Intrauterine Device Insertion
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Intrauterine device insertion is an outpatient procedure that should be performed by trained healthcare professionals. Intrauterine devices (IUDs) are an effective and increasingly popular form of reversible contraception. [1, 2] The increase in popularity has been attributed to their efficacy, ease of reversibility, and patient satisfaction, with minimal effort required for long-term use. [3, 4] IUDs are equivalent to tubal sterilization at preventing pregnancy; in addition to vasectomy, they are the most cost-effective method of long-term contraception available in the United States. [5, 6] The IUDs currently available in the United States include the copper T380A IUD (Paraguard) and 2 levonorgestrel-releasing intrauterine systems (Mirena and Skyla).
The World Health Organization and the Centers for Disease Control and Prevention (CDC) have developed guidelines for practitioners regarding IUD use in a variety of clinical circumstances. [7, 8] IUDs are considered appropriate for the majority of women, including nulliparous women and adolescents. Both immediate postpartum insertion (within 10 minutes of placental delivery) and delayed postpartum insertion (within 4 weeks of placental delivery) are acceptable. Similarly, postabortion (spontaneous or elective) insertion is acceptable.
IUD use is safe in women with the following conditions:
History of an ectopic pregnancy
History of pelvic surgery
Hypertension or other forms of heart disease
History of deep venous thrombosis
History of migraine headaches
Diabetes
Smoking
Also, women with a history of sexually transmitted infections or a history of pelvic inflammatory disease may safely use an IUD, provided they have been treated and a test of cure has been obtained. [7, 8, 9] .
Absolute contraindications for IUD use include the following:
Pregnancy
Significantly distorted uterine anatomy
Unexplained vaginal bleeding concerning for pregnancy or pelvic malignancy
Gestational trophoblastic disease with persistently elevated beta-human chorionic gonadotropin levels
Ongoing pelvic infection
Ongoing pelvic infections (eg, pelvic inflammatory disease, untreated cervicitis, puerperal sepsis, immediate postabortion or postpartum infection, endomyometritis, pelvic tuberculosis) are also absolute contraindications for IUD placement. [8, 7] In women with these infections, placement should be deferred for 3 months after treatment and a physical examination should be performed prior to insertion to exclude any evidence of persistent infection. [10]
In general, women with a new diagnosis of cervical cancer should not receive IUDs. Although the World Health Organization and the CDC do not recommend the use of IUDs in women with a new diagnosis of endometrial cancer, [7, 8] there are observational studies and case reports suggesting that the 52 mg levonorgestrel-releasing intrauterine system (Mirena) may be an acceptable alternative for treatment in women who strongly desire fertility. [11, 12]
The levonorgestrel-releasing intrauterine systems are contraindicated in women with a history of breast cancer or in women with a benign or malignant liver tumor.
The copper T380A IUD is contraindicated in women with a known copper allergy or in women with Wilson disease. [12, 11]
Complications from IUD placement are relatively rare. The most common complication is IUD expulsion, which occurs in approximately 2-10% of cases. [5] Patients should be encouraged to feel for their IUD strings on a regular basis at home to ensure correct placement. Placement in the immediate postpartum period is associated with a higher expulsion rate than delayed postpartum insertion. [13] Similarly, insertion immediately following first and second trimester spontaneous or elective abortion is also associated with a higher expulsion rate than delayed insertion. [14] There are, however, numerous advantages to postprocedural and postpartum insertion, which may outweigh the risk of expulsion (see Timing of Insertion).
Method failure is an exceedingly uncommon complication of IUD use. The 52-mg levonorgestrel-releasing intrauterine system (Mirena) has a failure rate of 0.2% in the first year of use. The 13.5-mg levonorgestrel-releasing intrauterine system (Skyla) has a failure rate of 0.4% in the first year of use. [15] The copper T380A IUD has a 1-year failure rate of 0.8%. [5] When pregnancy does occur following IUD placement, the pregnancy is more likely to be ectopic. [16] The World Health Organization and the U.S. Food and Drug Administration both recommend IUD removal if pregnancy occurs. Pregnancies that persist with an IUD in place are associated with high risk of complications, including spontaneous abortion and septic abortion. [17, 9]
Another uncommon complication of IUD placement is uterine perforation, which occurs in 0.1% of cases. [18] Severe pain or loss of resistance with sounding for IUD insertion are signs of perforation. If perforation is suspected, the procedure should be stopped and postponed. The patient’s vital signs should be assessed to identify and signs of hemorrhage. If any of these signs are evident, the patient should be transported to an emergency facility rapidly.
Rarely, a patient may experience a vasovagal episode as a result of cervical or uterine manipulation. If this occurs, the procedure should be stopped and patient’s condition managed appropriately.
All patients who express interest in an IUD should be counseled regarding alternative forms of contraception. Following this conversation, informed consent should be obtained from the patient. Both the levonorgestrel-releasing intrauterine systems and the copper T380A IUD have patient information included within IUD packaging; this should be provided to the patient, ideally at a visit prior to IUD insertion.
An essential part of preinsertion counseling involves clear communication regarding expectations with IUD placement and continued use. This counseling has been proven to decrease interval IUD removal rate. [19, 20]
Inform the patient that mild pain with insertion is common. With the levonorgestrel-releasing intrauterine systems, many women experience cramping for days to weeks following insertion. Additionally, levonorgestrel-releasing IUD users should be informed that although daily spotting may occur following insertion, periods usually become lighter. Further, amenorrhea has been reported in as many as 70% of women after 2 years of use. [21] With the copper T380A IUD, bleeding may initially increase and periods should continue owing to the nonhormonal mechanism of action. [22]
In preparation for IUD insertion, a thorough history should be obtained. The patient’s medical history should be assessed, including her sexual history, to ascertain her risk for sexually transmitted infections (STIs).
The risk of postinsertion pelvic infection appears to be the highest in the first 20 days following placement, [23, 24] which suggests that the mechanism of infection is more likely related to contamination of the upper genital tract at the time of insertion over presence of IUD. Therefore, it is important to assess patient risk for STIs prior to IUD placement.
With regard to preinsertion STI screening, the American College of Obstetrics and Gynecology (ACOG) recommends adherence to CDC guidelines for general assessment of STI risk and STI screening. [25, 9] In summary, ACOG does not recommend screening for STIs prior to IUD insertion in women who are at low risk. [9] Women at high risk for STIs, defined as age 25 years or younger or having multiple sexual partners, should be screened at the time of insertion. [9] If these tests are positive, the patient can be treated with the IUD remaining in place as there is low risk (< 5%) for developing pelvic inflammatory disease if this treatment is prompt. [26, 27]
If the preinsertion physical examination is concerning for ongoing infection (ie, cervicitis, mucopurulent discharge, cervical motion tenderness), the patient should be screened for infection and treated appropriately. In this setting, insertion should be deferred for 3 months. Similarly, IUD insertion is contraindicated within 3 months of treatment for pelvic inflammatory disease, endomyometritis, chorioamnionitis, puerperal sepsis, or a septic abortion. [7, 8]
Additionally, it is imperative to elucidate the patient’s risk for current pregnancy and time within her current menstrual cycle prior to IUD insertion. A negative urine pregnancy test is a prerequisite to placement of an IUD. Pregnancies occurring with IUDs in place have an increased incidence of complications, including spontaneous abortion and septic abortion. [17, 9] For this reason, many providers prefer to time IUD insertion within the first 5-7 days of the menstrual cycle, further assuring that the patient is not newly pregnant.
The equipment necessary for insertion include the IUD and package contents (see Devices), a speculum, a single-tooth tenaculum, a uterine sound, antiseptic solution, sterile gloves, and scissors. Also, having a cervical os finder available is recommended. If insertion occurs in the immediate postpartum period, ring forceps are needed.
Anesthesia
No anesthesia or analgesia is indicated for insertion of either the copper T380A or the levonorgestrel-releasing IUDs. [28, 29]
Pain during insertion is likely multifactorial; possible sources include placement of speculum, use of tenaculum on cervix, cervical and uterine irritation from passing the sound, and placement of the IUD. Patients who experience increased pain with insertion are more commonly nulliparous, under 30 years of age, are nonlactating, or have had a longer interval since their last pregnancy or last menses. [28] The preprocedure expectation of pain is also thought to contribute to perceived pain with IUD insertion, emphasizing the importance of preprocedure counseling. [29]
Anecdotally, paracervical blocks have been used if insertion was previously abandoned secondary to patient discomfort or there is significant concern regarding patient tolerance of procedure. Multiple studies have researched the effect of preinsertion nonsteroidal anti-inflammatory drugs (NSAIDs) on patient discomfort during IUD insertion, and no significant improvement in patient discomfort has been elucidated. [28, 29, 30]
Saav et al. [31] evaluated the effect of preprocedure placement of misoprostol for cervical ripening. While misoprostol given 1 hour prior to placement was found to facilitate placement, there was no significant effect on patient discomfort or procedural complications. This argues against routine use of misoprostol for cervical ripening prior to IUD placement.
Positioning
IUD insertion is best accomplished with the patient in dorsal lithotomy position.
Following IUD insertion, patients should schedule a follow-up visit in approximately 4 weeks. At this visit, any problems can be discussed and an examination should be performed to confirm the IUD strings are visible extending from the cervical os. Absence of the IUD strings during this examination is concern for migration of the IUD, possibly related to unrecognized uterine perforation, and warrants further evaluation.
No antibiotic prophylaxis is indicated for IUD insertion. Multiple studies have examined the effect of antibiotic prophylaxis on postinsertion infection in low-risk patients. Antibiotic prophylaxis has been convincingly shown to have no effect on the incidence of postinsertion pelvic inflammatory disease. [32, 33, 34]
Risk of infection is greatest the first 20 days after insertion, suggesting the etiology of infection is contamination at time of insertion rather than the IUD itself. [35, 23] Accordingly, prevention of infection is best accomplished by careful screening for infection by history and physical examination prior to and at the time of IUD insertion.
An IUD can be inserted at any time during the menstrual cycle. [9] It is imperative that the possibility of pregnancy be reasonably excluded by urine pregnancy test, as well as assessment of sexual history, inquiry regarding method of contraception leading up to IUD insertion, and timing within current menstrual cycle. This is especially critical in patients with no or unreliable contraception prior to IUD insertion.
Ideally, IUD insertion should occur within the first 7 days of menstrual cycle to decrease the risk of concurrent pregnancy. Also, insertion during the follicular phase is associated with fewer requests for IUD removal secondary to pain or irregular bleeding than insertion during the luteal phase. [36] Follicular insertion is, however, associated with a slightly higher risk of spontaneous expulsion when compared to luteal insertion [36]
A backup method of contraception should be used for 7 days following insertion of the levonorgestrel-releasing intrauterine systems except in the following circumstances: the IUD was inserted within the first 5 days of the menstrual cycle, the patient was reliably using contraception leading up to IUD placement, or the IUD is placed immediately postpartum or postabortion. No postinsertion backup contraception is indicated for the copper T380A IUD. [9]
Postpartum Insertion
Reliable data exist to support the safety and effectiveness of immediate (within 10 minutes) postpartum insertion of both the levonorgestrel-intrauterine systems and the copper T380A IUD. [37, 13] Insertion has been proven to be safe and effective after both vaginal delivery and cesarean delivery. [38]
Choosing the immediate postpartum period for insertion is advantageous for several reasons. First, in the immediate postpartum period patients are motivated regarding contraception, and this occasion eliminates concern regarding insertion timing and pregnancy risk. [37] Further, postpartum IUD insertion is theoretically less painful secondary to cervical dilation and labor analgesia and is more convenient for the patient. [37] Although previously a concern, the literature supports that neither the levonorgestrel-releasing intrauterine system nor the copper T380A has a negative effect on breastfeeding volume/duration or infant growth. [39]
Expulsion rates in patients who undergo postpartum insertion are higher than in women who delay insertion for postpartum follow-up appointments (23.5% versus 4.4%). However, delaying insertion to postpartum follow up visit is associated with a significantly decreased number of patients that follow through with IUD insertion. [13]
Given the higher expulsion rate, close follow-up is indicated following postpartum insertion to identify unrecognized spontaneous expulsions. IUDs should not be placed in the immediate postpartum period in women who have been diagnosed with chorioamnionitis or endometritis.
Insertion After Elective or Spontaneous Abortion
IUDs are a safe and effective means of contraception following spontaneous or elective abortion. [14, 40, 41] Women who have elective abortions are at risk for future unplanned pregnancy and immediate postabortion IUD insertion has been convincingly shown to decrease unplanned pregnancies in these women. [42, 43]
Although both immediate insertion and interval insertion 4–8 weeks after the procedure are safe, data support immediate insertion for several reasons. [44, 14] First, patients are often motivated regarding contraception at this time and have access to health care that they might not otherwise seek. [45, 46, 47]
Immediate insertion is also advantageous because it eliminates concern for timing of insertion with regard to potential pregnancy. In addition, postinsertion bleeding may be masked by postabortion bleeding, resulting less patient dissatisfaction with IUD as method of contraception. Lastly, less than one-third of women who report planning to use an IUD for contraception postabortion actually follow-up to have IUD placed. [44, 48]
Immediate postabortion insertion is associated with an increased expulsion rate compared with interval insertion. This expulsion risk is higher with second-trimester abortions compared to first-trimester abortions. [14, 44] Immediate postabortal insertion should not be considered in women with septic abortions or with concern for postprocedural infection (endomyometritis). [7, 8]
IUD for Emergency Contraception
The copper T380A IUD is safe and effective for use as an emergency contraceptive if inserted within 5 days of unprotected intercourse. Further, it is advantageous as it will continue to provide effective reversible contraception for up to 10 years from the time of insertion. [49, 50] Up to one-third of women are interested in IUD use for emergency contraception; however, it is not nearly that frequently utilized. The primary barrier to insertion was found to be cost. [51] The copper T380A IUD is more effective for emergency contraception than hormonal emergency contraceptive pills. [5] The levonorgestrel-releasing intrauterine systems are not to be used for emergency contraception.
Insertion of both the levonorgestrel-releasing IUDs and copper T380A IUD begins with a bimanual examination to ascertain uterine size and position.
Next, a speculum is used to gain clear visualization of the cervix. At this time, cervical gonorrhea and chlamydia tests should be obtained if indicated. The cervix and adjacent vagina are then cleansed with povidone-iodine or chlorhexidine. From this point forward, sterile gloves should be worn by provider.
Although the majority of women will tolerate placement of IUD without a local anesthetic, if placement has previously been challenging or patient preference dictates, a paracervical block may be performed at this time.
Using a single-tooth tenaculum, grasp the anterior lip of the cervix. Gentle traction on this tenaculum will facilitate both sounding of the uterine cavity and IUD placement by bringing into line the cervical canal and the uterine cavity. If the uterus is retroverted, placing the tenaculum on the posterior lip of the cervix may better facilitate alignment of the cervix and the uterine cavity.
While providing gentle downward traction on cervix, use a uterine sound to assess the size of the uterine cavity. Sounding helps the provider appreciate the direction of the cervical canal and endometrial cavity, allows for assessment of patency, and allows for a basic assessment of intrauterine anatomy. If the uterus sounds to less than 6 cm or greater than 10 cm, insertion should be stopped and further assessment of intrauterine anatomy with ultrasound should be considered.
The packaging is opened by an assistant, taking care to maintain the sterility of the package contents. Care is taken to ensure the arms of the IUD are in a horizontal position (see the image below).
The threads on the handle of the IUD insertion device are then released from the groove in the handle of the insertion device. While pushing the slider toward the insertion tubing, the strings at the base of the IUD handle should be pulled, which will retract the IUD arms into the insertion tubing. See the image below.
The threads are then secured in the thread cleft, as shown in the image below.
The flange on the insertion device is then set at the level to which the uterus sounds. This is accomplished by sliding the flange over the marked increments on the IUD insertion tube, as shown in the image below.
One hand is then used to provide gentle downward traction on the tenaculum. While continued upward pressure is applied to the green slider on the IUD handle, the insertion tubing is placed into the vagina at the level of the external cervical os. The insertion tubing is then gently advanced until the flange is approximately 1.5-2 cm from the external cervical os. See the image below.
Next, the slider on the handle is pulled backward to the level of the raised mark on the insertion handle, expelling the IUD arms from the insertion tubing (see the image below), and wait 10 seconds to allow the arms to open completely.
The insertion tubing is then advanced until the flange is at the external cervical os, thereby advancing the IUD to the level of the uterine fundus (see the image below).
While holding the insertion device steady, the slider is pulled all the way down to release the IUD. The IUD handle and insertion tubing are then gently retracted from the uterus and cervix. The strings will remain in place. See the image below.
Following removal of the insertion device, the IUD strings will be readily visualized in vagina. Using long-handled scissor, the strings are then trimmed so that approximately 3 cm are visible, extending from the external cervical os. [52] See the image below.
The copper T380A packaging is opened by an assistant, taking care to maintain the sterility of the package contents.
Load the IUD into the insertion tubing. This is accomplished by slightly withdrawing the insertion tubing and folding the horizontal arms of the IUD down along the vertical arm using your thumb and index finger. The insertion tubing is then advanced so that the horizontal arms sit securely within the insertion tubing. See the images below.
Next, the solid white rod is introduced into the bottom of the insertion tubing and advanced to the point that it touches the bottom of the IUD (see the image below).
The insertion tube is grasped at the open end and the blue flange is set to the level to which the uterus sounds. The insertion tubing is then rotated so that the horizontal arms of the IUD are parallel to the long axis of the blue flange. See the image below.
The loaded insertion tube is passed through the cervical canal until resistance is met at the uterine fundus and the blue flange should be at the external cervical os, as shown in the image below.
With the solid white rod steady, the insertion tubing is withdrawn approximately 1 cm, releasing the IUD.
The insertion tube is then gently moved up to the fundus of the uterus, ensuring placement of the IUD at the level of the fundus. Holding the insertion tubing steady, withdraw the white rod. Then, gently withdraw the insertion tubing. See the image below.
Following removal of insertion device, the IUD strings will be readily visualized in vagina. Using long-handled scissors, the strings are then trimmed so that approximately 3 cm are visible extending, from the external cervical os. [53] See the image below.
After performing a thorough physical examination to rule out any signs of intrauterine or cervical infection, either a levonorgestrel-releasing intrauterine system or the copper T380A IUD may be inserted using the steps outlined above.
Following delivery of the placenta, an assessment is performed by the provider to assess for uterine hemorrhage, atony, or signs of infection. If any of these conditions are present, insertion should be delayed. If the patient delivered vaginally, the IUD may be inserted using the steps outlined above.
Alternatively, the IUD may be removed from the insertion device, grasped with ring forceps, and placed though the dilated cervix and up to the level of the fundus, taking care to ensure that the horizontal arms of the IUD point toward the cornua. The provider also may place the IUD manually. No significant differences in complications, infection, or expulsion between various modes of insertion have been found. [54]
If the IUD is inserted immediately following a cesarean delivery, the IUD is removed from the insertion tubing and is similarly placed either manually or using ringed forceps. The IUD strings are then pushed inferiorly into the vagina and the hysterotomy is then closed. In this setting, trimming of strings can be delayed to the postpartum visit.
Three IUDs are approved by the FDA: the 2 levonorgestrel-releasing intrauterine systems (Mirena, approved in 2000 and Skyla, approved in 2013) and the T380A intrauterine copper contraceptive (Paraguard, approved in 1988). Mirena and Skyla contain levonorgestrel (a progestin) that is released for up to 3 years (Skyla) or 5 years (Mirena).
The levonorgestrel-releasing intrauterine systems consist of a T-shaped polyethylene frame with a hormone reservoir that contains 13.5 mg (Skyla) or 52 mg (Mirena) of levonorgestrel. See the image below.
Mirena is initially released at a rate of 20 µg/day and decreases to 11 µg/day after 5 years. [52] The levonorgestrel release results in endometrial suppression and changes in cervical mucus, which deter pregnancy. [55, 56] Skyla releases 13.5 mg of levonorgestrel at a rate of 14 µg/day after 24 days following insertion. The release rate declines to 5 µg/day after 3 years. [15]
Other factors thought to contribute to the contraceptive effect include inhibition of sperm migration, alterations in ovum transport, as well as damage to the ovum. [57] The pregnancy rate at 1 year of use of Mirena is approximately 0.2%, with a cumulative pregnancy rate over 5 years of 0.7%, representing the most effective form of reversible contraception available. [2, 5] The 1-year pregnancy rate with Skyla is 0.4%, with a cumulative pregnancy rate of 0.9% after 3 years of use. [15]
Mirena is FDA approved for contraception for 5 years and Skyla for 3 years, after which time the devices should be removed and replaced if continued contraception is desired. [52] In 2009, Mirena was also approved for treatment of heavy menstrual bleeding in women who have concurrent undesired fertility.
When compared with medical management of menorrhagia with progesterone-containing oral contraceptive pills, Mirena resulted in significantly less menstrual blood loss. Further, women who used Mirena were more satisfied with treatment (76%) compared with women who used oral contraceptive pills (22%). [58] Reid et al studied reduction in menstrual blood loss in women using Mirena compared with women taking mefenamic acid for treatment of menorrhagia. They found that although both significantly decreased blood loss, the effect was more pronounced in the IUD group. [59]
Studies that sought to compare Mirena with endometrial ablation for treatment of menorrhagia found both were equally effective at reducing menstrual blood loss, and there were no significant differences in patient satisfaction between the groups. [60, 61] Mirena is also more cost effective than endometrial ablation. [62] When compared with hysterectomy for treatment of menorrhagia, Mirena was found to be a cost-effective alternative with similar quality of life and patient satisfaction. [63, 64] A Cochrane review published in 2010 summarized and confirmed these results. [65]
The copper T380A IUD is a T-shaped polyethylene frame that is wrapped with a copper wire. See the image below.
It is approved for contraception for a 10-year interval, after which time it should be removed and a new device inserted. [53] The exact mechanism of action of the copper T380A IUD is unclear, but suggested theories include inhibition of sperm migration and viability, change in transport speed of the ovum, and damage to the ovum. [57] The pregnancy rate in the first year of use is 0.6%, which increases to 1.9% at 10 years of use. [5, 2]
Both the copper T380A IUD and the levonorgestrel-releasing intrauterine system are approved for prevention of pregnancy in women with undesired fertility. The copper T380A IUD is approved for a 10-year interval for contraception. After 10 years, the device should be removed and a new device inserted if the patient desires to continue with the method. [53] Reliable data exists validating that the copper T380IUD is effective for use as an emergency contraceptive if placed within 5 days of unprotected intercourse. [66]
Clinical guidelines on intrauterine contraception were released on November 11, 2018, by the Collège national des gynécologues et obstétriciens français (CNGOF) [67]
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Sarah Hagood Milton, MD Resident Physician, Department of Obstetrics and Gynecology, Virginia Commonwealth University Health System
Disclosure: Nothing to disclose.
Nicole W Karjane, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center
Nicole W Karjane, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, North American Society for Pediatric and Adolescent Gynecology
Disclosure: Received income in an amount equal to or greater than $250 from: Merck<br/>Served as Nexplanon trainer for: Merck.
Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine
Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists
Disclosure: Nothing to disclose.
Intrauterine Device Insertion
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