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, efficacy demonstrated for up to 7 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, efficacy demonstrated for up to 7 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
- Approved for 10 years, efficacy demonstrated for 12 years

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, 2016

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

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

Source: http://paragard.com/images/ParaGard_info.pdf
- Partially open plastic wrapper
- Without touching the IUD, flex the tips of the horizontal arms and tuck them into inserter tube
- Alternately sterile gloves may be used to load the IUD
Source: http://www.paragard.com/images/ParaGard_info.pdf
- Insert solid rod into distal end of inserter tube, until rod tip abuts vertical arm of IUD
- Adjust flange to measurement determined by uterine sounding
- Rotate the insertion tube so that the horizontal arms of the T and the long axis of the blue flange lie in the same horizontal plane
- Do not load Paragard® earlier than five minutes before it is inserted into the uterus
Source: http://www.paragard.com/images/ParaGard_info.pdf
- Pass the loaded insertion tube through the os, advancing until the IUD just touches the uterine fundus
- Stabilize IUD with the solid rod
- Slide insertion tube back towards you until inserter meets ring of rod
- Hold rod steady while pulling inserter
- This allows the IUD horizontal arms to expand
- Gently move the insertion tube upward toward the top of the uterus until slight resistance is felt
- This ensures the highest placement in the uterus
- Remove the white rod completely
- Remove the insertion tube
- If removed together the strings can get caught between the rod and tube and inadvertently remove the IUD
- With scissors, trim strings to a length of 3 - 4 cm
- Remove tenaculum and ensure hemostasis
- Remove speculum
These are important steps, because they facilitate insertion. The bimanual exam gives you a sense of where you’ll be placing the IUD. For example, if the uterus feels 10-week size, you would not expect to sound to 6 cm. Or, if the uterus is small, you’ll know to get worried if you sound to 12 cm. Good visualization of the cervix is obviously important, because it makes your job easier and increases safety of the procedure.

Source: http://www.paragard.com/images/ParaGard_info.pdf
- Insertion technique is basically the same for the LNG 20 (Mirena®), LNG 14 (Skyla®), and LNG 19.5 (Kyleena®)
- Skyla® and Kyleena ® are smaller than Mirena®
  - Insertion rod and “T” are both smaller
- The packaging of the device is slightly different
  - The strings are inside the inserter for the LNG 14
  - The strings are outside of the inserter for the LNG 20 and must be pulled to retract the arms into the inserter
Sources: http://hcp.mirena-us.com/placement-and-removal/precise-placement.php

Sources: http://labeling.bayerhealthcare.com/html/products/pi/Skyla_PI.pdf
- While holding inserter, lay IUD flat on internal packaging surface
- Pull strings firmly while holding slider all the way forward
- IUD will retract into inserter tube
- Fix the threads in the cleft of the handle to hold IUD in place
- Set the flange to the size of the uterus
- Using sterile technique push the slider all the way up
- IUD will retract into inserter tube. The tips of the arms will meet to form a rounded end that extends slightly beyond the insertion tube
- Do not move the slider downward at this time as this may prematurely release the threads of Skyla
- Set the flange to the size of the uterus
Source: http://labeling.bayerhealthcare.com/html/products/pi/Skyla_PI.pdf
- Place inserter through os; advance flange to 1.5 - 2 cm from the external cervical os
- Hold inserter steady
- Move slider back to indicator mark on handle
- Allow ~10 seconds for horizontal arms to open in uterus
Source: http://labeling.bayerhealthcare.com/html/products/pi/Skyla_PI.pdf
- Gently advance the inserter further into the uterine cavity until the flange meets the cervix and you feel fundal resistance
- Retract slider fully until “click” is heard and strings are released
- Remove insertion tube
- Cut the threads perpendicularly, leaving about 3 cm visible outside of the uterus
Sources: http://labeling.bayerhealthcare.com/html/products/pi/Mirena_PI.pdf, http://labeling.bayerhealthcare.com/html/products/pi/Skyla_PI.pdf
- FDA approved for 5 years
- Releases 17.5 mcg/day
- Placement
  - Step 1: Open the package in a sterile manner
  - Step 2: Push the slider forward as far as possible (see image)
  - Step 3: Set the flange to the uterine depth
  - Step 4: Place the device through the cervix until the flange is 1.5–2 cm away from the external os of the cervix (see image)
  - Step 5: Open the arms by moving the slider to the mark, wait 10 seconds to allow the device to open (see image)
  - Step 6: Advance the device to the fundus
  - Step 7: Push the slider all the way down to release Kyleena and remove the inserter (see image)
  - Step 8: Cut the strings approximately 3 cm away from the cervical os
- FDA approved for 3 years
- Releases 18.6 mcg/day
- Single-handed insertion option:
  - Step 1: Open the package
  - Step 2: Load Liletta: ensure both sliders are fully forward, place thumb on the blue slider and push forward, pull the strings of the IUD straight back until you feel a hard stop, lock threads into the cleft at the bottom end, continue forward pressure on the blue slider (see image)
  - Step 3: Adjust the flange to the uterine depth
  - Step 4: Advance the inserter through the cervix until the flange is 1.5 to 2 cm from the external cervical os (see image)
  - Step 5: Slide the blue slider back until you meet resistance. It should meet with the green slider. Do not move the green slider. Wait 10-15 seconds for the arms to open (see image)
  - Step 6: Advance the device to the fundus. The flange should touch the cervix
  - Step 7: Move both sliders (green and blue) down to release the device. If the strings did not release from the cleft, remove them before pulling back the inserter (see image)
  - Step 8: Cut the strings approximately 3 cm from the cervix
To load the IUD:
- Step 1: Open sterile package
- Step 2: Pull the threads back to dislodge from the flange
- Step 3: Remove the rod and place in the insertion tube at 5 cm mark
- Step 4: Pull down on the IUD strings to pull it into the insertion tube
- Step 5: Adjust the flange to the sounding length of the uterus
- Step 6: Pull the strings so that the tip of the IUD is at the tip of the insertion tube and slightly visible outside the tube
To place IUD:
- Step 1: Insert the insertion tube through the cervical os so that the flange is approximately 1.5–2 cm away from the external os of the cervix
- Step 2: Hold the rod and pull the insertion tube back over the rod until you reach the first notch. Wait 10–15 seconds for the IUD to deploy
- Step 3: While holding the rod, advance the insertion tube until it reaches the fundus of the uterus
- Step 4: Hold the rod steady while pulling the insertion tube back to the ring on the rod
- Step 5: Remove the rod while holding the tube steady
- Step 6: Remove the insertion tube
- Step 7: Cut the strings approximately 3 cm from the cervical os

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

Reaffirmed February 2021