One of the most significant factors necessitating IUD removal is pelvic pain, which includes insertional pain, intermenstrual cramps, often associated with spotting and bleeding, and increased dysmenorrhea. The larger and stiffer devices and those whose shape does not conform to that of the endometrial cavity produce localized endometrial ulceration and inflammation, which contribute to these symptoms. Endometrial prostaglandin release secondary to the presence of an intrauterine foreign body may also play an important role. In patients who have pelvic pain with an IUD it is of utmost importance to completely evaluate them and exclude other causes of pain, such as pelvic inflammatory disease, with and without abscess formation, and ectopic gestation.