An IUD slipping out of place is unsettling, but in the vast majority of cases it is not a medical emergency. Most expulsions happen gradually, cause mild symptoms like cramping or abnormal bleeding, and can be addressed at a scheduled appointment with your provider. That said, certain circumstances surrounding an expulsion, particularly signs of perforation, severe pain, heavy bleeding, or the possibility of pregnancy, do call for prompt or even emergency evaluation. Understanding which scenario you’re actually in matters more than panicking about the expulsion itself.
What IUD Expulsion Actually Looks Like
Expulsion means the IUD has moved partially or completely out of the uterine cavity, where it’s supposed to sit. A complete expulsion is when the device comes all the way out, sometimes falling into the toilet or turning up in your underwear. A partial expulsion is subtler: the IUD shifts downward toward or into the cervix but hasn’t fully left the uterus. Both situations mean the device is no longer doing its job reliably, but neither one, on its own, is dangerous.
The symptoms people notice most often are cramping, a change in bleeding patterns, or the feeling that something is off. You might feel the hard plastic of the device at the opening of your cervix, or your partner might notice it during sex. Sometimes the strings seem longer than usual, or you can’t feel them at all. Research on malpositioned IUDs found that nearly half of people whose device had shifted were completely asymptomatic, and visible strings were frequently present even when the IUD was out of place, which means string checks alone aren’t a reliable way to confirm everything is fine.1Journal of Ultrasound in Medicine. Clinical Relevance and Symptom Patterns for Malpositioned Intrauterine Devices
When You Should Seek Urgent Care
The expulsion itself is rarely the emergency. What can be urgent are the complications that sometimes accompany it or the situations it creates. Here are the scenarios that warrant same-day or emergency evaluation:
- Severe pelvic pain: Mild cramping is expected, but sharp, worsening, or one-sided pain could indicate perforation, where the device has pushed through the uterine wall. This is rare but does require medical imaging and sometimes surgical removal.
- Heavy, uncontrolled bleeding: Some spotting or heavier-than-usual flow is typical with expulsion, but soaking through a pad every hour or feeling lightheaded suggests you need evaluation.
- Fever or signs of infection: The risk of pelvic inflammatory disease among IUD users is very low overall.2Europe PMC. Intrauterine devices & infection: review of the literature But if you develop a fever, foul-smelling discharge, or escalating pain after noticing your IUD has moved, that combination deserves urgent attention.
- Possible pregnancy: If you had unprotected sex before realizing the IUD had shifted, or if a pregnancy test comes back positive, you need to see a provider promptly. A pregnancy with an IUD still partially in place carries increased risks, and the device usually needs to be removed as soon as possible.
A small case series documented emergency department removals of malpositioned IUDs in patients with acute pelvic pain and vaginal bleeding; removal in all four cases was uncomplicated and led to symptom improvement.3PubMed Central / Elsevier. Clinical outcomes after removal of malpositioned intrauterine devices in the emergency department That tells you two things: people do sometimes show up in the ER with a displaced IUD, and the actual fix tends to be straightforward. The trip to the emergency department was about ruling out something worse, not because the expulsion itself was life-threatening.
Expulsion Versus Perforation
People often confuse these two events, but they’re essentially opposites in direction. Expulsion means the device moves downward and out. Perforation means the device pushes through the uterine wall and into the abdominal cavity, which is a genuinely serious complication. A study tracking perforated IUDs found that about 71% of patients had symptoms like abnormal bleeding, abdominal pain, or missing strings, while the remaining 29% had no symptoms at all and were only identified because their strings had disappeared or they became pregnant.4Oxford Academic. Uterine perforation caused by intrauterine devices: clinical course and treatment Among the devices found in the abdomen, most had migrated to the omentum (a fatty tissue layer), and infections were uncommon.
The reason perforation matters in the context of your question is this: if your IUD strings suddenly vanish and you can’t feel the device, your provider needs to determine whether the IUD was expelled (meaning it came out and you may not have noticed) or perforated (meaning it’s now somewhere it shouldn’t be inside your body). An ultrasound or pelvic X-ray sorts this out. Perforation typically requires surgical retrieval, usually through a minimally invasive laparoscopic procedure. That distinction, expelled versus perforated, is the main reason a missing IUD warrants a medical visit even if you feel fine.5PubMed. Management of missing strings in users of intrauterine contraceptives
Pregnancy Risk After Expulsion
The moment an IUD is no longer correctly positioned, your contraceptive protection drops. This is the part that catches people off guard: you may not realize the device has shifted, especially since many expulsions are asymptomatic. If you discover your IUD has come out or moved, you should assume you’re no longer protected. Use backup contraception and talk to your provider about next steps.
If unprotected sex occurred around the time of expulsion and you’re concerned about pregnancy, a copper IUD can serve as emergency contraception when placed within five days of unprotected intercourse or ovulation.6BMJ. Emergency contraception So ironically, the same type of device that just failed you could be reinserted to prevent pregnancy from the exposure that happened while it was out of place. This is something to discuss with your provider urgently if the timing is relevant, but it’s a planned clinical visit, not a 911 call.
Who Is Most Likely to Experience Expulsion
The overall expulsion rate for IUDs is modest. A large study found that the one-year cumulative incidence was about 2.3% for both hormonal and copper devices, climbing to roughly 4.5–4.8% over five years.7PubMed. Association between intrauterine device type and risk of perforation and device expulsion: results from the Association of Perforation and Expulsion of Intrauterine Device study But certain groups face meaningfully higher odds.
Age is one of the strongest predictors. Adolescents and young adults under 20 have roughly two to three times the risk of expulsion compared to older users. One study found an adjusted hazard ratio of 2.26 for hormonal IUD expulsion and 3.06 for copper IUD expulsion in those aged 14 to 19, compared to older groups.8PubMed Central. Association of Age and Parity With Intrauterine Device Expulsion Higher BMI, parity of four or more, and heavy menstrual bleeding have also been identified as independent risk factors.9PubMed Central. Demographic, Reproductive, and Medical Risk Factors for Intrauterine Device Expulsion Older research on copper IUDs specifically pointed to young age, heavy flow, and severe menstrual cramping before insertion as contributors.10Contraception. Risk factors for copper T IUD expulsion: An epidemiologic analysis
Perhaps the most dramatic risk factor is timing relative to childbirth. A meta-analysis of postpartum IUD placement found that the pooled expulsion rate was about 1.9% when the IUD was placed at least four weeks after delivery, compared to 10% when placed within ten minutes of the placenta being delivered and nearly 30% when placed more than ten minutes postpartum but before four weeks.11PubMed Central. Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis A large observational study found a similar pattern: the five-year cumulative expulsion incidence was about 10.7% for insertions in the first three days postpartum and around 3.2% for those done after six weeks.12JAMA Network Open. Association of the Timing of Postpartum Intrauterine Device Insertion and Breastfeeding With Risks of Intrauterine Device Expulsion A randomized trial comparing early postpartum placement (within the first few days) versus interval placement found complete expulsion rates of 2% versus 0%, though partial expulsion rates were closer between groups.13JAMA. Early vs Interval Postpartum Intrauterine Device Placement: A Randomized Clinical Trial
The takeaway for postpartum insertion isn’t that it should be avoided. There are strong access-related reasons to place an IUD before a patient leaves the hospital. But if you had your IUD placed soon after delivery, being aware that expulsion risk is higher means you should be more vigilant about checking for signs of displacement in the following months.
Does the Type of IUD Matter?
Not as much as you might think. A systematic review and meta-analysis comparing hormonal (levonorgestrel-releasing) IUDs to copper IUDs found no statistically significant difference in expulsion rates between the two types, with copper devices at about 6.1% and hormonal devices at 4.9%.14The Lancet Regional Health / EClinicalMedicine. Efficacy and safety of levonorgestrel-releasing intrauterine devices compared to copper intrauterine devices: a systematic review and meta-analysis A separate large study reported one-year cumulative expulsion of 2.3% for both types, though the adjusted analysis did find a modestly lower hazard for hormonal devices.15PubMed. Association between intrauterine device type and risk of perforation and device expulsion: results from the Association of Perforation and Expulsion of Intrauterine Device study For practical purposes, if you’ve had one type expelled, switching to the other isn’t likely to solve the problem on its own.
Why the Uterus Pushes an IUD Out
The mechanism behind expulsion comes down to uterine muscle contractions. The IUD sits inside the uterine cavity, where the surrounding muscle (the myometrium) is always generating forces in various directions. Normally, the shape of the cavity and the multidirectional nature of those contractions hold the device in place. Expulsion happens when the dominant force vector runs from the top of the uterus toward the cervix and the muscle on either side fails to provide enough counterforce to keep the device anchored.16PubMed Central. Role of uterine forces in intrauterine device embedment, perforation, and expulsion
This helps explain why risk factors cluster the way they do. A uterus that contracts more forcefully (as with heavy periods or severe cramping) is generating more downward force. A postpartum uterus is larger and softer, providing less grip on the device. Younger users tend to have stronger myometrial activity. The IUD itself is passive; it doesn’t “migrate” on its own but gets pushed by muscle forces it cannot resist.
What Happens If You Get a Second IUD After Expulsion
Expulsion doesn’t mean IUDs are permanently off the table for you, but the odds of it happening again are meaningfully higher. Research on copper IUD reinsertion after a prior expulsion found a cumulative expulsion rate of about 21.7% at six months and 31.4% by the end of the first year, which is far above the baseline.17PubMed. Performance of copper intrauterine devices when inserted after an expulsion People whose first expulsion happened within the first three months of use had an even higher rate with the second device.
This doesn’t mean a replacement attempt is futile. Two out of three people in that study kept their second IUD in place through the first year. But if you’ve expelled one IUD, your provider should discuss whether your anatomy, risk factors, or preferences make a different contraceptive method a better fit. Some clinicians offer ultrasound-guided placement or may recommend a different device size or type for the second attempt, though evidence specifically supporting those strategies is limited.
Menstrual Cups and Expulsion Risk
If you use a menstrual cup alongside an IUD, this is worth knowing about. A systematic review identified 73 partial or total IUD expulsion events among menstrual cup users across seven studies. Three of those studies reported specific expulsion rates of 3.7%, 17.3%, and 18.6%, though the review noted the studies disagreed on whether the association was statistically significant.18Contraception and Reproductive Medicine. Menstrual cup and risk of IUD expulsion – a systematic review Time to expulsion ranged from under a week to over two years.
The concern is mechanical: breaking the suction seal of a menstrual cup before removal is supposed to prevent it from pulling on the IUD, but not everyone does this correctly every time. If you use both, the practical advice is to always break the seal before pulling the cup out, and to check that your IUD strings feel normal afterward. Some providers recommend trimming strings shorter for cup users to reduce the chance of the cup catching on them, though this can make string checks harder down the line.
Why String Checks Have Real Limits
You’ve probably been told to check your IUD strings regularly by reaching into the vagina and feeling for the thin threads at the cervix. This is reasonable advice, but its usefulness has limits that don’t always get communicated. As noted earlier, research found that visible strings were frequently present even in patients with confirmed malposition, and nearly half of those with displaced IUDs had no symptoms.19Journal of Ultrasound in Medicine. Clinical Relevance and Symptom Patterns for Malpositioned Intrauterine Devices That means “strings feel normal” doesn’t guarantee correct placement, and “strings feel different” doesn’t necessarily mean expulsion has occurred, since strings can curl, shift, or soften over time.
String checks are best understood as one signal among several. If your strings suddenly feel much longer, if you can feel hard plastic at your cervix, or if your strings disappear entirely, those are reasons to call your provider. But if your strings feel the same as always and you’re having no unusual symptoms, the device is probably fine. The point isn’t to make you anxious about string-checking technique; it’s to set realistic expectations about what the check can and can’t tell you. If something feels wrong, an ultrasound is the definitive way to know where your IUD actually is.
What to Do Right Now If You Think Your IUD Has Moved
If you’ve noticed something that makes you suspect expulsion, the first step is to stay calm and assess. Can you see or feel the device partially sticking out? Are you in severe pain, or is it more like mild cramping? Have you had unprotected sex recently?
If the device is visibly coming out, do not push it back in. You can gently remove it if it’s already mostly out, or leave it alone until you see your provider. Use backup contraception starting immediately. Call your provider’s office during business hours to schedule an evaluation. If you’re experiencing severe pain, heavy bleeding, or fever, that warrants an emergency department visit or urgent care, not because the expulsion itself is dangerous, but to rule out perforation, infection, or pregnancy complications.
For most people, the actual medical encounter after a suspected expulsion is anticlimactic: an ultrasound to confirm position, a conversation about whether to reinsert or switch methods, and reassurance. The event feels alarming in the moment, especially because it involves your reproductive health and a foreign object in your body. But the clinical reality is that expulsion is a known, well-understood complication of IUD use, and it almost always resolves without lasting harm.