Direct vs. standard method of insertion of an intrauterine contraceptive device: insertion pain and outcomes at 6 months

Differing Approaches to Pain Management for Intrauterine Device Insertion and Maintenance: A Scoping Review

Intrauterine devices (IUDs) are considered a reliable contraceptive option for women, but they can come with side effects. There is a disconnect in standard guidelines for IUD insertion within and without the U.S. The objective of this review was to address a gap in the literature regarding official procedures for pain management during IUD implantation. This scoping review was initiated using keywords to extract relevant articles from multiple databases: U.S. National Library of Medicine National Institutes of Health (PubMed), MEDLINE (Ovid), and Excerpta Medica dataBASE (EMBASE, Ovid). Initially, 457 articles were identified and after a rigorous screening and selection process, 37 articles were chosen to be further assessed to ascertain if they met the study's inclusion criteria. Those 37 articles were further evaluated fully to check for relevancy. From that process, 19 articles were chosen for the review, and all passed quality assessment evaluations using the JB Appraisal Tools. To best address the research question, the data from the 19 articles were divided into three categories: 1) circumstantial factors, 2) non-pharmacological methods, and 3) pharmacological methods. Circumstantially, women with previous vaginal deliveries experienced the lowest pain during the procedure, and nulligravid (never pregnant) women experienced the most pain. Lower pain scores were reported by lactating women compared to non-lactating. Black women experienced the most anticipated pain compared to other races. Regarding non-pharmacological methods, different insertion techniques, tools, and the use of a cold compress were found to not affect the level of pain during IUD insertion. Lastly, it was shown that pharmacological methods such as lidocaine gel, lidocaine paracervical block, and lidocaine combined with either diclofenac or prilocaine decreased pain scores at different time stamps of the procedure. Also, oral ketorolac and a vaginal combination of misoprostol and dinoprostone helped reduce pain. Findings from this scoping review revealed a lack of uniformity across practices when performing IUD insertions, possibly due to differences in procedures across circumstantial factors, non-pharmacological methods, and pharmacological methods. More research is needed to investigate the intricacies of pain with IUD insertion. Moving forward, especially following a potential increase in the use of IUDs after the reversal of Roe v. Wade, establishing this gap may lead to a more refined standardized protocol to mitigate pain with IUD insertions.

Effects of virtual reality on pain during intrauterine device insertions: A randomized controlled trial

OBJECTIVES

The trial aimed to compare the pain perceived by women during intrauterine device (IUD) insertion, with or without virtual reality (VR) therapy. Furthermore, anxiety during the insertions, pain after the insertions, and satisfaction with the insertions were compared.

METHODS

The trial was designed as a prospective, bi-centric, randomized, open-label interventional trial. All adult women that chose an IUD during a contraceptive consultation, and who provided informed consent were eligible. Women under legal guardianship, not affiliated to a national social security system, and with pre-existing dizziness, severe facial wounds, or epilepsy were not eligible. Eligible women were randomly allocated either standard care without VR therapy (Control group) or with VR therapy (Experimental group). Pain, anxiety, and satisfaction were measured using a 10-cm numerical scale.

RESULTS

Between September 2020 and April 2022, 100 women were randomized: 50 to each group. The mean pain scores during IUD insertion were 5.4 cm in the Control group versus 5.1 cm in the Experimental group (p = 0.54). Mean anxiety during insertion were 4.8 cm in the Control group versus 4.2 cm in the Experimental group (p = 0.13). While mean pain perceived after insertions were 2.4 cm in the Control Group and 2.4 cm in the Experimental group (p = 0.98). Mean satisfaction with the insertions was 9.6 cm in both groups (p = 0.87). Anxiety before IUD insertion, as well as anticipated pain, were significantly correlated with pain perceived during insertions.

CONCLUSIONS

VR therapy performed during the procedure did not alleviate perceived pain in women undergoing IUD insertions.

Effects of a short training workshop on the insertion/removal of intrauterine devices and contraceptive implants by general practice residents and their supervisors in France

OBJECTIVES

The skill of general practitioners (GPs) in performing the insertion/removal of intrauterine devices (IUDs) and contraceptive implants is one of the factors that determines patient's access to these contraceptive devices. In France, GP residents have few opportunities to perform these procedures during their internships. This study aimed to measure the effects of a single short training workshop on the number of residents and supervisors offering these procedures.

STUDY DESIGN

Each participant attended a unique 2-hour session. After a brief didactic review and video presentations, participants received hands-on training in technical procedures (insertion/removal of IUDs and contraceptive implants) using procedural simulators. The evaluation measured the number of GPs offering these procedures before, 1 month after, and 3 months after the workshops.

RESULTS

Fourteen sessions were organized from February 2017 to June 2022. Among the 387 residents and 123 supervisors invited, 143 (37.0%) and 56 (45.5%), respectively, participated in this workshop. Of 199 participants, 66.3% completed all questionnaires. There was a significant increase in the number of GPs inserting IUDs by direct method 3 months after training (20.5% vs 9.0%, p = 0.005). GPs providing information to patients about contraceptive implants were significantly higher at 1 month (80.6% vs 64.8%, p = 0.001) but this increase was no longer significant at 3 months (75.0%, p = 0.07). Residents changed their practices more than their supervisors, and women more than men.

CONCLUSIONS

A short training workshop increased the number of GPs inserting IUDs, influenced by the gender and the number of years practicing.

IMPLICATIONS

A single workshop had positive effects on IUD insertion and patient education about contraceptive implants. Repeating several times this training could be an option in the initial and ongoing training of general practitioners. Work on the general practitioners' own feeling of legitimacy in their practice context could also increase the effectiveness of these workshops and the practical implementation of the procedures taught.

Ultrasound-guided versus uterine sound-sparing approach during copper intrauterine device insertion: a randomised clinical trial

OBJECTIVE

To compare the outcomes of trans-abdominal ultrasound (TAS) guided approach and uterine sound-sparing approach (USSA) during copper intrauterine device (IUD) insertion.

STUDY DESIGN

A randomised open-label clinical trial (Clinical Trials.Gov: NCT03383432) included multiparous women requesting Copper IUD insertion for birth control were invited to participate. The eligible women were randomised into two groups (44 women in each group); group I (TAS-guided IUD insertion) and group II: USSA. The primary outcome was to measure the satisfaction score of IUD insertion in both methods. Secondary outcomes included the easiness score (ES), the difference in pain scores during IUD insertion, the duration of insertion, and the successful device placement after one week and one month evaluated by transvaginal ultrasound (TVS).

RESULTS

Eighty-eight women were analysed in both groups. The VAS for satisfaction was significantly higher in the USSA group than the TAS-guided group (7.80 ± 1.27 vs. 5.45 ± 1.42, p = .0001). There was significantly lower VAS of pain scores during IUD insertion in the USSA group as compared with the TAS-guided IUD (p = .001). A lower ES and a significantly shorter duration of IUD insertion were also determined among the USSA group (p = .0001).

CONCLUSIONS

USSA is associated with higher satisfaction and less pain during insertion than the TAS-guided IUD insertion approach. However, both techniques have optimal intra-uterine device positioning.

Vaginal dinoprostone versus placebo for pain relief during intrauterine device insertion: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To systematically and meta-analytically investigate the efficacy and safety of vaginal dinoprostone versus placebo in pain relief during intrauterine device (IUD) insertion.

METHODS

PubMed, Scopus, Web of Science, and Cochrane Library were screened till 1 October 2020. Only randomised placebo-controlled studies were included and assessed for risk of bias. Main outcomes included IUD insertion related pain, patient satisfaction, provider ease of IUD insertion, and side effects. Pooled outcomes were summarised as standardised mean difference (SMD), weighted mean difference (WMD), or risk ratio (RR) with 95% confidence interval (95% CI).

RESULTS

Five studies were included, comprising 862 patients; equally 431 patients received vaginal dinoprostone and placebo. All studies showed an overall low risk of bias. When compared to placebo, dinoprostone significantly correlated with decreased pain at tenaculum placement (SMD = -0.79, 95% CI [-1.43, -0.16], p = 0.01), decreased pain at uterine sounding (SMD = -0.88, 95% CI [-1.54, -0.22], p = 0.009), decreased pain at IUD insertion (SMD = -1.18, 95% CI [-1.74, -0.61], p < 0.001), decreased need for additional analgesia (RR = 0.34, 95% CI [0.22, 0.53], p < 0.001), increased patient satisfaction (SMD = 1.41, 95% CI [0.62, 2.20], p < 0.001), and increased provider ease of IUD insertion (SMD = -1.17, 95% CI [-1.62, -0.73], p < 0.001). Fever was statistically significantly higher in dinoprostone versus placebo group (RR = 3.73, 95% CI [1.47, 9.44], p = 0.006). All other side effects-including nausea, vomiting, shivering, diarrhoea, abdominal cramps, vasovagal attack, uterine perforation, and postprocedural bleeding-did not substantially differ between both groups.

CONCLUSIONS

This first ever meta-analysis advocates that dinoprostone compared with placebo is safe, effective, and yields favourable analgesic outcomes during IUD insertion.