Intrauterine Device Insertion

Aka: Intrauterine Device Insertion, IUD Placement, Difficult IUD Removal, Missing IUD Strings

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II. Preparation

  1. Informed Consent
    1. See Intrauterine Device
    2. Contraindications
    3. Adverse effects
  2. Infection risk reduction
    1. Screen for Gonorrhea and Chlamydia before placing
    2. Antibiotic prophylaxis is not indicated
      1. Not indicated for routine prevention
      2. Not indicated for SBE Prophylaxis
  3. Pretreatment
    1. Misoprostol
      1. Previously Misoprostol (Cytotec) was recommended prior to IUD insertion to make the insertion easier
      2. No longer recommended due to no benefit in recent trials and risk of adverse effects
      3. Edelman (2011) Contraception 84(3): 324-39 [PubMed]
  4. Analgesia
    1. Ibuprofen 600-800 mg po 1 hour before procedure
  5. Timing of placement
    1. May be placed at any time in cycle
  6. Labs
    1. See Quick Start Algorithm for Intrauterine Device
    2. Document negative urine HCG prior to procedure
  7. Precautions: Conditions that may make placement more difficult
    1. Prior Cesarean Section (Cervix repositions behind pubic bone)
    2. Prior Cervical LEEP procedure (sound may not pass cervical os)
    3. Uterine Fibroids
      1. May require IUD insertion under Ultrasound guidance
  8. Precautions: Increased uterine perforation risk in Breastfeeding (first 36 weeks postpartum)
    1. Exercise caution on uterine sounding and IUD insertion
    2. Heinemann (2017) Contraception 91(4): 274-9 [PubMed]
    3. Heinemann (2017) Contraception 95(6): 605-7 [PubMed]

III. Preparation: Equipment for procedure

  1. Betadine or Hibiclens poured into pack of 4x4 gauze
  2. Sterile exam gloves
  3. Sterile equipment on tray
    1. Uterine sound
    2. Vaginal speculum
    3. Ring forceps
    4. Suture scissors (long)
    5. Single tooth tenaculum
    6. Sterile IUD package

IV. Technique: IUD Placement

  1. Prepare IUD prior to starting procedure
    1. Use sterile technique
    2. Review insertion technique in package insert
  2. Place vaginal speculum
    1. Short speculum may prevent pushing Cervix posteriorly
  3. Prepare vaginal wall with Betadine or Hibiclens
  4. Apply tenaculum at anterior (12:00) cervical position
    1. Tenaculum helps to stabilize the Uterus while inserting uterine sound and IUD
    2. Mild traction to the tenaculum may also be used to reorient a anteflexed or retroflexed Uterus
  5. Insert and remove uterine sound
    1. Confirm depth of Uterus at least 6 cm
    2. Clears path for IUD insertion
  6. Place IUD according to package insert
    1. Each IUD uses a proprietary insertion device
    2. Pearls if insertion is difficult
      1. Dilate endocervical canal with both 3 mm and 4 mm sound (often one on each side of sound)
      2. Consider smaller diameter IUDs (e.g Skyla, Kyleena)
    3. Pearls if tight cervical os (e.g. prior LEEP)
      1. Consider Paracervical Block if discomfort occurs
      2. Cervical os finder
      3. Graduated metal dilator
  7. Cut IUD threads 2-3 cm from cervical os

V. Technique: IUD Removal

  1. Precautions
    1. Offer alternative Contraception at time of removal if patient is not planning pregnancy
  2. Standard IUD Removal
    1. Consider pretreatment with Ibuprofen or Tylenol
    2. Place speculum and visualize the Cervix
    3. Identify the IUD strings
    4. Grasp the IUD strings with a ring forceps or similar
    5. Firmly withdraw the IUD strings toward the vaginal opening
  3. Difficult IUD Removal due to Missing IUD Strings
    1. Consider Pregnancy Test
    2. Twirl cytobrush (used for Pap Smear) within cervical external os
      1. Remove IUD if strings found
    3. Consider occult IUD expulsion (e.g.Menorrhagia)
      1. Pelvic Ultrasound
        1. Refer to Gynecology if IUD appears embedded
      2. Single View AP Pelvis XRay
        1. Consider if IUD not seen on Ultrasound (or XRay more readily available)
        2. Refer to gynecology if IUD found outside Uterus
        3. Assume IUD expulsion if not seen on XRay
    4. Attempt removal if IUD found in Uterus but does not appear embedded
      1. Consider Paracervical Block
      2. Cervical dilation if needed
      3. Catch IUD or strings with a thread retriever, IUD hook or aligator forceps
  4. Difficult IUD Removal due to Embedded IUD (resistance on traction)
    1. Attempt to loosen the IUD with gentle twisting
    2. Vacuum aspirator suction (after cervical dilation) for those trained in intrauterine suctioning
    3. Refer to gyencology if unsuccessful for possible hysteroscopy

VI. References

  1. Warrington (2023) Crit Dec Emerg Med 37(8): 13
  2. Prine (2018) Am Fam Physician 98(5): 304-9 [PubMed]

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