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Simulation

Intrauterine Device (IUD) Insertion

Module

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Equipment Needed for Intrauterine Device Insertion

  • Tenaculum: to stabilize cervix
  • Uterine sound: to measure uterine cavity
  • Scissors: to trim strings

May need cervical dilators in some situations Use betadine or alternative cleanser prior to insertion

Hormonal Intrauterine Devices

  • Mirena® FDA approved for 5 years Releases levonorgestrel (LNG) 20 mcg/day/ 32 mm x 32 mm Insertion rod 4.4 mm
  • Skyla® FDA approved for 3 years Releases LNG 13.5 mcg/day 28 mm x 30 mm Insertion rod 3.8 mm/li>
  • Kyleena® FDA approved for 5 years Releases LNG 19.5 mcg/day/ 28 mm x 30 mm Insertion rod 3.8 mm
  • Liletta® FDA approved for 3 years Releases LNG 18.6 mcg/day 32 mm x 32 mm

Copper Intrauterine Devices

  • Paragard®
    • Contains copper
    • Non-hormonal
    • “T” measures 36 mm x 32 mm

Effectiveness and Failure Rates

LNG-IUD 14 LNG-IUD 20 Cu-380
Duration of FDA-approved use 3 years 5 years 10 years
Duration of effectiveness - 7 years 12 years
1st year pregnancy rate (%) (Perfect use) .41 0.1 0.6
1st year pregnancy rate (%) (Typical use) .41 - .96 0.1 - 0.2 0.5 - 0.8
Cumulative pregnancy rates over life of device .9 - 1.7 1.1 2.2

Adapted from: http://labeling.bayerhealthcare.com/html/products/pi/Skyla_PI.pdf, http://paragard.com/images/ParaGard_info.pdf, http://labeling.bayerhealthcare.com/html/products/pi/Mirena_PI.pdf.

Pre-evaluation for Intrauterine Device

  • Informed consent
    • Effectiveness
    • Benefits
    • Risks
    • Possible side effects
  • Sexually transmitted disease (STD) testing
    • Universal versus risk-based
    • Universal may not be cost-effective
    • Risk factors include
      • Age younger than 25 years
        • New partner
        • Multiple partners
        • Recently treated STD
  • Select IUD: hormonal or non-hormonal
    • Size of “T” and inserting rod and duration of effectiveness

Contraindications to the Intrauterine Device

  • Pregnancy
  • Acute, recent, or recurrent uterine infection
  • Untreated cervicitis
  • Severe distortion of uterine cavity
  • Malignant gestational trophoblastic disease
  • Endometrial or cervical cancer

Source: Centers for Disease Control and Prevention. CDC Medical Eligibility Criteria for Contraceptive Use, 2010

Not Contraindications to the Intrauterine Device

  • Nulliparity or nulligravidity
  • Adolescence
  • Prior history of Pelvic Inflammatory Disease
  • Prior STD history
  • Multiple partners
  • Fibroids (unless they distort uterine cavity enough to prevent insertion)
  • Prior history of ectopic pregnancy

Intrauterine Device Insertion Steps

  1. Bimanual exam: Size and direction of uterus
  2. Insert speculum, visualize cervix, cleanse cervix with an antiseptic solution
  3. Grasp anterior lip of cervix with tenaculum
  4. Sound uterus to fundus
  5. Make a note of sounding length

Troubleshooting Difficult Intrauterine Device Insertions

  • Use small dilator to dilate internal os
    • Os finder can sometimes be useful
    • If this doesn’t work, reassess uterine position and abnormalities
    • Consider putting tenaculum on posterior lip of the cervix
  • Consider ultrasound guidance
  • Consider paracervical block

Follow-up Steps after Placement

  • 4-6 weeks and yearly, thereafter
  • If IUD strings are not visible, ultrasound should be used to ensure the IUD is still intrauterine
    • Paragard “lights up” very well on USG, Skyla® , Liletta® and Kyleena® have a silver ring that “lights up” on USG
    • With Mirena® typically the shadow is easier to see than the device
  • If you are unable to confirm the IUD is in the uterus, check a pregnancy test and use back-up birth control until you can complete the assessment

Misoprostol

  • Effectiveness is controversial
  • Not routinely indicated
  • May have benefit in some nulliparous women or those with prior failed insertion attempt
  • No ideal regimen
  • 400 mcg buccally, vaginally, or sublingually
    • 2-3 hours before insertion

Complications with Insertion

  • Vasovagal reaction
    • More common in nulliparous patients
    • Usually responds to conservative measures
  • Perforation
  • Pain, cramping, or both

IUD Insertion Summary

  • There are currently 5 IUDs available in the United States
  • It is important to review the insertion technique for the specific device you are inserting prior to the procedure
  • Typically IUD insertions are well tolerated, but having some trouble shooting ideas in mind can be helpful for the provider and the patient

Authors

  • Nikki B. Zite, MD, MPH Professor, Residency Program Director Obstetrics and Gynecology The Department of Obstetrics and Gynecology The University of Tennessee Graduate School of Medicine
  • Eve Espey, MD, MPH Professor and Chair University of New Mexico
  • Anne Burke, MD, MPH Associate Professor Johns Hopkins University

Developed in association with the Society of Family Planning

Version 2.0, reaffirmed March 2017