IUD Insertion Technique and Patient Advice
Pre-Procedure Patient Preparation
Administer naproxen 500-550 mg or ketorolac 20 mg orally 1 hour before the procedure (or 2 over-the-counter naproxen sodium = 440 mg), always taken with food. 1 Alternative NSAIDs like ibuprofen 800 mg can be used if naproxen is unavailable. 2
Essential Pre-Procedure Counseling
- Explain the three specific moments of discomfort: placement of cervix holder (tenaculum), measuring the uterus (sounding), and gentle placement of the IUD. 1
- Compare discomfort to menstrual cramps using a 0-10 scale, acknowledging that patients might feel nothing or experience pressure, pulling, nausea, or cramping. 1
- Use trauma-informed care principles: Screen for history of trauma before any pelvic procedure and apply therapeutic language throughout. 1
- Advise patients to eat a light meal and drink water beforehand to prevent vasovagal reactions. 1, 2
- Emphasize patient control: "You are in control. We can stop at any time. We can reschedule if now is not good for you." 1
Anxiolytic Considerations
- Offer benzodiazepines to patients with significant anxiety, but obtain informed consent for IUD placement before drug administration and ensure someone is available to take them home. 1
Insertion Technique
Initial Steps
- Perform bimanual examination to determine uterine size and position. 3
- Insert appropriately sized speculum (consider Pederson for nulliparous patients). 2
- Cleanse the cervix with betadine or another antiseptic solution. 2
Pain Management During Procedure
For patients at higher risk of pain, apply topical anesthetic to the cervix (5 mL EMLA cream or 10% lidocaine spray) or consider paracervical/intracervical block. 1, 2 The 2025 American Journal of Obstetrics and Gynecology guidelines specifically recommend these intraprocedural pharmacological options. 1
Critical Insertion Steps
- Use therapeutic language throughout: Say "cervix holder" (not tenaculum), "measuring your uterus" (not uterine sound), "gentle placement" (not insertion). 1
- Grasp the anterior lip of the cervix with a ring forceps or single-tooth tenaculum. 2
- Apply gentle traction to straighten the cervico-uterine angle. 2
- Gently insert the uterine sound to determine depth and direction of the uterine cavity. 2 Note that one study explored omitting sounding in 50 patients with 80% success, but this is not standard practice and requires immediate ultrasound confirmation. 4
- If dilation is needed, use the smallest possible dilator. 2
- Ensure high fundal placement to reduce expulsion rates—this is the single most important technical factor. 2, 5
Device-Specific Technique
- Load the IUD into the insertion tube according to manufacturer instructions. 2
- Set the flange to the measured uterine depth. 2
- Insert the loaded device through the cervix until the flange is at the external os. 2
- Release the IUD arms, advance to ensure fundal placement, then release the IUD by pushing the slider forward. 2
- Remove the inserter while holding the threads. 2
Post-Insertion Management
Immediate Aftercare
- Keep the patient lying flat for 5 minutes with legs out of stirrups, then gradually raise the head of the table in increments to prevent vasovagal reactions. 2
- Train clinical support staff to recognize signs of impending vasovagal events (pale skin, sweating, dilated pupils, complaints of dizziness, nausea). 1
- Provide a heat pad for cramping if needed. 2
Post-Procedure Instructions
- Continue NSAIDs for 24 hours: naproxen 440-550 mg every 12 hours or ibuprofen 600-800 mg every 6-8 hours. 2, 6
- Provide written patient instructions at the time of counseling. 1
- Instruct patients on expected side effects including cramping and irregular bleeding. 2
Special Populations
Nulliparous Patients
- Anticipate higher pain scores (6.6-8.1/10 compared to 3.7/10 for multiparous patients) and proactively offer additional pain management including topical anesthetics or paracervical block. 2
Immediate Postpartum Insertion
- After vaginal delivery: Cut strings to 10-12 cm and ensure high fundal placement manually or with ring forceps. 2, 5
- After cesarean delivery: Place the IUD in the uterine fundus manually or with ring forceps after initiating hysterotomy closure, placing strings into the cervix before completing closure. 2
- Counsel patients that expulsion rates are higher with immediate postpartum insertion (7-15% at six months) compared to interval insertion. 5
Timing and Contraindications
Timing Flexibility
- IUD insertion can occur at any time during the menstrual cycle as long as pregnancy is reasonably excluded—there is no "best time" for placement. 1, 7
- In most cases, only one visit is needed for all necessary testing including pregnancy screening, STI testing, and cervical cancer screening. 1, 6
Absolute Contraindications
- Current purulent cervicitis, active gonorrhea or chlamydia infection, current pelvic inflammatory disease, or other active pelvic infections. 7, 8
- Women with very high individual likelihood of STD exposure should undergo testing and treatment before IUD insertion. 6
STI Screening Approach
- Screen all women by history and physical examination for STI risk. 8
- Women at increased risk should be tested prior to or at the time of insertion; it is not necessary to delay insertion until results are returned. 8
- Routine antibiotic prophylaxis is not recommended prior to IUD insertion. 8
Common Pitfalls and How to Avoid Them
Failure to Achieve Fundal Placement
- Always perform uterine sounding and ensure the IUD is placed at the fundus—high fundal placement is the most critical factor in preventing expulsion. 2, 5
Vasovagal Reactions
- Have the patient eat before the procedure, use gentle technique, keep the patient supine after insertion, and gradually elevate the head of the table. 2
Infection Risk
- The small increased risk of pelvic inflammatory disease occurs only in the first 20 days after insertion, not throughout use. 7, 8
- Standard practice includes cleansing the cervix and sterilizing instruments prior to insertion. 8