Intrauterine Contraceptive Device Insertion

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Chapter 246 Intrauterine Contraceptive Device Insertion

DESCRIPTION

Placement of an intrauterine contraceptive device (IUCD).

INDICATIONS

Elective, desiring contraception. (The IUCD is associated with an efficacy rate that is comparable to sterilization and oral contraceptives.) The IUCD may be a particularly good choice for women with diabetes, thromboembolism, menorrhagia, or dysmenorrhea. The copper IUCD may be preferable for those breastfeeding or with breast cancer or liver disease. The copper IUCD may be placed up to 5 days after unprotected intercourse as an emergency contraceptive measure. The progestin-releasing IUCD may be used as a treatment for menorrhagia in selected patients.

CONTRAINDICATIONS

Active cervical infection, acute sexually transmitted disease, allergy to any component of the device, dysfunctional uterine bleeding (undiagnosed), dysmenorrhea, genital actinomycoses, history of ectopic pregnancy (relative), immediate postpartum period (less than 8 weeks), immunocompromise (relative), IUCD in situ (unremoved), malignancy (uterine or cervical, known or suspected), multiple sexual partners (relative), pelvic inflammatory disease (PID) (current or past 3 months), pregnancy (known or suspected), sexually transmitted disease (current), uterine cavity malformation, vaginitis, Wilson disease (copper IUCD only).

REQUIRED EQUIPMENT

• Intrauterine contraceptive device in sterile package
• Skin (vaginal) preparation materials (iodine-based antibacterial solution [e.g., Betadine] or other suitable cleansing agents)
• Vaginal speculum
• Tenaculum
• Uterine sound (optional)
• Nonsterile examination gloves
• Scissor (long)
• Sterile gloves (optional with “no touch” technique)

TECHNIQUE

The discomfort of an IUCD insertion may be decreased by premedicating with a single oral dose of a nonsteroidal anti-inflammatory agent given in doses usually used to treat dysmenorrhea or through the use of 2% intracervical lignocaine gel. Before beginning the procedure, the size, shape, and location of the uterus should be determined. The cervix should be visualized with the aid of a speculum and then disinfected. In patients who are parous without significant uterine flexion, a tenaculum is often not needed.

The technique used to place the contraceptive device in its proper location in the uterine cavity varies slightly based on the device. Each use follows the same general sequence of steps: loading the IUCD into its carrier or placement device, placing the IUCD in position in the uterine cavity, withdrawing the placement instrument leaving the IUCD behind, verifying correct placement, and trimming the marker sting(s).

ParaGuard T380A

The IUCD must be loaded into its insertion device, which may be accomplished using either sterile gloves or a “no touch” technique. With sterile gloves the device is grasped, folded, and inserted into the distal end of the insertion tool. In the “no touch” method the same ends must be accomplished, but manipulating the IUCD through the outer package wrapper carries them out.

Once the IUCD is in the insertion device, the movable flange is moved backward on the insertion tube until it corresponds to the expected or measured depth of the uterus. The IUCD and inserter are placed at the disinfected external cervical os and gently advanced until resistance indicates that the fundus has been reached. With the obturator held in place, the insertion tube is withdrawn, leaving the device in the correct position. The obturator should not be advanced as the insertion tube is withdrawn. (The insertion tube may be slightly readvanced to ensure that the IUCD lies against the fundus, and it then is withdrawn completely.) The string of the device should be trimmed at a point approximately 1 to 2 cm from the external os.

Mirena

The Mirena IUCD is supplied with a self-loading inserter. To insert this device, the package is opened, taking care to maintain the sterility of the contents. The threads of the IUCD must be freed from the base of the inserter, and the slider (located in the handle of the inserter) advanced to the position closest to the IUCD itself. The arms of the device itself should be in a horizontal position when the centimeter scale of the inserter is facing upward. Immediately prior to insertion, the IUCD is retracted into the inserter tube by traction on the strings where they emerge from the handle of the inserter. This will result in the arms of the IUCD folding inward and their distal knobs occluding the inserter tube. The treads of the IUCD must now be locked into place by raising them into the cleft in the handle. The flange on the inserter tube should be moved on the centimeter scale so it coincides with the measured uterine depth.

To place the IUCD in the uterine cavity, the tip of the IUCD and insertion tool are placed against the disinfected cervical os, and traction on the os is applied. Gentle pressure is exerted, advancing until the flange is approximately 1.5 to 2 cm from the cervix. This will allow sufficient room for the arms of the IUCD to expand on deployment. While this position is maintained the slider is pulled back to the raised horizontal line on the handle. This will release the arms from the inserter tube. After 30 seconds are allowed for the arms to regain their full extension, the inserter should be gently advanced until the flange meets the cervix, ensuring proper fundal placement of the device. While the inserter is held steady, the slider is pulled to its fully retracted position, releasing the IUCD. Being careful that the treads are hanging freely, the device is now removed and the threads trimmed about 3 cm from the cervix.

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Although an IUCD may be placed at any point in a menstrual cycle (after pregnancy has been ruled out), it is preferable to insert it 7 to 10 days after the onset of menstruation. Insertion at this point of the cycle is associated with a lower expulsion rate. The patient must be counseled to use a backup method of contraception during this cycle.

When gentle pressure does not result in the IUCD insertion tool’s advancing through the cervix, a tenaculum may be used to stabilize the cervix. Traction on the tenaculum may result in some straightening of the canal, further aiding insertion. In some cases, it may be necessary to use a sterile uterine sound to identify the axis of the canal, provide modest cervical dilation, or confirm the depth to the uterine cavity.

IUCDs should not be left in the folded position inside the inserter for more than 1 to 2 minutes. Prolonged folding will result in a device that will not unfold properly in the uterine cavity, increasing the risk of expulsion or contraceptive failure.

COMPLICATIONS

Vasovagal reaction, pain, uterine perforation (approximately 1 in 1000 insertions), infection (uterine or pelvic, most common in the first 20 days after insertion), bleeding, expulsion of the device.

FOLLOW-UP

Generally, women should be re-evaluated 1 to 4 weeks after IUCD placement. The patient should be advised to periodically verify the presence and length of the IUCD strings. Expulsion is most common during menstruation and during the first 6 months of use. Amenorrhea in a woman using the copper IUCD should prompt a pregnancy test. Any woman who misses a period and experiences pain should have ectopic pregnancy ruled out. Women should be instructed about warning signs of pelvic infection, particularly in the first month after insertion of the device, when the risk of pelvic infection is greater.

CPT CODE(S)

58300 Insertion of intrauterine device (IUD), not including device
X4633 Charge for cost of copper IUD
X4634 Charge for cost of progesterone IUD

REFERENCES

Level I

Oloto EJ, Bromham DR, Murty JA. Pain and discomfort perception at IUD insertion—Effect of short-duration, low-volume, intracervical application of two per cent lignocaine gel (Instillagel (TM)) —A preliminary study. Br J Fam Plann. 1997;22:177.

Walsh TL, Bernstein GS, Grimes DA, et al. Effect of prophylactic antibiotics on morbidity associated with IUD insertion: results of a pilot randomized controlled trial. IUD Study Group. Contraception. 1994;50:319.

Level II

Anteby E, Revel A, Ben-Chetrit A, et al. Intrauterine device failure: relation to its location within the uterine cavity. Obstet Gynecol. 1993;81:112.

Duenas JL, Albert A, Carrasco F. Intrauterine contraception in nulligravid vs parous women. Contraception. 1996;53:23.

Farley TM, Rosenberg MJ, Rowe PJ, et al. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 1992;339:785.

Grimes DA, Schulz KF. Prophylactic antibiotics for intrauterine device insertion: a metaanalysis of the randomized controlled trials. Contraception. 1999;60:57.

Hubacher D, Lara-Ricalde R, Taylor DJ, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med. 2001;345:561.

Lethaby AE, Cooke I, Rees M. Progesterone or progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 4, 2005. CD002126

Polis CB, Schaffer K, Blanchard K, et al. Advance provision of emergency contraception for pregnancy prevention. Cochrane Database Syst Rev. 2, 2007. CD005497

Zhou L, Xiao B. Emergency contraception with Multiload Cu-375 SL IUD: a multicenter clinical trial. Contraception. 2001;64:107.

Level III

American College of Obstetricians and Gynecologists. Intrauterine device. ACOG Practice Bulletin 59. Obstet Gynecol. 2005;105:223.

American College of Obstetricians and Gynecologists. Noncontraceptive uses of the levonorgestrel intrauterine system. ACOG Committee Opinion 337. Obstet Gynecol. 2006;107:1479.

Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet. 2000;356:1013.

Mishell DRJr. Family planning. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:306.

Stanford JB, Mikolajczyk RT. Mechanisms of action of intrauterine devices: update and estimation of postfertilization effects. Am J Obstet Gynecol. 2002;187:1699.

World Health Organization. Mechanism of action, safety and efficacy of intrauterine devices. Geneva: WHO, 1997.

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