A Randomized Controlled Trial of No-Strings Intrauterine Device (IUD) Removal Techniques: Alligator Forceps Versus Manual Vacuum Aspiration (MVA) [ID 1330]

INTRODUCTION: The objective was to compare first-pass and overall removal rates of manual vacuum aspiration (MVA) versus alligator forceps for intrauterine devices (IUDs) with no visible strings. METHODS: We enrolled people seeking IUD removal with no visible strings into a randomized, single-blind trial. Participants were randomized to removal with alligator forceps (standard of care) or MVA. If removal with MVA was unsuccessful after three attempts, alligator forceps were used. The primary outcome was successful first-pass removal. Secondary outcomes included successful removal, post-procedure recall of maximum pain (100-mm visual analog scale), need for cervical dilation, procedure time, satisfaction, and complications. We required 46 participants to detect a 40 percentage-point difference in first-pass removal success rates with a two-sided α=0.05 and 80% power. RESULTS: We stopped enrollment after 13 participants (6 alligator forceps, 7 MVA) due to significant concerns with patient-reported pain in the MVA group. First-pass removal was successful in 33% in the alligator forceps group versus 14.2% in the MVA group ( P =.55), and overall success rates were 100% with alligator forceps and 33.3% for MVA ( P =.07). Intention-to-treat analysis demonstrated maximum pain = 31.5 mm (±17.5) for alligator forceps versus 61.7 mm (±17.6) for MVA ( P =.01). Procedure time, need for dilation, and participant satisfaction were similar between groups, and there were no complications. CONCLUSIONS/IMPLICATIONS: In a high-resource setting, alligator forceps remains the standard of care to remove IUDs without visible strings, as removal with MVA may be more painful. Further strategies are needed for IUD removal with no strings in low-resource settings, including those without ultrasound guidance.