**7. The technique of inserting and removing IUDs**

IUD represents the choice method of contraception for many women as its effects are reversible after removal.

The insertion technique is easy and well tolerated by selected female patients after taking into consideration the contraindications, as well as the health benefits for women with anemia, menorrhagia, or dysmenorrhea [73]. First, it is advisable to have a documentation of a negative pregnancy test as a precaution. Also, exclusion of a possible Chlamydia or gonorrhea is advisable before an IUD is inserted [74]. The insertion can be performed at any time during the menstrual cycle [42]. In the past, the technique was preferred to be done during menses to exclude pregnancy, but this is associated with a higher risk of expulsion. Several studies found that the pain during the insertion is lower during the sixth and the tenth days of the menstrual cycle [26]. Regarding the insertion of a hormonal IUD, the appropriate timing is considered to be within the first 5 days of menstrual bleeding or immediately after childbirth, abortion, or switching from an alternative contraceptive method [42, 75]. Backup contraception is recommended for a period of 7 days after the hormonal IUD insertion and is not needed after the copper IUD insertion [48]. In cases of emergency contraception, the insertion of the copper IUD can be done within the 5 days of the unprotected intercourse to prevent pregnancy [25]. The use of a hormonal IUD has not been yet studied and so it is not recommended for emergency contraception. The removal of both the copper IUD and the hormonal IUD can be performed anytime preferably during the menstrual cycle. As mentioned before, antibiotic prophylaxis is not needed before IUD insertion or removal, even in patients at risk for endocarditis [76]. The insertion procedure is usually done by a trained provider in the office, and only in special circumstances, such as mentally limited patients and nulliparous young women, it can be done under sedation. The physician must discuss all risks and benefits of IUD with the patient and must obtain an informed consent. The use of misoprostol before IUD insertion to allow an easier procedure was proposed in 2007 [77]. However, more recent researches found no benefit but increased side effects with misoprostol, and no recommendation has been yet made [78, 79]. On the other hand, the use of a nonsteroidal anti-inflammatory drug, respectively, 600–800 mg of ibuprofen 1 h before the procedure can alleviate discomfort [80]. Also, the physician must educate the patient in locating the IUD threads after each menstruation and consulting earlier if incapacity to locate [80]. IUD insertion is similar for copper IUD and for hormonal IUD. The preparation before IUD insertion must include the determination of uterus position. This can be done by a bimanual examination or by an ultrasound examination. All proper equipment must be sterile and assembled before the procedure. The cervix and vagina must be cleansed with antiseptic solution. A speculum is used to visualize the cervix and a tenculum to stabilize the cervix. Local anesthesia is preferred with lidocaine gel in the cervical canal, or a paracervical block. The uterine depth must be verified using a hysterometer and the IUD is inserted as shown in the accompanying written material of any IUD. After proper insertion, the threads should be cut to a length of 3 cm. A post-procedure ultrasound should be performed to verify the IUD position [81]. The removal procedure should be considered anytime on patient request. If any contraindication appears or adverse effects persist, IUD can be easily removed by grasping the threads at the external os. Special conditions include impossibility to remove the IUD with a simple traction; deeply embedment IUD should be suspected and in such cases, hysteroscopy is mandatory. Cervical screening is performed the same as in IUD non-users. Colposcopy is performed the same, but excisional procedure for cervical dysplasia must be performed after IUD removal [81].

there are no general guidelines for a routine transvaginally US verification after IUD insertion [84]. The 3D US technique has the advantage to allow subsequent reconstruction of the coronal plane [83]. This approach provides a correct diagnosis regarding the malposition, expulsion, displacement, embedment, or perforation (**Figure 5**). It can also detect more specifically uncommon complications such as fragmentation and calcification [81]. So, 3D has become crucial as it is more sensitive in assessing symptomatic IUD users, but also for routine evaluation. However, familiarity with the transvaginal 2D/3D US techniques is

**Figure 5.** Ultrasound image of a malpositioned copper IUD. (A) 2D image; (B) 3D rendering of the coronal plane showing

copper IUD displacement; (C) 3D rendering showing copper IUD partial embedment into myometrium.

**Figure 4.** Ultrasound image of hormonal IUD. (A) 2D image; (B) 3D rendering, with reconstruction of the coronal plane.

Birth Control and Family Planning Using Intrauterine Devices (IUDs)

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essential.

#### **8. The role of ultrasound in IUD users**

US evaluation of the pelvis, especially transvaginally, has become an important part of the gynecological care and is essential for the assessment of IUD position after insertion [81]. Moreover, the lack of a pelvic US examination before IUD insertion may predispose to malposition or serious complications such as perforation [82]. US assessment is cheap, easy to learn, perform and interpret, efficient, and without side effects [81]. A correct positioned IUD is visualized in the middle of the endometrial cavity with no extension in the myometrium, with both arms spread toward the uterine horns and the inferior part of the vertical body of the IUD just above the isthmic portion of the uterus [83] (**Figure 4**). The two-dimensional technique has some limits in the evaluation of the IUD position, as the most important plane for this purpose, the coronal plane, usually cannot be imagined. Three-dimensional (3D) assessment is also helpful to identify hormonal IUD, because of the lack of echogenicity (**Figure 4B**), unlike copper IUD that are easily identified due to its high echogenity.

About 10% of IUDs are malpositioned and so the efficacy in contraception is significantly decreased. More than half of the patients with a malpositioned IUD are asymptomatic. Still,

or removal, even in patients at risk for endocarditis [76]. The insertion procedure is usually done by a trained provider in the office, and only in special circumstances, such as mentally limited patients and nulliparous young women, it can be done under sedation. The physician must discuss all risks and benefits of IUD with the patient and must obtain an informed consent. The use of misoprostol before IUD insertion to allow an easier procedure was proposed in 2007 [77]. However, more recent researches found no benefit but increased side effects with misoprostol, and no recommendation has been yet made [78, 79]. On the other hand, the use of a nonsteroidal anti-inflammatory drug, respectively, 600–800 mg of ibuprofen 1 h before the procedure can alleviate discomfort [80]. Also, the physician must educate the patient in locating the IUD threads after each menstruation and consulting earlier if incapacity to locate [80]. IUD insertion is similar for copper IUD and for hormonal IUD. The preparation before IUD insertion must include the determination of uterus position. This can be done by a bimanual examination or by an ultrasound examination. All proper equipment must be sterile and assembled before the procedure. The cervix and vagina must be cleansed with antiseptic solution. A speculum is used to visualize the cervix and a tenculum to stabilize the cervix. Local anesthesia is preferred with lidocaine gel in the cervical canal, or a paracervical block. The uterine depth must be verified using a hysterometer and the IUD is inserted as shown in the accompanying written material of any IUD. After proper insertion, the threads should be cut to a length of 3 cm. A post-procedure ultrasound should be performed to verify the IUD position [81]. The removal procedure should be considered anytime on patient request. If any contraindication appears or adverse effects persist, IUD can be easily removed by grasping the threads at the external os. Special conditions include impossibility to remove the IUD with a simple traction; deeply embedment IUD should be suspected and in such cases, hysteroscopy is mandatory. Cervical screening is performed the same as in IUD non-users. Colposcopy is performed the same, but excisional procedure for

US evaluation of the pelvis, especially transvaginally, has become an important part of the gynecological care and is essential for the assessment of IUD position after insertion [81]. Moreover, the lack of a pelvic US examination before IUD insertion may predispose to malposition or serious complications such as perforation [82]. US assessment is cheap, easy to learn, perform and interpret, efficient, and without side effects [81]. A correct positioned IUD is visualized in the middle of the endometrial cavity with no extension in the myometrium, with both arms spread toward the uterine horns and the inferior part of the vertical body of the IUD just above the isthmic portion of the uterus [83] (**Figure 4**). The two-dimensional technique has some limits in the evaluation of the IUD position, as the most important plane for this purpose, the coronal plane, usually cannot be imagined. Three-dimensional (3D) assessment is also helpful to identify hormonal IUD, because of the lack of echogenicity (**Figure 4B**),

About 10% of IUDs are malpositioned and so the efficacy in contraception is significantly decreased. More than half of the patients with a malpositioned IUD are asymptomatic. Still,

cervical dysplasia must be performed after IUD removal [81].

unlike copper IUD that are easily identified due to its high echogenity.

**8. The role of ultrasound in IUD users**

266 Family Planning

**Figure 4.** Ultrasound image of hormonal IUD. (A) 2D image; (B) 3D rendering, with reconstruction of the coronal plane.

there are no general guidelines for a routine transvaginally US verification after IUD insertion [84]. The 3D US technique has the advantage to allow subsequent reconstruction of the coronal plane [83]. This approach provides a correct diagnosis regarding the malposition, expulsion, displacement, embedment, or perforation (**Figure 5**). It can also detect more specifically uncommon complications such as fragmentation and calcification [81]. So, 3D has become crucial as it is more sensitive in assessing symptomatic IUD users, but also for routine evaluation. However, familiarity with the transvaginal 2D/3D US techniques is essential.

**Figure 5.** Ultrasound image of a malpositioned copper IUD. (A) 2D image; (B) 3D rendering of the coronal plane showing copper IUD displacement; (C) 3D rendering showing copper IUD partial embedment into myometrium.
