The uterine cavity should be measured with a uterine sound. The depth of the cavity should measure at least 6 cm from the external os. A smaller uterus is not likely to tolerate currently available IUDs.
3.
Use of a tenaculum for insertion is mandatory to prevent perforation. The cervix is grasped with a tenaculum and gently pulled downward to straighten the angle between the cervical canal and the uterine cavity. The IUD, previously loaded into its inserter, is then gently introduced through the cervical canal.
4.
With the copper T380A, the outer sheath of the inserter is withdrawn a short distance to release the arms of the T and is gently pushed inward again to elevate the now-opened T against the fundus. The outer sheath and the inner stylet of the inserter are withdrawn, and the strings are cut to project about 2 cm from the external cervical os.
5.
The levonorgestrel T IUD is inserted somewhat differently from the copper T380A. The inserter tube is introduced into the uterus until the preset sliding ﬂange on the inserter is 1.5 to 2 cm from the external os of the cervix. The arms of the T device are released upward into the uterine cavity, and the inserter is pushed up under them to elevate the IUD up against the uterine fundus.
In nulliparous women, insertion may be more difficult because of a narrower cervical canal than in parous women. Mechanical dilation may be necessary. Pretreatment with misoprostol may be beneficial in difficult IUD insertions (99).
If an intrauterine pregnancy is diagnosed and the IUD strings are visible, the IUD should be removed as soon as possible to prevent later septic abortion, premature rupture of the membranes, and premature birth (100). When the strings of the IUD are not visible, an ultrasound examination should be performed to localize the IUD and determine whether expulsion has occurred. If the IUD is present, there are three options for management: 1.
2.
Ultrasound-guided intrauterine removal of the IUD 3.
Continuation of the pregnancy with the device left in place
If the patient wishes to continue the pregnancy, ultrasound evaluation of the location of the IUD should be considered (101). If the IUD is not in a fundal location, ultrasound-guided removal using small alligator forceps may be successful. If the location is fundal, the IUD should be left in place. When pregnancy continues with an IUD in place, the patient must be warned of the symptoms of intrauterine infection and should be cautioned to seek care promptly for fever or ﬂulike symptoms, abdominal cramping, or bleeding. At the earliest sign of infection, high-dose intravenous antibiotic therapy should be given and the pregnancy evacuated promptly.
Duration of Use
Annual rates of pregnancy, expulsions, and medical removals decrease with each year of use (102,103). Therefore, a woman who has no problem by year 5, for example, is very unlikely to experience problems in the subsequent years. The copper T380A is FDA approved for 10 years and the levonorgestrel T for 5 years, though as previously noted, good data support use of the copper T380A through 12 years and of the levonorgestrel T through 7 years (66,86).
Choice of Devices
Both of the IUDs available in the United States, the copper T380A and the levonorgestrel T, provide protection for many years, have remarkably low pregnancy rates, and substantially reduce the risk of ectopic pregnancy. The levonorgestrel T reduces the amount of menstrual bleeding and dysmenorrhea. The copper T380A initially can be expected to increase menstrual bleeding. It is the most effective means for emergency contraception.
Management of Bleeding and Cramping with Intrauterine Devises