Intrauterine Contraceptionctcfp.org/wp-content/uploads/IUC_Cason_Reiter.pdfIntrauterine Contraception (IUC) • Generic term for the method or any of the devices Terms can be used

Intrauterine Contraception

Patty Cason MS, FNP-BC Charlotte Curtis, MSN, WHNP-BC Suzanne Reiter, MM, MSN, WHNP-BC, FAANP

F a m i l y P l a n n i n g N a t i o n a l C l i n i c a l T r a i n i n g C e n t e r · S u p p o r t e d b y O f f i c e o f P o p u l a t i o n A f f a i r s

Disclosures – Suzanne Reiter Nothing to disclose


Disclosures – Charlotte Curtis

Nothing to disclose


Disclosures – Patty Cason

Advisory Board Teva (ParaGard, LeCette) Merck (HPV vaccines) Actavis (Levosert IUD in development)

Speakers’ Bureau Teva (ParaGard) Merck (Nexplanon, Gardasil, NuvaRing,

Contraception) Bayer (Mirena, Skyla)


Learning Objectives

Discuss the comparative effectiveness of IUDs

Describe the myths and explain the evidence to dispel those myths regarding patient selection for IUD use

Demonstrate the hand skills necessary for placement of the copper IUD and the two levonorgestrel IUDs

F a m i l y P l a n n i n g N a t i o n a l C l i n i c a l T r a i n i n g C e n t e r · S u p p o r t e d b y O f f i c e o f P o p u l a t i o n A f f a i r s 6

Terminology

Intrauterine Device (IUD) Intrauterine Contraception (IUC)

• Generic term for the method or any of the devices

Terms can be used interchangeably

Presenter

Presentation Notes

Multiple terms reflect the history of intrauterine contraception: Intrauterine devices (IUCs) were first described by their shape and size, material composition or property, by inventor or manufacturer, i.e. Mazlin spring, framed IUC, Copper 7®, Lippes Loop. As the science and community of reproductive health developed, other terms were introduced to better describe the method. Levonorgestrel intrauterine system (LNG IUC) describes an IUC which delivers levonorgestrel to the endometrium enhancing its mechanism of action. Its developers felt that it was more than a device, but a two part system, the device and the levonorgestrel depository. Intrauterine Contraception (IUC) is the recently introduced term that better describes all forms of this method—the LNG IUC and the Copper T IUC. [Note to faculty: some faculty members have suggested that the terminology gets confusing within the slide set. If you find this to be the case when you are giving presentations, you may “search and replace” the term “IUC” with “IUC” throughout the slide set.]


Terminology: Levonorgestrel IUDs

LNG 20 IUD (Mirena) LNG 13.5 IUD (Skyla) In reference to either or both:

• LNG IUD • LNG IUC • Intrauterine System (IUS)

Presenter

Presentation Notes



Terminology: Copper IUD

Cu IUD Copper IUD Cu IUC Cu-T380A ParaGard® Can’t call it an IUS

Presenter

Presentation Notes



Take Home the “IUDs”

Keep one in your lab coat One in each room Give them to your patient to hold, feel and

play with while discussing the method Show her how to feel the threads with it


Unintended Pregnancy in U.S.

51%

Of 6.6 million

pregnancies per year

3.4 million are

unintended

Finer LB et al. AmJPubHealth, 2014,104(S1):S44-S48


Contraceptive Typical Use: First Year Failure Rate

Trussel Contraception 2011

85.0


Presenter

Presentation Notes

We don’t need to exhaustively run through each of the methods with each client. In the last several years, contraception counseling has taken a revolutionary turn. Traditionally, birth control methods were discussed using a previous version of the Tiered Effectiveness Chart that began with the least effective (client controlled) methods and ending at the bottom with the methods that were inserted by the clinician that are now know to be the most effective methods. The re-configuration of this chart, based on effectiveness, has been very instrumental in increasing the use of all Long Acting Reversible Contraceptive (LARC) methods. The Tiered Effectiveness chart is to be used along with patient education materials that define and explain the contraceptive methods for complete counseling of the client. It is important to always remember that the goal of contraceptive counseling is to assist the client in making an informed decision supporting the client’s reproductive goals.


Characteristics of IUC’s

• Highest patient satisfaction among methods

• Rapid return of fertility • Safe • Offer long-term protection • Highly effective • Cost saving


IUC Mechanism of Action

Ortiz ME. Contraception. 2007


Copper-T IUC

Thonneau, PF. Am J Obstet Gynecol. 2008.: Fortney JA. J Reprod Med. 1999.: Trussel J. Contraceptive Technology. 2007.


Copper IUC: Menstrual Effects •Longer/heavier menses/ dysmenorrhea

•NSAIDs prophylactically WITH FOOD • Pre-emptive use for 1st 3 cycles • Start before onset of menses for anti-prostaglandin effect

⁻ Naproxen sodium 220mg x2 BID (max 1100mg/day)

⁻ Ibuprofen 600-800mg TID (max 2400mg/day)

Presenter

Presentation Notes

Evidence shows NSAIDs decrease intermenstrual bleeding in women using hormonal implants. Anecdotal reports indicate NSAIDs are also effective in reducing intermenstrual bleeding and heavy bleeding in IUC users.



Levonorgestrel Intrauterine System

• Brand name® Mirena Lng - 52 IUS • 20 mcg levonorgestrel/day • Approved for 5 years’ use • Amenorrhea in ~20% of users by 1 year

Mirena Prescribing Information. 2000.: Trussel J. Contraceptive Technology. 2007; Hidalgo M. Contraception. 2002.


Newest LNG IUS

Brand name Skyla® Levonorgestrel releasing like Mirena Identifiable by silver ring at top Small inserter tube Smaller IUD Ideal for nulliparous women LNG 13.5 IUS

⁻ 14 mcg per day Three year effectiveness


LNG 20 IUS: Treatment for Heavy Menstrual Bleeding

Nelson, AL. Presented at XIX FIGO World Congress, S. Africa, 10/2009

Med

ian

MBL

(mL)


LNG-IUC: “Off Label” Non-contraceptive Benefits

• Decreased ⁻ Dysmenorrhea ⁻ Iron deficiency anemia ⁻ Long term risk of endometrial cancer

• Can be left in place during and after transition to menopause for use with ET

ACOG Practice Bulletin. No. 73: Use of hormonal contraception in women with coexisting medical conditions. Obstet Gynecol. 2006;107:1453–1472.


LNG-IUC: “Off Label” Additional Therapeutic use

• Symptomatic fibroids • Endometrial hyperplasia • Symptomatic endometriosis, adenomyosis

Matteson KA, et al. Obstet Gynecol. 2013; 121(3):632-643; Fraser IS. Contraception. 2013 Mar;87(3):273-9


Copper T: Emergency Contraception

• Prospective, multicenter cohort clinical trial: 1,963 women in China; CuT380 placed within 120 hours of unprotected intercourse

• No pregnancies at 1 month follow-up visit • 94% parous women and 88% nulliparous

women continued at 1 year

Wu S, et al. BJOG 2010; Epub 2010 Jul7

Presenter

Presentation Notes

BJOG. 2010 Sep;117(10):1205-10. Epub 2010 Jul 7. Copper T380A intrauterine device for emergency contraception: a prospective, multicentre, cohort clinical trial. Wu S, Godfrey EM, Wojdyla D, Dong J, Cong J, Wang C, von Hertzen H


Will Patients Choose Cu T380A for EC?

60% chose oral LNG 40% chose the copper IUD

Turok DK, et al. Contraception. 2010

Presenter

Presentation Notes

Contraception. 2010 Dec;82(6):520-5. Epub 2010 Jul 15. A pilot study of the Copper T380A IUD and oral levonorgestrel for emergency contraception. Turok DK, Gurtcheff SE, Handley E, Simonsen SE, Sok C, Murphy P.


Client Choice of IUC Type

Copper T IUC • Don’t want or

can’t use hormonal contraception

• Like having a regular menses

LNG IUC’s • Want less menstrual

flow • Hx dysmenorrhea • OK with possible

amenorrhea


Dispelling Myths About IUCs

• Are not abortifacients • Do not cause ectopic

pregnancy • Do not cause pelvic

infection • Do not decrease the

likelihood of future pregnancies

• Are not large in size • Can be used by

nulliparous women

• Can be used by women who have had an ectopic pregnancy

• Do not need to be removed for PID treatment

• Do not have to be removed if inflammatory changes are noted on a Pap test

Forrest JD. Obstet Gynecol Surv. 1996.; Lippes J. Am J Obstet Gynecol. 1999. Duenas JL. Contraception. 1996.; Otero-Flores JB. Contraception. 2003.; WHO. 2009.


Dalkon Shield


Dalkon Shield: Multi-filament String


IUCs Do Not Cause PID or Infertility

• PID incidence for IUC users same as the general population

• Risk is increased only during the first month after placement

• Preexisting STI at time of placement, not the IUC itself, increases risk

• Use of IUC is not associated with increased risk of tubal occlusion; rather chlamydia infection is

• No reason to restrict use based on sexual behaviors

Svensson L, et al. JAMA. 1984; Sivin I, et al. Contraception. 1991; Farley T, et al. Lancet. 1992; Grimes DA, Lancet 2000.; Hubacher D, et al. Engl J Med 2001

Presenter

Presentation Notes

Talking Point The presence of a preexisting sexually transmitted infection (STI) at time of insertion, not the IUC itself, increases the risk of PID. References Svensson L, Westrom L, Mardh PA. Contraceptives and acute salpingitis. JAMA. 1984;251(19):2553-5. Sivin I, Stern J, Coutinho E, et al. Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUCS. Contraception. 1991;44(5):473-80. Farley T, Rowe P, Meirik O, et al. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 1992;339:1904. Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet 2000;16:356:1013–9. Hubacher D, Lara-Ricalde R, Taylor DJ, Guerra-Infante F, Guzmán-Rodríguez R R. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345:561–7 - - - Original content for this slide submitted by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in April 2007. Original funding received from Bayer HealthCare Pharmaceuticals through an unrestricted educational grant. Last reviewed/updated by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in May 2007.


Rate of PID by Duration of IUC Use

n=∼20,000 women.

Baseline PID risk: 1-2 cases /TWY

Adapted from Farley T, et al. Lancet. 1992;339:785-788.

Rate per 1000 woman-years

Duration of Use

Presenter

Presentation Notes

Longer duration of IUC use is associated with a lower rate of pelvic inflammatory disease. Among approximately 20,000 women using the device for 21 days to 8 years, incidence of the disease was approximately 1 per 1000 woman-years, as opposed to a rate of nearly 10 in 1000 woman-years among women using the IUC for 20 days or less. Reference: Farley T, Rowe P, Meirik O, Rosenber MJ, Chen J-H. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992;339:1904.


Ectopic Pregnancy Risk with IUC*

If a pregnancy occurs while using these methods, the risk of ectopic pregnancy is higher. These methods prevent intrauterine pregnancies better than they prevent ectopic pregnancies.

Alvarez F, et al. Fertil Steril 1988;49(5):768-773 *Per 100,000 Women


Furlong , Reprod Med. 2002

Ectopic Pregnancy Risk When Contraception Fails

Presenter

Presentation Notes

Furlong LA, Ectopic pregnancy risk when contraception fails. A review. J Reprod Med. 2002 Nov;47(11):881-5.




Free and User-Friendly


US Medical Eligibility Criteria Category Definition Recommendation

1 No restriction in contraceptive use

Use the method

2 Advantages generally outweigh theoretical or proven risks

More than usual follow-up needed

3 Theoretical or proven risks outweigh advantages of the method

Clinical judgment that this patient can safely use

4 The condition represents an unacceptable health risk if the method is used

Do not use the method


IUC Use with Common Medical Concerns


IUC Use with Common Medical Concerns


Poor Candidates for IUC Use (Both IUC’s)


Poor Candidates (cont.)

(By IUC type)


Age/Parity Considerations

Menarche to age 20 US MEC -2 Age 20 and older US MEC -1 Nulliparity US MEC -2 Parous US MEC -1


Timing of IUC Placement

Grimes DA et al. Cochran Database Syst Rev. 2010;(6):CD003036; Mohamed S et al. Med Princ Pract. 2005;(12):120-125

• Can be placed anytime in cycle-as long as patient is not pregnant No benefit to placement during menses No impact on pain/discomfort during

placement • Immediate post-partum • Immediate post-abortion

Presenter

Presentation Notes

Talking Points Intrauterine contraception can be inserted at any time during the menstrual cycle, as long as the provider is reasonably certain the woman is not pregnant. The practice of inserting intrauterine contraception only during menses is unnecessary and inconvenient for the patient. When the copper T is used as emergency contraception (off-label use), rule out existing pregnancy by history and HCG, if indicated. The LNG IUC should not be used as emergency contraception. References: Alvarez PJ. [IUC insertion during cesarean section and its most frequent complications]. Ginecol Obstet Mex. 1994;62:330-5. O’Hanley K, Huber DH. Postpartum IUCs: keys for success. Contraception. 1992;45:351-61. - - - Original content for this slide submitted by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in April 2007. Original funding received from Bayer HealthCare Pharmaceuticals through an unrestricted educational grant. Last reviewed/updated by the Clinical Advisory Committee for the Clinical Update on Intrauterine Contraception project in May 2007.


Pre-IUC placement Screening • No routine screening tests

• CT/GC: ⁻ If age <26 and due for annual screening ⁻ If high risk for STI

• Pap test only if due • Pregnancy test if pregnancy suspected • Baseline Hgb-may be helpful for later

management • Any indicated screening test can be performed at

time of IUC placement Sufrin C, et al. Obstetrics and Gynecology 2012; Sufrin C, et al. Contraception 2010; Intrauterine

Contraceptives (IUCs), Family PACT Clinical Practice Alert. 2011

Presenter

Presentation Notes

Sufrin C, Postlewaite D, Armstrong MA, Merchant M, Steinhauer Comparison of the Incidence of PID in IUD users by GC & CT screening stategies. Oral Abstract Contraception 2010;82:186 Secura G, Allsworth J, Madden T, Mullersman JL, Piepert J. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception Am J Obstet Gynecol 2010;203:115.e1-7. U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2007;147:128–34. U.S. Preventive Services Task Force. Screening for gonorrhea: recommendation statement. Ann Fam Med 2005;3:263–7 Skjeldestad FE, Halvorsen LE, Kahn H, Nordbø SA, Saake K. IUD users in Norway are at low risk for genital C. trachomatis infection. Contraception 1996;54:209–12. Faúndes A, Telles E, Cristofoletti ML, Faúndes D, Castro S, Hardy E. The risk of inadvertent intrauterine device insertion in women carriers of endocervical Chlamydia trachomatis. Contraception 1998;58:105–9. Acta Obstet Gynecol Scand. 2009;88(3):246-50. Infection risk and intrauterine devices. Martínez F, López-Arregui E


Pre-placement Medication

•Prophylactic antibiotics ⁻ No value for routine administration

•Premedication ⁻ NSAID 30-60 minutes before placement is

common, but no effect on insertion pain or discontinuation

⁻ Misoprostol given prior to insertion-no effect on pain scores

⁻ Consider paracervical block if history of cervical os or canal stenosis

Walsh T et al. Lancet. 1998 Apr 4;351(9108):1005-8.

Presenter

Presentation Notes

Grimes AD, Schulz K. Prophylactic antibiotics for intrauterine device insertion: a metaanalysis of the randomized controlled trials. Contraception 1999; 60: 57–63


Post-IUC Placement Counseling

• Remind client about menstrual changes • Menstrual calendar to track menses

helpful • Should return if

⁻ String cannot be located (use barrier method)

⁻ Symptoms of pregnancy/infection ⁻ Sudden unexplained pelvic pain occurs ⁻ Excessively heavy bleeding

Presenter

Presentation Notes

Prepare the patient for the insertion procedure by explaining that, as with any pelvic procedure, a woman may feel some cramp-like discomfort. Reassure her that you will take care to minimize discomfort and that the insertion procedure is brief. Advise the patient to call the office afterward if she cannot locate the string; her menstrual period returns to its pre-insertion pattern of flow or duration; she notices symptoms suggesting pregnancy - nausea, breast tenderness, etc.; or if she experiences sudden onset of unexplained pelvic pain.


IUC Complications


Genital Tract Infections • If cervical or vaginal infection diagnosed

⁻ IUC removal not necessary ⁻ Treat infection ⁻ Counsel re: prevention of STI transmission

• If PID diagnosed ⁻ IUC removal usually not necessary ⁻ Treat infection ⁻ Recommendations to remove IUC are not evidence-

based ⁻ Consider removal if no improvement 48-72 hours

after starting treatment

Penney G. J Fam Plann Reprod Health Care. 2004; WHO. Selected Practice Recommendations for Contraceptive Use. 2012

Presenter

Presentation Notes

Intrauterine contraception users who develop STIs or PID should be tested for relevant organisms and treated with appropriate antibiotic therapy. Clinical guidelines state that removal of the intrauterine contraception is not necessary unless symptoms fail to improve within 72 hours of treatment initiation. References: Penney G, Brechin S, de Souza A, et al; Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. Penney Guidance (January 2004). The copper intrauterine device as long-term contraception. J Fam Plann Reprod Health Care. 2004;30(1):29-41. World Health Organization. Selected Practice Recommendations for Contraceptive Use. Geneva: WHO, 2002.



Missing IUC String

Absent

•No IUC string in canal •Pregnancy test negative

In Situ

Ultrasound

Desires removal

Extract ± ultrasound guidance

Desires retention

Ultrasound Flat plate of abdomen

In Situ Absent

Flat plate of abdomen

Refer for hysteroscopy

Present

Perforated

Absent

Expelled

Absent Absent Present

Ultrasound

Absent

Perforated

In Situ

OR

Extracted


Pregnancy With IUC In Situ

• Determine site of pregnancy (IUP or ectopic) • If intrauterine pregnancy confirmed

⁻ Termination planned: await procedure ⁻ Continue pregnancy: remove IUC if strings

visible ⁻ Removal decreases risk of spontaneous

abortion, premature delivery • Retention of IUC (if strings not visible)

⁻ Increase surveillance for SAB, pre-term birth ⁻ No greater risk of birth defects (extra-amniotic)

Presenter

Presentation Notes

If pregnancy occurs with an IUC in place, it is necessary to determine whether the pregnancy is intrauterine or ectopic. If the IUC strings are visible, the IUC should be removed as early as possible in the first trimester. Studies indicate that spontaneous abortions are more common in women whose IUCs remain in place than in those whose IUCs are removed in the first trimester. Early IUC removal decreases risks of first-trimester spontaneous abortion, second-trimester spontaneous abortion, and premature delivery. If ectopic, IUC does not need to be removed. References: UK Family Planning Research Network. Br J Fam Plann. 1989;15:7. Foreman H, Stadel BV, Schlesselman S. Intrauterine device usage and fetal loss. Obstet Gynecol. 1981 Dec;58(6):669-77. Atrash HK, et al. In: Proceedings from the Fourth International Conference on IUCs. 1994:76.


Actinomyces-Like Organisms

(ALO) • Actinomyces israelii has characteristics of both

bacteria and fungus; part of GI flora • May asymptomatically colonize the frame of

the IUC, which in itself is not dangerous • Very small percentage of women with IUC +

actinomyces will develop pelvic actinomycosis ⁻ Presentation is similar to severe PID

• Women with ALO on Pap smear ⁻ Should be examined to exclude PID ⁻ If none, don’t treat actinomyces or remove

IUC


Vasovagal Reaction

• Due to bradycardia + peripheral vasodilation • Prevention: advise client to be well fed and

hydrated prior to insertion • Management: -Isometric muscle contractions of extremities -Client should remain supine; elevate legs -If heart rate <60, give atropine 0.4 mg IV

Grubb BP N Engl J Med 2005


IUC Placement Practicum


Take Home the “IUDs”

Keep one in your lab coat One in each room Give them to your patient to hold, feel and

play with while discussing the method Show her how to feel the threads with it


Honing Your Skills

• Know resources in your area • For mentorship/proctoring • To discuss challenging cases • To manage complications

• CTCFP LARC Mentor Program • Link you with experienced LARC provider

near you for mentoring/proctoring www.ctcfp.org/larc

http://www.ctcfp.org/larc


Steps for IUC Placement • Perform bimanual pelvic exam to determine

uterine position • Achieve good visualization of cervix with

speculum • Inspect cervix for mucopurulent discharge -Collect pre-insertion CT/GC, pap as indicated

• Cleanse cervix with antiseptic • Use of sterile gloves vs. “no-touch” technique


Tenaculum Purpose

Stabilize the cervix to allow passage of sound and IUD through the os Straighten any irregularities in the cervical canal Straighten uterine curvatures or flexion


To Place Tenaculum

Dominant hand in “palm-up” position

Thumb in one ring

Middle or ring finger in the other ring


Tenaculum Choose Site for Placement

Anterior lip

Posterior lip

Typically a horizontal bite, some

prefer vertical


Tenaculum Size of Bite

1-1.5 cm wide

1 cm deep

Not too shallow- may tear through

Not too deep- unnecessary


Tenaculum Placement

Once the teeth are in contact with the cervix, press into the tissue

Once the ratchet is closed, test your

application gently to be sure it is secure


Tenaculum Pain Prevention

Not too deep or wide

Close the ratchet only 1-2 clicks

Close the ratchet silently

Squeeze closed EXCEEDINGLY slowly


Tenaculum Pain Prevention

Local anesthetic to tenaculum site

Have patient cough (…hold onto the speculum)


Tenaculum Use When Sounding

Change hands; hold the tenaculum with the non-dominant hand while sounding and for IUC placement

OK to let tenaculum lay on speculum

when picking up the sound or IUD


Tenaculum Hand Position While Sounding and for IUC

Placement

“Palm up” with thumb on top of ratchet and fingers below

Avoid the rings

Avoid inadvertent movements

USE the tenaculum


Uterine Sound Purpose

Insure that you can pass through the internal os Informs the direction and pathway through the os up to the fundus


Uterine Sound Purpose

Measures the depth/distance from the external os to the fundus

• Appropriate for IUD placement (6-10 cm)

• Tells you where to set the flange


Sound Which One?

Can use metal sound , plastic sound or endometrial sampler


Sound

If metal; bend sound to mimic uterine flexion

Hold it like a pencil or dart Use Wrist action Brace fingertips on speculum to

achieve control of force while advancing the sound


Placement of Copper IUC


Copper IUC Placement


ParaGard Placement* • Load arms into inserter Sterile gloves vs “no-touch”

* Excerpted from package insert


ParaGard Placement

• Load arms into inserter, adjust flange to correspond to uterine depth


ParaGard Placement

• Advance insertion tube to fundus

• Fundal resistance should be coincident with the marker reaching the exocervix


ParaGard Placement

• Pull back on inserter tube while holding white rod steady to deposit IUC in cavity


ParaGard Placement

• Push inserter tube until resistance to seat the arms of the IUC in the fundus


ParaGard Placement

• Withdraw the white rod while holding inserter tube steady


ParaGard Placement

• Slowly withdraw the inserter from the cervical canal

• Trim threads to 3-4

cm.


Placement of LNG-IUS


Mirena: The Inserter

“Never let go of the Slider!!”


1. Open sterile package

2. Release the threads

3. Make sure the slider is

….in the furthest position

….away from you

4. Check that the arms of

the IUC are horizontal

Mirena® Placement*

* Excerpted from package insert


5. Pull on both threads to draw IUC system into insertion tube

6. Both knobs at ends of IUC arms are now within the inserter

Mirena® Placement


7. Fix threads tightly into the cleft at near end of inserter shaft

Mirena® Placement*


8. Set upper edge of

movable green flange to the

depth of uterine sound

Mirena® Placement


9. Hold slider with forefinger, or thumb, firmly in furthermost position 10. Move inserter thru cervical canal until flange is about 1.5- 2.0 cm from cervix - allows sufficient space for IUC arms to open

Mirena® Placement


11. While holding inserter steady, release arms of IUC by pulling slider back until it reaches the raised mark on inserter

IMPORTANT: Allow 10-15 seconds for arms to unfold

Mirena® Placement


12. Push inserter gently until flange touches cervix. The IUC should be in fundal position

Mirena® Placement


13. Pull down on slider all the way; threads will uncleat automatically and release IUC system

Double check that the strings are uncleated before withdrawing the inserter

Mirena® Placement


Reduce expulsion rate by waiting for strings to be released from cleft before withdrawal

OBG Management | Vol. 21 No. 2 | February 2009


14. Remove inserter and cut threads about 2-4 cm from cervix

Use inserter tube as a guide for cutting the strings

15. Record string length in chart

Mirena® Placement


Skyla™ Inserter (continued) Skyla ® Placement: The Inserter


Skyla ® Placement


Skyla ® Placement


Skyla ® Placement


Skyla ® Placement


Skyla ® Placement


Skyla ® Placement


Skyla ® Placement


Skyla ® Placement


Difficult IUC Placement


Difficulty Sounding

• Use greater outward traction on the tenaculum to minimize canal-to-endometrial cavity angulation

• Place paracervical or intracervical block to relax cervical smooth muscle and reduce pain

• Use os finder device, if available • Dilate internal os with metal dilators to #13F (4.1

mm) • If unsuccessful, return at a later date with use of

misoprostol for cervical priming


Os Finder Device

Os Finders Pratt Dilators


Prophylactic Misoprostol

• Pain scores no different in the two groups • Increase in preinsertion side effects • In one trial:

⁻ Insertion considered easier ⁻ “Misoprostol facilitates IUD placement and

reduces the number of difficult and failed attempts of placements in women with a narrow cervical canal”

Saav I et. al., Human Reproduction 2007; 22, (10): 2647; Shaefer E et al, Contraception 2010; Edelman AB, et al. Contraception. 2011

Presenter

Presentation Notes

Prophylactic misoprostol prior to IUD insertion in nulliparous women�Shaefer E et al, Contraception 2010; 82(2):188


Helpful Resources

National Clinical Training Center for Family Planning: www.ctcfp.org

U.S. MEC Guidelines: www.cdc.gov/mmwr LARC Practice Resources: www.acog.org/goto/larc ParaGard®: www.paragard.com Mirena®: www.mirena-us.com Skyla®: www.skyla-us.com App Store (iPhone/Pod/Pad): U.S MEC Guidelines

http://www.ctcfp.org/

http://www.cdc.gov/mmwr

http://www.acog.org/goto/larc

http://www.paragard.com/

http://www.mirela-us.com/

http://www.skyla-us.com/

Documents

Intrauterine Contraceptionctcfp.org/wp-content/uploads/IUC_Cason_Reiter.pdfIntrauterine Contraception (IUC) • Generic term for the method or any of the devices Terms can be used