Intrauterine Devices: Separating Fact From Fallacy

, Magee-Womens Hospital, University of Pittsburgh School of Medicine

Disclosures
In This Article

Inserting an IUD

Timing. An IUD can be safely inserted at any time during the menstrual cycle. Traditionally, clinicians have been taught to insert an IUD during menses because the patient was very unlikely to be pregnant and because they have been told that the cervix "dilates" during menstrual flow, allowing easier introduction of the IUD. No literature exists proving cervical dilation occurs with menses. Moreover, the expulsion rate and rates of discontinuation for bleeding, pain, and pregnancy are lower if insertions are performed after day 11 of the menstrual cycle.[33] (This decrease in pregnancy rate is easily understandable because of the copper-containing IUD's action as a postcoital contraceptive.) IUD insertions during the menstrual cycle can invite problems by placing a foreign body into the uterus at a time when the intrauterine environment contains bloody, necrotic material. Midcycle insertion avoids this potential hazard.

When an IUD is chosen as the contraceptive method after a first-trimester abortion, the device can be inserted at any time so long as infection is not present. After a second-trimester abortion, insertion should be delayed until after uterine involution is completed. Copper-containing IUDs can be inserted between 4 and 8 weeks postpartum without an increase in pregnancy rates, expulsion, uterine perforation, or removal for pain and/or bleeding.[34]

Technique. Insertion of an IUD is a relatively straightforward, simple office procedure that takes only a few minutes. Each IUD package contains a full explanation of the risks and benefits of the IUD and a description of the insertion and removal procedures. The clinician should review this material with the patient. The patient should be shown her IUD prior to insertion and receive an explanation of the insertion procedure.

A bimanual examination must first be performed to evaluate uterine position, size, and mobility. If the clinician finds the pelvic organs to be abnormal or there is excessive tenderness on uterine or cervical manipulation, IUD insertion should be postponed until further investigation ensures the absence of infection. The uterus must be sounded to ensure that its size is between 6 and 10cm, inclusive of the cervical canal (for a ParaGard, the recommended upper limit is 9cm). Immediately prior to insertion, the IUD should be loaded into its plastic inserter according to the directions provided with the package.

The IUD should be inserted using aspectic technique. The cervix is swabbed with an antiseptic solution and the anterior lip grasped with a tenaculum. Steady traction is exerted on the tenaculum to straighten the cervical canal, and the inserter advanced through the cervical os into the uterine cavity. The directions should then be followed to place the IUD high in the fundus. The retaining string is cut to a length of about 4cm from the external os. If the strings are cut too short initially, they will be difficult for the inexperienced user to feel. The strings can always be cut shorter later if they protrude from the introitus. Since most women experience uterine cramping during and immediately after insertion, NSAIDs should be administered before insertion and as needed thereafter.

After insertion. Following insertion, the woman should examine herself vaginally to palpate the strings or should be given a piece of the cut string to feel. It can be helpful to use a mirror so that she can actually see the cervix and protruding strings before feeling them. She should palpate the strings before each act of intercourse until she returns for a follow-up examination after her next menses. Thereafter, self-examination following each menses is adequate to ensure that her IUD is in place. She should also be instructed to use another contraceptive and return for evaluation if she fails to feel the IUD strings.

Follow-up visit. Subsequent to insertion, the follow-up visit after the first menses should include the patient's account of her experience with the IUD, including her ability to feel the string and changes in her menses. The visit should also include a pelvic examination to determine the intrauterine position of the IUD and to assess for cervical or abdominal tenderness requiring further workup for possible pelvic infection. Continuation rates (and reasons for discontinuation) differ among different investigators and patient populations. The package inserts for both the ParaGard and Progestasert contain data that differ from other data published in the literature (Table II). Overall, IUDs are discontinued by 10% to 20% of users in the first year. Approximately 5% of discontinuations are because of expulsion; the other most common reasons are pain or bleeding.

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