Version May 2024
INTRODUCTION — Intrauterine contraception is highly effective, very safe, and generally well tolerated by most patients. Intrauterine device (IUD) insertion and removal are usually relatively simple procedures that can be performed in the office setting by trained providers. The technical skills required for device insertion and removal can be obtained through proctored hands-on training in the clinical setting and/or may be provided by the manufacturers of these devices. This review is not intended as a substitute for hands-on clinical training.
This topic will address technical issues regarding the insertion and removal procedures for the copper-releasing and progestin-containing IUDs. Other aspects of intrauterine contraception, including detailed review of candidates, device selection, and management of complications, as well as selection of contraception in general and specifically postpartum, are reviewed separately:
●(See "Intrauterine contraception: Candidates and device selection".)
●(See "Intrauterine contraception: Management of side effects and complications".)
●(See "Contraception: Counseling and selection".)
●(See "Contraception: Postpartum counseling and methods".)
In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
IUD NOMENCLATURE — The term intrauterine device (IUD) encompasses intrauterine contraceptives (IUC) and intrauterine systems (IUS, for progestin-containing devices). In this topic, we use the Society of Family Planning-preferred term IUD for all types of intrauterine contraception [1].
Five types of IUDs are currently available in the United States (US); one contains copper and three release the progestin levonorgestrel (LNG) at differing doses. A discussion of the various IUD types is presented elsewhere. (See "Intrauterine contraception: Background and device types".)
For this topic, we will use the following abbreviations:
●Copper 380 mm2 IUD (US commercial name ParaGard)
●Levonorgestrel 52 mg IUD (US commercial names Mirena or Liletta): LNG 52 mg
●Levonorgestrel 19.5 mg IUD (US commercial name Kyleena): LNG 19.5 mg
●Levonorgestrel 13.5 mg IUD (US commercial name Skyla): LNG 13.5 mg
IUD DEVICES, EFFICACY, AND DURATION OF ACTION — The components of the various IUDs, efficacy, duration of action, and non-contraceptive benefits are presented in detail separately. (See "Intrauterine contraception: Background and device types".)
PREPROCEDURE — Preprocedural planning should include evaluating the candidacy of your patient for IUD use, counseling regarding risks and benefits of the device, and assessing the timing of insertion and the need for pain medication.
Candidates, device selection, and contraindications — There are very few contraindications to IUD use. Most patients, including those who are nulliparous, adolescent, immediately postpartum or postabortion, have acute or chronic medical conditions, and/or desire emergency contraception are candidates for an IUD [2-4]. The Centers for Disease Control and Prevention (CDC) provides comprehensive evidence-based guidelines regarding safety of various contraceptive methods in patients with specific characteristics or medical conditions (United States Medical Eligibility Criteria (USMEC) for Contraceptive Use) [2].
Further information about IUD candidacy and contraindications as well as the advantages and disadvantages of the various types of devices are discussed in detail separately. (See "Intrauterine contraception: Candidates and device selection".)
Counseling and consent — The various methods of contraception, including their risks, benefits, and noncontraceptive effects, must be discussed as part of the counseling and consent process. High-quality interpersonal communication is associated with improved uptake, satisfaction, and continuation of IUDs [5]. We find the website bedsider.org to be a noncommercial, patient-friendly, and accurate source of information for patients that reviews the benefits and risks of all contraceptive methods and compares IUDs with all other birth control options. Further information about contraceptive counseling and specific IUD devices are discussed separately. (See "Contraception: Counseling and selection" and "Intrauterine contraception: Candidates and device selection".)
Timing of insertion and pregnancy testing — An IUD may be inserted at any time during the menstrual cycle if pregnancy can be reasonably excluded by the presence of any of the criteria in the following table (table 1). Timing IUD insertion with menses ensures that the patient is not pregnant, but does not reduce pain or improve patient outcomes. A 2013 systematic review concluded that the timing of copper 380 mm2 insertion with regard to menses has little effect on insertional pain or short or long term expulsion rates (one study reported reduced pain with menstrual insertion, one reported increased pain, and two reported no difference) [6]. Moreover, delays in scheduling IUD insertion to coincide with menses may increase patient risk of unplanned pregnancy. Thus, we do not recommend routinely waiting to schedule IUD insertion to coincide with menses.
Given the risks associated with IUD insertion in a setting of concomitant intrauterine pregnancy, documentation of a negative pregnancy test prior to IUD insertion is advised for most patients, but particularly for those with lactational amenorrhea or other conditions that lead to irregular intervals between menses (unclear timing of ovulation) or questionable compliance with contraception. To increase reliability, the pregnancy test should be obtained two or more weeks after her last episode of unprotected intercourse. Clinics that offer IUD insertions should have a protocol that includes counseling, screening (including exclusion of pregnancy), and insertion of the IUD in one visit [7]. Single-visit insertion results in more IUD placements than when two visits are required.
Patients switching from another method
For patients who are using a different contraceptive method and wish to initiate an IUD, the copper 380 mm2 IUD and 52 mg LNG IUDs are effective immediately upon insertion. Thus, patients who choose this method do not require any back-up contraception regardless of prior method of contraception.
However, it is not known if the 13.5 mg and 19.5 mg LNG IUDs provide immediate contraception and we advise patients use back-up contraception or practice abstinence for seven days after IUD insertion unless the patient:
●Has a sure and reliable last menstrual period less than five days ago
●Received injectable contraception less than 14 weeks ago
●Is exchanging a hormonal IUD and has a therapeutically active levonorgestrel IUD removed at the time of new hormonal IUD insertion
Sexually transmitted infections — As sexually transmitted infections (STIs) can be asymptomatic, we counsel all patients about STI risk and offer voluntary screening for gonorrhea and chlamydia to all Individuals presenting for IUD insertion regardless of risk factors. Additionally, we routinely recommend screening based on the CDC STD & HIV Screening Recommendations [8]. Since age is the strongest risk factor for STI incidence [9,10], we encourage gonorrhea and chlamydia screening at the time of IUD placement for all patients age 25 and younger. It is important to emphasize that for all patients without symptoms, screening can be performed at the time of IUD insertion, and insertion should not be delayed for test results [2,11].
If gonorrheal or chlamydia testing obtained at time of IUD placement subsequently returns positive, the infection should be treated per the CDC Sexually Transmitted Diseases Treatment Guidelines, and the IUD can be left in situ [12]. (See "Intrauterine contraception: Management of side effects and complications" and "Treatment of Chlamydia trachomatis infection" and "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents".)
Contraindications to IUD insertion related to infection include (1) active, diagnosed gonorrheal or chlamydia cervicitis (regardless of symptomatology); (2) symptoms suggestive of active gonorrheal or chlamydia cervicitis, such as cervical tenderness or mucopurulent cervical discharge; and (3) patients with known or suspected upper genital tract infection, such as pelvic inflammatory disease or tubo-ovarian abscess [2]. For these individuals, IUD insertion should be delayed until the patient has (1) completed diagnostic work-up and her full treatment course, (2) her symptoms have resolved completely, and (3) her cervical and pelvic physical examinations are normal. Optimal timing for IUD insertion after completion of treatment for cervicitis or an upper genital tract infection is unknown. Sexual partners should also complete treatment according to standard guidelines [12]. If the patient remains at risk of reinfection, a reassessment of IUD eligibility and a negative test for gonorrhea and/or chlamydia, usually done three to four weeks after treatment, should be confirmed prior to placing an IUD. (See "Intrauterine contraception: Management of side effects and complications".)
In contrast to gonorrhea and chlamydia, no large studies have evaluated the outcome of IUD insertion in the presence of bacterial vaginosis (BV) or trichomoniasis. In one small prospective study, five subjects with documented BV had an IUD inserted without complications [13]. A larger prospective study found that subjects with BV at the time of IUD insertion were more likely to have dysmenorrhea, but not other complications, at their six-month follow-up [14]. If a vaginal discharge suspicious of infection is seen, the device manufacturers recommend diagnostic testing and treatment of infection, but there is no evidence to support routine screening for BV in asymptomatic patients or to delay IUD insertion during diagnostic work-up for BV. The CDC specifically states that for patients with vaginitis, including BV and trichomoniasis, the advantages of IUD insertion typically outweigh theoretical or proven risks [2].
Antibiotic prophylaxis — Antibiotic prophylaxis for the placement of an IUD is not recommended [3,15-19], even for individuals with valvular heart disease [16,20]. The use of routine prophylactic antibiotics for the prevention of IUD complications has been investigated in four large randomized trials. A meta-analysis of these trials found that prophylactic antibiotics (doxycycline or azithromycin) decreased the frequency of unscheduled visits post-IUD insertion (odds ratio [OR] 0.82, 95% CI 0.70-0.98), but there was no significant decrease in occurrence of pelvic inflammatory disease (OR 0.89, 95% CI 0.53-1.51) [18].
There is also no evidence to support antibiotic prophylaxis to prevent endocarditis. In one study, there was a 0 percent incidence of bacteremia following IUD insertion [20]. The American Heart Association does not include IUD insertion as an indication for endocarditis prophylaxis [21].
Analgesia
Approach to analgesia — In our practice, pain management is a shared decision-making process that includes preprocedure counseling, support during the procedure, use of nonsteroidal anti-inflammatory drugs, and, for some patients, a paracervical block.
●Assess patients concerns for pain – Preprocedural planning should consider a patient's general tolerance for office procedures. An individual's perception of pain is influenced by their prior experiences and personal history, anxiety, anticipated level of pain, and relationship with the clinician. Risk factors for increased pain scores with gynecologic procedures include nulliparity, postmenopausal status, history of dysmenorrhea, anxiety, or high anticipated pain levels [22,23]. While most patients tolerate the IUD insertion process well with standard comfort measures, a small minority of patients (such as those with a history of trauma, developmental delay, or significant anxiety or pain disorders) may require placement with sedation.
●Patient support during the procedure – During the procedure, we inform the patient about what is happening, what they should be feeling, and what is going to happen next. We also tell the patient when they should expect no sensation and can rest and recover, such as during glove changes or preparation of the IUD applicator. We also emphasize that they retain bodily autonomy and are in complete control and can ask to pause or terminate the procedure at any time. We find that providing distraction, such as asking about life outside of the examination room, or positive suggestion can be helpful. Support staff can also support the patient by holding their hand, talking to them, and providing them with comfort measures such as application of warm or hot packs to the abdomen and cool compresses to the face or chest as needed. For patients who use anxiolytics for other indications, pretreatment with these medications before IUD insertion can be helpful. We find that patients do quite well with this approach because it allows them to feel prepared and in control and manage the mild discomfort of the insertion process.
●Use of medications
•Nonsteroidal anti-inflammatory drugs (NSAIDs) – Despite the conflicting literature, we offer periprocedural nonsteroidal anti-inflammatory medications (eg, oral ibuprofen 800 mg or naproxen 550 mg, based on medication availability and onset of action) for multiple reasons: (1) studying pain in a research setting can be challenging, and subject-reported pain at certain time-points on a visual analog scale may not capture the whole IUD insertion patient experience accurately; (2) there is biological plausibility for this treatment to improve cramping both with the procedure and in the hours after the procedure as the uterus accommodates the new IUD; (3) it is a safe therapy that presents minimal risk or side effects; and (4) it may provide the patient emotional comfort to know that their discomfort is being validated and an attempt at treatment is being made.
•Paracervical block – After educating patients as to what to expect during the procedure and the risks and benefits of the analgesic options, our patients frequently decide against a paracervical block for IUD insertion. Contributing factors include that the injection itself is painful, prolongs the procedure duration, and numbs only the lower nerve branches of uterine nerve plexus [24]. However, we encourage paracervical block for patients who require additional cervical manipulation for IUD insertion (eg, cervical dilation) or in patients who are extremely nervous and may be calmed to know they are receiving some numbing medicine [25]. Prior to block injection, we explain that the patient will feel the injection as well as some procedural discomfort.
Review of analgesia options — Available data on the efficacy of pain medicine for IUD insertion conflict, in part because of multiple treatment options and doses [26]. Treatments that have been studied for reduced discomfort with IUD insertion include multiple formulations of nonsteroidal anti-inflammatory drugs, paracervical blocks, topical anesthetics (eg, gels and sprays), misoprostol, nitrous oxide, and conscious sedation.
●NSAID – Multiple formulations and doses of nonsteroidal anti-inflammatory drugs (NSAIDs) have been studied for preprocedural analgesia at the time of IUD insertion with mixed results. A 2015 meta-analysis that evaluated seven trials of NSAIDs compared with placebo reported oral naproxen reduced pain in one of two trials; oral ibuprofen was not associated with pain reduction in four trials, including a trial of high-dose 800 mg ibuprofen; and intramuscular ketorolac was associated with reduced pain after insertion for nulliparous but not multiparous patients [24]. Subsequent trials reported that preprocedure oral ketorolac 20 mg reduced discomfort with IUD insertion [27], but preprocedure treatment with oral naproxen 550 mg did not [28]. However, use of naproxen was associated with lower median postprocedure pain scores at both 5 and 15 minutes postinsertion.
●Paracervical block – In a 2015 meta-analysis that assessed two trials comparing paracervical block with 1 percent lidocaine to either no intervention or placebo (saline), both trials reported reduced pain with tenaculum placement, but only one trial noted reduced pain with IUD insertion [24]. A subsequent 2017 multicenter single-blind, sham-controlled randomized trial of 10 mL 1% lidocaine paracervical block in 14- to 22-year-old adolescents and young people reported a significant decrease in IUD insertional discomfort in those subjects who received a paracervical block [25]. The technique for paracervical block is presented elsewhere. (See "Pudendal and paracervical block".)
●Topical anesthetics – Since the discomfort with tenaculum placement is fleeting, we rarely utilize topical anesthetics in our practice but recognize that other clinicians may reasonably choose this approach. In a 2015 meta-analysis assessing pain reduction at the time of IUD insertion after placement of topical anesthetic compared with placebo, pain was reduced following use of topical lidocaine 4% gel, lidocaine 10% spray, and lidocaine-prilocaine cream [24]. Lidocaine 2% gel was not associated with pain reduction. A subsequent trial that compared topical lidocaine-prilocaine cream with placebo reported reduced pain with tenaculum placement, sound, and IUD insertion [29]. In a trial comparing lidocaine injection, lidocaine spray, and lidocaine cream with placebo, patients receiving lidocaine spray and injection groups reported lower pain scores with insertion, but those who received spray reported a reduction in pain only associated with tenaculum placement, not IUD insertion [30]. A later trial comparing patient self-insertion of vaginal lidocaine 2% gel with placebo reported similar insertion pain for both groups [31].
●Misoprostol – Based on its use of a cervical ripening agent, it has been hypothesized that misoprostol may facilitate IUD placement, particularly in nulliparous patients. However, misoprostol has not been demonstrated to reduce insertional discomfort. Both a 2015 meta-analysis and a 2016 systematic review reported that misoprostol use consistently did not reduce pain with IUD insertion. Misoprostol use was associated with more discomfort because of the abdominal cramping caused by this prostaglandin [24,32]
Of note, we do use misoprostol in specific patients who benefit from cervical ripening. (See 'Misoprostol' below.)
●Nitrous oxide – Nitrous Oxide is a short-acting anesthetic that has been theorized to calm patients as well as provide analgesia. Because of the short half-life, patients are able to drive themselves home after the IUD insertion under nitrous oxide. Although this inhalant is used in other obstetric and gynecologic procedures, it is of unclear benefit for IUD insertion. In a double-blind, randomly-assigned trial of nulliparous patients undergoing IUD insertion, inhaled nitrous oxide conferred no benefit over placebo for pain reduction with IUD insertion [33].
Use of nitrous oxide is discussed in detail elsewhere. (See "Inhalation anesthetic agents: Clinical effects and uses", section on 'Procedural sedation (nitrous oxide)'.)
●Conscious sedation – There may be occasional patients in which an office-based IUD insertion is highly desired but is prohibited due to inability to tolerate the procedure without sedation. Examples include extremes of reproductive age where greater cervical manipulation or dilation may be necessary, patients with profound anxiety surrounding gynecologic procedures, or individuals in whom obesity or scarring from prior obstetric or gynecologic procedures makes access to the cervix impossible without improved patient relaxation and positioning. For individuals who require moderate or deep sedation for IUD insertion, we perform the insertion in a procedure suite and typically administer intravenous midazolam (2 to 3 mg) and fentanyl (100 to 200 mcg).
The use and administration of conscious sedation is presented separately. (See "Procedural sedation in adults in the emergency department: General considerations, preparation, monitoring, and mitigating complications".)
PROCEDURE — Training for IUD insertion may be obtained through proctored hands-on-training in the clinical setting and/or may be provided by the manufacturers of these devices. This review is not intended as a substitute for hands-on training.
Equipment — The following equipment is required for routine IUD insertion: sterile, packaged IUD device; speculum; single-tooth tenaculum; uterine sound (either metal sound or alternative like a 3 mm flexible endometrial biopsy Pipelle); scissor (ideally long with curved blade); an antiseptic solution (povidone iodine or chlorhexidine) [19]. Routine antibiotic prophylaxis is not required prior to IUD insertion. Ideally, sterile gloves should also be available, although a "no touch" technique is acceptable.
Preinsertion planning and examination — Prior to IUD insertion, we try to identify potential risk factors that could complicate the insertion process, as discussed in a related topic. (See "Intrauterine contraception: Management of side effects and complications", section on 'Risk factors for complications'.)
In addition, equipment that facilitates IUD insertion (eg, procedure chair that allows for provider movement and flexibility, an os finder, cervical dilators, and if possible an ultrasound) should be readily accessible to the provider if unexpected difficulties are encountered. Improved provider experience contributes to greater ease with placement [34,35]. Thus, when a clinician is in the learning phases of IUD insertion, availability of a more experienced practitioner can be extremely helpful.
General steps for IUD insertion — The following steps are performed for insertion of the copper or levonorgestrel-releasing IUDs:
●Pelvic examination – A pelvic examination is essential to assess the size and position of the uterus and evaluate for signs of active genital infection, such as cervical motion tenderness or pelvic pain [15]. A speculum is inserted, cervical cultures are performed if indicated (see 'Sexually transmitted infections' above), and the cervix is cleaned with an antiseptic solution. If the clinician sees signs of active cervicitis, the procedure should be aborted and a diagnostic work-up should be initiated.
●Tenaculum placement – IUD insertion begins by obtaining adequate grasp of the anterior lip of the cervix with a tenaculum. We strongly recommend a single-toothed tenaculum to control uterine movement and straighten out the uterine angle, which allows both the sound and the IUD to easily pass to the top of the fundus while minimizing risk of perforation or malpositioned placement. While there is insufficient evidence, anecdotal evidence suggests that having the patient cough or take a deep breath at time of tenaculum placement and closing the tenaculum slowly and incompletely may be more comfortable for the patient.
For individuals who are anticoagulated or who have a bleeding diathesis, we recommend an atraumatic tenaculum or ring instead of a single-tooth tenaculum. Holding anticoagulation therapy or adding prophylactic medication (ie, desmopressin or tranexamic acid) is generally not required, as bleeding complications are rare even in these populations [36].
●Sound uterine cavity – The purpose of sounding the uterus before opening the IUD kit is to ensure that (1) cervical stenosis is not present or can be treated immediately to allow instrumentation of the uterus, (2) the patient will be able to tolerate the cramping associated with IUD placement, and (3) the uterine cavity is within the size range necessary for effective intrauterine contraception. Performing this step prior to opening the IUD kit avoids having to waste an expensive device if the pre-IUD insertion portions of the procedure cannot be successfully performed.
While placing the tenaculum on gentle traction with the nondominant hand to straighten the uterine axis, a uterine sound is passed through the cervix to the uterine fundus in order to measure the depth of the uterine cavity (figure 1). Manufacturer recommendations for minimal and maximal uterine sounding length vary by device.
Per the prescribing information:
•LNG 52 mg IUD – Given the mechanism of action and the highly effective nature of the LNG 52 mg IUDs, we feel comfortable using either LNG 52 mg for contraception in uterine cavities up to 14 cm, and in even larger uteri for control of symptoms such as menorrhagia. However, this approach represents off-label use as prescribing information for the two available products is as follows:
-Per the prescribing information, the LNG 52 mg (commercial name Mirena) device should be limited to cavities of 6 to 10 cm [37]. However, in clinical practice, this device is frequently used in larger cavities for both contraception and symptom management in patients with moderate fibroid disease or adenomyosis that may lengthen the cavity size.
-The LNG 52 mg (commercial name Liletta) package insert allows for this clinical judgment, giving only a lower limit of cavity size of 5.5 cm and no upper limit on cavity length [38].
•LNG 19.5 and 13.5 mg IUDs –The LNG 19.5 mg and LNG 13.5 mg do not give upper or lower limits of cavity size within the prescribing information [39,40]. Given the lower dose of these smaller IUD frames, there is biologic plausibility to think these two devices would not work as well to control symptoms of heavy bleeding in anatomically large uteri (eg, fibroids or adenomyosis). Therefore, we encourage the LNG 52 mg devices rather than the lower LNG IUDs in patients with a large uterus.
•Copper 380 mm2 IUD – The prescribing information for the copper 380 mm2 IUD indicates a cavity size range of 6 to 9 cm [41]. Given that the mechanism of action of the copper 380 mm2 is dependent on direct contact with the entire endometrial cavity, we adhere to this guideline and do not place this device in cavities greater than 10 cm in size.
If the uterine cavity appears to measure less than 6 cm when assessed with a sound, it is possible that the sound has not traversed the internal os or across the entire length of the uterine cavity. Ultrasound assessment of the uterine cavity with the sound in place can help distinguish between a small cavity and a sound that is stuck at the internal cervical os. If the provider is unsure if the uterine fundus was reached when they measured a small uterine cavity, ultrasound evaluation should be performed to measure the uterine cavity in order to help with IUD candidacy determination and IUD size considerations [42]. (See "Intrauterine contraception: Management of side effects and complications", section on 'Perforation'.)
Device-specific insertion steps — Once the uterus has been measured with the sound, the subsequent insertion steps are device specific. Detailed insertion steps can be found in the product packaging or the webpage of each manufacturer [37-45].
While simplified insertion techniques have been described, these were evaluated in the hands of specialized family planning providers [46]. As with any procedure, modification of the standard insertion procedures, described below, becomes reasonable with increased experience. For most providers, we advise following the standard insertion techniques.
Copper 380 mm² IUD — The sterile copper 380 mm2 package contains the IUD with attached strings, an insertion tube with an adjustable elliptical flange, and a solid white plastic rod with a ring at one end (figure 2 and figure 3) [41]. Insertion of this device requires the clinician to use both hands when loading the IUD into the applicator and to touch the device while using sterile gloves. Alternately, the device can be loaded into the applicator by only touching the IUD through the outside of the partially opened sterile package (figure 4). We most frequently open the package completely and touch the IUD with sterile gloves to load it, but we discuss both methods below.
The critical steps include [47]:
●When using sterile gloves, the provider assembles the IUD by simultaneously bending both horizontal arms downwards to be parallel with the stem of the device and then tucks them into the clear tube to hold the arms (in this downward position) for easy entry through the cervical canal (figure 5). In order to avoid IUD breakage or permanent device memory of the arms bent in this position, the horizontal arms should not be kept in this position in the clear insertion tube for more than a few minutes before insertion.
Neither the IUD nor the portion of the insertion tube that enters the uterus should ever be touched with a nonsterile hand. If sterile gloves are not available, the device can be assembled within the partially opened IUD package. The provider partially opens the package to the level of the lower aspect of the IUD stem. With careful handling the distal end of the insertion tube with a nonsterile hand and handling the device itself through the clear, sterile cellophane of the unopened end of the package, the arms of the IUD can be bent down to be parallel with the stem and inserted into the clear tube to hold them in place (figure 5 and figure 4).
●After positioning the IUD at one end of the insertion tube, the white plastic rod is passed through the opposite end, with the ringed end of the rod protruding from the base of the clear tube. Care should be taken to pass the rod only to the point where it just touches the IUD (it must touch the stem); pushing the rod further will expel the device from the insertion tube. If we are using sterile gloves and have already touched the IUD to load the arms, we actually hold the IUD in place with our index finger while the white rod is threaded to the level of the IUD stem to ensure the newly loaded IUD is not pushed out of the tube. The blue elliptical flange can then be slid along the insertion tube to position it corresponding to the sounded depth of the uterine cavity. The wide diameter of the flange is oriented in the same alignment as the horizontal arms of the IUD to allow correct orientation of the IUD upon insertion.
●While applying gentle traction on the tenaculum, the insertion tube is passed through the cervical os and up the full length of the uterine cavity to the point at which resistance is felt as the IUD reaches the top of the uterine fundus. This should also correspond with the flange meeting the external cervical os if it was properly set based on uterine sounding. Once the IUD is at the fundus, the tenaculum should be allowed to gently fall as the remaining portion of the insertion requires two hands. While holding the white plastic rod steady in space, the clear tube is drawn back as far as it will go until it hits the ring of the white rod, about 1 cm. This allows the arms of the IUD to deploy at the fundus. Recognize that the white rod is not an inserting tool; the IUD should not be pushed forward out of the insertion tube with the rod, as this would cause perforation through the fundus (figure 6).
●Next, while now holding the clear insertion tube steady in space, draw the white rod all the way out and set aside. The clear insertion tube should then be similarly drawn all the way out and set aside, and the strings will be seen protruding from the cervix. Removing the rod first followed separately by the tube decreases the risk that the strings may get caught on the rod and the IUD device would be inadvertently moved down in the fundus. If the IUD stem is visible within or protruding through the endocervical canal, it should be retrieved by pulling the strings and, if it has remained sterile, it may be reloaded and a reinsertion may be attempted. Of note, this is in contrast to hormonal IUDs that cannot be reloaded within their complicated handles.
●After proper placement is confirmed by visualization of just the strings protruding from the os, the strings are carefully trimmed to approximately 2 to 3 cm. We suggest cutting the strings at least 2 cm long to leave enough length for the strings to soften and curve around the face of the cervix and project towards the cervical-vaginal fornix instead of along the length of the vagina. Additionally, we recommend cutting the strings with a curved scissor perpendicular to the thread length to minimize chance of sharp edges cut on a bias that could cause partner discomfort.
Levonorgestrel-releasing IUDs — As noted above, there are three common types of levonorgestrel-containing IUDs sold under four brand names. The Mirena LNG 52 mg IUD, LNG 19.5 mg (commercial name Kyleena), and LNG 13.5 mg (commercial name Skyla) all have the same manufacturer, applicator, and insertion technique. The Liletta 52 mg IUD has a different inserter and technique. (See 'IUD nomenclature' above.)
An online video is available from the manufacturer demonstrating insertion of the LNG 52 mg (Mirena), 19.5 mg, and 13.5 mg IUDs [43,44].
●LNG 52 mg (commercial name Mirena) – The current insertion system for the LNG 52 mg IUD (commercial name Mirena) changed in 2014, allowing for single-handed insertion (the device requires only one hand for use, but a second hand is still required to hold the tenaculum) (figure 7). Using sterile technique, grasp the inserter handle underhanded with the dominant hand. Using your thumb, advance the blue slider on the handle forward as far as possible in the direction of the arrow, thus moving the insertion tube over the IUD body to load it into the insertion tube (figure 8). This results in the tips of the arms meeting, extended up above the stem of the IUD. The strings are completely contained in the handle and do not need to be secured. The loaded handle should be held underhanded with the blue slider held in place at all times by the operator's thumb. The elliptical flange can be adjusted with the operator's sterilely gloved nondominant hand or by careful advancement over the grooved surface of the IUD plastic package to reflect the depth of the uterus, as measured with a uterine sound.
While applying gentle traction on the tenaculum with the nondominant hand, the loaded IUD applicator is then advanced through the cervix with the dominant hand until the flange is 1.5 cm from the cervix. Alternatively, some providers prefer to advance the loaded IUD applicator through the cervix until receiving tactile feedback of reaching the fundus and then pull back 1.5 cm. With the applicator held here, 1.5 cm from the stop of the fundus, the blue thumb slider is moved down 1 cm, stopping at the gray mark designated on the handle. This downward thumb slider movement allows the arms of the IUD to be released. We recommend a delay here of 3 to 10 seconds to allow the arms to relax back into the correct T-shaped configuration (figure 9). After this delay, the applicator is then advanced until the blue flange touches the cervix and resistance is felt to indicate that the IUD is correctly positioned at the top of the fundus. Holding the inserter in place, the IUD is released by moving the blue thumb slider all the way back down to the bottom of the handle.
The inserter can then be gently removed entirely from the cervix, exposing the gray strings that should then be cut to 2 to 3 cm from the external cervical os. We suggest cutting the strings at least 2 cm long to leave enough length for the softened strings to curve around the face of the cervix and project towards the cervical-vaginal fornix instead of along the length of the vagina. Additionally, we recommend cutting the strings with a curved scissor perpendicular to the thread length to minimize chance of sharp edges cut on a bias that could cause partner discomfort.
While the new one-handed handle allows for an easier insertion, the fact that the strings are contained within the device means that the IUD cannot be reloaded within the applicator should the IUD be deployed or inserted incorrectly. (See "Intrauterine contraception: Management of side effects and complications".)
●LNG 52 mg (commercial name Liletta) – In 2016, the Liletta LNG 52 mg IUD manufacturer switched to a two-handed preloaded applicator that has an IUD that is partially loaded within the insertion tube with the strings extruding through the distal end of the tube. Instructional videos and documents for the insertion technique are available on the manufacturer's website [45].
The device must first be loaded. To begin, hold the device underhanded in the dominant hand and push your thumb up to ensure both the blue thumb slider and the green thumb slider are fully advanced as far up as they will go in the handle. The IUD can then be retracted into the insertion tube by laying the device's free arms flat (horizontal) on the sterile inside plastic surface of the package, placing the dominant thumb on the blue slider to keep it fully advanced with gentle pressure while simultaneously pulling the strings down firmly with the nondominant hand until the IUD slides completely into the tube with the arms extended up. The blue flange is then slid along the insertion tube to position it to correspond to the sounded depth of the uterine cavity using a sterile or no-touch technique.
Once the IUD is loaded, it is ready for insertion. Using the nondominant hand, gentle traction is placed on the tenaculum while the loaded IUD applicator is then advanced through the cervix with the dominant hand until the flange is 1.5 cm from the cervix. For insertion into most uteri, we recommend that this applicator be held underhanded with the dominant thumb on the thumb slider at all times. With the applicator held 1.5 cm from the top of the fundus, the blue thumb slider is moved down 1 cm, stopping at the mark designated on the handle. This downward thumb slider movement allows the arms of the IUD to be released. We recommend a 3 to 10 second delay to allow the arms to relax back into the correct T-shaped configuration. After this delay, the applicator is then advanced until the blue flange touches the cervix and resistance is felt to indicate that the IUD is correctly positioned at the top of the fundus. Holding the inserter in place, the IUD is released by moving both blue and green thumb sliders all the way back down to the bottom of the handle. If the green slider is moved all the way down, a green indicator is exposed at the very base of the insertion handle to denote that the strings are free (no longer locked). The inserter can then be gently removed entirely from the cervical canal, exposing the blue strings that should then be cut to 2 to 3 cm. We suggest cutting the strings at least 2 cm long to leave enough length for the strings to soften and curve around the face of the cervix the cervical-vaginal fornix instead of along the length of the vagina. Additionally, we recommend cutting the strings with a curved scissor perpendicular to the thread length to minimize chance of sharp edges cut on a bias that could cause partner discomfort.
The Liletta LNG 52 mg IUD was originally available as an unloaded device that required more complexity to bring it into the applicator; insertion instructions are available in the manufacturer's instructions that are packaged with the device.
●LNG 19.5 mg IUD – The LNG 19.5 mg IUD (commercial name Kyleena) has a preloaded insertion system (figure 10) that is slightly thinner but otherwise identical to the Mirena LNG 52 mg applicator. The device is intended for single-hand insertion, and the steps are the same as for Mirena LNG 52 mg system above, except the elliptical flange and thumb slider are purple. Insertion instructions, with images, are available online from the manufacturer [39].
●LNG 13.5 mg IUD – The LNG 13.5 mg IUD (commercial name Skyla) has the same preloaded insertion system as the LNG 19.5 mg listed above (figure 11). This is slightly thinner but otherwise identical to the Mirena LNG 52 mg applicator. The insertion is the same as for the string-free LNG 52 mg above, except the elliptical flange and thumb slider are pink. An online video is available from the manufacturer demonstrating insertion of the LNG 13.5 mg [44].
Difficult insertion
Our approach — IUD insertion can be challenging in patients who have a cervix that is flush with vagina, cervical stenosis, a tortuous cervix, and/or a steeply angled or fibroid-containing uterus. For individuals who require cervical dilation, a paracervical block may be helpful for pain reduction. For those who require significant cervical or uterine manipulation, procedural sedation may be required. (See "Pudendal and paracervical block", section on 'Gynecologic procedures'.)
●For patients with a cervix that is flush to the vagina or who have had prior cervix or uterine procedures, an os finder can be used to identify the os and dilate the cervical path.
●For patients with cervical stenosis or a cervical canal path that is difficult to identify, use of Pratt dilators (13 to 15 French) or similar (eg, Hanks or Hegar dilators) can be useful. If the stenosis is severe, a lacrimal duct probe can be used as a very thin dilator. Alternatively, a 3 mm flexible endometrial biopsy Pipelle can be used instead of a rigid metal sound to identify and dilate the canal. Analgesia such as a paracervical block may be warranted for cervical dilation or manipulation. At times, a circuitous path or cervical divots may allow easy passage of the smooth metal dilators or sound but prevent easy passage of the flexible plastic IUD applicator. In this setting, over dilation to 21 to 23 French can allow for unrestrictive passage of the flexible IUD inserter.
●Other solutions for difficult entrance into the uterus include ultrasound guidance (see 'Ultrasound guidance' below), use of a smaller IUD inserter (the LNG 19.5 mg and LNG 13.5 mg applicator diameter dimension is 3.8 mm compared with Mirena at 4.4 mm and Liletta at 4.8 mm), or rotating the IUD applicator 180 degrees to allow improved angling of the device applicator along the posterior uterine aspect, particularly in retroverted uteri.
Ultrasound guidance — While not required for IUD placement, ultrasound guidance can be useful in resolving difficult IUD insertions. Specifically, ultrasound guidance can guide dilator insertion in patients with cervical stenosis or a tortuous cervical canal. It can also identify distorted uterine anatomy such as sharp uterine flexion (anteverted or retroverted) or fibroids (particularly submucosal tumors). Additionally, ultrasound can be used immediately postinsertion to confirm correct IUD placement.
Misoprostol — Although not routinely used for IUD insertion, pretreatment with misoprostol may benefit some patients, including those in whom IUD insertion is known to be difficult or has failed, or individuals who are nulliparous or have only had cesarean deliveries [48-52]. However, routine use of misoprostol has not been demonstrated to increase the rates of successful IUD insertion. In a systematic review of six trials, routine pretreatment with misoprostol did not lead to improved ease or success of IUD insertion and resulted in more insertional discomfort, particularly in nulliparous patients [32]. As this lack of benefit for most patients must be balanced against uncomfortable side effects, we rarely prescribe misoprostol. We generally reserve misoprostol for individuals with a prior unsuccessful attempt at IUD insertion, presumed secondary to cervical stenosis.
Misoprostol regimens vary; 400 mcg can be administered vaginally, buccally, or sublingually, ideally two to three hours before insertion. Side effects can include nausea, cramping, and diarrhea and tend to be higher in patients who receive sublingual dosing as compared with buccal or vaginal administration [53]. Given the convenience of buccal administration, as compared to vaginal dosing, and the improved side effect profile when compared with sublingual dosing, our preferred dosing regimen is misoprostol 400 mcg placed buccally at least two hours before the IUD procedure.
POSTABORTION (INDUCED OR SPONTANEOUS) PLACEMENT — IUDs can be inserted immediately after surgical uterine evacuation for pregnancy termination or miscarriage, or after confirmation of passage of the pregnancy in the setting of medical abortion or spontaneous miscarriage [54,55]. Insertion of IUDs during these pregnancy events has several advantages: The timing is convenient as the patient is already receiving medical care; some of the insertion procedure steps overlap with the surgical abortion management, which minimizes IUD insertional time and risk; the patient may be highly motivated to avoid a repeat pregnancy; anesthesia provided for the uterine evacuation will help ease the IUD insertion experience; and the woman is known not to be pregnant at time of IUD placement. These benefits must be weighed against an elevated IUD expulsion rate when placed postpartum after first, second, and third trimester delivery. The optimal candidates for the different IUD insertion timings and the risk of IUD expulsion is discussed in detail separately (See "Contraception: Postpartum counseling and methods", section on 'Intrauterine devices'.)
While the general steps for postabortion IUD insertion are similar to the procedure described above for nonpregnant persons, the clinician must make minor modifications to technique. IUD placement should not be performed if there is suspicion of endometritis or if a complication was encountered during the suction procedure, such as perforation or unresolved significant bleeding.
●Insertion following surgical pregnancy interruption in the first and second trimester – An IUD may be inserted immediately following a uterine aspiration in the first trimester or a D&E in the second trimester. Both progestin and copper 380 mm2s can be used in these settings. (See "Contraception: Postpartum counseling and methods".)
After uterine evacuation and prior to immediate postprocedure IUD insertion, the provider should verify that the evacuation is complete with no suspicion for retained products or ongoing bleeding. The method of insertion is highly similar to that with an interval procedure, with the primary differences being an already dilated cervix and a larger uterine cavity. Need for repeat cervical preparation with antiseptic after uterine evacuation and before IUD insertion is controversial, and there is limited evidence to support or refute the practice. Until further data are available, both approaches are reasonable.
Since the tenaculum is already in place for the uterine aspiration, it should be left in place. Also, we don't sound the uterus in this setting. Since the cervix is already known to be adequately dilated to accommodate the IUD, the length of the uterine cavity is already known from the evacuation procedure, and the uterine size is irrelevant since it is going to change with involution, sounding the uterus provides one more opportunity for uterine perforation without much benefit. This is especially true if the uterine evacuation is performed under ultrasound guidance, as the clinician can see themselves correctly place the IUD in the fundus. Loading, inserting and deploying the IUD is all unchanged from the interval insertion process described above. The strings again can be cut to about 2 cm, but the patient should be warned that, with uterine involution, the strings may become too long and may need to be trimmed in a number of weeks in the clinic. This is especially true with placement after a second trimester procedure.
●Insertion following medication interruption of pregnancy (spontaneous or induced abortion) – IUDs can be inserted after misoprostol treatment for a spontaneous abortion or after combined mifepristone and misoprostol for an induced abortion. Prior to insertion, complete abortion is confirmed either by demonstrating absence of a gestational sac on transvaginal ultrasound (typically 5 to 14 days after spontaneous or induced abortion) or by comparing the postprocedure hCG value with the hCG value obtained on the day of mifepristone administration (a >80 percent drop in >5 days is commonly used as a marker of complete medical abortion) [56-58]. (See "Contraception: Postabortion".)
Several studies have evaluated the safety and efficacy of placing an IUD within one week of medication abortion, once confirmation of the gestation sac expulsion has occurred [54,55]. A prospective cohort study of patients who had medication abortion followed by LNG or Cu380A IUD placement at the one-week follow-up visit reported low expulsion rates (4 percent) at three months [55]. Similarly, a trial comparing placement of the Cu380A IUD at one week or six weeks following medication abortion reported the rates of IUD expulsion and continuation were the same between the two arms [54].
●Insertion following spontaneous abortion – Given the unpredictable nature of spontaneous miscarriage, there is limited literature to help guide practice of IUD insertion in this setting [54]. However, there is biological plausibility to extrapolating the medication abortion literature noted above to the setting of spontaneous miscarriage. Therefore, once the gestational sac has passed and/or there is a rapid decline in hCG values to indicate the great majority of the pregnancy has been expelled, we feel comfortable placing an IUD (assuming there are no other risk factors, such as infection). The hCG trend does not need to be followed to a negative value before an IUD can be placed, and the IUD should not affect the rate of hCG drop. Similarly, resumption of menses does not need to happen before we place the IUD. Once we can be reasonably assured that the pregnancy has passed based on patient symptoms, ultrasound evaluation, and/or hCG trends, we immediately place an IUD if desired by the patient. (See "Contraception: Postabortion".)
POSTPARTUM INSERTION
Immediate post-placental insertion
●Timing – Immediate post-placental insertion is performed within 10 minutes after delivery of the placenta [59] and has been practiced and studied extensively following both vaginal and cesarean deliveries [55,60,61]. However, while IUD insertion within 10 minutes of placenta delivery has been defined for guideline and research purposes [59], there is no known limit as to how much time can pass between delivery of the placenta and safe IUD insertion. There may be no difference in clinical outcomes with longer placenta-to-insertion time intervals [62]. Immediate post-placental insertion is well tolerated with or without regional analgesia (ie, epidural) [63].
●Fundal placement – The main challenge of post-placental IUD insertion is placing of the IUD high in the fundus before the uterus regains so much tone that it prevents proper placement.
●Risk of expulsion – Expulsion rates of IUDs placed immediately postpartum have been reported to reach 20 to over 35 percent [64]. Meta-analysis of continuation and expulsion outcomes demonstrates that immediate IUD placement following placenta delivery has higher expulsion rates than delayed or interval IUD placement. However, due to poor postpartum follow-up rates, the initiation and long-term continuation rates of IUDs placed immediately postpartum are ultimately significantly higher, and more patients are ultimately protected with highly effective contraception [65].
Additional information on IUD expulsion rates by timing of insertion and device type is available in related content. (See "Contraception: Postpartum counseling and methods", section on 'Expulsion'.)
●Insertion following vaginal delivery – Once the placenta has been delivered and uterine bleeding has stabilized, the cervix is visualized with the help of retractors or speculum and grasped with a ring forceps. The cervix is prepped with betadine.
Next, we remove the IUD from the applicator with the strings intact and either gently place the device between the index and middle fingers of our dominant hand (figure 12) or we very gently grasp the IUD with a ring forceps. We prefer to place the IUD manually, rather than use the inserter, because the copper 380 mm2 inserter is typically too short and the LNG IUD applicators generally require manipulation within the vagina, which we find awkward. If the ring forceps are to be used, great care is to be taken to grasp the IUD with minimal pressure, as tightening the forceps may lead to a full break of the IUD or lead to enough damage to affect the rate of levonorgestrel or copper ion release. Once the IUD is positioned in the dominant hand or ring forceps, the device is inserted into the cervix, passed through the entire length of the uterine cavity, and released at the top of the fundus (figure 13). We typically perform postpartum insertion in the standing position and place our nondominant hand on the patient's abdomen to help stabilize the fundus. Once the IUD has been deposited at the fundus, we take care to remove the hand or the ring forceps without catching and pulling downward on the strings.
The copper 380 mm2 IUD strings may not actually be long enough to extend all the way through the cervix and, even if they are, they likely do not need to be cut. The LNG IUD strings are typically long enough to extend through the cervix and may be cut but should be deliberately kept long to keep them from migrating back up into the open cervix. Given the increased literature on the safety of immediate postpartum IUD insertion and the increase of IUD provision in this setting, specific postpartum IUD inserters are in development (picture 1).
●Insertion following cesarean delivery — IUD insertion after a cesarean delivery is similar to placement after vaginal delivery. Since uterine tone increases with time following removal of the placenta, it is likely best to minimize delay of insertion. To allow room for our hands or instruments, we typically do this before we start the hysterotomy repair. However, some clinicians find it helpful to start the hysterotomy repair and then place the IUD when repair is about halfway complete. Typically we are able to use the IUD applicator for insertion at time of cesarean. However, as with vaginal insertion, an alternative option is to remove the IUD and the intact strings from the applicator and secure the IUD with the dominant index and middle figure (figure 12) or the ring forceps. We place the IUD at the top of the fundus while controlling the uterus with our non-dominant hand. We then direct the strings towards the vagina using long forceps such as DeBakey, though we do no other measures to directly bring the strings through the cervix. IUD strings migrate down through the cervix in about a half of the patients who have it placed at time of cesarean delivery and can be visualized during speculum examination at the postpartum visit [66]. For those patients in whom strings cannot be seen at the postpartum visit, the IUD is likely in the fundus but the strings are in the lower uterus or cervix. We perform an office ultrasound to check for IUD location and reassure the patient.
Delayed postpartum IUD insertion
●Early-delayed – Early-delayed IUD insertion is less common and generally is performed when a woman expressed her desire for an IUD after delivery but prior to discharge (between 10 minutes and one week after delivery) [59]. During this time, uterine tone is quite strong but involution is not yet completed. The insertion technique for early delayed postpartum insertion is the same as the immediate postpartum insertion above. (See 'Immediate post-placental insertion' above.)
●Late-delayed – Late delayed insertion typically refers to insertion intervals of a few weeks postpartum, but less than six weeks [59]. Intervals of two to three weeks have been studied and demonstrate feasibility without adverse outcomes [67,68]. Since patient surveys report that a majority of postpartum patients resume intercourse before six weeks postpartum [69-71], shortening the postpartum insertion window is desirable to prevent unintended pregnancy. The insertion technique for late delayed insertion is the same as the IUD insertion technique described above in the non-postpartum setting. (See 'Procedure' above.)
Interval postpartum insertion — Interval postpartum insertion typically refers to insertion six weeks or beyond after delivery. Uterine involution and tone should be completely normalized to the prepregnancy state by this time. Therefore, the counseling and insertion of the IUD at this postpartum interval is the same as the non-postpartum patient. (See 'Procedure' above.)
POSTINSERTION COUNSELING — Following IUD interval or postpartum insertion, the woman should be counseled to return for fever, worsening pelvic pain, abdominal pain, syncope, unusually heavy vaginal bleeding, suspected expulsion, foul smelling vaginal discharge, or pregnancy-like symptoms. She should also return if she wants to discontinue the method. Management of side effects and problems related to IUD insertion, including bleeding and cramping, is discussed in detail separately. (See "Intrauterine contraception: Management of side effects and complications", section on 'Immediate post-insertion: 0 to 7 days'.)
●Back-up contraception – Whether or not they were using a prior contraceptive, individuals who have a LNG 19.5 mg or 13.5 mg IUD inserted are advised to use another method for back-up contraception for seven days following device placement. (See 'Patients switching from another method' above.)
●Self-IUD string check – We counsel patients that routine self-IUD string checks are safe, but not required, as there are no data to support this practice. Furthermore, many individuals are uncomfortable with and/or unable to feel their own IUD strings even when their IUD is properly positioned. For an interested patient, we offer them the cut string fragment to feel at time of IUD placement so they can familiarize themself with how the strings feel should they want to do a digital self-examination to reassure themself that they can feel the strings at their cervix in the future. If a patient is unable to feel an IUD string that was previously palpable, we advise use of back-up contraception until an the patient can be examined by a clinician. (See "Intrauterine contraception: Management of side effects and complications", section on 'Problems noted at time of follow-up examination'.)
●Follow-up visit – There is no evidence to support required follow up visits for routine IUD string check with a provider, although one study reported that the majority of patients prefer such a visit [72]. In the absence of problems, we offer a follow-up examination in one to three months as we would after the initiation of any other medication. At the follow-up visit, we evaluate their satisfaction with the method, provide support to promote satisfaction, address any concerns or potential side effects, assess changes in their health status that may impact IUD use, and check the IUD strings. (See "Intrauterine contraception: Management of side effects and complications", section on 'Problems noted at time of follow-up examination'.)
IUD REMOVAL (WITH OR WITHOUT REPLACEMENT) — The IUD can be removed by a clinician any time a patient desires pregnancy or becomes dissatisfied with the method. Otherwise, the IUD is removed at the end of its active duration, as specified by the device package insert.
Limited data support longer duration of use beyond that of the package insert for some of the IUDs and in some clinical scenarios, such as perimenopausal patients. For individuals who become menopausal while the LNG IUD is still active, the device can be removed if desired or continued for non-contraceptive benefits such as endometrial protection.
●(See "Intrauterine contraception: Background and device types".)
●(See "Intrauterine contraception: Candidates and device selection", section on 'Management at menopause'.)
●(See "Intrauterine contraception: Candidates and device selection", section on 'Endometrial protection'.)
An IUD can be removed any time during the menstrual cycle. Patients should be informed that fertility can return immediately after IUD removal (figure 14). Management of patients who do not desire pregnancy and wish to have another IUD inserted or switch to a different contraceptive method is discussed above. (See 'Patients switching from another method' above.)
Patients continue to ovulate and have their normal menstrual cycles with the copper 380 mm2 and, to a lesser extent with the LNG-containing IUD. Typically, if a patient is amenorrheic or oligomenorrheic with an LNG-containing IUD menses often returns within the first one to two months following removal, though may take longer. They should be advised that continued amenorrhea does not mean that they are not ovulating and that pregnancy can occur even in the absence of return of menses.
Removal is accomplished by grasping the strings with long Kelly forceps (also known as Boseman), ring forceps, or a similar instrument, and gently pulling the IUD out in one swift maneuver. A quick, transient cramp and/or spotting is normal during removal. Antibiotic prophylaxis, culture, or pathologic examination is unnecessary for routine removals, though the clinician should immediately examine the IUD to ensure that it is removed intact. Techniques for removing the device when the strings are not visible, when the device has embedded in the myometrium, or in the setting of unintended pregnancy are described separately. (See "Intrauterine contraception: Management of side effects and complications".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contraception".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Intrauterine devices (IUDs) (The Basics)" and "Patient education: IUD insertion (The Basics)" and "Patient education: IUD removal (The Basics)")
●Beyond the Basics topic (see "Patient education: Long-acting methods of birth control (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Nomenclature and devices – Intrauterine device (IUD) encompasses intrauterine contraceptive (IUC) and intrauterine system (IUS, for progestin-containing devices). Four types of IUDs are commonly available globally; one contains copper (copper 380 mm2 IUD) and three release the progestin levonorgestrel at differing doses (LNG 52 mg, 19.5 mg, or 13.5 mg). Other IUD types are available in specific geographic regions. (See 'IUD nomenclature' above.)
●Candidates – There are very few contraindications to IUD use. Most patients, including those who are nulliparous, adolescent, immediately postpartum or postabortion, have acute or chronic medical conditions, and/or desire emergency contraception are candidates for an IUD. (See 'Candidates, device selection, and contraindications' above.)
●Timing of IUD insertion – An IUD may be inserted at any time during the menstrual cycle if pregnancy can be reasonably excluded by the presence of any of the criteria in the following table (table 1). Documentation of a negative pregnancy test prior to IUD insertion is advised for most patients, but particularly for those with lactational amenorrhea or other conditions that lead to irregular intervals between menses (unclear timing of ovulation), or questionable compliance with contraception. (See 'Timing of insertion and pregnancy testing' above.)
•Postprocedure insertion – IUDs can be inserted immediately after surgical uterine evacuation for pregnancy termination or miscarriage, or after confirmation of passage of the pregnancy in the setting of medical abortion or spontaneous miscarriage. (See 'Postabortion (induced or spontaneous) placement' above.)
•Postpartum insertion – IUDs can be inserted following vaginal or cesarean delivery. Immediate post-placental insertion is preferred because of the higher initiation and continuation rates, although expulsion rates are also higher compared with delayed or interval insertion. (See 'Postpartum insertion' above.)
●STI counseling and screening – We counsel all patients about risk of sexually transmitted infections (STI) and offer voluntary screening for gonorrhea and chlamydia to all individuals presenting for IUD insertion regardless of risk factors. Additionally, we routinely screen based on the Centers for Disease Control and Prevention STD & HIV Screening Recommendations. If no evidence of acute pelvic infection is present, STI screening should not delay IUD insertion. (See 'Sexually transmitted infections' above.)
●Antibiotics not indicated – Antibiotic prophylaxis for the placement of an IUD is not recommended, even for individuals with valvular heart disease. (See 'Antibiotic prophylaxis' above.)
●Options for analgesia – In our practice, pain management is a process that includes preprocedure counseling, support during the procedure, use of nonsteroidal anti-inflammatory drugs, and, for some patients, a paracervical block. We perform shared decision-making with the patient to select an individualized approach. (See 'Approach to analgesia' above.)
•NSAID – Despite the conflicting literature, we offer patients nonsteroidal anti-inflammatory drugs (oral ibuprofen 800 mg or naproxen 550 mg, based on medication availability and onset of action) either before or after IUD insertion. Pretreatment with misoprostol does not reduce insertion pain. (See 'Approach to analgesia' above.)
•Paracervical block – In general, we find that patients frequently reject the option of a paracervical block for general IUD placements following a risk-benefit patient-centered discussion. However, patients with significant concerns regarding pain management, anxiety regarding the procedure, or with history of difficult IUD insertion for any reason may benefit from paracervical block. (See 'Approach to analgesia' above.)
Other analgesics that have been evaluated include misoprostol, topical anesthetics, nitrous oxide, and conscious sedation. (See 'Review of analgesia options' above.)
●Equipment for insertion – The following equipment is required for routine IUD insertion: sterile, packaged IUD device, speculum, single tooth tenaculum, uterine sound (either metal sound or alternative like a 3mm flexible endometrial biopsy pipelle), scissor (ideally long with curved blade), an antiseptic solution (povidone iodine or chlorhexidine. Ideally, sterile gloves should also be available, although a "no touch" technique is acceptable. (See 'Equipment' above.)
●IUD insertion – General steps common to insertion of any IUD include examining the pelvis, placing a tenaculum on the cervix, and sounding the uterine cavity. (See 'General steps for IUD insertion' above.)
The specific IUD insertion process varies by device. The clinician should be familiar with the specific steps for the various devices. (See 'Device-specific insertion steps' above.)
●Cervical dilation and ultrasound guidance – We do not routinely pretreat patients with misoprostol prior to IUD insertion, but misoprostol pretreatment can be helpful in select individuals, such as those with a stenotic cervix. For patients in whom the IUD insertion was difficult or failed, cervical dilators and ultrasound guidance can aid insertion. (See 'Difficult insertion' above.)
●Postinsertion counseling – Postinsertion counseling includes a discussion of concerning symptoms and use of back-up contraception as indicated. (See 'Postinsertion counseling' above.)
ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Gillian Dean, MD, MPH, and Alisa B Goldberg, MD, MPH, who contributed to an earlier version of this topic review.
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