What are the steps and recommendations for Intrauterine Contraceptive Device (IUCD) insertion?

IUCD Insertion: Steps and Recommendations

IUD insertion can be performed anytime during the menstrual cycle with only bimanual examination and cervical inspection required before the procedure, while most other routine tests including Pap smears are unnecessary. 1

Pre-Insertion Requirements

Essential Examinations (Class A - Mandatory)

• Bimanual examination and cervical inspection are the only mandatory examinations before IUD insertion to assess uterine size, position, and detect cervical or uterine abnormalities that might prevent insertion 1, 2
• These examinations help identify infection or anatomical issues that could complicate the procedure 1

Non-Essential Tests (Class C - Not Required)

The following tests do not contribute substantially to safe IUD use and are not needed 1:

• Blood pressure measurement 1
• Weight/BMI (though baseline measurement may help monitor changes) 1
• Cervical cytology (Pap smear) 1, 2
• Glucose, lipids, liver enzymes, hemoglobin 1
• HIV screening 1

STI Screening Approach

• Most women do not require additional STI screening at insertion if already screened per CDC guidelines 1, 2
• If not previously screened, screening can be performed at insertion time and should not delay the procedure 1
• Absolute contraindications (do not insert): purulent cervicitis, current chlamydial infection, or gonorrhea 1, 2, 3
• Women with very high STI exposure risk (e.g., currently infected partner) should delay insertion until testing and treatment complete 1

Timing of Insertion

When to Insert

• IUDs can be inserted anytime during the menstrual cycle if reasonably certain the woman is not pregnant 1
• No need to wait for menses 1

Backup Contraception Requirements

• Copper IUD: No backup contraception needed regardless of cycle timing 1
• Levonorgestrel IUD: If inserted >7 days after menses started, use backup method or abstain for 7 days 1

Patient Preparation and Counseling

Pre-Visit Instructions

• Schedule sufficient time for counseling and procedure 1
• Advise patient to eat and drink beforehand 1
• Encourage appropriate clothing (comfortable, able to remove bottoms while keeping top on) 1
• Consider premedications (NSAIDs, anxiolytics if needed) 1
• Provide pre-visit patient resources 1

Pain Management Strategy

Therapeutic language and trauma-informed approach are essential 1:

• Explain three steps where discomfort may occur: cervix holder placement, uterine measuring, and IUD placement 1
• Use empowering language: "gentle placement" not "insertion," "cervix holder" not "tenaculum," "measuring your uterus" not "sounding" 1
• Patient maintains control at all times - can pause or stop for any reason 1
• Set realistic expectations: compare discomfort to menstrual cramps 1

Analgesic options 1:

• NSAIDs (pre-procedure)
• Local anesthetics
• Paracervical block for office-based placement
• Moderate or deep sedation in OR if available

Insertion Technique Consideration

• The "direct method" of insertion causes less pain than standard manufacturer-recommended method (8.3 mm less on pain scale, 95% CI -14.3 to -2.3) with no increase in adverse effects 4
• Direct method associated with higher satisfaction rates at 6 months (93.6% vs 87.4%, p=0.019) 4

Post-Insertion Follow-Up

Routine Follow-Up

• No routine follow-up visit is required 1
• Advise women to return anytime to discuss side effects, problems, or desire to change methods 1
• Inform when IUD needs removal 1
• Consider checking for IUD string presence at routine visits 1

Key Counseling Points

• Discuss side effects (irregular bleeding is primary reason for discontinuation) and management strategies 1
• Provide emergency contraceptive pill information and consider advance supply 1
• Develop action plan for correct and consistent use 1

Critical Pitfalls to Avoid

• Do not delay insertion for STI screening results if woman meets screening guidelines 1
• Do not insert if active purulent cervicitis or confirmed chlamydia/gonorrhea 1, 3
• Do not require unnecessary tests (Pap smear, blood pressure) that create barriers to access 1
• Avoid triggering language and maintain trauma-informed approach throughout 1
• Ensure proper technique to prevent rare but serious complications like uterine perforation and migration 5