1. Intrauterine Device Training
Presenter:
LaBetta Wallenmeyer, MSN, APRN
Leanna Harkess, APRN, CNP, CNM
Oklahoma State Department of Health

2. Disclosure Statement
I have no relevant financial or affiliations with commercial interests to disclose

3. Objectives Upon completion of this presentation, participants will be able to:
List the steps in preparation and insertion of the IUDs presented
Describe complications that can occur with IUD insertions/removal
Demonstrate insertion and removal of the Paragard, Mirena and Liletta IUDs

4. Preparation
Timing: Ensure the patient is not pregnant and screen for STIs if high risk
Tools: Assemble items required for inseertion
Technique: Perform steps of insertion

5. Timing
Anytime during the menstrual cycle is acceptable as long as the provider can be reasonably certain that a woman is not pregnant!
In 2013 the CDC came out with a MMWR entitled: U.S. Selected Practice Recommendations for Contraceptive Use, 2013
In this report they gave 6 criteria by which if any one is met, the provider can be reasonably certain the woman seeking contraception is not pregnant

6. Six criteria : Is < 7 days after start of a normal menses
Has not had sexual intercourse since the start of last normal menses
Has been correctly and consistently using a reliable method of contraception
Is < days after spontaneous or induced abortion
Is within 4 weeks postpartum
Is fully or nearly fully breastfeeding, amenorrheic, and < 6 months postpartum

7. STI screening
Women should be routinely screened for chlamydia and gonorrhea according to national screening guidelines (see CDC Sexually Transmitted Diseases Treatment Guidelines) Results not necessary for placement, however if having clinical S&S such as purulent cervicitis or known chlamydia/gonorrhea infection or exposure, IUD placement should be delayed.

8. Tools

9. Technique: Prior to insertion
Perform a bimanual exam to assess uterine size and position
Insert a speculum to visualize the cervix
Cleanse the cervix with an antiseptic solution (betadine or hibiclens)
Sound the Uterus

10. Uterine positions

11. Technique: Applying Tenaculum
Grasp the cervix with tenaculum forceps
Upper lip of cervix if anteverted or antiflexed
Lower lip of cervix if retroverted or retroflexed
Apply traction to stabilize and align cervical canal with uterine cavity
Maintain traction throughout entire insertion procedure
Sound the uterus

12. Technique: Sounding the Uterus

13. Technique: Sounding the Uterus
If you encounter any difficulty or encounter cervical stenosis
Use dilation to overcome resistance
Allow time for spasm to pass
Uterus should sound to a depth of 6 to 10 cm.
Insertion of IUD into a cavity below 6 cm may increase incidence of expulsion, bleeding, pain, perforation or pregnancy

14. Insertion of IUD

15. Bayer manufactured IUDs
Types of IUDs
Bayer manufactured IUDs
Mirena (Approved for 5 years, Levonorgestrel 52 mg)
Kyleena (Approved for 5 years, Levonorgestrel 19.5 mg)
Skyla (Approved for 3 years, Levonorgestrel 13.5 mg)

16. Allergan manufactured IUD
Types of IUDs (Cont.)
Allergan manufactured IUD
Liletta IUD (Approved for 3 years, Levonorgestrel 52mg)
Teva Manufactured IUD
Paragard (Non-hormonal, Copper)

17. Insertion of Mirena, Kyleena and Skyla

26. Insertion of Liletta

27. Liletta IUD

28. Loading the Liletta Inserter

29. Loading the Liletta Inserter (Cont.)

30. Loading the Liletta Inserter (Cont.)

31. Inserting Liletta into Uterus

32. Inserting Liletta into Uterus (cont.)

33. Releasing the Liletta

34. Releasing the Liletta (cont.)

35. Cutting the Threads

36. Insertion of Paragard

37. Insertion of Paragard

38. Insertion of Paragard
Do not bend the arms of the Paragard earlier than 5 minutes before it is to be placed in the uterus.
Remember to use aseptic technique when handling the Paragard and the part of the insertion tube that will enter the uterus.
My personal preference is to prepare the Paragard with sterile gloves opposed to trying to manage within the package.

39. Loading Paragard into Inserter

40. Inserting Paragard

41. Inserting Paragard

42. Inserting Paragard

43. Inserting Paragard

44. Removing Paragard Inserter

45. Paragard Insertion Tips

46. Complications and Considerations

47. Rotation of the IUD
It is important to check the rotation of the IUD prior to inserting.
Make sure the IUD arms are parallel to the uterus and have no tilt when inserting into insertion applicator

48. Uterine Perforation
Always maintain gentle traction on the tenaculum when inserting sound or IUD into the uterine cavity
Traction will straighten the uterus and remove flexion
Be careful when inserting sound not to push too fast or hard (stop when you feel resistance)

50. Pain with Insertion
Normal for client to experience severe cramping during both the sounding of uterus and insertion of IUD
Consider having client take an NSAID prior to procedure
Vasovagal Reaction including Syncope can occur
Have the client remain supine until she stops having syncopal symptoms
Have the client sit up gradually and continue to sit upright for a while before attempting to stand

51. Potential for incorrect insertion
Always palpate the cervix following IUD insertion to check strings and feel for plastic
Check placement with transvaginal ultrasound if incorrect insertion is suspected
Consult a Gynecologist if perforation or other issues are a clinical concern following placement (examples would be exceptional pain or bleeding during or after insertion)

52. IUD Follow UP
4-6 weeks after insertion IF client is unable to feel strings OR is having discomfort or other problems with IUD
Once a year
Anytime client is having problems/pain with her IUD or is not able to feel her strings

53. IUD Removal IUDs are all removed the same way
Items you need for removal include
Speculum
Gloves
Ring forceps

54. Removal Insert speculum to visualize the cervix
Strings should be visible
If strings are not visible, try using a endocervical brush to disengage the strings from the cervical canal
Grasp the strings with the ring forceps
Use gentle, steady traction on the IUD strings
After removal, ensure that the IUD is intact

55. Use of Endocervial Brush

56. Complications of Removal
If IUD threads are not visible and can not be disengaged with the endocervical brush, refer to Gynecologist
If unable to remove the IUD with steady firm traction, could indicate IUD is imbedded in uterine wall, refer to Gynecologist
IUD not removed intact, refer to Gynecologist

57. References
Centers for Disease Control and Prevention (2016). U.S. selected practice recommendations for contraceptive use, 2016: MMWR 2016:65. Retrieved from
Centers for Disease Control and Prevention (2016). U.S. medical eligibility criteria for contraceptive use, MMWR 2016:59. Retrieved from

58. References Cont. http://hcp.skyla-us.com/index.php

59. Pictures • • • •