A randomised trial comparing pain and ease of use of two different stabilising forceps for insertion of intrauterine contraception

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.

Safety and Efficacy of an Atraumatic Uterine Cervical Traction Device: A Pilot Study

Introduction: Alignment of the uterine cervix with the vaginal canal is often required during insertion of an intrauterine contraceptive device (IUD). Currently available instruments are traumatic tenacula, which can cause pain and bleeding and represent an obstacle for certain patients to pursue their medical follow-up. A novel investigational cervical vacuum tenaculum, enables atraumatic traction of the cervix using a semi-circular suction pad, designed to conform to the anatomical shape of the external cervical os. Suction is generated by manually pulling out a sliding tube in a vacuum chamber.

Methods: We performed a single arm non-comparative pilot study to assess the safety and efficacy of the cervical vacuum tenaculum in 13 women receiving an IUD. Data on procedural efficacy, safety, patient-reported pain scores at specific time points during IUD insertion procedure and patient satisfaction were collected prospectively.

Results: Insertion of IUD was successful with use of the study device in 7 of the 13 enrolled patients (54%). No bleeding or only limited ecchymosis were caused by the device. No adverse events were reported. Participants reported very little pain (mean Visual Analog Scale <10) when applying the device. Participants who achieved IUD insertion with the device reported strong overall satisfaction with the procedure.

Conclusions: The suction-based atraumatic tenaculum can be used to manipulate the cervix during IUD insertion with satisfactory efficacy and safety. The results of this pilot study support further studies of this device in larger populations comparing with standard single-tooth tenaculum.

Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT 04441333.

Pain perception with cervical tenaculum placement during intrauterine device insertion: a randomised controlled trial

INTRODUCTION

'Slow' and 'cough' techniques for tenaculum placement are commonly used. This trial sought to determine if one method of placement resulted in less pain for patients.

METHODS

This study was a randomised controlled trial of patients presenting for intrauterine device placement. Sixty-six participants were randomised to tenaculum placement via the 'slow' method (closure of tenaculum over a 5-s period) versus the 'cough' method (closure of tenaculum at the time of patient's cough). The primary outcome was pain at time of tenaculum placement measured on a 100 mm visual analogue scale. The study was powered to detect a 16 mm difference in pain. Secondary outcomes included pain with insertion and provider satisfaction with tenaculum grasp. Pain scores were analysed with Wilcoxon rank-sum test.

RESULTS

Sixty-six women were enrolled, 33 randomised to each group. Demographics were similar in each group. The primary outcome of pain with tenaculum placement showed a median pain score of 44 (IQR=21, 63) with slow placement and 32 (IQR=19, 54) with cough placement. There was no significant difference in pain scores between methods of tenaculum placement (p=0.16). There was no significant difference in overall pain scores (p=0.12). Provider satisfaction was not associated with one method of placement (p=1). Pre-procedure anxiety was significantly associated with pain at the time of tenaculum placement (p=0.01).

CONCLUSIONS

Neither the slow method nor cough method is superior for pain reduction or provider satisfaction. Pain with tenaculum use is significantly associated with anxiety.

CLINICAL TRIAL REGISTRATION

NCT02969421.

Interventions for the prevention of pain associated with the placement of intrauterine contraceptives: An updated review

A 2013 review found no evidence to support the routine use of pain relief for intrauterine contraceptive (IUC) placement; however, fear of pain with placement continues to be a barrier to use for some women. This narrative review set out to identify (1) new evidence that may support routine use of pain management strategies for IUC placement; (2) procedure‐related approaches that may have a positive impact on the pain experience; and (3) factors that may help healthcare professionals identify women at increased risk of pain with IUC placement. A literature search of the PubMed and Cochrane library databases revealed 550 citations, from which we identified 43 new and pertinent studies for review. Thirteen randomized clinical trials, published since 2012, described reductions in placement‐related pain with administration of oral and local analgesia (oral ketorolac, local analgesia with different lidocaine formulations) and cervical priming when compared with placebo or controls. Four studies suggested that ultrasound guidance, balloon dilation, and a modified placement device may help to minimize the pain experienced with IUC placement. Eight publications suggested that previous cesarean delivery, timing of insertion relative to menstruation, dysmenorrhea, expected pain, baseline anxiety, and size of insertion tube may affect the pain experienced with IUC placement. Oral and local analgesia and cervical priming can be effective in minimizing IUC placement‐related pain when compared with placebo, but routine use remains subject for debate. Predictive factors may help healthcare professionals to identify women at risk of experiencing pain. Targeted use of effective strategies in these women may be a useful approach while research continues in this area.

[Intrauterine contraception: CNGOF Contraception Guidelines]

OBJECTIVE

To provide national clinical guidelines focusing on intrauterine contraception.

METHODS

A systematic review of available literature was performed using Pubmed and Cochrane libraries. American, British and Canadian guidelines were considered as well.

RESULTS

Intrauterine contraception (IUC) displays a wide panel of indications, including adolescents, nulliparous, patients living with HIV before AIDS (Grade B) and women with history of ectopic pregnancy (Grade C). Cervical cancer screening should not be modified in women with IUC (Grade B). Bimanual examination and cervix inspection are mandatory before device insertion (Grade B). Patients should not systematically undergo screening for sexually transmitted infections (STI) before device insertion (Grade B). Screening for STI should be preferably done before insertion but it can be performed at the time of device insertion in asymptomatic women (Grade B). Routine antibiotic prophylaxis and premedication are not recommended before insertion (Grade A). A follow-up visit may be offered several weeks after insertion (Professional consensus). Routine pelvic ultrasound examination in not recommended after device insertion (Grade B). In patients with IUC, unscheduled bleeding, when persistent or associated with pelvic pain, requires further investigation to rule out complication (Professional agreement). Suspected uterine perforation warrants radiological workup to locate the device (Professional consensus). Laparoscopic approach should be preferred for elective removal of intrauterine device from abdominal cavity (Professional consensus). In case of accidental pregnancy with intrauterine device in situ, ectopic pregnancy should be excluded (Grade B). In case of viable and desired intrauterine pregnancy, intrauterine device removal is recommended if the strings are reachable (Grade C). Detection of Actinomyces-like organisms on pap smear in asymptomatic patients with intrauterine contraception does not require further intervention (Grade B). Immediate removal of intrauterine device is not recommended in case of STI or pelvic inflammatory disease (Grade B). Device removal should be considered in the absence of clinical improvement after 48 to 72 hours of appropriate treatment (Grade B).

CONCLUSION

Intrauterine contraception is a long-acting and reversible contraception method displaying great efficacy and high continuation rate. In contrast, complication rate is low. It should thus be offered to both nulliparous and multiparous women.

Use of a novel suction cervical retractor for intrauterine device insertion: a pilot feasibility trial

INTRODUCTION

The Bioceptive suction cervical retractor (SCR) is a novel device that can replace the standard single-tooth tenaculum to place traction on the cervix. A feasibility trial was conducted on the device for intrauterine device (IUD) placement.

METHODS

Our three-stage feasibility process began with Stage 1, where the device was tested on in-vitro and ex-vivo samples. In Stage 2, 10 women received their IUD using the device. In Stage 3, a feasibility trial, we randomly assigned 25 consenting women to receive their IUD using either the Bioceptive SCR or the standard single-tooth tenaculum. In Stages 2 and 3, we collected pain scores using an electronically adapted 100-point visual analogue scale (VAS) at eight timepoints during and after the insertion procedure, as well as satisfaction and acceptability measures. The primary outcome was the pain score after attaching the SCR or tenaculum (VAS 3). Wilcoxon rank sum tests compared pain scores between devices.

RESULTS

In Stage 2, pain scores with the SCR were lower than historical controls with the single-tooth tenaculum. In Stage 3, the median VAS 3 pain scores were 31 and 57 for the intervention and control groups, respectively. The differences in pain scores were not statistically significant but the trend was to lower pain scores with the intervention. Reported patient satisfaction with the SCR device was 80% in Stage 2% and 90% in Stage 3.

CONCLUSIONS

The Bioceptive SCR has potential as an atraumatic alternative to standard cervical retractor devices for gynaecological procedures. These findings can guide point estimates for future clinical studies.

TRIAL REGISTRATION

NCT02283463.