(1) An IUD may be inserted any time in a menstrual cycle as long as pregnancy has been ruled out.
(2) The patient should be educated thoroughly before insertion. Gynopharma and Berlex provide a very complete patient education pamphlet that reviews everything from composition to side effects, effectiveness rate, and how to check the IUD postinsertion. The patient should read this material carefully before the device is inserted. The more informed the patient is, the better selected the patient will be. For insertion instructions see package inserts and other written sources (Fig. 1).
(3) Prophylactic antibiotics: Two published studies differ on whether the use of antibiotics is necessary at the time of insertion. I prefer to use them. At this time it is well established that antibiotics should be used after insertion due to the fact that at insertion time bacteria from the vagina is introduced and may cause infection.
(a) Giving 200 mg of doxycycline at the time of insertion and 100 mg 12 hours after insertion is appropriate in women who are not breast-feeding.
(b) In women who are breast-feeding erythromycin 500 mg orally (PO) 1 hour before insertion and 500 mg 6 hours after is appropriate. Azithromax also may be used.
(Fig. 1).Withdrawal technique for an intrauterine device
e. IUD removal: Paragard CU T 380A is now approved for 10 years of use; Mirena for 5 years. Removal should be done gently with ring forceps or any type of long grasping forceps.
Difficult removals may require cervical dilation with dilators or laminaria. An IUD hook or Novak’s curette may be used to grasp an IUD in which strings are not visible.
f. Pregnancy with an IUD.
(1) Ectopic pregnancy must be ruled out.
(2) The patient must be informed of signs and symptoms of infection and perforation if IUD strings are not seen.
(3) If IUD strings are seen, remove IUD gently.
(1) There is a 1 in 1000 incidence.
(2) The most common sites include fundus, body of the uterus, and cervical wall.
(3) If IUD partially perforates it can be removed as a simple IUD removal.
(4) If total perforation is diagnosed by ultrasound and x-ray film, PID or bowel obstruction may occur. In this case antibiotics and removal by laparoscopy is suggested. If no PID or obstruction occurs, then patient has option of leaving the IUD and watching for signs or symptoms of PID or obstruction.
h. If PID develops, treatment should be instituted, the IUD removed, and hospitalization with intravenous (IV) antibiotics started.
A simple mnemonic device to remind patients of symptoms that indicate a problem with the IUD is:
P Period late (pregnancy), abnormal bleeding
A Abdominal pain
I Infection exposure, abnormal discharges
N Not feeling well, fever, chills
S String missing, shorter, or longer