Resources

Fitter resources

Step-by-step instructions to guide you through the preparation and fitting of IUS/IUD.

The summary of product characteristics should be referred to before fitting an IUS or IUD.

Key considerations when preparing for an IUS/IUD insertion:
Obtain informed consent and arrange for chaperone.
An appropriately trained assistant should be present (to monitor & support the patient and assist in an emergency).
Basic risk assessment includes gathering information about previous intrauterine procedures. Patients who have had previous adverse events during insertion are more likely to have them again.
Pulse rate and blood pressure should be documented.
The need for pain relief during insertion should be discussed with the patient.
Routine antibiotic prophylaxis is not recommended pre-insertion. Women who have symptoms suggestive of STI should usually delay insertion of IUC for routine contraception. However, if immediate insertion of an IUD (for emergency contraception) is required, antibiotic cover could be considered.

Mirena^® (levonorgestrel 52mg) is contraindicated in those with current genital infection and current or recurrent pelvic inflammatory disease.^*
Kyleena^® (levonorgestrel 19.5mg) and Jaydess^®▼ (levonorgestrel 13.5mg) are contraindicated in acute or recurrent pelvic inflammatory disease or conditions associated with increased risk for pelvic infection.^*

^{* For a full list of contraindications, please refer to the Summary of Product Characteristic.}

Inserting an IUS/IUD – the procedure
For women with symptomatic pelvic infection, postpone fitting and treat infection. Treatment should be complete before another attempt at insertion.
A pelvic examination should be performed prior to inserting the device, to assess the size, shape, position and mobility of the uterus. It should also be done in order to detect any signs of acute genital infections or other contraindications for the insertion and to exclude pregnancy.
Assessment of uterine size by sound measure.
Forceps (tenaculum) are used to stabilise the cervix during insertion and reduce risk of perforation.
Some fitters offer para-cervical block for the procedure.
Many fitters use local anaesthetic gel on the cervix.
Documentation should be made in the case notes of pre- and post-insertion counselling, the procedure, the type of device inserted, and any adverse events.

Mirena^® (levonorgestrel 52mg) is contraindicated in those with current genital infection and current or recurrent pelvic inflammatory disease.
Kyleena^® (levonorgestrel 19.5mg) and Jaydess^®▼ (levonorgestrel 13.5mg) are contraindicated in acute or recurrent pelvic inflammatory disease or conditions associated with increased risk for pelvic infection.

Practical aspects of fitting an IUS

Only to be inserted by a trained healthcare professional using aseptic technique.

Step 1

First, open the sterile package completely. Then use sterile technique and sterile gloves.

IMPORTANT!

Do not pull the slider downwards as this may prematurely release the LNG-IUS.
Once released, the LNG-IUS cannot be re-loaded.

REMOVAL:

Mirena^® (levonorgestrel 52mg) should be replaced after 4-8 years (depending on indication)
Kyleena^® (levonorgestrel 19.5mg) should be replaced after 5 years
Jaydess^®▼ (levonorgestrel 13.5mg) should be replaced after 3 years.

Mirena^® (52mg levonorgestrel) Prescribing Information

Kyleena^® (19.5mg levonorgestrel) Prescribing Information

Jaydess^®▼ (13.5mg levonorgestrel) Prescribing Information

Practical aspects of fitting an IUD

The IUD may be used by trained medical staff only. We recommend using sterile gloves to minimise the risk of contamination.

IUD List

a) Insertion tube e) Nylon threads

b) Insertion body f) IUD stem

c) Plunger g) Side arms

d) Blue flange h) Blue marking

Steps 1 & 2

Open the sterile packaging of the T-Safe^®CU 380A QL.
While holding the nylon threads (e) straight, place the plunger (c) into the insertion body (b) up to the lower end of the IUD stem (f). By carefully pushing the plunger up to the blue marking on the insertion tube (a), both side arms (g) of the IUD slip into the tube. The upper end of the now ready-loaded IUD must jut only 2 mm out of the insertion tube.

NOTE:

Due to the soft and flexible insertion tube, the side arms may twist while being pushed upwards. Please adjust the sliding blue flange as described in step 3, above. The side arms of the T-Safe^® Cu 380A QL must not remain bent for over five minutes within the insertion tube, or they may not bend back completely and may not return to their original 90^° angle.
REMOVAL: T-Safe

Potential problems at the time of insertion

Vasovagal collapse/cervical shock:
Stop the procedure, lower the head and/or raise the legs. The IUD/IUS may need to be removed. An assistant should monitor observations. Ensure a clear airway. ‘ABC approach’ in basic resuscitation.
Oxygen and suction as required. Consider use of atropine IV/IM for persistent bradycardia. Consider use of adrenaline IM 1:1000 for management of anaphylaxis.
Automated external defibrillator (AED) should be available. Arrange ambulance transfer if there is no improvement.
Syncope:
Syncope may be experienced at insertion secondary to vagal stimulation from the cervix. Bradycardia is more common in nulliparous women.
Suspected uterine perforation:
If perforation is suspected the system should be removed as soon as possible; surgery may be required.

Post-insertion advice

Provide patients with a patient information leaflet and advice post-insertion of IUS/IUD is an important component of patient care.

Key advice to be offered includes:

Expect cramping that usually lasts for 24-48 hours
But may last longer and resolves thereafter and usually does not persist.
Informing the patient
On how to feel the threads (e.g. before the next episode of sexual intercourse and after her next menses) and advise her to seek medical advice if she is unable to feel them.

Discuss the following points with patients:

Bleeding
Infection
If the patient is feeling well enough to leave and is comfortable
A follow-up appointment with the patient for 6 weeks’ time

Good practice points for documentation

Detailed documentation is a key component of good practice in IUS/IUD fitting. Important points to document include:

Information, advice and counselling
Information, advice and counselling
Contraceptive choices discussed/preparation chosen
Risks/benefits/uncertainties discussed
How it works and efficacy
Potential side effects
Choice of device and duration of use
Effects on bleeding pattern
Risk of spontaneous expulsion and perforation and advisability of thread check and teaching
Risk of post-insertion pelvic infection and record of any swabs taken, if applicable
Bleeding pattern
Explanation of insertion and removal procedure
Consent obtained
Leaflets given including manufacturer’s PIL
Advice given on practising safe sex
Details of insertion procedure
Details of insertion procedure
Name of clinician/assistant
Any tests undertaken
Bimanual/speculum examination findings
Analgesia/local anaesthesia if used, including batch number and expiry date
Tenaculum/Allis application used
Uterine sounding/utero-cervical length
Type of device inserted including batch number and expiry date
Use of no-touch technique
Problems encountered, if any, and action taken
Post-insertion advice and follow-up advice given
Post-insertion advice and follow-up advice given
Other treatment, if any e.g. antibiotics
Special instructions, if any e.g. additional contraception for 7 days
Follow up date if arranged; “see if any problems” acceptable

Adapted from FSRH 2019

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References
1
Johnson BA. Insertion and removal of intrauterine devices. Am Fam Physician. January 2005 1; 71(1): 95-102
2
FSRH. Intrauterine Contraception [online] October 2015. Available at: https://www.fsrh.org/standards-and-guidance/documents/ceuguidanceintrauterinecontraception/ (Last Accessed February 2024)
3
Mirena® Product Monograph.
4
Mirena® Summary of Product Characteristics
5
Mirena® SmPC Bayer PLC.
6
T Safe Cu 380A QL Intrauterine Contraceptive Device, Physicians Instructions, EurimPharm.
7
Farmer M, Webb A; Intrauterine device insertion-related complications: can they be predicted? J Fam Plann Reprod Health Care. 2003 Oct;29(4):227-31.
8
Faculty of Sexual and Reproductive Healthcare. Service Standards for Record Keeping in Sexual and Reproductive Healthcare Services, July 2019. Available at: https://www.fsrh.org/standards-and-guidance/documents/fsrh-service-standards-for-record-keeping-july-2019/ (Last Accessed February 2024)