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http://www.obgyn.ufl.edu/obgyn101/Text/Contraception/IUD.htm

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The Dalkon Shield
While many IUDs were known to be safe and effective, one in particular, the Dalkon Shield, seemed to have more than its' share of problems, the most important of which was infection. Pelvic infections, infrequent and usually minor with the other IUDs, tended to be more frequent and more severe among Dalkon Shield users. Many of these infections were so serious as to render the patient permanently sterile or to necessitate a hysterectomy.

There were two reasons for these infections; a design flaw and a marketing flaw. The design flaw was located in the "tail" or string used to remove the IUD. After insertion, the string is left protruding through the cervix so it is visible on pelvic exam. This confirms that the IUD is correctly placed and facilitates removal at a later date. The Dalkon Shield string was made up of many tiny plastic filaments and encased in a plastic sheath. This design inadvertently caused the string to act as a wick, constantly drawing vaginal bacteria up through the cervix and into the uterine cavity where they could cause infection. The other IUDs had monofilament strings which did not have the same wicking capacity. The design, in retrospect, predisposed the Dalkon Shield to infections.

The marketing flaw was to promote IUD among young, single women without children. These women tended to have greater risk of exposure to sexually transmitted disease and multiple sexual partners. They tended to be more likely to seek medical attention late in the course of the illness. The consequences of permanent infertility among these young women was devastating.

While the design and marketing flaws of the Dalkon Shield are of primarily historical interest, the lessons learned at a terrible cost should not be forgotten in looking at more modern IUDs.

Infection
With the newer designs, the risk of infection has been significantly reduced. Sooner or later, about 3-5% of IUDs will be removed because of infection. Most of these infections are minor, with mild symptoms of vague pelvic discomfort, painful intercourse and possibly a low-grade fever. The uterus is tender to palpation although the adnexa usually are not. Treatment of such mild infections generally involves prompt removal of the IUD, oral broad spectrum Antibiotics and complete resolution of symptoms. Infertility following such mild infections is uncommon.

With the less common, serious infections, a high fever can be found, movement of the cervix causes excruciating discomfort and the adnexa are extremely tender. In addition to prompt removal of the IUD, IV Antibiotics are recommended to treat this moderate to severe PID. In these cases, recovery is generally slow (days to weeks) and infertility is a distinct possibility.

Perforation
The overall risk of perforation of the IUD through the uterine wall is about 1 in 1,000. Most of these occur during the insertion of the IUD or shortly thereafter. More common than perforation is the "disappearance" of the IUD string. While such a disappearance may suggest the possibility of perforation, a more likely explanation is that the string has coiled up inside the cervical canal or even inside the uterus.

A truly perforated IUD is usually removed from the abdominal cavity with laparoscopic or open surgery.

Missing IUD String
When confronted with a missing IUD string, most clinicians will gently probe the cervical canal to see if they can tease the string back down through the os. A cotton-tipped applicator or a Pap smear brush works well for this purpose. Once the string is brought down into the vagina (and about 3/4 will be found this way), nothing further needs to be done.

If the string is not inside the cervical canal, then further evaluation and treatment will be needed from an experienced and well-equipped gynecologic consultant. X-ray can confirm that the IUD remains somewhere within the pelvis. Ultrasound can demonstrate the presence of the IUD inside the uterine cavity. For an IUD which is clearly inside the uterine cavity but whose string has retracted into the cavity, a careful judgment must be made.

In some circumstances, the IUD is removed with an IUD hook, D&C or hysteroscopy
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