Executive Summary
A recent American College of Obstetricians and Gynecologists (ACOG) webinar, “LARC Challenges,” reviewed such common concerns as management of non-palpable implants; non-fundal intrauterine devices; management strategies for IUD malpositioning, expulsion, and perforation; and diagnosis and treatment of infections and pregnancy with an IUD in place.
-
Intrauterine devices may be inserted without technical difficulty in most adolescents and nulliparous women, according to an ACOG committee opinion.
-
Recent data suggests that ketorolac, a nonsteroidal anti-inflammatory drug, can help with sounding, insertion, and post-procedure discomfort for nulliparous women and for post-procedure discomfort in all women.
-
Pelvic inflammatory disease is rare in IUD users. However, when a patient does get PID with an IUD in place, it often might be possible to treat the patient with the IUD left in situ.
How do you deal with difficult intrauterine device (IUD) insertions, as well as diagnosis and treatment of infections and pregnancy with an IUD in place? A recent American College of Obstetricians and Gynecologists (ACOG) webinar, “LARC Challenges,” looked at these issues.
The webinar reviewed such common concerns as management of non-palpable implants; non-fundal IUDs; management strategies for IUD malpositioning, expulsion, and perforation; and diagnosis and treatment of infections and pregnancy with an IUD in place. It was led by Nikki Zite, MD, MPH, professor and residency program director at the University of Tennessee Graduate School of Medicine in Knoxville, and Nichole Tyson, MD, an OB/GYN at Oakland, CA-based Kaiser Permanente, Northern California.
Often insertions and removals in nulliparous women are no more challenging than in multiparous women, notes Zite. A 2012 ACOG committee opinion echoes Zite’s observation and noted “Intrauterine devices may be inserted without technical difficulty in most adolescents and nulliparous women. Little evidence suggests that IUD insertion is technically more difficult in adolescents compared with older women.”1 However, Zite offers tips that often can help in difficult cases:
-
Although clinicians want to be flexible with timing of insertion so unnecessary barriers are not created, placing while on menses or on a withdrawal bleed ensures the woman is not pregnant and can make insertion easier.
-
Always use a tenaculum, and have dilators readily available. Consideration can be given to placing the device with ultrasound guidance if clinicians meet more than expected resistance or an attempt already has been made without success, Zite notes.
-
Misoprostol has not been shown to improve insertion success or decrease pain,2 so it should not be used routinely, observes Zite. However, it can be reserved for cases in which an attempt has been unsuccessful.
-
Data on paracervical blocks are inconsistent,3 notes Zite. They should be reserved for cases when dilation is needed, or the patient is not tolerating insertion but is motivated to continue to try inserting the device.
-
Recent data suggest that ketorolac, a nonsteroidal anti-inflammatory drug, can help with sounding, insertion, and post-procedure discomfort for nulliparous women and for post-procedure discomfort in all women,4 states Zite. It requires intramuscular dosing 30 minutes before the procedure, so it might not be an option in all settings. However, many women might appreciate this option, she says.
How about IUD removals in nulliparous women? Removals are typically not difficult unless the threads are missing, notes Zite. She advises that the “absolute first step” when considering a removal if threads are not present is to confirm the device is in the uterus. Once this presence is established, clinicians can proceed in the same manner for nulliparous and multiparous women in locating the threads: First, sweep the cervix with a cytobrush, says Zite. If that action is not successful, use an IUD hook, stone forceps, or long nose packing forceps to try to grasp the strings or device.
“Occasionally dilation will be needed, and then all the suggestions made for challenging placements apply here as well,” states Zite. “As with insertions, a tenaculum helps straighten the angle between the cervix and uterus and often makes a difficult removal easier.”
What is the risk of pelvic inflammatory disease (PID) in IUD users? Such infection is very rare: less than 1%,5 says Tyson. As with any infection after a uterine procedure, the risk is increased in the first three weeks after insertion and then drops to baseline, she notes. “It is well-established that the old mythical thinking that an IUD causes PID is just that: old, mythical thinking,” says Tyson. “IUDs do not cause PID.”
However, when a patient does develop PID with an IUD in place, the patient can be treated with the IUD left in situ, notes Tyson. The treatment outcomes are the same whether the IUD is removed or left in place.6
Bacterial vaginosis might be seen more often in IUD users, says Tyson. This condition might be due to the unscheduled bleeding or spotting that might increase vaginal pH, which makes the environment more susceptible to bacterial vaginosis, she notes. Because the irregular bleeding decreases over time, this problem is usually a short-term one, Tyson observes.
One common issue that comes up is the incidental finding of actinomyces-like organisms on routine cytology results, which occurs in about 7% of IUD users, says Tyson. Most of these women have no symptoms, and no treatment is needed, so there is no need to remove the IUD, she states.
What if a pregnancy occurs with an IUD in place? In women who have a desired pregnancy with an IUD in place, the best strategy is to remove the IUD if it can be done without an invasive procedure, says Tyson.
“Attempting removal with ultrasound guidance is not invasive and can be quite helpful,” she says. “If the IUD is in a location that removal would lead to disruption of the pregnancy, it is best to just leave it in place and counsel that the pregnancy will be at higher risk for miscarriage, stillbirth, and preterm delivery.”
-
Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group, The American College of Obstetricians and Gynecologists. Committee opinion no. 539: Adolescents and long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2012; 120(4):983-988.
-
Espey E, Singh RH, Leeman L, et al. Misoprostol for intrauterine device insertion in nulliparous women: A randomized controlled trial. Am J Obstet Gynecol 2014; 210(3):208.e1-5.
-
Mody SK, Kiley J, Rademaker A, et al. Pain control for intrauterine device insertion: A randomized trial of 1% lidocaine paracervical block. Contraception 2012; 86(6):704-709.
-
Ngo LL, Ward KK, Mody SK. Ketorolac for pain control with intrauterine device placement: A randomized controlled trial. Obstet Gynecol 2015; 126(1):29-36.
-
Meirik O. Intrauterine devices — Upper and lower genital tract infections. Contraception 2007; 75(6 Suppl):S41-47.
-
Ness RB, Soper DE, Holley RL, et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: Results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002; 186:929-937.
