Browse the corpus

The intrauterine device is one of the most effective contraceptive methods available, with failure rates comparable to certain forms of sterilization. Intrauterine devices offer numerous advantages, including high efficacy, ease of use, reversibility, and excellent patient satisfaction, particularly for those seeking long-term contraception with cost-effectiveness. There are 2 types of intrauterine devices—copper-containing and levonorgestrel-releasing devices. Although both these devices are indicated for contraception, each type has specific indications based on its unique properties and the specific goals of the patient. Intrauterine devices are primarily placed for nonpregnant women seeking long-term protection against pregnancy. The highest-dose levonorgestrel intrauterine device is also approved for treating menorrhagia and providing endometrial protection during hormone replacement therapy. Similarly, there are specific indications for intrauterine device removal. The primary indication for removal is the patient's preference for any reason, including desire for pregnancy, irregular bleeding pattern, heavy vaginal bleeding, and pain or discomfort, which may represent malposition of the device. This activity reviews the indications, contraindications, risks, and benefits of intrauterine device placement and removal. Participants also explore best practices for ensuring patient safety and satisfaction, highlighting the collaborative role of the interprofessional team in delivering optimal care for patients undergoing intrauterine device placement and removal procedures. Objectives: Identify the indications and contraindications for intrauterine device placement and removal. Determine the necessary equipment, personnel, preparation, and techniques for intrauterine device placement and removal. Assess patients thoroughly for complications of intrauterine device placement and removal. Implement interprofessional team strategies to enhance care coordination for intrauterine device placement and removal, optimizing clinical outcomes and patient satisfaction. Access free multiple choice questions on this topic.

The intrauterine device (IUD) is one of the most effective contraception options available today, with failure rates as low as certain sterilization methods.[1] In the United States, 2 types of IUDs currently available—the copper-containing IUD and levonorgestrel-containing IUD, which have similar rates of preventing pregnancy, with failure rates of 0.08% and 0.02%, respectively. These devices are more than 99% effective in preventing pregnancy.[2] Additional benefits of IUDs include efficacy, ease of use, reversible nature, and patient satisfaction, especially for women seeking long-term use and cost-effectiveness.[3] In the United States, the use of long-acting reversible contraception (LARC) has increased since 1995. This use has continued to rise annually, with 14% of females using contraception opting for LARC methods.[1] With the increased use of LARC, there has been a significant decrease in the number of unplanned pregnancies.[1]

Complications with IUDs occur in fewer than 1% of women.[20] When counseling patients about the risks associated with the insertion of IUDs, it is important to realize that specific factors may contribute to a poor or unexpected outcome. Given their individual histories, patients should be counseled regarding their particular risks. A study investigated the ability to predict complications based on numerous characteristics of patients and healthcare professionals.[7] Less experienced healthcare professionals placing the IUD and women who had never had a vaginal delivery were found to be more likely to have a difficult insertion or a failed IUD insertion. Issues with cervical dilatation and bradycardia or vasovagal symptoms were more common in nulliparous women, likely due to cervical manipulation. Older women also had issues with appropriate cervical dilatation. In challenging cases, clinician expertise and ability to manage complications were critical in preventing adverse outcomes.[7] There are a few complications associated with IUDs. The most common complication is displacement or accidental removal of the IUD after insertion, typically occurring within the first 3 months of insertion.[23] There is also an increased risk of expulsion if placed after vaginal delivery or an abortion.[24][25] However, the benefit to placing IUDs in patients immediately postpartum is that patients do not always follow up for a postpartum visit and contraception, putting them at risk of unwanted pregnancy.[24] The most concerning complication for a patient is unintended pregnancy. Although becoming pregnant with an IUD is exceedingly rare, this can happen in a small percentage of patients. The percentage of patients who become pregnant with the copper IUD is approximately 0.6%, and for 20 mg levonorgestrel IUD, the rate is approximately 0.2%.[8]

The most concerning complication for a patient is unintended pregnancy. Although becoming pregnant with an IUD is exceedingly rare, this can happen in a small percentage of patients. The percentage of patients who become pregnant with the copper IUD is approximately 0.6%, and for 20 mg levonorgestrel IUD, the rate is approximately 0.2%.[8] There is a risk of uterine perforation during IUD insertion. Data regarding the perforation rate are inconsistent, as initial perforations may go undetected during the procedure.[26] Some estimates report an occurrence of approximately 1 in every 1000 insertions. Some data indicate that the levonorgestrel-releasing IUD has a slightly higher risk of uterine perforation compared to the copper IUD. However, the study reporting this finding was placing the largest levonorgestrel device.[26] Perforation rates appear higher with early postpartum IUD placement.[27] Perforation can be complete or partial, with the IUD either fully entering the abdominal cavity or penetrating the uterine wall to varying extents. Complete perforation often causes severe abdominal pain. The device is commonly found in the pouch of Douglas but may migrate within the abdominal cavity, attaching to organs, the bowel, the mesentery, or the omentum, potentially causing further perforations or obstructions. Although quite rare, complete perforation is a life-threatening condition requiring immediate surgical intervention.[28][29] More common complications associated with IUDs include malpositioned IUDs that do not perforate the myometrium, along with dysmenorrhea and amenorrhea (see Image. Plain Radiograph Showing Intrauterine Device Malposition).[30] Risk factors for malpositioning include obesity, a history of uterine rupture or window, and copper IUD placement.[31] Malpositioned IUDs are often located in the lower uterus, potentially causing abnormal bleeding, pain, and an increased risk of pregnancy. Although not all malpositioned IUDs require removal, removal is generally recommended due to the potential loss of contraceptive efficacy. Reduced efficacy is considered greater with malpositioned copper IUDs than with levonorgestrel-releasing devices.

More common complications associated with IUDs include malpositioned IUDs that do not perforate the myometrium, along with dysmenorrhea and amenorrhea (see Image. Plain Radiograph Showing Intrauterine Device Malposition).[30] Risk factors for malpositioning include obesity, a history of uterine rupture or window, and copper IUD placement.[31] Malpositioned IUDs are often located in the lower uterus, potentially causing abnormal bleeding, pain, and an increased risk of pregnancy. Although not all malpositioned IUDs require removal, removal is generally recommended due to the potential loss of contraceptive efficacy. Reduced efficacy is considered greater with malpositioned copper IUDs than with levonorgestrel-releasing devices. A transvaginal ultrasound or, less commonly, a computed tomography scan can accurately diagnose IUD malposition (see Image. Sonographic Evaluation of the Uterus Demonstrating a Malpositioned Intrauterine Device). If the IUD has partially perforated the myometrium (become embedded) and the strings are visible, removal by pulling the strings should be attempted. If the IUD is not easily removed, then removal under anesthesia with hysteroscopy is generally indicated. With both insertion and removal of IUDs, there is a risk of vasovagal symptoms and associated bradycardia that may occur when manipulating the cervix. Affected patients should be managed symptomatically. These symptoms are more likely to occur in nulliparous women or women who perceive greater pain at the time of insertion or removal.[32] Levonorgestrel-containing IUDs can very rarely be associated with acute liver injury; hence, they are contraindicated in women with underlying hepatic injury or tumors.[33] However, the association between liver injury and progestins is not absolute, and the 2024 United States Selected Practice Recommendations for Contraceptive Use do not recommend routine screening for elevated liver enzymes, given the rarity of undiagnosed disease.[34]

Optimizing IUD placement and removal requires a multidisciplinary approach involving clinicians, advanced practitioners, pharmacists, and other healthcare providers. Key considerations related to skills, strategy, ethics, responsibilities, interprofessional communication, and care coordination can improve patient-centered care, outcomes, safety, and team performance. Clinicians and advanced practitioners require proficiency in IUD placement and removal techniques, including managing complications, such as embedded devices and uterine perforation. Nurses are essential in patient education, screening for contraindications, and providing pre- and post-procedure care. They also assist during procedures and recognize early signs of complications. Pharmacists provide medication counseling for pain management and ensure access to hormonal IUDs through inventory management and insurance coordination. Patient-centered counseling, clear team role delineation, and streamlined workflows can optimize care. All team members should be trained in emergency procedures to address adverse events such as syncope, vasovagal reactions, or uterine perforation. Regular team debriefings and training improve procedural efficiency and reinforce best practices. A collaborative, well-structured approach involving diverse healthcare professionals ensures that IUD placement and removal are safe and effective while optimizing the healthcare team's performance.