The cervical surface is cleansed with an antiseptic solution, and sterile instruments and a sterile IUD are used. A tenaculum is placed on the cervical lip, and the canal and uterine cavity are straightened by applying gentle outward traction. The cav ity is then probed by a uterine sound to identiy its direction and depth. Speciic steps of ParaGard and Mirena insertion are tive package inserts.
Following insertion, only the threads should be visible trailing from the cervix. These are trimmed to allow 3 to 4 cm to protrude into the vagina, and their length is recorded. If improper device positioning is suspected, placement should be confirmed, using sonography if necessary. If the IUD is not positioned completely within the uterus, it is removed and replaced with a new device. An expelled or partially expelled device should not be reinserted.
Contraception can be provided by thin, pliable progestincontaining cylinders that are implanted subdermally and release hormone over many years. One of these, Nepanon is a single-rod implant with 68 mg of etonogestrel covered by an ethylene vinyl acetate copolymer cover. The implant is placed subdermally on the medial surface of the upper arm 8 to 10 cm from the elbow in the biceps groove and is aligned with the long axis of the arm. It may be used as contraception for 3 years, removed, and then replaced at the same site or in the opposite arm (Merck, 2016a).
Nexplanon is radiopaque, and its inserter device is designed to assist with subdermal positioning and avert deeper placement. This device replaced Implanon, which is not radiopaque. A misplaced Implanon may be identiied with sonography using a 10-to IS-MHz linear array transducer (Shulman, 2006). In some cases, MR imaging may be required if supplemental information is needed despite sonography (Correia, 2012). Both implants are similarly shaped and pharmacologically identical. They are highly efective, and the mechanism of action for progestin-only products is described later (p. 689) (Croxatto, 1998; Mommers, 2012). Implanon is safe and still approved by
Flange 1.5cm
After slider moved back, inserter tube removed
FIGURE 38-2 Insertion of the Mirena intrauterine system. Initially, threads from behind the slider are first released to hang freely. The slider found on the handle should be positioned at the top ofthe handle nearest the device. The IUD arms are oriented horizontally. A flange on the outside ofthe inserter tube is positioned from the IUD tip to reflect the depth found with uterine sounding. A.As both free threads are pulled, the Mirena IUD is drawn into the inserter tube. The threads are then tightly fixed from below into the handle's cleft. In these depictions, the inserter tube has been foreshortened. The inserter tube is gently inserted into the uterus until the flange lies 1.5 to 2 cm from the external cervical os to allow the arms to open. B. While holding the inserter steady, the IUD arms are released by pulling the slider back to reach the raised horizontal mark on the handle, but no further. C. The inserter is then gently guided into the uterine cavity until its flange touches the cervix. D. The device is released by holding the inserter firmly in position and pulling the slider down all the way. The threads will be released automatically from the clet. The inserter may then be removed, and IUD strings trimmed. (Reproduced with permission from Stuart GS: Contraception and sterilization. In Hoffman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, McGraw-Hili Education, 2016.)
Tip of IUD inserter rod Inserter tube Flange A B