Case Report

The Chinese Ring

A Contraceptive Intrauterine Device

Taylor L. MacDonald, MS, Eugenio O. Gerscovich, MD,

John P. McGahan, MD, Maria Fogata, MD

he stainless steel ring (SSR; Figure 1) is a commonly used Chinese intrauterine

device (IUD) that has a typical appearance when shown on sonography.
Considering the large number of Chinese immigrants coming to the United
States and the 2.7 million Chinese-born immigrants currently living here, it is
not surprising that many family practitioners, obstetricians, sonographers, and sonologists will see the SSR at some point in their careers.1 General knowledge about the
effectiveness, risks, and sonographic appearance of the SSR is important for physicians
who may encounter this particular IUD in their practices. To the best of our knowledge,
no previous reports of the sonographic appearance of the SSR have been reported in
the English language imaging literature.

Case Report

Abbreviations
IUD, intrauterine device; SSR, stainless steel ring

Received November 2, 2005, from Kirksville College

of Osteopathic Medicine, Kirksville, Missouri USA
(T.L.M.); and Department of Radiology, University of
California, Davis Medical Center, Sacramento,
California USA (E.O.G., J.P.M., M.F.). Manuscript
accepted for publication November 15, 2005.
Address correspondence to Eugenio O.
Gerscovich, MD, Department of Radiology,
University of California, Davis, 4860 Y St, Suite 3100,
Sacramento, CA 95817 USA.
E-mail: eugenio.gerscovich@ucdmc.ucdavis.edu

A 41-year-old Chinese woman, immigrant to this country, went to her family practitioner for a yearly well
woman examination. On questioning, the patient stated
she had been having regularly timed menses with occasional heavy flow. This had been occurring since placement of an IUD, inserted approximately 8 years before
while she was still living in China. The device was placed
after an uneventful delivery of her first pregnancy. The
patient denied any pregnancies since the IUD was inserted, despite being sexually active. A thorough physical
examination was performed, including a pelvic examination with a speculum. The pelvic examination revealed
no gross abnormalities; however, the primary care physician was unable to identify an IUD string. In light of the
lack of visual evidence of an IUD, the provider assumed
the IUD had been lost and ordered pelvic sonography
to confirm. Transabdominal sonography was performed, which showed a curvilinear strong echogenicity in the lumen of the patients uterus. Endovaginal
sonography showed the echogenicity as corresponding
to a ringlike structure in the endometrial cavity (Figure 2).

2006 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2006; 25:273275 0278-4297/06/$3.50

The Chinese Ring

The interpreting radiologist identified the object

as a Chinese SSR IUD, and the primary care
physician was notified. The risks associated with
the device were explained to the patient, who
ultimately declined removal of the SSR for the
time being, with possible reevaluation if menstrual bleeding increased or anemia developed.

Discussion

Figure 1. Stainless steel ring. Courtesy of Jeff Bradley, RDMS,

OBGYN.net (http://www.obgyn.net/us/us.asp?page=/us/present/9808/Bradley, accessed October 21, 2005). Photography of
IUDs provided by Joseph S. K. Woo, MBBS, FRCOG.

The SSR is an IUD that has been used as the main

method of birth control in China, accounting for
90% of all IUD use. One reason for the high
prevalence of the SSR is the low cost associated
with production, estimated to be less than one
fourth the price of the Copper T IUD.2 Low cost

Figure 2. Endovaginal sonograms of the uterus with the SSR in place. AC, Coronal views at different levels of the IUD. D, Sagittal
view. Observe the circular configuration of the IUD. Arrows indicate SSR and U, uterus.

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MacDonald et al

combined with national family-planning practice

policy encouraging maternal IUD insertion after
the first child for population control purposes has
resulted in more than 50 million Chinese women
using the SSR.2 However, both physician and
patient should be aware of the significant risks
associated with the SSR. One study performed by
the China State Family Planning Commission
showed 12-month failure rates of 10.6% for the
SSR compared with rates of 1.7% for the Copper T
and 2.1% for the Copper V.3 A second study confirmed these high rates of undesired pregnancy
(IUD failure), showing an 8% failure rate at 2 years
for the SSR versus rates of 2.1% and 1% for the
Copper V and T, respectively.4 The same study
also showed expulsion rates of 12.6% for the SSR,
whereas the Copper T had a 1.7% rate, and the
Copper V had a 1.6% rate.4 This high rate of expulsion is worrisome, especially given the fact there
is no IUD string attached; therefore, there is no
way on speculum to check to see whether the
IUD is in place. Thus, in questionable cases,
sonography may be used as a method to check
the location of this IUD. In light of the higher rates
of complications, it is not surprising that the government of China decided to convert from the
SSR to the TCu220C and TCu380A devices beginning in 1993. By doing so, it is estimated that
more than 55 million pregnancies, including 35.6
million induced abortions, will have been avoided over the last decade.5
Despite the change, the early marriage rates and
encouragement of IUD insertion after the birth of
the first child result in millions of Chinese women
of child-bearing age still using the SSR. With more
than 2.7 million Chinese immigrants living in the
United States as of 2000, there is a high likelihood
that practitioners with obstetric and gynecologic
patients will encounter a patient at reproductive
age with the SSR.1
Proper identification of the SSR with its distinct
appearance, a ringlike hyperechoic structure on
sonography without a string for removal, is diagnostic. Risks and benefits of retaining the device,
including substantial failure rates, should be discussed with the patient, as well as plans for future
care. Removal via endocavitary instrumentation
is possible, and cases have been described involving successful removal early in gestation with the
use of a stone clamp under sonographic guidance.6 The technique described in these cases
was similar to the technique used for transcervical chorionic villous sampling.7
J Ultrasound Med 2006; 25:273275

References
1.

US Census Bureau. 2000 Census of Population and

Housing: Population and Housing Unit Counts. United
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2004.

2.

Kaufman J. The cost of IUD failure in China. Stud Fam Plann

1993; 24:194196.

3.

State Family Planning Commission of China. A clinical trial

of three commonly used IUDs. In: Condensed Summary of
Family Planning Scientific Research Results During the Sixth
Five Year Plan. Beijing, China: State Family Planning
Commission of China; 1985:1921.

4.

Gao J, Shen H, Zheng S, et al. A randomized comparative

clinical evaluation of the Steel Ring, VCu200 and TCu220C
IUDs. Contraception 1986; 33:443454.

5.

World Health Organization Special Program of Research.

China changes from the stainless steel ring to modern IUDs.
Prog Hum Reprod Res 1993; 27:7.

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Sachs BP, Gregory K, McArdle C, Pinshaw A. Removal of

retained intrauterine contraceptive devices in pregnancy.
Am J Perinatol 1992; 9:139141.

7.

Rodeck CH, Mossman JM, Nicholaides KH, McKenzie C,

Gosden CM, Gosden JR. A single-operator technique for
first trimester chorion biopsies. Lancet 1983; 2:13401341.

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