Firstly, prepare people well to instil confidence. It really seems to make a difference to pain if you have established trust and rapport with the patient.
It’s really helpful to sign the consent at a separate time so that on the day when they come in for the procedure you can keep things light and chatty and not have to talk about things like perforation.
Discuss the option to have the IUD inserted under sedation. It is empowering for people to have made an active decision to have insertion with you in your rooms and this also seems to reduce fear and improve pain tolerance. Give them written instructions beforehand. They need to know it is a procedure and requires some planning, like having something to eat and drink beforehand, and some recovery time, so they don’t think they can just rush straight back to work or pick up kids from school.
With regards to pre-medication, there is little evidence that it makes much difference to the insertion procedure. But a couple of studies have shown some reduction in post insertion cramping so we usually recommend it. Most of us probably recommend using Panadol or Naprogesic or both.
Make sure you’re not in a rush. I book my IUD insertions for the end of the session, either the morning or the afternoon, so that I’m not stressed about people waiting in the waiting room.
It’s a good idea to have an assistant, the ‘vocal local’ that helps keep things nice and relaxed and looks after the patient.
The procedure needs to be conducted in a smooth, orderly, and professional manner. Get orgainsed and have all your equipment ready.
For the procedure itself, you can use a 10% lignocaine spray. A 2016 Turkish study showed that was very helpful and that has become a routine part of my practice.
InstillaGel lignocaine gel is another option. You can insert it with a little plastic syringe quill (no needle) right up into the cervical os. While there is no robust data to support a pain reduction benefit, anecdotally a lot of inserters report that it helps. I have found it quite helpful for trickier insertions and for people who’ve had a painful insertion previously.
Some people use the ‘green whistle’ Penthrox. There are also paracervical blocks, but I personally don’t think they fit very well into general practice IUD insertions because they require some more complicated dental needles.
~ Answered by Dr Rebecca South – Women’s Health General Practitioner, Clinical Lead at Inner West Women’s Health
It’s common to get an ultrasound report saying an IUD is low-lying. You might not get a measurement, or you might not think that measurement actually means it is low-lying. You can contact the radiologist to clarify the measurements. It’s also useful to remember to specify on your ultrasound request forms that you want them to give the distance from the fundus.
Generally, we consider that copper IUDs may be less effective if they are greater than 2 cm below the fundus. In this case we would usually discuss removal and replacement. But they can shift within the uterus over time, so you could use alternative contraception for a couple of months, repeat the ultrasound and check if it has repositioned itself into an acceptable location.
Efficacy of progesterone releasing IUDs is thought to be less affected by their position in the uterus because of their hormonal effect on the endometrium and the thickening of the cervical mucus. Any IUD that is in the endocervical canal should be removed because of increased failure risk.
~ Answered by Dr Sarah Callister – General Practitioner; Senior Medical Educator and Medical Officer, Family Planning Australia
This situation is not common, but it is really important that it is well managed when it does occur. The usual advice is if the woman wishes to continue the pregnancy, then removal of the IUD should be attempted provided the strings are visible at the os.
However, the woman must be made aware that this procedure carries around a 20% chance of pregnancy loss. If the IUD remains in situ, there is approximately a 30% to 50% chance of a later miscarriage (sometimes a septic miscarriage) and a 15% chance of a premature delivery.
If the strings are not visible, the first step is to organise an ultrasound to establish that the IUD is still in the uterus. One of the reasons somebody can fall pregnant with an IUD is that it has been expelled without the woman realising that it is no longer there. And sometimes an ultrasound will find that the IUD has perforated the uterine wall and lies outside the uterine cavity. This is of course another reason for contraceptive failure, but also means that the misplaced IUD must be retrieved as well as dealing with the unintended pregnancy.
One problem is that uterine enlargement may draw the IUD strings up beyond easy reach at the cervical os. If the strings are not easily seen and the woman wishes to continue the pregnancy, hysteroscopy may allow retrieval of the device. Quick referral to a sympathetic local obstetrician optimises the chances of a successful removal. Most of the literature suggests that though there is still a risk of pregnancy loss if the IUD is removed via hysteroscopy in the first trimester, that risk remains lower than the risk of complications down the track if the IUD is left in situ. Using a very fine hysteroscopic cannula and minimal instillation of fluid is apparently associated with the best chance of being able to remove the IUD without damaging the pregnancy. And if IUD removal is impossible and the pregnancy goes ahead, it is important that the obstetric team at delivery know about the IUD. It will usually be found embedded in the placenta.
If the woman is sure that she does not want to continue with the pregnancy and the strings are visible, you can try to remove the IUD. There are also strategies you can use to try to locate the strings and remove the IUD successfully (see below). The IUD can also be removed at the time of a surgical abortion and some women opt for this in place of prior attempted removal. An IUD must be removed before a medical abortion.
You can also take steps to help avoid this situation. There is no 100% effective contraception, and our patients need to know that should their periods disappear while using a copper IUD or should they get some unusual bleeding on their Mirena, it’s important they do a pregnancy test. The overriding message should be to come back for advice as soon as pregnancy is suspected, since this gives us the most options.
~ Answered by Dr Terri Foran – Sexual Health Physician; Conjoint Senior Lecturer, School of Women’s and Children’s Health, UNSW.
Once you have the speculum in, you can use a cytobrush to gently sweep the surface of the cervical canal and try to locate the strings.
They are often sitting just inside the cervical canal and you can draw them down enough to grip them and remove the IUD. If you have a pair of long, fine forceps, you can also use them to gently probe inside the cervical canal. You open and then close the forceps, rotating them and retracting to try to grip and draw down the threads.
You can use a specific instrument called a thread retriever (often known as a pelican), but this would normally be done after an ultrasound has confirmed the IUD is in the uterus and by someone trained to use the device.
If the strings cannot be retrieved, most specialist gynae ultrasound services can do ultrasound-guided removals, which have a very high success rate. Occasionally a hysteroscopy may be needed.
~ Answered by Dr Sarah Callister
“Sometimes applying a little bit of local anaesthetic spray directly into the cervix will open it up and the strings may pop out that way.” Dr Terri Foran
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