IUD (Intrauterine device) Insertion – Technique and Overview

Name of Procedure

IUD (Intrauterine Device) Insertion 

Also see the separate IUD removal guide.

Sample Opnote

After having reviewed the contraindications, side effects, and risks and benefits of all major options for reversible contraception, the patient chose the [IUD-product-name] IUD for contraception. We discussed the risks of insertion, pelvic infection, and the possibility of failure. The patient stated that she has a good understanding of all that we discussed, and all questions were answered regarding IUD use. The consent was signed.

Pelvic examination was normal. Pap smear is current. Urine pregnancy test negative.

With the patient in the dorsal lithotomy position, a speculum was placed into the vagina. The cervix and vagina were prepped with Betadine, the cervix was stabilized with a tenaculum, and the uterus was sounded (internal cervical os entered without any resistance) to a depth of [  ]cm. The [IUD-product-name] IUD was then placed in the endometrial cavity as directed without complications. The strings were trimmed to approximately 2 cm.

The patient tolerated the procedure well.

Goal

Placement of an intrauterine device into the uterus.

Indications

  • Undesired fertility
  • Dysmenorrhea
  • Menorrhagia
  • Emergency contraception (Paragard: only if inserted within 5 days of unprotected intercourse)

Non-hormonal IUD

  • Paragard: Copper IUD; 10 years duration of effectiveness 

Hormonal IUDs: levonorgesterol

  • Mirena: 52 mg; 7 years for effective contraception; 5 years for use as treatment for dysmenorrhea/menorrhagia
  • Liletta: 52 mg; 6 years
  • Kyleena: 19.5 mg; 5 years
  • Skyla: 13.5 mg; 3 years

Contraindications

Universal contraindications for the use of any IUD: 

  1. Known or suspected pregnancy
  2. Significant distorted uterine anatomy
  3. Unexplained vaginal bleeding or concern for pelvic malignancy 
  4. Ongoing or recurrent pelvic infection
  5. Gestational trophoblastic disease
  6. Acute pelvic inflammatory disease or sexually transmitted disease at the time of insertion

For the progesterone based IUDs (Mirena, Liletta, Kyleena, Skyla)

  1. Confirmed or suspicion of breast malignancy or other progestin-sensitive cancer
  2. Liver tumors or active or liver disease

For the copper IUD (Paragard)

  1. Wilson’s disease
  2. Sensitivity to copper

Anatomy

Intrauterine; see below 

Equipment/Skills/Setup

Non-sterile

  • Gloves
  • Speculum
  • Lubricant
  • Large cotton Q-tips, long or large cotton swabs

Sterile

  • Betadine or chlorhexidine
  • Sterile gloves
  • Tenaculum
  • Ring forceps
  • Uterine sound or Endometrial cell sampler
  • Long scissors
  • Cervical dilators
  • Monsel’s solution or silver nitrate sticks
  • Anesthesia if performing a paracervical block 
    • 10-20 mL of 1% lidocaine 
    • 18g needle to draw up medication 
    • 25g 1 ½” or longer needle to attach to syringe 
    • 10 mL syringes

Landmarks and Patient Positioning

Dorsal lithotomy

Technique

  1. Perform a urine pregnancy test (see below to meet the criteria for an accurate test)
  2. Place the patient in dorsal lithotomy position
  3. Perform a bimanual exam to assess if the uterus is retroverted, anteverted and the location of the cervix 
Insertion Tray: IUD
  1. Insert a speculum and identify the cervix 
    1. Clean the cervix and vaginal fornices with betadine using the large cotton swabs or Q-tips; if allergic to iodine – use chlorhexidine
  2. Switch to sterile gloves, grasp the anterior lip of the cervix with tenaculum and apply gentle traction to straighten the cervical canal
    1. If the uterus is retroverted it may be better to grasp the posterior lip of the cervix instead
MCPC – Dilatation and curettage – Health Education To Villages
  1. Using a sterile uterine sound or endometrial cell sampler determine the depth of the uterine cavity (usually 6-9 cm). Note: steady, moderate pressure is required to insert the sound through the closed internal cervical os
    1. If there is difficulty sounding the uterus:
      1. Try cervical dilators, starting with the smallest size followed by insertion of successively larger dilators until the sound passes easily to the fundus
      2. If the patient is having a lot of pain consider a paracervical block (lidocaine 1% at the 4 and 8 o’clock positions [10-20 ml total])
  2. Once the uterine depth is determined, follow the package instructions for the specific IUD being inserted (Mirena/Kyleena/Skyla vs Liletta vs Paragard). Note: Do not open the IUD package until uterus depth is sounded successfully.
    1. When inserting, make sure not to insert any further than the depth of the uterine cavity (from the step above).
    2. Doing so could potentially perforate the uterus.
  3. Once the IUD is inserted in the uterine cavity and strings are visible, cut the strings to a length of 2-3 cm with long scissors
Mirena® IUD Insertion & Removal | HCP
  1. Remove the tenaculum
    1. If there is any bleeding from the tenaculum insertion site then apply pressure for 2-3 mins, if bleeding persists – use monsel’s solution or silver nitrate sticks for bleeding cessation
  1. Remove the speculum once the bleeding has stopped
  2. Give the IUD placement card from the package. Note the following on this card: patient info, date of the procedure and duration of the IUD.
  3. Schedule the patient for a IUD follow-up visit in 4-6 weeks to discuss any side effects, and for string check to ensure proper placement.

Tips

  1. Scheduling:
    1. Generally you should schedule the patient for IUD insertion on day 2-3 of menses (the cervix may be most dilated at this time) but it is not always necessary
    2. If you want to insert the IUD the same day as the consultation (“quick start method”):
      1. Make sure one of the following criteria is met:
        1. Less than seven days after the start of regular menses
        2. No sexual intercourse since the start of last menses
        3. Consistently using another form of contraception reliably
        4. Less than 7 days after spontaneous or induced abortion
        5. 4 weeks postpartum
        6. Fully or nearly fully breastfeeding and amenorrheic, and less than six months postpartum
      2. Make sure a pregnancy test is negative
  2. Full risks/benefits/side effects are beyond the scope of this article, but a few high-value things for patients to consider:
    1. Levonorgestrel IUDs:
      1. Often lead to lighter menses or even complete cessation of menses
      2. some patients may develop irregular bleeding and/or spotting with lower dose IUDs
    2. Copper IUDs – may lead to heavy bleeding and prolonged menses
  3. Bridging contraception pre and post procedure:
    1. If using levonorgestrel IUD and if it is placed >7 days after the start of menses, an additional form of birth control should be used for 7 days.
  4. Pre-procedure pain control
    1. Especially useful in nulliparous women or patients with difficult IUD insertion in the past
    2. Naproxen 500 mg or Ibuprofen 800 mg 30-60 mins before the procedure
    3. Misoprostol – to help with cervical dilation
  5. Providers need to obtain training prior to performing IUD procedures
    1. IUD Training (For mirena/kyleena/skyla)

References

  1. Intrauterine Device – StatPearls – NCBI Bookshelf
  2. Colposcopy & the Evaluation of Abnormal PAPs
  3. Insertion Tray: IUD
  4. MCPC – Dilatation and curettage – Health Education To Villages
  5. Mirena® IUD Insertion & Removal | HCP