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Difficult IUD insertions

I read with interest Dr Isabel Draper’s letter1 regarding difficult intrauterine device (IUD) insertions published in the January 2008 issue of this Journal. I agree with Dr Draper’s views and would like to share my experience on this subject. I am an instructing doctor and do two IUD/intrauterine system (IUS) training clinics every week. One training clinic is at The Palatine Centre in Manchester and the other is a Gynaecology Tier 2 clinic in Stockport with facilities for on-site ultrasound scanning for difficult IUD/IUS insertions/removals. On an average five patients are seen in each clinic for IUD/IUS insertions. Nearly 30% of patients I see are under the age of 25 years and nulliparous. In my experience I have found that insertion of TT380 Slimline®, TCu380®, QuickLoad® or TSafe 380A®, which are current recommended gold standards, can be at times difficult and painful to insert in this group of patients. I agree with the author’s comments that insertion of the IUS can also be challenging in this group of women. I find the following methods helpful in reducing the discomfort associated with IUD/IUS insertions. 1 Injection of local anaesthetic directly into the cervix (intracervical block) at the 3, 6, 9 and 12 o’clock position is very effective. A 27gauge dental syringe is used to inject 3% Mepivacaine (Scandonest®) or Articaine® with adrenaline (Septanest®), which is available in cartridges. In order to divert the women’s attention I usually ask the patient to cough at the time of injection. 2 Anaesthetic gel such as Instillagel® (lidocaine 2% and chlorhexidine gluconate solution 0.25%) used with Instillaquill® applied on the ectocervix and directly into the endocervical canal takes up to 5 minutes to work. Therefore I rely on its lubricant properties in enhancing ease of uterine instrumentation. 3 Topical application of lidocaine ointment (5%) on the ectocervix. There is a lack of randomised controlled trials investigating the use of topical or intracervical anaesthesia during IUD/IUS insertions. Methods used to aid clinicians in dilating the cervical os if resistance is encountered are listed below. 1 A plastic disposable graduated uterine sound and dilator is available from Durbin Sales. Dilatation up to 5.5 mm can be achieved with this disposable plastic instrument that has a graduated cervical dilator at one end and a sound at the other end. It is marked at 1 cm intervals, and the dilator end is tapered with gradual increase in width to 5.5 mm and has a gentle curve. In my experience it is easy to use compared to the metal Hegars dilators. 2 Vaginal use of misoprostol (200 μg) inserted 3 hours prior to IUD/IUS insertion softens the cervix. This may cause some vaginal bleeding and cramps, and due to the risk of teratogenicity should be used during a period or a reliable method of contraception should be advised during that cycle. Previous Caesarean section is a risk factor for perforation.2 Risk of perforation is directly proportional to the degree of difficulty encountered during insertion, clinician experience and technique. I can foresee that these potential difficult cases will be referred to specialist clinics or will be done by experienced practitioners. I share Dr Draper’s concerns about trainees who would have to learn in this environment and the need for more training sessions to enable them to achieve adequate skills.