Removal of an intrauterine device (IUD)

• Evidence on whether or not to remove an intrauterine device in a woman who has pelvic inflammatory disease is limited and conflicting. There are no long term data on the effects on fertility.
• Expert opinion differs regarding women with pelvic inflammatory disease (PID) who have an IUD:
• Expert advice in the Faculty of Sexual and Reproductive Healthcare clinical guideline on intrauterine contraception does not routinely recommend the removal of an IUD. The Faculty's Clinical Effectiveness Unit supports the continued use of intrauterine contraception and appropriate antibiotic treatment if PID is suspected; there is no need to remove the IUD unless symptoms fail to resolve within 72 hours or the woman wants it removed [FFPRHC, 2006; FSRH, 2007].
• Expert opinion in guidelines on the management of acute PID from the Royal College of Obstetricians and Gynaecologists [RCOG, 2009] advises that consideration be given to removing the IUD especially if symptoms have not resolved within 72 hours.
• The British Association for Sexual Health and HIV recommend considering removing the IUD if the woman develops PID. They advise balancing the decision to remove the IUD against the risk of pregnancy if the woman has had sexual intercourse in the preceding 7 days [BASHH, 2005a].
• Selected practice recommendations for contraceptive use from the World Health Organization state that [WHO, 2004]:
• There is no need for removal of the IUD if the woman wishes to continue its use.
• If the woman wishes removal, remove it after antibiotic treatment has been started.
• If the infection does not improve then generally the course would be to remove the IUD and continue antibiotics. If the IUD is not removed then the antibiotic should be continued and the woman should be monitored closely.

Presence of actinomyces-like organisms (ALOs)

• Expert opinion in guidelines from the Faculty of Sexual and Reproductive Healthcare is that [FSRH, 2007]:
• The role of ALOs in infection in women using intrauterine contraception is unclear. Actinomyces israelii is a commensal organism in the female genital tract and although these organisms may be found on cervical smears or swabs, their presence is not diagnostic or predictive of disease. Therefore, there is no need to remove an IUD if the woman does not have symptoms.
• If PID is suspected in a woman who has a history of ALOs on a cervical smear, it is important to consider that the infection may be due to other organisms.
• It may be appropriate to remove the IUD.