you know what to expect — early cramping, the possibility of expulsion, the value of self-check, and the warning signs — improves outcomes.

A follow-up at 4-8 weeks lets your doctor confirm placement, address early concerns, and catch any early expulsion.

Managing heavy bleeding and cramps. For copper-IUD users with significant early cramping, NSAIDs (mefenamic acid, ibuprofen, naproxen) reduce both cramps and the uterine contractility that can contribute to expulsion. For very heavy periods, tranexamic acid reduces flow and the associated uterine response.

What can't be changed. Despite all this, expulsion still occurs in a percentage of users because of non-modifiable factors — uterine size variations, individual contractile patterns, and unknowns. The 2-10% rate cannot be reduced to zero. The realistic goal is early detection and good management when it does occur.

A few less common situations are related to, or confused with, expulsion.

Pregnancy with an IUD in place. Despite high effectiveness (Pearl Index 0.6-0.8 for copper, under 0.2 for hormonal IUS), pregnancy occasionally occurs. When it does, the device is either still in place (about half of cases) or has been silently expelled or displaced (the other half). A pregnancy with an IUD in place carries a higher risk of ectopic pregnancy (around 6% of IUD failures versus 1-2% of pregnancies in non-users), of miscarriage (about 40-50% if the device is left versus a background ~15%), and of preterm delivery and infection. If you wish to continue the pregnancy and the strings are visible, removing the device early lowers the miscarriage risk; if the strings aren't visible, removal is harder and the device is often left in place. This situation needs an experienced gynaecologist.

Ectopic pregnancy — implantation outside the uterus, usually in a fallopian tube — is a medical emergency. Symptoms include one-sided lower abdominal pain, light bleeding or spotting after a missed period, shoulder-tip pain, and collapse if a tube ruptures. Any IUD user with a missed period or new pelvic pain should have ectopic pregnancy excluded with a pregnancy test, beta-hCG, and ultrasound. Treatment is medical (methotrexate) for early stable cases or surgical (laparoscopy) for ruptured or unstable ones.

Uterine perforation — the device passing through the uterine wall — is rare, about 1 in 1,000 insertions, and is most often detected at insertion. Occasionally it's found later when the device can't be seen in the uterus. X-ray locates it, and removal needs laparoscopy. Most perforations heal without lasting consequences once the device is out.

Embedded device. Sometimes the IUD becomes partly embedded in the uterine muscle over time without full perforation, which can cause pain or abnormal bleeding and make removal harder; ultrasound or hysteroscopy guides assessment.

Lost strings without expulsion. The strings can simply retract into the cervical canal while the device stays correctly in place — this is not expulsion, and ultrasound confirms the device is fine. If needed, a thin instrument can bring the strings back down.

Device fragmentation is very rare with modern devices but has been reported; ultrasound or hysteroscopy identifies and removes any retained fragment.

The broader message: expulsion is the most common IUD issue, but awareness of warning signs, prompt evaluation, and good gynaecology care mean even rarer situations are handled effectively.

• World Health Organization — Selected Practice Recommendations for Contraceptive Use
• ACOG — Long-Acting Reversible Contraception (IUDs and Implants), Practice Bulletin
• NHS — Intrauterine device (IUD)
• FSRH (UK Faculty of Sexual & Reproductive Healthcare) — Intrauterine Contraception Guideline
• Ministry of Health & Family Welfare, Government of India — Reference Manual for IUCD Services