Editorial

BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2021-201341 on 13 June 2022. Downloaded from http://jfprhc.bmj.com/ on March 18, 2023 by guest. Protected by copyright.
A proposed classification for
intrauterine device position:
the Tal-­Reeves classification
Michael G Tal,1 Matthew F Reeves ‍ ‍,2,3,4,5 Mark J Hathaway,6
Juan M Canela,7 Bob Katz8

1
Hadassah Medical Center, BACKGROUND the IUD and uterine fundus and the
Jerusalem, Israel
2 The lack of a common system for classifi- distance to the fundal-­ most portion of
DuPont Clinic, Washington, 7
DC, USA cation of intrauterine device (IUD) posi- endometrial cavity. Not surprisingly, the
3
Department of Obstetrics & tion is problematic. In one study, where position of the IUD changes during the
Gynecology, Stanford University IUD position was determined by expert menstrual cycle.2 Movement within the
School of Medicine, Stanford,
California, USA
opinion alone, increased IUD removal uterine cavity is normal, but, as an intra-
4
Department of Obstetrics resulted in more pregnancies, while no uterine contraceptive, the IUD should
& Gynecology, The George pregnancies occurred among those with not be located below the internal cervical
Washington University School of a ‘mal-­positioned’ IUD with no specific
Medicine and Health Sciences, os, the anatomic landmark defining the
criteria used.1 In practice, physicians often
Washington, DC, USA start of the uterine cavity. Using distance
5
Department of Population, see patients with IUDs located in different
from the fundus, the location of the IUD
Family, and Reproductive Health, areas of the uterus and the position
relative to the internal cervical os is not
Johns Hopkins Bloomberg School changes over time.2 After initial place-
of Public Health, Balitmore, captured.
Maryland, USA ment, some IUDs are found higher in the
6 uterus while others are found lower. Aside Similarly, extension of the arms of an
Jhpiego, Baltimore, MD, USA
7
La Clinica Canela, La Romana, from the multiple locations of the IUD in IUD into the myometrium (commonly
Dominican Republic the uterus, unilateral or bilateral ‘embed- referred to as ‘embedment’) has been asso-
8
ForwardVue Pharma, Inc, San ciated with pain and bleeding.8 Thus it is
Jose, California, USA ment’ or penetration of the IUD’s arms
into the myometrium is also common. important to capture intramural exten-
Correspondence to Patients using IUDs often present symp- sion of IUD arms in a classification of IUD
Dr Matthew F Reeves, DuPont toms relating to the device including position. Currently, this imaging feature is
Clinic, Washington, District of not routinely used as part of the imaging
Columbia, USA; ​mreeves5@​
pain, menstrual cramps and bleeding. The
jhu.​edu symptoms may be related to the position description of the position of IUDs.
of the IUD in the uterus and the amount We developed this classification system
Received 10 September 2021 of arm embedment into the myometrium, over the course of a randomised study
Accepted 25 October 2021
Published Online First but without a system for classification of two copper IUDs. In one arm of
13 June 2022 of position, it is not possible to conduct this study, we performed transvaginal
adequate clinical research on the relation- ultrasonography and hysterosalpingog-
ship between position and symptoms. raphy before and after each insertion of
Terminology for describing IUD loca- 99 copper T-­ shaped IUDs (T380S). At
tion has not been standardised.1 3 4 IUD 3-­month intervals over the first year, we
position has been studied in terms of performed transvaginal ultrasonography
relationship to the uterine fundus.5 6
and, if ultrasonography was not clearly
However, in clinical practice, the distance
normal, we also performed hysterosal-
from the uterine fundus is irrelevant.
pingography. During the course of the
The distance from the fundus depends
on the size of uterine cavity rather than study we observed a substantial number
© Author(s) (or their
employer(s)) 2022. Re-­use migration. If the uterine cavity is large of participants with partial expulsion and
permitted under CC BY-­NC. No
and the IUD is within the uterine cavity, intramural extension of the arms, leading
commercial re-­use. See rights to the development of this classification
and permissions. Published by the distance from the fundus has no
BMJ. known clinical value. In contrast, in a system. However, as this classification
small nulliparous uterus, an IUD which system developed through discussion over
To cite: Tal MG, Reeves MF,
Hathaway MJ, et al. BMJ Sex is 2 cm from the fundus may extend into the course of the study, we did not clas-
Reprod Health the cervix. Furthermore, symptoms do sify IUD position prospectively to allow
2022;48:157–159. not correlate with the distance between correlation with symptoms.

Tal MG, et al. BMJ Sex Reprod Health 2022;48:157–159. doi:10.1136/bmjsrh-2021-201341     157
 Editorial

BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2021-201341 on 13 June 2022. Downloaded from http://jfprhc.bmj.com/ on March 18, 2023 by guest. Protected by copyright.
Figure 2 Hysterosalpingogram images of the Tal-­Reeves classification of
Figure 1 Conceptual diagram of the Tal-­Reeves classification of intrauterine device position.
intrauterine device position.

‘normal position’ is less important than defining what

PROPOSED IUD POSITION CLASSIFICATION is abnormal.
We propose classifying IUD position based on IUD This system does not include IUD position within
location in relation to the cervix and intramural exten- the abdomen or other unusual positions which are,
sion of the IUD arms, using a two-­part nomenclature of fortunately, much less common. Although these IUD
one letter and one number. The letter defines the posi- locations are well known, over 130 person-­years of
tion of the inferior-­most point of the IUD: (A) above observation with the T380S we did not find any cases
the internal cervical os (ICO); (B) inferior tip of IUD is that could not be described using this system, indi-
below the ICO; (C) IUD completely within the cervix, cating the relative infrequency that other positions are
usually visible on speculum examination; and (D) IUD observed. Importantly, those rare IUD positions can
outside cervix (complete expulsion). We classified the be accurately described based on other anatomic land-
IUD arms as follows: (0) no intramural extension; (1) marks. Adding those positions to the proposed system
unilateral; or (2) bilateral extension into the myome- is unlikely to be useful.
trium. Figure 1 shows conceptual diagrams of the We believe that the proposed system parsimoniously
classification system. Figures 2 and 3 show examples balances precision with simplicity. Although one could
of hysterosalpingogram and ultrasonographic images, contemplate measuring the distance that the IUD lies
respectively, of this classification system. above or below the internal os, the distance is only
relevant for a particular uterus. For example, an IUD
4 cm below the internal os could be in position B
DISCUSSION (inside the cervix) for a patient with a 5 cm cervix, or
We propose a simple, feasible and practical classifica- for a patient with a 3 cm cervix, the IUD could be in
tion that uses the position of the IUD in relation to position C, extending outside the external os.
the internal os rather than the fundus. Modern ultra- On ultrasound imaging, the relationship of the
sound imaging enables visualisation of the location of bottom of the IUD and the internal os is easily identi-
the IUD in relationship to the cervical os as well as fied by anyone experienced in sonography (figure 3).
extension into the myometrium. The goal of the Tal-­ The difference between classification A and B is
Reeves classification system is to allow standardisa- defined simply by that relationship. If it is above the
tion of reporting of IUD location both for clinical use internal os it is A (Above), and if it is below, it is B
and research for evaluation of new IUD designs. The (Below). If it is seen through the cervix (you can ‘C’ it)
system proposed is based on the concept that defining it is C, and if it is not seen at all it is D (Disappeared).

158 Tal MG, et al. BMJ Sex Reprod Health 2022;48:157–159. doi:10.1136/bmjsrh-2021-201341
 Editorial

BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2021-201341 on 13 June 2022. Downloaded from http://jfprhc.bmj.com/ on March 18, 2023 by guest. Protected by copyright.
Contributors MGT and MFR developed the concepts
and wrote the manuscript. MJH, JMC and BK assisted in
development of the concepts and critically reviewed the
manuscript.
Funding The authors have not declared a specific grant for this
research from any funding agency in the public, commercial or
not-­for-­profit sectors.
Competing interests MFR, MJH and JMC were consultants
for ContraMed and now Sebela Pharma. MGT and BK were
employees of ContraMed LLC. MJH does Nexplanon training
for Merck.
Patient consent for publication Not applicable.
Ethics approval Not applicable.
Provenance and peer review Not commissioned; externally
peer reviewed.
Open access This is an open access article distributed in
accordance with the Creative Commons Attribution Non
Commercial (CC BY-­NC 4.0) license, which permits others
to distribute, remix, adapt, build upon this work non-­
commercially, and license their derivative works on different
terms, provided the original work is properly cited, appropriate
credit is given, any changes made indicated, and the use is non-­
commercial. See: http://creativecommons.org/licenses/by-nc/4.​
0/.

ORCID iD
Matthew F Reeves http://orcid.org/0000-0001-7749-7447

REFERENCES
1 Braaten KP, Benson CB, Maurer R, et al. Malpositioned
intrauterine contraceptive devices: risk factors, outcomes, and
future pregnancies. Obstet Gynecol 2011;118:1014–20.
2 Faúndes D, Bahamondes L, Faúndes A, et al. T-­shaped IUD
move vertically with endometrial growth and involution during
the menstrual cycle. Contraception 1998;57:413–5.
3 Shipp TD, Bromley B, Benacerraf BR. The width of the uterine
cavity is narrower in patients with an embedded intrauterine
device (IUD) compared to a normally positioned IUD. J
Ultrasound Med 2010;29:1453–6.
4 Boortz HE, Margolis DJA, Ragavendra N, et al. Migration of
intrauterine devices: radiologic findings and implications for
Figure 3 Ultrasonographic images of the Tal-­Reeves classification of patient care. Radiographics 2012;32:335–52.
intrauterine device position.
5 Aleem HA, Kamel HS, Aboul-­Oyoun EM. Role of
ultrasonography in managing IUD-­related complaints.
We observed excellent correlation between hysterosal- Contraception 1992;46:211–20.
pingography and ultrasonography findings, suggesting 6 Petta CA, Faúndes D, Pimentel E, et al. The use of vaginal
that the classification can be made based on ultrasound ultrasound to identify copper T IUDs at high risk of expulsion.
imaging alone. Contraception 1996;54:287–9.
Imaging of IUDs is increasingly common both in 7 Faúndes D, Bahamondes L, Faúndes A, et al. No relationship
clinical practice and in research. We need a common between the IUD position evaluated by ultrasound and
complaints of bleeding and pain. Contraception 1997;56:43–7.
language to communicate the IUD position. In newer
8 Benacerraf BR, Shipp TD, Bromley B. Three-­dimensional
IUD efficacy studies, ultrasonography is used almost
ultrasound detection of abnormally located intrauterine
universally but with differing definitions of partial
contraceptive devices which are a source of pelvic pain and
expulsion.9 10 The use of a classification system would abnormal bleeding. Ultrasound Obstet Gynecol 2009;34:110–
provide a common language for communicating IUD 5.
position. We believe that the Tal-­Reeves classification 9 Eisenberg DL, Schreiber CA, Turok DK, et al. Three-­year
proposed here can fulfil that need. In the future, we efficacy and safety of a new 52-­mg levonorgestrel-­releasing
hope that having a common language for reporting intrauterine system. Contraception 2015;92:10–16.
IUD position will facilitate research into the relation- 10 Nelson A, Apter D, Hauck B, et al. Two low-­dose
ship between position and clinical outcomes. levonorgestrel intrauterine contraceptive systems: a
randomized controlled trial. Obstet Gynecol 2013;122:1205–
Twitter Matthew F Reeves @reevesdupont 13.

Tal MG, et al. BMJ Sex Reprod Health 2022;48:157–159. doi:10.1136/bmjsrh-2021-201341 159