Intrauterine device insertion-related complications: can they be predicted?

Abstract

IntroductionAs a result of a critical event experienced during a postcoital intrauterine device (IUD) insertion procedure, this study was undertaken to see whether lessons could be learned and applied in future practice in order to prevent further events. If insertions at high risk of complications can be predicted and risk factors for these insertions identified, then it may be possible to reduce the incidence of problems at insertion or at least be prepared for a possible adverse event.One hypothesis is that because of patient anxiety after unprotected intercourse, postcoital insertions have an increased incidence of complications or failure. The alternative hypothesis, namely that there is no difference between complication incidence in postcoital and routine insertions, is also a possibility. It may be that a higher proportion of patients having postcoital insertions are nulliparous and that this increases the incidence of insertion problems. If IUD insertion complications cannot be predicted then there needs to be constant awareness of this possibility and updating of resuscitation techniques.A MEDLINE search from 1966 to 2001 revealed few recent studies on IUD insertion failures and complications and the data quite often did not relate to modern IUDs in use today. Some risk factors for IUD insertion complications and failure have already been identified. However, whether an insertion is postcoital (as opposed to routine) had not been studied as a risk factor in the studies identified.The insertion-related complications of interest in this study included insertion failure, problems negotiating the cervix, syncope, bradycardia, convulsions, perforation and expulsion.From the literature search one author identified that the incidence of IUD insertion failure was between 2.3 and 8.3 per 1000 insertions, 1,2 and pain during the insertion procedure was associated with increased likelihood of IUD insertion failure. However, as this is a concomitant event it cannot be used to predict patients at high risk of an insertion failure.Risk factors for cervical spasm have not been studied directly. However, nulliparity is a risk factor for requiring cervical dilatation, and breastfeeding women are less likely to require cervical dilatation. 3 Syncope has also been studied, revealing an incidence at IUD insertion of 2.1%. 4 The risk factors identified from previous studies are moderate to severe pain at insertion 4 and nulliparity. 5 Electrocardiographic changes induced by Dalkon ® shield insertion have been studied in one series of 25 women of whom 24 were nulliparous. This study reported an incidence of sinus bradycardia (<60 bpm) of 32%. 6 Transient arrhythmias were noted in two patients. Another study has shown that the incidence of bradycardia is dependent on IUD type, with large and stiff IUDs associated with a higher frequency of bradycardia.

What motivates patients to become involved in postgraduate medical training in a family planning clinic?

“…This would be particularly relevant, for example, when IUD fitting is being learned, since inexperienced doctors have three times more failed fittings than experienced doctors. 13 This point was not understood by all of the patients as the following comments demonstrate. Patients need to be aware of the potential drawbacks of involvement in training if they are to give fully informed consent.…”

The copper intrauterine device for emergency contraception: an opportunity to provide the optimal emergency contraception method and transition to highly effective contraception

“…In one study of women who received an IUD for EC, 19% had a failed insertion, meaning that the provider was unable to place the IUD during that visit and these women received oral EC instead [96]. This failure rate is significantly higher than reported elsewhere in the literature [65,75,[107][108][109][110][111], even accounting for the high rate of nulliparous women (67%) and the fact that all insertions were performed by advanced practice clinicians. The EC visit may present IUD insertion challenges beyond simply nulliparity; for example, women may not have come in planning on getting an IUD, and may be anxious about their risk of pregnancy, which can increase perceived pain and contribute to the difficulty of the insertion [112].…”

Intrauterine devices and adolescents

“…One disadvantage of IUD use among nulliparous women is that the insertion of the IUD through a narrow cervix may be technically difficult as well as painful [17,18]. In one study, 86% of adolescents reported mild-to-severe pain with insertion [3 ,19].…”