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IUD Insertion


1. Purpose

  • IUD = Small T shaped device inserted into uterus for contraception
  • Highly effective method for preventing pregnancy
  • Offers long term contraception (in the span of years)
  • Reversible fertility - 90% females conceive within 2 years of removal
  • Does NOT protect against STIs - must be counselled about barrier methods

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2. Indications

  • Effective contraception desired for several years
  • Daily compliance of contraceptive is an issue
  • Other methods of contraception are not tolerated or contraindicated in the patient
  • Off label uses (Mirena): menorrhagia, endometriosis, dysmenorrhea

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3. Benefits/Adverse Effects

Copper T

  • Polyethylene device with 380mm2 of exposed surface area of copper on its arms and stem
  • The copper ions interfere with sperm mobility and causes a foreign body reaction that creates a spermicidal environment
  • May increase cramping and lead to heavier periods
  • $175 / 10 years protection
  • 99.2-99.4% effective
  • Protection for 10 yrs instead of 5 years and more affordable than the Mirena IUD

Mirena

  • Contains 52mg of levonorgestrol (a progestin) that is secreted in tiny amounts (20mcg) per day into the uterine cavity
  • Progestin works by thinning out the uterus lining and thickening the cervical mucus to prevent sperm from passing through the cervical canal
  • Endometrium thinning leads to lighter periods, decreased menstrual flow and less cramping (some women become amenorrheic)
  • Irregular bleeding/spotting usually occurs within the first 3 months post insertion but decreases significantly by 12 months
  • $380/ 5 years protection
  • 99.5-99.9% effective
  • Higher upfront cost than Copper T but benefits of lighter, less painful periods and amenorrhea in some women

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4. Ideal Patient Profile

  • No recent or active pelvic inflammatory disease/STI
  • Parous women in stable mutually monogamous relationship with no history of PID
  • If patient has a remote history of PID, but has been pregnant after the PID and is not currently at risk for infection, then she can be candidate
  • Note: Nulliparous women have higher expulsion and failure rates and also offer more challenging insertion because they have a smaller uterine cavity, but this does not exclude them from considering an IUD

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5. Contraindications

  • Pregnancy
  • Acute PID
  • Current STI
  • Multiple sexual partners
  • Postpartum endometritis or septic abortion in previous three months
  • History of ectopic pregnancy
  • Abnormal uterine bleeding of unknown cause
  • Immunodeficiency /immunosuppressive therapy
  • Uterine abnormality or large fibroids that distorts the uterine cavity
  • Uterine cavity < 5cm
  • Cervical or uterine malignancy (hormone responsive tumors)
  • Copper allergy or severe anemia (copper T)
  • Active liver disease (Mirena)

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6. Preparation

  • Prior to the procedure, the patient must be informed of the procedure, and verbal or written consent obtained
    • A thorough discussion about alternative contraceptive methods should be discussed at an earlier visit
  • Ensure not pregnant
    • May be inserted at any time of the menstrual cycle; however, inserting it during or soon after menses provides additional reassurance of nonpregnancy
    • If inserted during luteal phase, pregnancy test cannot always detect early pregnancy and another nonhormonal contraceptive should be used until after the next menses
  • Pelvic exam, pap smear, and screen for gonorrhea/ chlamydia are recommended at a previous visit (American College of Obstetrics and Gynecology)
  • Premedication:
    • Ibuprofen 800mg 1 hr prior to insertion to alleviate discomfort
    • Misoprostol 200mcg 2 tabs pv the night before (or 4-12 hrs prior to) the procedure for slight cervical dilatation

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7. Equipment

Click Image below to enlarge:

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8. Procedure: Mirena IUD

  1. Don nonsterile gloves
  2. Perform bimanual exam to determine position of cervix
  3. Insert vag speculum and visualize the cervix
  4. Cleanse the cervix with betadine/chlorhexidine gauzes
  5. Sound the uterus to determine its size (usually 6-8cm)
  6. Open the Mirena package enough to reveal the shaft of the inserter
  7. Don sterile gloves
  8. Pick up IUD and ensure slider is at furthermost position away from you
  9. Ensure the arms of IUD are in horizontal position by aligning them on sterile surface of packaging
  10. Pull on the threads to retract the system into the shaft and secure threads in the cleft at the end of the shaft
  11. Set the upper edge of the flange to the distance of uterine sound measured previously
  12. Apply tenaculum to cervix and pull gently towards yourself to straighten/stabilize cervix
  13. Advance IUD insertion tube into cervix until flange is 2cm distal to the cervix
  14. Pull the slider back (towards yourself) to the mark on the inserter – this releases the arms of the system, wait 30sec for arms to deploy
  15. Insert the tube further into uterus until the flange touches the cervix (entire depth of uterus)
  16. Once the tube is inserted all the way, pull the slider back all the way towards yourself – this releases the IUD
  17. Remove the insertion tube from the uterus
  18. Cut the threads to 5cm / 2 inches from the cervix

Procedure: Copper T IUD

  1. Don nonsterile gloves
  2. Perform bimanual exam to determine position of cervix
  3. Insert vag speculum and visualize the cervix
  4. Cleanse the cervix with betadine swabs
  5. Sound the uterus to determine its size (usually 6-8cm)
  6. Open the IUD package enough to expose device
  7. Don sterile gloves
  8. Pick up IUD and ensure blue flange is aligned with IUD arms and set at the distance the uterus was sounded
  9. Fold arms of IUD into insertion tube
  10. Place white inserter rod into the insertion tube at the end opposite to arms
  11. Insert the tube into uterus until the flange touches the cervix (entire depth of uterus)
  12. Pull back on the clear inserter tube by 2 cm to release the arms into a “T”
  13. Advance the inserter tube slowly back into uterus until flange touches cervix to ensure correct positioning
  14. Remove the insertion rod entirely by holding the insertion tube in place
  15. Then remove the insertion tube and tenaculum
  16. Cut the threads to 5cm / 2 inches from the cervix

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9 . After Care

  • Teach patient how to locate IUD threads after the insertion
  • Strings should be checked after each menses
  • Follow up appt should be arranged after the next menses (1 month) to check threads with the patient, address any concerns or adverse effects
  • Follow up with patient as needed thereafter and check strings at each pap smear
  • Counsel patient about possible side effects/complications (below) and give instructions for when to contact a doctor
  • If uterine perforation occurred during insertion, the IUD should be removed and the patient treated with antibiotics appropriate for PID

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10. Complications

  • Cramping
  • Irregular bleeding (usually within first 3 months)
  • Amenorrhea (Mirena) or heavier painful bleeding (Copper T)
  • Progestin related effects / premenstrual symptoms (usually diminishes within 3 months)
  • Cervical/Uterine perforation on insertion (rare ~ 6/1000)
  • Vasovagal reaction on insertion
  • Expulsion of IUD (highest during first 2 wks after insertion)
  • Displaced threads
  • Embedment or fragmentation of IUD
  • Ectopic pregnancy
  • Pelvic infections (risk of PID is highest in the first 4 wks post insertion)
  • Infertility - long term IUD use > 78 months (6.5yrs) may be associated with slight increased risk of fertility impairment (Evidence Level C, prospective cohort study)

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11. Removal of IUD

Remove:

  1. At expiration date
  2. On patient’s request
  3. Pre-excisional /endometrial biopsy
  4. If intolerable, persistent adverse effects

Procedure: Removal of IUD

  • Securely grasp threads at the external cervical os with ring forceps
  • Apply traction away from cervix
  • If resistance is met, removal should be abandoned until determined why IUD not moving
  • Deeply embedded IUD / lost strings may have to be removed hysteroscopically

 

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12. Quiz

Take the IUD Insertion Quiz

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13. Video - Mirena Insertion

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14. Video - Copper Insertion

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15. References

References


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