Residency · Residency · Family Medicine
IUD and Implant Insertion and Removal
Introduction
Long-acting reversible contraceptives (LARCs), including intrauterine devices (IUDs) and subdermal implants, are the most effective reversible contraception methods available, with failure rates under 1%. Family physicians trained in LARC insertion and removal can significantly expand access to these highly effective methods, particularly in underserved communities.
Types of LARCs
Intrauterine Devices
| Device | Type | Duration | Mechanism | Key Features |
|---|---|---|---|---|
| Paragard | Copper IUD | 10 years | Spermicidal copper ions + inflammatory response | Non-hormonal; EC within 5 days |
| Mirena | LNG-IUD (52 mg) | 8 years | Local progestin | Reduces HMB; therapeutic use |
| Liletta | LNG-IUD (52 mg) | 8 years | Local progestin | Similar to Mirena |
| Kyleena | LNG-IUD (19.5 mg) | 5 years | Local progestin | Smaller frame; less hormonal effect |
| Skyla | LNG-IUD (13.5 mg) | 3 years | Local progestin | Smallest frame |
| Nexplanon | Etonogestrel implant | 3-5 years | Ovulation suppression | Subdermal arm; radiopaque |
The copper IUD (Paragard) is non-hormonal, effective for up to 10 years, and works via spermicidal copper ions and a local inflammatory response. Levonorgestrel IUDs release progestin locally, with several options varying in duration: Mirena (8 years), Kyleena (5 years), Liletta (8 years), and Skyla (3 years). Hormonal IUDs reduce menstrual bleeding and can be used therapeutically for heavy menstrual bleeding and dysmenorrhea. The copper IUD also serves as emergency contraception when inserted within 5 days of unprotected intercourse.
Subdermal Implant
Nexplanon is a single-rod etonogestrel implant effective for up to 3 years (with some guidelines extending to 5 years). It is inserted subdermally in the medial aspect of the non-dominant upper arm and is radiopaque for localization if it becomes non-palpable. The most common side effect is irregular bleeding, particularly in the first 6 to 12 months.
Patient Selection and Counseling
Eligibility
The CDC Medical Eligibility Criteria (MEC) should be used to determine appropriateness. IUDs are classified as Category 4 (contraindicated) in cases of current pelvic inflammatory disease, puerperal sepsis, unexplained vaginal bleeding, and cervical or endometrial cancer. The copper IUD is additionally contraindicated in Wilson disease and copper allergy. The implant has very few contraindications, with Category 4 applying only to current breast cancer. IUDs can safely be inserted in nulliparous women, as nulliparity is not a contraindication.
Pre-Insertion Counseling
Counseling should cover expected bleeding pattern changes, efficacy, duration, and side effects. Common misconceptions should be addressed, including the facts that IUDs do not cause infertility and ectopic pregnancy risk is not increased. Informed consent should include the risks of perforation, expulsion, infection, and failure. Routine STI testing is not required prior to insertion; screening should follow usual guidelines, and positive results should be treated.
IUD Insertion Procedure
Timing
An IUD can be inserted at any time during the menstrual cycle as long as pregnancy is reasonably excluded. Immediate post-placental insertion, within 10 minutes of placental delivery, is safe and effective. Post-abortion insertion is also safe and reduces subsequent unintended pregnancy rates.
Technique
A bimanual exam is performed first to assess uterine size and position. A speculum is inserted to visualize the cervix, which is cleansed with antiseptic. The uterus is sounded to determine depth, typically 6 to 9 cm; a depth less than 6 cm or greater than 10 cm may increase complication risk. The IUD is loaded into the insertion device per manufacturer instructions, inserted through the cervical os, and deployed at the fundus. Strings are trimmed to 3 to 4 cm from the external os. Pain management options include pre-procedure NSAIDs, paracervical block for patients who request it, and topical lidocaine.
Post-Insertion
Proper placement is confirmed by visualizing strings at the cervical os. Ultrasound confirmation is not routinely required but can be performed if placement is uncertain. A string check at 4 to 6 weeks is standard, and the patient should be taught to perform self-checks. No routine follow-up imaging is needed if the patient is asymptomatic.
Implant Insertion Procedure
The insertion site is marked 8 to 10 cm above the medial epicondyle of the non-dominant arm, in the sulcus between the biceps and triceps. The area is cleaned and draped, and local anesthesia is applied with 1% lidocaine. The applicator is inserted at a 30-degree angle, then reduced to horizontal, and advanced subdermally. Palpability should be confirmed immediately after insertion. A pressure dressing is applied, with the adhesive bandage removed after 24 hours and Steri-Strips after 3 to 5 days.
IUD Removal
The strings are grasped with ring forceps, and steady, gentle traction is applied. If strings are not visible, retrieval should be attempted with an IUD hook or alligator forceps through the cervical os. If the IUD cannot be retrieved in the office, ultrasound is used to confirm its location, and hysteroscopy may be considered. When strings are missing and no IUD is seen on ultrasound, an abdominal X-ray should be obtained to evaluate for perforation and intraperitoneal migration. Fertility returns immediately after removal.
Implant Removal
The implant is palpated and both ends are marked. Local anesthesia is injected beneath the implant, and a 2 to 3 mm incision is made near the distal tip. The implant is pushed toward the incision and grasped with mosquito forceps. If the implant is non-palpable, imaging (ultrasound or X-ray) should be obtained for localization before attempting removal, and referral may be necessary.
Complications
IUD perforation occurs in approximately 1 per 1,000 insertions, with higher risk in postpartum insertion and breastfeeding. IUD expulsion occurs in 2 to 10% of insertions, with higher risk in patients with heavy menses, immediate postpartum insertion, and nulliparity. The risk of pelvic inflammatory disease increases slightly in the first 20 days after insertion but does not increase long-term. Implant migration is rare but may require surgical removal when it occurs. Regarding ectopic pregnancy, LARCs reduce overall pregnancy risk and therefore reduce the absolute risk of ectopic pregnancy; however, if pregnancy does occur with an IUD in situ, ectopic pregnancy must be excluded.
Key Clinical Pearls
LARCs are first-line contraception for most patients due to superior efficacy and user-independent action. Same-day insertion using the "quick start" method improves LARC uptake, and patients should not be required to return during menses. IUD insertion in nulliparous women is safe and should not be discouraged; smaller-frame devices such as Kyleena and Skyla are available. Implant palpability should always be confirmed immediately after insertion, as a non-palpable implant requires imaging before successful placement can be assumed.
References
- Curtis KM, et al. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep. 2016;65(3):1-103.
- ACOG Practice Bulletin No. 186: Long-Acting Reversible Contraception. Obstet Gynecol. 2017;130(5):e251-e269.
- Diedrich JT, et al. Association of short-term bleeding and cramping patterns with LARC continuation. Am J Obstet Gynecol. 2015;212(2):187.e1-8.
- Winner B, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998-2007.