Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Intrauterine contraceptive device: Insertion and removal

Daniela A Carusi, MD, MSc
Alisa B Goldberg, MD, MPH
Section Editor
Robert L Barbieri, MD
Deputy Editor
Kristen Eckler, MD, FACOG


Insertion of intrauterine contraception is an office procedure requiring specific patient preparation and technical skills. Training may be obtained in the clinical setting or may be provided by the manufacturers of these devices. This review is not intended as a substitute for training.

Several terms are used to describe intrauterine contraception, including intrauterine device (IUD) and intrauterine contraceptive (IUC); the progestin-containing device is also referred to as an intrauterine system (IUS). In this topic, we use the term IUC for all types of intrauterine contraception.

This topic will address technical issues regarding the insertion procedure for the IUCs available in the United States: a copper IUD (TCu380A, Paragard) and two doses of levonorgestrel-releasing IUDs (LNg20 andLNg14). Other aspects of intrauterine contraception are reviewed separately. (See "Intrauterine contraception: Devices, candidates, and selection" and "Intrauterine contraception: Management of side effects and complications".)


Candidates for and selection of an IUD — Appropriate candidates for intrauterine contraception, types of intrauterine devices (IUDs), and the advantages and disadvantages of the various devices are discussed in detail separately. Nulliparous women, adolescents, women who are postpartum or postabortion, and women desiring emergency contraception or sterilization should be included among those considered to be appropriate candidates for intrauterine contraception [1]. (See "Intrauterine contraception: Devices, candidates, and selection".)

Contraindications — The provider should ensure that the patient has no absolute contraindications to IUD use (table 1). If relative contraindications are present (table 2), these should be discussed and then the provider and patient can decide together whether the overall benefits of IUD use outweigh potential patient-specific risks.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Feb 4, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Allen RH, Goldberg AB, Grimes DA. Expanding access to intrauterine contraception. Am J Obstet Gynecol 2009; 201:456.e1.
  2. Darney PD, Klaisle CM. Contraception-associated menstrual problems: etiology and management. Dialogues Contracept 1998; 5:1.
  3. El-Tagy A, Sakr E, Sokal DC, Issa AH. Safety and acceptability of post-abortal IUD insertion and the importance of counseling. Contraception 2003; 67:229.
  4. Whiteman MK, Tyler CP, Folger SG, et al. When can a woman have an intrauterine device inserted? A systematic review. Contraception 2013; 87:666.
  5. Cheng L, Che Y, Gülmezoglu AM. Interventions for emergency contraception. Cochrane Database Syst Rev 2012; :CD001324.
  6. Bergin A, Tristan S, Terplan M, et al. A missed opportunity for care: two-visit IUD insertion protocols inhibit placement. Contraception 2012; 86:694.
  7. Farley TM, Rosenberg MJ, Rowe PJ, et al. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992; 339:785.
  8. Sufrin CB, Postlethwaite D, Armstrong MA, et al. Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease. Obstet Gynecol 2012; 120:1314.
  9. Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1.
  10. Pham AT, Kives S, Merovitz L, et al. Screening for bacterial vaginosis at the time of intrauterine contraceptive device insertion: is there a role? J Obstet Gynaecol Can 2012; 34:179.
  11. Mohllajee AP, Curtis KM, Peterson HB. Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review. Contraception 2006; 73:145.
  12. Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet 2000; 356:1013.
  13. FEI Products LLC. Paragard T380A intrauterine copper contraceptive: Prescribing information and instructions for use. 2003.
  14. Berlex. Mirena levonorgestrel-releasing intrauterine system: Physician package insert. 2003.
  15. U.S. Preventive Services Task Force. Screening for chlamydial infection: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2007; 147:128.
  16. Handsfield HH. Screening asymptomatic women for Chlamydia trachomatis: abstract and commentary. JAMA 1998; 280:1800.
  17. Howell MR, Quinn TC, Gaydos CA. Screening for Chlamydia trachomatis in asymptomatic women attending family planning clinics. A cost-effectiveness analysis of three strategies. Ann Intern Med 1998; 128:277.
  18. Centers for Disease Control and Prevention. Trends in reportable Sexually Transmitted Diseases in the United States, 2004. 2005. www.cdc.gov/std/stats/04pdf/trends2004.pdf (Accessed on March 01, 2006).
  19. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol 2011; 118:184.
  20. Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group, The American College of Obstetricians and Gynecologists. Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2012; 120:983.
  21. Grimes DA, Schulz KF. Antibiotic prophylaxis for intrauterine contraceptive device insertion. Cochrane Database Syst Rev 2001; :CD001327.
  22. US Selected Practice Recommendations for Contraceptive Use, 2013. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6205a1.htm (Accessed on March 04, 2016).
  23. Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:887.
  24. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 116:1736.
  25. Durack DT. Prevention of infective endocarditis. N Engl J Med 1995; 332:38.
  26. Allen RH, Bartz D, Grimes DA, et al. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev 2009; :CD007373.
  27. Sääv I, Aronsson A, Marions L, et al. Cervical priming with sublingual misoprostol prior to insertion of an intrauterine device in nulliparous women: a randomized controlled trial. Hum Reprod 2007; 22:2647.
  28. Mody SK, Kiley J, Rademaker A, et al. Pain control for intrauterine device insertion: a randomized trial of 1% lidocaine paracervical block. Contraception 2012; 86:704.
  29. Chudnoff S, Einstein M, Levie M. Paracervical block efficacy in office hysteroscopic sterilization: a randomized controlled trial. Obstet Gynecol 2010; 115:26.
  30. Maguire K, Davis A, Rosario Tejeda L, Westhoff C. Intracervical lidocaine gel for intrauterine device insertion: a randomized controlled trial. Contraception 2012; 86:214.
  31. McNicholas CP, Madden T, Zhao Q, et al. Cervical lidocaine for IUD insertional pain: a randomized controlled trial. Am J Obstet Gynecol 2012; 207:384.e1.
  32. Allen RH, Raker C, Goyal V. Higher dose cervical 2% lidocaine gel for IUD insertion: a randomized controlled trial. Contraception 2013; 88:730.
  33. American College of Obstetricians and Gynecologists Women's Health Care Physicians, Committee on Gynecologic Practice. Committee Opinion No. 571: Solutions for surgical preparation of the vagina. Obstet Gynecol 2013; 122:718.
  34. http://hcp.mirena-us.com/hcp_center/mirena_videos.php.
  35. http://hcp.skyla-us.com/insertion-and-removal/skyla-insertion-and-removal-video.php.
  36. Bednarek PH, Micks EA, Edelman AB, et al. The effect of nitroprusside on IUD insertion experience in nulliparous women: a pilot study. Contraception 2013; 87:421.
  37. Micks EA, Jensen JT, Bednarek PH. The effect of nitroglycerin on the IUD insertion experience in nulliparous women: a pilot study. Contraception 2014; 90:60.
  38. Li YT, Kuo TC, Kuan LC, Chu YC. Cervical softening with vaginal misoprostol before intrauterine device insertion. Int J Gynaecol Obstet 2005; 89:67.
  39. Vickery Z, Madden T. Difficult intrauterine contraception insertion in a nulligravid patient. Obstet Gynecol 2011; 117:391.
  40. Scavuzzi A, Souza AS, Costa AA, Amorim MM. Misoprostol prior to inserting an intrauterine device in nulligravidas: a randomized clinical trial. Hum Reprod 2013; 28:2118.
  41. Heikinheimo O, Inki P, Kunz M, et al. Double-blind, randomized, placebo-controlled study on the effect of misoprostol on ease of consecutive insertion of the levonorgestrel-releasing intrauterine system. Contraception 2010; 81:481.
  42. Dijkhuizen K, Dekkers OM, Holleboom CA, et al. Vaginal misoprostol prior to insertion of an intrauterine device: an RCT. Hum Reprod 2011; 26:323.
  43. Swenson C, Turok DK, Ward K, et al. Self-administered misoprostol or placebo before intrauterine device insertion in nulliparous women: a randomized controlled trial. Obstet Gynecol 2012; 120:341.
  44. Edelman AB, Schaefer E, Olson A, et al. Effects of prophylactic misoprostol administration prior to intrauterine device insertion in nulliparous women. Contraception 2011; 84:234.
  45. Lathrop E, Haddad L, McWhorter CP, Goedken P. Self-administration of misoprostol prior to intrauterine device insertion among nulliparous women: a randomized controlled trial. Contraception 2013; 88:725.
  46. Espey E, Singh RH, Leeman L, et al. Misoprostol for intrauterine device insertion in nulliparous women: a randomized controlled trial. Am J Obstet Gynecol 2014; 210:208.e1.
  47. Hayes JL, Cwiak C, Goedken P, Zieman M. A pilot clinical trial of ultrasound-guided postplacental insertion of a levonorgestrel intrauterine device. Contraception 2007; 76:292.
  48. Chen BA, Reeves MF, Hayes JL, et al. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol 2010; 116:1079.
  49. www.who.int/reproductive-health/publications/spr/spr_2008_update.pdf (Accessed on May 11, 2015).
  50. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep 2016; 65:1.
  51. Grimes DA, Lopez LM, Schulz KF, et al. Immediate post-partum insertion of intrauterine devices. Cochrane Database Syst Rev 2010; :CD003036.
  52. Chi IC, Balogh S. Interval insertion of intrauterine device in women with previous cesarean section. Contraception 1984; 30:209.
  53. IUD insertions following cesarean deliveries examined. Netw Res Triangle Park N C 1984; 5:4.
  54. Chi I, Feldblum PJ, Rogers SM. IUD--related uterine perforation: an epidemiologic analysis of a rare event using an international dataset. Contracept Deliv Syst 1984; 5:123.
  55. Andersson K, Ryde-Blomqvist E, Lindell K, et al. Perforations with intrauterine devices. Report from a Swedish survey. Contraception 1998; 57:251.
  56. Caliskan E, Oztürk N, Dilbaz BO, Dilbaz S. Analysis of risk factors associated with uterine perforation by intrauterine devices. Eur J Contracept Reprod Health Care 2003; 8:150.
  57. Van Houdenhoven K, van Kaam KJ, van Grootheest AC, et al. Uterine perforation in women using a levonorgestrel-releasing intrauterine system. Contraception 2006; 73:257.
  58. Kaislasuo J, Suhonen S, Gissler M, et al. Intrauterine contraception: incidence and factors associated with uterine perforation--a population-based study. Hum Reprod 2012; 27:2658.
  59. Hatcher R, Trussell J, Stewart F, et al. Contraceptive technology, 17th ed, Ardent Media, Inc, New York 1998.