How is an Intrauterine Device (IUD) inserted into the uterus without puncturing the uterine wall?

How an IUD is Inserted Without Puncturing the Uterine Wall

An IUD is safely inserted without puncturing the uterine wall through proper technique that includes visualization of the cervix, careful passage through the cervical canal, and confirmation of fundal placement before device release, with ultrasound guidance recommended when available to ensure correct positioning. 1

Proper IUD Insertion Technique

The insertion process follows these key steps:

1. Cervical Visualization and Preparation:

   • The cervix is visualized using a speculum
   • The anterior lip of the cervix is grasped with ring forceps
   • The cervical canal is aligned with the uterine cavity

2. Insertion Through Cervix:

   • The IUD is passed through the cervix under direct visualization
   • The inserter is advanced gently until reaching the fundus
   • Resistance indicates fundal placement

3. Confirmation of Placement:

   • Fundal placement is confirmed before releasing the device
   • The provider moves laterally when removing forceps to avoid displacement 2
   • High fundal placement decreases expulsion rates

4. Post-Insertion Verification:

   • Manual verification by palpating the uterine fundus abdominally
   • Transabdominal ultrasound is recommended to ensure proper fundal placement 1

Risk Reduction Strategies

Several techniques help minimize the risk of perforation:

• Ultrasound Guidance: Significantly reduces pain, complications, and insertion failures, especially in women with retroverted flexed uteri 3
• Bimanual Examination: Determines uterine position prior to insertion 4
• Uterine Sounding: Measures the depth of the uterine cavity to guide insertion depth 4
• Timing Considerations: Avoid insertion during the puerperium when the uterine wall is thin and risk of perforation increases 5

Perforation Risk Factors

Perforation is rare (0.12-0.68/1000 insertions) but potentially serious 6. Risk factors include:

• Type of IUD
• Uterine size and position
• Timing relative to recent delivery or abortion
• Provider experience 6
• Postpartum state (increased risk) 5

Simplified Insertion Approaches

Recent research has explored simplified techniques:

• A 2016 study demonstrated successful IUD insertion without prior pelvic examination and sounding in 80% of cases, with no perforations recorded 7
• This approach may reduce instrument use and associated pain during insertion

Management of Suspected Perforation

If perforation is suspected:

• Evaluate for signs including pain, bleeding, or missing IUD strings 2
• Use ultrasound to locate the IUD if strings are not visible
• If the IUD cannot be located by ultrasound, it may have been expelled or perforated the uterine wall 2
• Laparoscopy may be required for diagnosis and treatment of perforation 6

Key Pitfalls to Avoid

• Failure to confirm fundal placement before releasing the device
• Improper insertion technique or excessive force
• Ignoring anatomical variations (like retroverted uterus)
• Overlooking the increased risk during postpartum period 5

Following these evidence-based techniques ensures safe IUD placement with minimal risk of uterine perforation, maintaining the high effectiveness of this contraceptive method.