Intrauterine Device Insertion and Removal

Sandra M. Sulik, MD, MS, FAAFP
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Subject: Intrauterine Device Insertion and Removal

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Introduction

The intrauterine device (IUD) is the most commonly used method of reversible contraception worldwide. However, it is used by only 1% of women in the United States who desire reversible contraception. The infrequent use in this country results from public fear of health risks, complicated and promoted by medicolegal factors. 
The IUD was developed in the United States and was popular in this country until the mid-1970s, when the Dalkon Shield came into use and was associated with ascending uterine infections. This complication was not intrinsic to all IUDs, but was caused by use of a braided IUD string, that provided a path for bacteria to enter the uterus. This resulted in ascending infections, pelvic inflammatory disease, and infertility. The device was removed from the market in 1975. Although other IUDs, especially those containing copper, were safe and effective, litigation and other economic factors led to most of them being removed from the market in the early 1980s. 
Currently there are two types of IUD’s available in the United States. The ParaGard copper IUD (copper IUD) and the Mirena Intrauterine System (LNG IUS). The Copper T380A (ParaGard, Ortho-McNeil, Raritan, NJ), introduced in 1988, is now commonly used by primary care practitioners. It contains copper on a polyethylene T-shaped frame that is 32 mm wide and 36 mm long. It may be used for 10 years before replacement and has a failure rate of <1%. The Copper T380A is one of the most thoroughly studied IUDs. Careful patient selection, good patient education, and thorough informed consent have greatly reduced the medicolegal risk with this IUD. The Mirena IUS, a 5-year IUD containing levonorgestrel (Mirena, Berlex Laboratories, Montville, NJ) emerged on the U.S. market in the 1990s. The major advantage of this device is the reduction of bleeding after 6 months of use. Approximately 20% of women experience amenorrhea after 1 year of use. 
The primary mechanism of action of the Copper T380A IUD is probably through the spermicidal effects of the copper. Sperm are damaged in transit, and few reach the ovum. Those that do ascend are generally in poor shape. There also may be alterations in cervical mucus produced by the IUD. IUDs also cause a foreign body inflammatory reaction. The levonorgestrel-releasing system provides pregnancy prevention by thinning the lining of the uterus, inhibition of sperm movement, and thickening of cervical mucus. There is minimal scientific evidence (despite more than 30 years of study) that the IUD is an abortifacient. However, if a patient is not able to accept this as a possible minimal mechanism of action, she may wish to consider an alternative form of birth control. IUDs have a lower actual failure rate in clinical use than oral contraceptives and most other reversible contraceptive methods (0.1% to 0.8% vs 5% for the combined oral contraceptive). Fertility usually returns promptly after removal of an IUD. 
IUDs may be inserted any time after delivery, after abortion, or during the menstrual cycle. The advantages of insertion during a menstrual period include a possibly more open cervical canal, the masking of insertion-related bleeding, and the knowledge that the patient is not pregnant. Insertions can be more difficult when the cervix is closed between periods. 
Insertion can be performed between 4 and 8 weeks postpartum without an increase in pregnancy rates, expulsion, uterine perforation, or removal for bleeding or pain. Insertion can even occur immediately after a vaginal delivery without an increased risk of infection, uterine perforation, postpartum bleeding, or uterine subinvolution if no infection is present. Expect a slightly higher expulsion rate compared with insertion 4 to 8 weeks postpartum. The IUD also can be inserted at the time of cesarean section, with the expulsion rate slightly lower than immediately after vaginal delivery. Insertion of an IUD in breast-feeding women is associated with a lower removal rate for bleeding or pain. An IUD can be inserted immediately after a first-trimester abortion, but the patient should wait after a second-trimester abortion until uterine involution occurs. 
Patient satisfaction studies have revealed higher ratings for IUDs than for most other contraceptive methods. Increased menstrual bleeding and cramping is a typical side effect of IUD use. Bleeding causes removal of the T380A during the first year in 5% to 15% of patients. Nonsteroidal anti-inflammatory drugs often help reduce these problems. 
Infections caused by IUDs usually occur within the first 20 days after insertion. The overall rate of infection is only 0.3%. Routine antibiotic prophylaxis is not needed for the insertion of an IUD. Cases of tuboovarian actinomycosis associated with IUD use have been reported. If this organism is reported on a Papanicolaou (Pap) smear in an asymptomatic patient, the IUD should be removed and may be replaced when a repeat Pap smear is negative. 
The ectopic pregnancy rate with use of the IUD is lower than with no contraception (90% reduction in risk). However, if a patient becomes pregnant with an IUD in place, it is more likely that the pregnancy is ectopic. There is no increase in ectopic pregnancy with a history of prior IUD use. Intrauterine pregnancy with an IUD in place causes a 20-fold increased risk of developing life-threatening, second-trimester septic abortion. The IUD, therefore, should be removed as early as possible if intrauterine pregnancy occurs. 
Spontaneous expulsion occurs in 5% of women during the first year, most often during the first menses after insertion. Partial expulsion or displacement is marked by lengthening of the IUD string. The IUD may be immediately reinserted if no infection is present (prophylactic antibiotics are recommended). 
Displacement of the IUD may occur, and absence of the string on the patient’s self examination is cause for further evaluation. Plain films of the abdomen can determine the presence of the IUD, and ultrasonography or hysteroscopy can be used to determine its location or to extract the device. If the device is in the abdominal cavity, laparoscopy is usually successful at removal. Uterine perforation may occur during insertion but is uncommon. 
Patients with newly inserted IUDs should attempt to feel the strings before they leave the examining room. Give the patient the cut ends of the strings as a sample of what to feel. The patient should make a follow-up visit in 1 month to confirm presence of the IUD and to trim the string if it is too long. Palpation of the strings should be performed monthly by the patient to verify continuing presence of the IUD after each menstrual flow. 

Equipment

  • Speculum

  • Exam gloves

  • IUD or IUS

  • Light source

  • Iodine/Povidine solution in a small basin with cotton balls

  • Ring forceps or long Kelly

  • Cervical tenaculum

  • Uterine sound

  • Large absorbant swabs (Scopettes)

  • Long-handled scissors

  • Nonsterile gloves for bimanual exam and sterile for IUD insertion

Indications

  • Reversible contraception for patients in a monogamous relationship at low risk for STDs

  • Consider for women with the following medical conditions:

    • Diabetes

    • Thromboembolism

    • Menorrhagia/dysmenorrhea (LNG IUS—off-label use)

    • Breast-feeding

    • Breast cancer (Copper IUD only)

    • Liver disease (Copper IUD only)

    • Severe dysmenorrhea/menorrhagia (LNG IUS)

Contraindications

  • Pregnancy

  • Undiagnosed genital bleeding

  • Wilson’s disease and allergy to copper (copper IUD)

  • Known or suspected cervical or uterine neoplasia

  • Pelvic inflammatory disease/septic abortion present or within 3 months of insertion

  • Severe dysmenorrhea or menorrhagia (copper IUD)

  • An abnormally shaped uterus, or fibroids that distort the uterine cavity (the uterine cavity should sound to 6 to 10 cm)

  • Sign of cervicitis or vaginitis on the day of insertion

  • Patients at high risk for endocarditis (e.g., prosthetic valves, major valve abnormalities, shunt lesions)

  • Use with great caution with anticoagulation (copper IUD)

The Procedure

Insertion of ParaGard Copper IUD

Step 1
Explain the IUD insertion procedure, and obtain informed consent. Review current Pap smear and culture results. American College of Obstetrics and Gynecology guidelines do not recommend checking cultures in low-risk women. If Pap is not current, repeat just prior to insertion of the IUD. Check urine pregnancy test prior to insertion of device. With the patient in the lithotomy position, perform a bimanual examination to determine the uterine size and position and to rule out structural abnormalities. Place a sterile speculum in the vagina, and swab the cervix with an antiseptic solution such as an iodine or benzalkonium preparation. Make sure the IUD package is intact and that all of the parts are present. 
Step 2
Using sterile technique, grasp the anterior lip of the cervix with a tenaculum and sound the uterus (should be between 6 and 10 cm). A paracervical block can be used to decrease the pain of the procedure. Inject 2% lidocaine just off the cervix at the 3- and 9-o’clock positions (or 4- and 10-o’clock positions if preferred). 
  • PITFALL: A paracervical block takes a few minutes for full effect. Wait 2 to 3 minutes following the injections before initiating the procedure.

Step 3
With sterile gloves or through the sterile wrapper, fold down the arms of the IUD into the insertion tube just enough to hold them in place during insertion. The phalange on the insertion tube is set to the distance of the sounding. This permits visual confirmation of when the top of the IUD reaches the fundus. 
  • PITFALL: Fold the arms right before or during the procedure. Prolonged bending of the arms causes them to release slowly and increases the likelihood of device expulsion.

Step 4
Insert the device into the uterine cavity until it meets resistance at the fundus, and then slightly withdraw (i.e., a few millimeters). 
Step 5
While holding the insertion rod in place, withdraw the insertion tube 1 to 2 cm to release the arms of the IUD in the horizontal plane of the uterus. 
  • PITFALL: Do not push the insertion rod upward to elevate the IUD. This practice is painful for the patient and increases the risk of perforation.

Step 6
Withdraw the insertion rod and tube, leaving the string protruding from the cervical os. You can ensure that the Copper T380A is in a high fundal position if, after removing the solid rod, you push the insertion tube up against the cross arm of the T before withdrawing it. 
Step 7
Cut the string to a length that allows the patient to easily palpate it on self-examination (i.e., 2.5 to 4 cm). 
  • PITFALL: Do not cut the strings too short; err on the side of too long because the strings can always be cut again. If the strings are cut too short, they tend to impale the end of the glans penis and cause pain during intercourse.

  • PITFALL: Despite proper placement, early expulsion is possible. Inform the patient of this possibility, and instruct her to return the IUD to your office. The manufacturer will provide a sterile replacement for reinsertion at no cost.

Insertion of Mirena Intrauterine System

Step 8
Follow first two steps above. Mark the depth of the uterus with the green phalange on the intrauterine system (IUS). Free the strings from the IUS and pull down on the strings as you push the green slider towards the IUS. 
  • PITFALL: Make sure that the arms of the IUS are horizontal to the insertion device in order to assure proper loading. The entire tips of the IUS should be loaded into the device prior to insertion.

Step 9
Using traction from the tenaculum, insert the IUS through the cervical os and to the depth marked on the IUS. Gently pull the entire system back 1 cm away from the cervix. 
Step 10
Release the slider (green phalange) to the marked position (only!) on the side of the device. (This releases the arms of the IUS.) 
  • PITFALL: Only move the slider to the first mark, not all of the way to the end of the slide (which releases the strings.)

    Step 10
    Step 10

Step 11
Then, advance the entire device back to the uterine depth marker on the IUS. This will place the IUS at the fundus of the uterus. 
Step 11
Step 11
Step 12
Pull the slider (green phalange) all the way back to release the string. Remove the inserter from the uterus. Cut the strings at a depth of 2.5 to 4 cm. Remove the tenaculum and speculum and instruct the patient in how to find the strings to check for placement. 
Step 12
Step 12

IUD Removal

Step 13
Place a cervical speculum and find the IUD strings. Removal of an IUD usually can be accomplished by grasping the string with a ring forceps and exerting firm, steady traction (usually during the menstrual period). 
Step 13
Step 13
Step 14
If strings cannot be seen, they can often be extracted from the cervical canal by rotating two cotton-tipped applicators or a Pap smear cytobrush in the endocervical canal. 
Step 14
Step 14
Step 15
If IUD strings cannot be identified or extracted from the endocervical canal, a light plastic uterine sound should be passed into the endometrial cavity after administration of a paracervical block. The IUD can frequently be felt with the sound and localized against the anterior or posterior wall of the uterus. The device can then be removed using polyp- or alligator-type forceps directed to where the device was felt. 
  • PITFALL: Because there is a risk of perforation with this procedure, patients are often referred for hysteroscopic removal at this stage.

    Step 15
    Step 15

Complications

  • Pregnancy (rare <1%)

  • PID (only in the first 20 days after insertion)

  • Perforation (extremely rare)

  • Spontaneous expulsion (most occur within first 6 months)

  • Lost IUD string (rule out pregnancy, look in endocervical canal)

  • Actinomyces (usually asymptomatic, pull IUD and treat, replace IUD when actinomyces is no longer present on Pap)

  • Uterine bleeding and cramping (usually within the first 3 months of insertion)

Pediatric Considerations

This procedure is not used in children. Although not commonly used in adolescents, the procedure is the same. 

Postprocedure Instructions

Once the IUD insertion is complete, wipe off the strings and hand them to the patient to feel. Have the patient feel for the strings before she leaves the office. Explain that some spotting initially is normal. Give the patient the IUD handout that comes with each IUD package insert. 
Remind the patient that routine Pap smears are still necessary and that the IUD will not protect from STDs; therefore, condoms should also be used. Review the signs of expulsions with the patient—severe cramping being the most important. Tell the patient to call if she cannot find the strings and to use a backup method until the presence of the IUD can be confirmed. Counsel the patient to report any excessive bleeding, malodorous discharge, unexplained fever, pain with intercourse, prolonged bleeding, amenorrhea, or prolonged pelvic pain. 

Coding Information and Supply Sources

ICD-9-CM Diagnostic Codes

Instrument and Materials Ordering

ParaGard IUDs can be obtained from Ortho-McNeil Pharmaceuticals (phone: 1-800-322-4966). A physician can establish an account free of charge and place orders for the product. They may be ordered singly or in a box of five at a lower cost per unit. 
Mirena may be ordered from Berlex Laboratories, Inc. (phone: 1-866-647-3646). Before any insertion, it is important to obtain training on the proper technique specific to Mirena. Training can be found at http://www.mirena-us.com or by writing Berlex Laboratories, Inc., 6 West Belt Road, Wayne, NJ 07470-6806. 
Instruments and materials in a standard gynecological tray are listed in Appendix H: Instruments and Materials in a Standard Gynecological Tray. 

Bibliography

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