Simplifying insertion of intrauterine devices
Awarded 2013
Complex Family Planning Fellowship Research
Kamilee Christenson, MD
Stanford University School of Medicine

Unintended pregnancy remains a huge problem for the United States where ~50% of pregnancies are unplanned.  The best ways to decrease the rate of unplanned pregnancy are to educate women on the most effective methods of contraception while also facilitating the use of the most effective methods.  Intrauterine contraceptive devices (IUDs) include the Mirena IUD and Paragard IUD. IUDs are highly effective methods of contraception and have been shown to decrease the rates of unintended pregnancies in many populations.  Unfortunately, IUDs account for less than 10% of contraceptive use in the US. While many factors contribute to the low rate of IUDs fear of pain particularly at the time of insertion are likely limiting factors.  Current insertion techniques require pre-placement bimanual examination and uterine sounding, both of which are known to be painful.  A simplified insertion technique, which eliminates both of these steps, may decrease pain and ultimately help to encourage uptake of these effective contraceptive methods.  Furthermore, in developing countries the more we are able to simplify the procedure we are able to decrease cost of IUD placement and train more people to insert IUDs and improve access for these women as well.
The purpose of the study was to investigate an alternate method of IUD placement in an effort to simplify the procedure.  We successfully completed a pilot study. 50 patients who presented requesting IUD placement were enrolled in our study.  The study protocol involved directly placing the patient’s chosen IUD in our simplified insertion technique (speculum placed, cervix grasped with a tenaculum and IUD placed directly to the fundus. An os finder, or small dilator was allowed if necessary.)  Immediately after the procedure a transvaginal ultrasound was performed to ensure proper placement.  All patients were followed up ~8 weeks after placement and assessed for any complications and another ultrasound was performed.  
The study was completed in just under a year and in all 50 patients we were able to place the IUD without the use of bimanual examination or sounding.  Meaning the simplified insertion technique was successful in 100% of patients.  We had no serious complications with placement – meaning we had no perforations (placing an IUD outside of the uterus in the abdominal cavity), malpositioned IUDs, or infections.  We did have three patients who experienced complete or partial expulsion (where the IUD falls out) all of the patients reported being happy with the insertion technique and two of the three requested that another IUD be placed in the same simplified method. 
These results were very exciting. This pilot study served as an introductory study to prove that this simplified method is in fact feasible. Now that we have shown that simplified insertion is feasible and successful in 100% of patients we are planning on doing additional studies comparing pain with this insertion technique compared to standard technique.  Ultimately we hope to encourage other institutions within the US and abroad to use these simplified technique and increase uptake of these highly effective methods for women around the world. 

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