IUD Insertion: Tips, Tricks and Troubleshooting Erin Hendriks, MD Allison Ursu, MD Objectives

1. Provide appropriate anticipatory guidance prior to IUD insertion 2. Perform the basic steps of IUD insertion. 3. Identify strategies to manage difficult IUD insertion and common complications 4. Offer a variety of treatments for common side effects after LARC insertion Unintended Pregnancy in the US

• In 2011, nearly half (45% or 2.8 million) of the 6.1 million pregnancies in the United States each year were unintended.1 • Traditional estimates understate the risk of teen pregnancy among adolescents because they typically include all women, whether or not they are sexually active. When rates are recalculated including only those sexually active, women aged 15–19 have the highest unintended pregnancy rate of any age-group.2 Adolescent Stats

• The proportion of women at risk of unintended pregnancy who are not using a method is highest among 15–19-year-olds (18%) and lowest among women aged 40–44 (9%).3 • In 2012, 4.3% of female contraceptive users aged 15– 19 used a long-acting reversible contraceptive method (IUD or implant) in the last month. This was a slight decrease from 4.5% in 2009, but an increase from 1.5% in 2007 and just 0.3% in 2002.4,5 Unintended pregnancy by consistency of contraception use

Consistent use 5%

Nonuse 54% Inconsistent use 41% One year failure rates

Effectiveness Contraceptive Typical-use Perfect-use pregnancy rate pregnancy rate Ineffective Chance 85% 85%

Less effective Condoms 14% 3%

More effective Pill/patch/Ring 8% 1-3%

Highly effective IUDs 0.8 – 2% 0.8 – 2%

Injectable 0.1 – 0.3% 0.1 – 0.3%

Implant 0.1 – 0.3% 0.1 – 0.3%

Sterilization 0.1 – 0.3% 0.1 – 0.3% (male and female) IUD Options IUD Comparison

Copper IUD Levonorgestrel Levonorgestrel Levonorgestrel (ParaGuard™) 52 mg IUD 18.5 mg IUD 13.5 mg IUD (Mirena™, (Klyeena™) (Sklya ™) Liletta™) • No hormones • Progestin treats • Marketed for • No evidence yet • Menses continues menorrhagia, nulliparous for menorrhagia, • Menses can be anemia women anemia heavier, more • Causes • Duration 5 years • Does not change cramps amenorrhea menses • Effective as • Duration 3 - 7 • Duration 3 years Emergency years Contraception within 5 days • Duration 10-12 years Mechanism of Action: Copper IUD

Copper-releasing IUD (ParaGuard™): 380 mm2 copper exposed on plastic T base • Interferes with sperm motility. • Causes spermicidal foreign-body reaction. • Alters uterine environment, “hostile” to sperm.

ParaGard (Copper) IUD

Mechanism Interferes with sperm transport

Size 32mm(horizontal) x 36mm(vertical) Duration 10 years

Effectiveness 99.2-99.4% Mechanism of Action: Hormonal IUDs

• Hormone-releasing IUD - levonorgestrel on its arms and stem released at decreasing rate with time • Thickens cervical mucus (acting as a sperm barrier) • Thins uterine lining. • Partial inhibition of ovulation.

• Presence of plastic alone may have some efficacy Hormonal IUD

Mirena Liletta Skyla Kyleena Mechanism Thickens cervical Thickens cervical Thickens cervical Thickens cervical mucous by mucous by mucous by mucous by releasing 20mcg releasing 20mcg releasing 14mcg releasing of levonorgestrel of levonorgestrel of levonorgestrel 17.5mcg of per day per day per day levonorgestrel per day

Size 32x32mm 32x32mm 28x30mm 28x30mm

Duration 5 years 5 years 3 years 5 years

Effectiveness >99% >99% >99% >99% United States Medical Eligibility Criteria for Contraceptive Use Risk Level 1 Method can be used without restriction

Advantages generally outweigh theoretical or proven 2 risk Method usually not recommended unless other, more 3 appropriate methods are not available or not acceptable

4 Method not to behttp://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf used

There’s an APP for that:

- Can be downloaded on iOS and Android operating systems (https://www.cdc.gov/mobile/mobileapp.html) Rosa

Supplies

Sterile Instruments: Also: – Small – One 10 mL syringe of – combined: – Scissors • 2.5 mL of 1 % Lidocaine • 2.5 mL of 0.9% – Ringed Bacteriostatic NaC – Needle extender • 0.5 mL of 8.4% Sodium – Metal cup Bicarbonate – 4 x 4’s – 18 g needle to draw up medication – Disposable uterine sound – 22 g 1 ½ inch needle to attach to syringe IUD Insertion Workflow Informed consent and determine need for pap or STI screening

Pelvic examination and speculum placement

Swab with antiseptic

+/- Lidocaine and tenaculum placement

Sound the uterus

Load and insert IUD Let’s Practice!

• Station #1: Pelvic Exam • Station #2: Tenaculum Placement and Sounding the Uterus • Station #3: Loading the Device • Station #4: Progestin IUD Insertion • Station #5: Copper IUD Insertion Troubleshooting Nicole Policy Statements

• ACOG encourages use of LARC methods for all candidates including nulliparous women and adolescents.6 • AAP policy recommends LARCs be considered first-line contraceptive choices for adolescents.7 United States Medical Eligibility Criteria for Contraceptive Use Risk Level 1 Method can be used without restriction

Advantages generally outweigh theoretical or proven 2 risk Method usually not recommended unless other, more 3 appropriate methods are not available or not acceptable

4 Method not to behttp://www.cdc.gov/mmwr/pdf/rr/rr59e0528.pdf used

Troubleshooting Tips

When stopped at the uterine-cervical angle: – Apply tension to the tenaculum to straighten the angle – Try a shorter speculum – Give yourself more room by by opening the bottom blade – Tilt the speculum in the direction of the angle – Try a different sound Sound vs. Sound with Troubleshooting Tips For cervical stenosis: – Use an os finder – Use a small cervical dilator – Misoprostol 400mcg buccal or vaginal 1-3 hours prior to procedure – Try a paracervical block to reduce discomfort – Ultrasound guidance Os Finders Troubleshooting Tips

Vasovagal Syncope: – Moderate hypotension and bradycardia are common. Transient seizure-like muscular activity can occur. – Trendelenburg position (elevate legs) – Obtain vital signs, attend to ABCs – Smelling salts Troubleshooting Tips Managing of early spotting and cramping: – Anticipatory guidance! – Offer an exam – Reassurance – NSAIDS – OCPs Troubleshooting Tips For missing strings: – Use a cytobrush to twirl in the os – Use a colposcope and endocervical speculum for better visualization into the os – Try alligator forceps to grasp the strings – IUD finder or hook – Ultrasound – MVA with a 5-6 cannula – Hysteroscopy

Challenges: Removal

• Missing Strings • Malpositioned IUD • Embedded IUD Ultrasound

• To confirm if IUD in place if patient returns with concerns Embedded IUD • May only become apparent when removal efforts unsuccessful, feels “stuck” or strings break off • Ultrasound confirmation is the next step • Usually needs to be removed hysteroscopically Jasmine

Troubleshooting Tips For Retroversion/Retroflection: – Position yourself higher up on the stool – Try placing tenaculum at the 6 o’clock position – Use an os finder to determine the correct angle of insertion – Consider cervical stenosis Troubleshooting Tips For cervical stenosis: – Use an os finder – Use a small cervical dilator – Misoprostol 400mcg buccal or vaginal 1-3 hours prior to procedure – Try a paracervical block to reduce discomfort – Ultrasound guidance Troubleshooting Tips

Suspected Uterine Perforation: – Immediately stop the procedure – Monitor for bleeding – Perform ultrasound if available to monitor the cul-de- sac for accumulation of blood – Monitor patient in the office with serial abdominal exams, vital signs, orthostatics and point of case Hg/Hct – If stable > 2 hours send home with 24 hour emergency contact number, precautions and antibiotics Dr. G Tips for Integrating IUDs into a Busy Practice • Pre-printed consents and take home information forms • Instrument packs • Set up instructions for MA • If possible, arrange a procedure session. • Templates can be downloaded at www.reproductiveaccess.org Easy Set Up

References

1. Finer LB, Unintended pregnancy among U.S. adolescents: accounting for sexual activity, Journal of Adolescent Health, 2010, 47(3):312–314. 2. Finer LB and Zolna MR, Declines in unintended pregnancy in the United States, 2008–2011, New England Journal of Medicine, 2016, 374(9):843–852. www.guttmacher.org 3. Jones J, Mosher WD and Daniels K, Current contraceptive use in the United States, 2006–2010, and changes in patterns of use since 1995, National Health Statistics Reports, 2012, No. 60, http://www.cdc.gov/nchs/data/nhsr/nhsr060.pdf. 4. Finer, LB, Jerman J and Kavanaugh ML. Changes in use of long-acting contraceptive methods in the U.S., 2007–2009, Fertility and Sterility, 2012, 98(4):893–897. 5. Kavanaugh ML, Jerman J and Finer LB, Changes in use of long-acting reversible contraceptive methods among United States women, 2009–2012, Obstetrics & Gynecology, 2015, 126(5):917– 927. 6. Increasing access to contraceptive implants and intrauterine devices to reduce unintended pregnancy. Committee Opinion No. 642. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e44–8. 7. American Academy of Pediatrics. Policy Statement: Contraception for Adolescents. Accessed online Accessed November,2018. http://pediatrics.aappublications.org/content/134/4/e1244 8. Creinin MD, Jansen R, Starr RM, et al. Levonorgestrel release rates over 5 years with the Liletta 52-mg intrauterine system. Contraception 2016;94:353-356. 9. US Medical Eligibility for Contraceptive Use, 2010. MMWR. 2010. Appendix E. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5904a6.htm Photo Credits

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