– [Renyea] Now I'd like to
introduce our presenter,
Dr. Michael Policar.
Dr. Policar served as the
clinical professor of obstetrics,
gynecology and reproductive sciences
at the University of
California San Francisco
school of medicine.
From 2005 to 2014 he was medical director
of support and evaluation
for the Family PACT program,
the family planning access,
care and treatment program
operated by the California
Department of Healthcare
Services' office of family planning.
He currently serves as professor
emeritus of obstetrics,
gynecology and reproductive
sciences at UCSF.
Thank you for joining us, Dr. Policar,
and the floor is yours.
– [Dr. Policar] Okay,
great, thank you Renyea
and thank you all for joining us today.
Let me give you a little background
about what we're gonna talk about
and then we'll jump in and get started,
and as you heard earlier there will be
plenty of time for questions at the end.
So as you know, Family
PACT has made a real effort
over the last few years to try to prepare
as many clinic sites as
possible, ideally all of them,
to be able to provide both
IUD and implant services.
So I assume that those
of you who have logged in
have gone through a training,
either one that the office
of family planning sponsored
or possibly another through
where you initially did
your training or through a contemporary
forums meeting, something like that.
So, today we're not
gonna cover the basics,
we are going to go into
somewhat greater detail
about managing the rare complications
that occur in relation to IUDs,
and more importantly how to prevent them.
I also wanna mention that this is
actually part of a series of webinars.
In that you'll notice today that
I'm not covering pain management at all.
We're actually planning on
having a separate webinar
on that topic some time in
January or February of 2019.
Where we will go into
much more detail about
pain management for various
types of office procedures.
So with that, let's go
ahead and get started.
I have two disclosures, one
is that in the last month
I have been a litigation consulting,
litigation consultant, excuse me,
for Bayer Healthcare
for a class action suit
that has to do with the Mirena IUD.
And then more recently I've trained with
Cebela Pharmaceuticals to become a proctor
for Phase III trials of a
copper IUD called VeraCept,
wherein the clinical trials
have just been getting started.
So, as you know as experienced
IUD placement clinicians,
most IUD insertions and
virtually all removals are easy.
However, the tough ones
can be really tough.
And one of the areas where I
have some experience with this,
and you'll hear me referring
to it in the talk is that
at the San Francisco General Hospital
in our women's health clinic,
we actually have a periodic clinic session
which is called our complex
contraception clinic.
A majority of those women who are seen
in complex contraception are there
because of difficult IUD removals,
IUDs with missing strings, and so on.
So we've come to develop an appreciation
that while the vast
majority of circumstances
where women are using IUDs
are completely uncomplicated
and satisfactory, that when
the more difficult ones happen
they are important to focus on
in getting the management correct.
So what we'll do is start
with a couple of scenarios
that have to do with
difficult IUD placements,
and then in part two we'll go to
complications right after that.
So let's start with Kristin
who is a 29 year old,
non gravid woman who's seen for
a levonorgestrel IUD placement.
She's been on Depo-Provera
for the last three years,
she had a LEEP for a
CIN 3 lesion at age 25,
but has had negative cytology since.
A tenaculum was applied to her cervix
but the clinician was unable
to pass a metal sound.
So in the circumstance where you run into
a patient who has cervical stenosis,
especially in a circumstance like Kristin
where she has a good reason
for that, given her prior LEEP.
What are the things
that you can do to help
deal with that cervical stenosis,
and successfully achieve
the IUD placement?
Well, what we'll go through
is a 10 or 11 step process
in terms of things that you can do
to make tenaculum use, as
well as sounding the uterus,
easier to do in the context of
women who have cervical stenosis.
The first thing relates to the tenaculum,
and that is changing
the amount of traction.
Remember the reason for
the tenaculum is to help
straighten out the angulation,
particularly of the endometrial cavity
relative to the endocervical os.
And possibly by using less
traction or more traction
in your direction, pulling toward you,
you'll be able to get
through the os that way.
Second is that you can apply traction
in a different direction.
In other words as you
pull towards yourself
with the tenaculum, instead
of straight at your chest
or your eye level, you
can lift the tenaculum
a little cephalad or directed a little bit
more posteriorly as a
way of finding the canal
and the internal os in that way.
Third is to gently hold the sound
at the internal os and then wait.
Oftentimes what happens
is that the internal os
will involuntarily contract
during the time that you try
the instrument of the cervix.
And just holding the sound
against the internal os,
sometimes for 30 to 60 or even 90 seconds,
will be enough for that muscle to relax,
and then the sound will be able
to go through the internal os.
Now if those things don't
work, the next thing you can do
is change the curvature of the sound.
The way that most of us use metal sounds
is that they are fairly straight
and have a little upward bend,
or if you flip that 180 degrees
a downward bend at the end.
But some women can be more
anti-flexed or more retroflexed
than the way that you
originally adjust the sound.
So if you are using a
malleable metal sound,
try adjusting the curvature,
either through sterile paper
or with sterile gloves,
and possibly you'll be
successful after that.
Next is to apply light
pressure at various angles
360 degrees around the cervix
as you're looking for an opening.
So remember now what you're doing is
pulling on the tenaculum with
one hand, towards yourself,
and now with the sound,
you're trying various angles
where you sweep the sound out
to the right or to the left,
up or down, to try to
find the more tortuous
endocervical canal that
will lead you to the os.
And particularly approaching
somewhat more anteriorly
or posteriorly by the use of the sound
will be able to get you through.
Now if those things don't work,
step six is to find an os finder device.
And these are really helpful products
to have in your clinic.
You can either buy the disposable type,
or there's also a product
where the set of three
can be sterilized and reused.
And as you can see from the photograph
the os finder devices have either
rather minimal tapers or a
very very long gradual taper.
And having these available
are very very helpful
if you're not able to make adjustments
in the tenaculum or the
sound and be able to get in.
Then fairly early on
you should switch over
to using the os finder in order to be able
to find the direction of the canal,
to dilate the internal os a little bit,
and you'll find that the sound
will go in much more easily.
And I would say that really
for those of you who are doing
almost any kind of endometrial procedure,
whether it's endometrial biopsies or,
certainly with IUD insertions,
that having these os finder devices
is really quite helpful.
Next is that (coughs) excuse me,
you can use a thinner sound.
What many clinicians do
if they can't get through
with a metal sound and they
don't have a plastic sound
available is to use an
endometrial sampler.
What by brand name is
referred to as a Pipelle.
But there are other
brands out there as well,
and oftentimes that will make it through
and allow you to sound in
a way that a metal sound,
because of its greater diameter, will not.
Next thing you can do
as we go down the list
is to reposition the tenaculum.
We've talked about moving the tenaculum
at different angles,
but what this refers to
is that if you put the
tenaculum on the anterior lip,
try to move it to the posterior lip.
Or if you put it on horizontally,
reapply it vertically,
and sometimes just that
changing of the position
of the tenaculum will be enough
to help you get through the internal os.
Now the last couple things that we can do
are to try a shorter, wider speculum
that will help bring
the cervix closer to you
as you pull down with a tenaculum.
That one to use in that case is called
a Moore-Graves speculum, it's a standard,
duckbill gray speculum.
The Moore adaptation is
that the speculum is about
an inch shorter, and given
the fact that the blades
are not as long you can pull
the cervix more towards you
in your direction, and
oftentimes that'll straighten out
the angulation of the canal
in the internal os in the lower segment,
and allow you to get in.
Then sort of the last couple steps
is to actually dilate the internal os
with either a small metal dilator
or a small plastic dilator
if you have experience with that.
Next is that if you've been
completely unsuccessful
but the patient still has some interest
in having an IUD insertion,
then you can try priming with misoprostol.
The one good study on this topic
that was reported from Chile,
the regiment was misoprostol
200 mg per vagina
10 hours before the IUD insertion,
that would be the night before,
and then again four hours
before the placement.
Now I do wanna emphasize the
fact that this does not mean
routinely using misoprostol,
there are at least six studies that show
that that does not help to reduce pain
or to increase the success rate.
But in the case of a failed dilation,
a failed insertion of an IUD,
the study that I mentioned
to you from Chile
actually shows that with
the use of misoprostol
for the second try, that
it actually increases
the likelihood of the second try.
Then the last thing to
mention on this topic is that
at any point, it would be helpful
to place a cervical block,
either in the form of a paracervical block
or an intracervical block,
for a couple reasons.
Obviously number one to make
this much more comfortable
for the patient as you're
trying to dilate her cervix,
and then number two,
just to help with the relaxation
of the smooth muscle of the internal os.
Now what if you are
able to pass the sound,
but not able to put the
inserter in for the IUD?
Almost always that's because of the fact
that the plastic inserter
has a tendency to bow.
So you've opened up the internal os
enough to be able to get in the sound,
but when you try to put the
inserter through the os,
it bends.
So a way of making the inserter stiffer
is to choke up on the inserter handle.
That will make the tip of it more rigid.
Second is to place some sterile lubricant
on the tip of the inserter which,
perfectly reasonable to do
that as long as it's sterile,
it will help it sort of slip through that
now preliminarily dilated internal os.
Then another trick which
seems to help is to leave
a small plastic sound in the canal
and then come alongside
it with the inserter.
Because by leaving that
small sound in the canal,
basically you've now charted a pathway
through the canal,
through the internal os,
and you can just pass the
inserter right past it.
And of course the next step
is to take the sound out,
leave the inserter in,
and then proceed with
doing the IUD insertion.
All right, let's go on to our
next topic which is Betsy.
She's a 19 year old non gravid woman
who tells you that she faints easily.
Betsy has a history of feeling
light-headed at the sight of blood,
and in fact she recently
had a fainting spell
after having a HPV,
Gardasil, immunization.
As you know that agitant
that's in Gardasil
can be quite painful for some people
and there are reported
cases of women having
vasovagal fainting, or
for that matter men,
after having a HPV immunization injection.
She told her primary care
provider about this problem,
she listened to Betsy's heart,
ordered an electrocardiogram,
they were all normal.
Now while Betsy is having her
levonorgestrel IUD placed,
she says, is this gonna take much longer?
I really need to go to the bathroom.
And when you hear that,
you know that that's always a tip-off,
whether you're doing an IUD placement,
an implant placement in the arm,
even a colposcopy or
an endometrial biopsy,
that when patients all of a sudden
really have to go to the bathroom,
that is particularly characteristic
of an impending vasovagal episode.
So, what happens with vasovagal episodes
is that by the stretching of the cervix,
although it could be any
other type of procedure,
sometimes it's just the sight of blood.
What it does is to trigger a reflex
where a person has extreme
peripheral vasodilation,
that is to say the blood pools
in the veins of their arms and legs.
Another part of that reflex
is the heart rate will drop
quite low, usually in the
ballpark of around 30 or 35,
and of course there's a drop
in blood pressure that happens
both because the heart rate is less
as well as the peripheral vasodilation.
In my experience,
where I've diagnosed lots
of vasovagal episodes,
I do that primarily
based on the bradycardia.
So if the patient says she
feels like she's gonna faint,
I grab her wrist, I feel her radial pulse.
And if it's less than 40,
I know she's undergoing
an impending vasovagal.
Now these episodes are more likely
with the pain of cervical
manipulation, irrespective of why.
Cervical biopsies, endometrial
biopsies, putting in an IUD.
It's also more likely in
women with previous episodes
of vasovagal fainting,
and more likely to happen
in women who are dehydrated
or who have been NDO
before their procedure.
The full spectrum of
symptoms includes weakness,
light-headedness, visual blurring
or the complaint of tunnel vision,
a complaint of nausea, vomiting,
feeling like she's gonna throw up,
feeling excessively warm or cold,
tinnitus which means
a ringing in the ears,
and we've already talked about this
sudden need to either urinate or defecate.
Now the signs of an impending
vasovagal are a facial pallor,
in other words the blood sort
of drains out of the face.
And a woman who's about
to have a fainting episode
will oftentimes have this
distinct sort of green hue
to her face before she actually faints.
Other things which happen
before the sinkable
fainting episode is
yawning, pupillary dilation,
a sense of nervousness,
diaphoresis means that
you're having a hard time
catching your breath,
and sometimes even slurred
or confused speech.
So the ways you prevent a vasovagal,
which by the way are unavoidable
in women who are having IUD insertions.
They don't happen often,
but sooner or later
you will run into a
patient with a vasovagal,
is that people should be well-hydrated
before they have their procedure,
in fact it's a good idea in your clinic
to have a supply of a sports drink around
so that people can hydrate beforehand
if they haven't actually done that.
Eat something before placement,
so women should never be NPO
before they have an IUD placed.
And then prophylactically have
the woman control her muscles
if she has a known history
of a vasovagal episode.
This by the way is exactly what
should have been done for Betsy.
Is to explain to her that
she's at risk of this
happening again with her IUD insertion
and that she really needs to
squeeze down on her muscles
given her past history
of vasovagal episodes,
particularly with her Gardasil injection.
Now how do you explain that?
So it is isometric,
meaning equally bilateral
contractions of the arms and the legs.
So you can actually model for her
just intense squeezing down of her hands,
her arms, her feet, and her leg muscles.
It doesn't help to squeeze
your abdominal muscles
or to squeeze down at all in your trunk.
But you do try to squeeze
down as hard as you can,
as much as you can in your
hands and arms, feet, and legs.
What that does is it brings
the blood back to the core
and will often abort the response.
There's no need to take the
speculum out immediately,
have her change position,
just instruct her how to
tense her arms and her legs.
And as I said, these contractions
will then push the blood
back to the center of the
body and abort the reflex.
Now most of the time
that's all she needs to do
is to squeeze down for
maybe 30 to 60 seconds
and her heart rate will
come up, she'll feel better.
If that doesn't help,
then it's usually better
to desist, to stop doing the procedure.
Possibly have her lie on her side,
and then with the help of assistants,
do something to lift her legs up
as a way of draining that blood
from her legs into her trunk.
And if it still doesn't
work, then what's recommended
is to actually use an
injection of atropine IV,
one ampule, which is
.4 milligrams or one CC
of atropine given IV,
which is kind of the,
sort of the last resort
we do for vasovagals.
But in the vast majority of circumstances,
simply contracting down
your arms and your legs
is enough to abort the vasovagal.
And in a woman who's had that before,
who's had that problem before,
anticipating it, teaching
her how to squeeze down
her arms and her legs even
before you start the procedure
can be very helpful.
All right, let's go on, and
now begin our discussion
about complications themselves.
Now, specifically what complications
are we talking about with IUDs?
Well, they're things that
should be familiar to you
that I'm sure that you tell people about
as you do their informed consent.
But let's talk about how
common they are first
and then we'll talk specifically
about IUD complications
and how to prevent them and manage them.
So one is a perforation, meaning
that either with the sound
or the inserter, a hole is made
in the muscle of the uterus.
The risk of that is
about one in a thousand,
they are mostly benign.
Second is an expulsion of the IUD.
And half the time a woman realizes
that she's expelled her IUD,
the other half of the
time they are expulsions
which are asymptomatic and the patient
didn't even know she's lost her IUD.
The likelihood that that will
happen is somewhere between
one and 6% of all IUD insertions.
Now, they are relatively less likely
in a woman who has what's
an interval IUD insertion,
she hasn't been pregnant recently.
Then the likelihood of expelling an IUD
is somewhere around 3%.
But on the other hand
if she has a postpartum
or a post-abortal insertion of an IUD,
then the risk of an
expulsion is somewhat higher.
Next is the risk of an
unsuccessful placement.
Sometimes we feel kinda
bad about what happened
if we try to do an IUD
placement and it doesn't work.
Well in a big study done in the UK,
somewhere around 9% of
attempts at putting in an IUD
are unsuccessful, although
when you try again
that number drops down to about 6%
are unsuccessful after the second attempt.
Next is that the IUD fails
and the woman actually becomes pregnant.
That is less than one per
hundred women per year.
And the rate of PID, pelvic
inflammatory disease,
while it is slightly
increased in the first 20 days
after an IUD insertion,
then goes to a rate of about
one to two cases of PID per
thousand women per year,
which is the same as
the general population.
Now some of the tip-offs
of these complications
are the fact that if a
woman calls or comes in
with severe bleeding or abdominal cramping
three to five days
after her IUD insertion,
we think about the possibility
that she may have an embedded IUD,
or that potentially it's in
the process of expelling,
a partial expulsion, or she could have
one of those infections which happen
in the first three weeks
after the IUD insertion.
Second is that for women
who have irregular bleeding
or pain every single cycle,
especially beyond three months
when you would expect that to go away.
We should think that the
IUD may be dislocated,
which means that it's embedded
or that it's partially expelled,
or again the possibility
that there's a perforation,
which is the problem.
Next is if she has fever, sweats, chills,
unusual vaginal discharge, of
course, we would think about
either a vaginal infection or a PID.
Other things to watch for
are pain during intercourse,
which can either be due to
PID or a partial expulsion,
missed menstrual period or
other signs of pregnancy
of course we think about
being pregnant in that circumstance.
And we'll talk in a few
minutes about the threads
being shorter, longer,
or missing entirely.
So let's go back to our cases,
and our next patient is Jennifer
who's a 39 year old gravida two para two
whose question is, what was that pain?
So Jennifer came in for a
six week postpartum visit
after a spontaneous vaginal delivery,
and disclosed that she
wanted a copper IUD.
She is breastfeeding, and she
has no postpartum bleeding.
By manual exam her uterus
was eight to nine weeks size,
but it was quite firm and non-tender,
what one would expect at a
six week postpartum visit.
However, during sounding
to put in her copper IUD,
moderate resistance was
met at the internal os,
and then the sound just continued to go
all the way up to 14 centimeters,
which is quite a bit more
than what you would expect.
She complained of pain only during
the initial part of
the sounding procedure.
So, what's happening with
Jennifer almost certainly
is the fact that she's had
perforation with the sound.
There was a moderate amount of resistance
at the internal os, then once
that resistance was overcome
the sound just kept going and going.
We would have expected
in her postpartum status
her uterus might have sounded
to nine or 10, maybe even 11.
But if it goes without
any resistance at all
to 14 centimeters,
then you would certainly need
to think about a perforation.
Another less likely possibility is that
she just has a rather large uterus
and it sounded to 14 centimeters
because of her postpartum state.
But with this particular
picture of the resistance
at the internal os followed
by no resistance at all
after 14 plus centimeters,
you almost certainly have a perforation.
What are you gonna do
in that circumstance?
What you would worry
about is this patient,
in her x-ray you may notice
in her right upper quadrant
there's an IUD up there, it
looks like probably a Mirena
that's literally under her
diaphragm up near her gallbladder
which is the result of a translocation,
a perforation where the IUD is actually
left in the abdominal cavity.
So let's talk a little
bit about perforations.
They are more likely to occur
when the uterus is tipped
very backwards, so if you have
a retro-flexed or a posterior uterus,
perforations are quite a bit more likely.
Postpartum placement,
especially in lactating women.
So this is an attitude
which has kinda gone
back and forth over time,
but the most recent article
which was quite a large
series from Scandinavia
showed that while the
overall rate of perforations
is about one in a thousand,
in postpartum women,
especially lactating women,
it's more like about six in a thousand.
And that's definitely not a
reason we should not be putting
IUDs in postpartum women, that's
still a relatively low rate
at six in a thousand, but
it is quite a bit higher
than it is in women
who are not postpartum.
Then the third issue that has
to do with uterine perforation
is the skill and the
experience of the provider.
The more IUDs you've done,
the less likely you are to
encounter a perforation.
The typical location
is right in the midline
at the uterine fundus.
So think about a sound,
or even an inserter,
going through the very top of the uterus.
There are no significant
arteries or veins in that area,
of course there's a blood
supply but no major vessels,
and if a sound or a inserter
goes through the top of the fundus,
it would be extremely uncommon
to cause any kind of damage higher up
in the intestines, or in the mesentery,
or in the retroperitoneal organs.
And for that reason, fundal perforations
are almost always asymptomatic
and they're almost always benign.
Think of what happens when a
woman has an amniocentesis.
A large needle is put through
the muscle of the uterus.
Basically that's what's
happening with a perforation.
You make a tract through
the uterine muscle,
that tract will go down,
will go away, rather,
will close down, very quickly.
The problem is not so much
the hole in the uterus,
the problem is if the IUD
is left in that tract,
that's what's called an embedment,
where if the IUD works
its way through the tract
and ends up in the abdominal cavity,
that's called a translocation.
We'll talk more about
those in just a minute.
So when you would suspect a perforation
is if the sounding is much
deeper than you expected.
Or if you have a lot of resistance,
particularly at the internal os,
followed by absolutely none at the fundus.
And if you have realtime
ultrasound in your office,
it can be used to help confirm
the fact that a perforation
actually has occurred.
It's really quite easy to see,
when you use realtime ultrasound,
either the sound hitting the
top of the endometrial cavity
or literally going through a tract.
But you don't have to
have the IUD available,
I'm sorry, you don't have to
have the ultrasound available,
it's helpful if you do.
Now what about management of our patient?
We suspected that we caused
a uterine perforation with the sound.
So if the perforation happens
before the IUD is deployed,
stop the procedure, certainly
don't make any attempt
to put the IUD in place after
a sound-induced perforation,
just stop.
She may be able to have another attempt
in a few weeks or a month.
Number two, if you detect
the fact that there's been
a perforation during the
placement of the IUD itself,
you should remove it.
So the best example of that
is you've been able to sound
appropriately but when you're
doing the IUD insertion itself
the inserter goes much much
further than you expect it to.
And maybe you deployed the IUD or not.
If you can retrieve it,
then that's the optimal circumstance.
Now if you've detected the fact
that the patient does have
a uterine perforation,
again usually in the case with the sound,
what you do is monitor her for 30 minutes
for excessive pain or bleeding.
Remember that if she does bleed
it won't be coming from her vagina,
it'll be into her abdominal cavity.
But it's usually a very small amount
of bleeding that happens.
Most patients will feel
completely fine and back to normal
within 20 or 30 minutes,
and they can be discharged.
However, she doesn't have an IUD,
so provide her with an alternate
method of contraception.
And what we typically do is wait
until the after the next
menstrual period to try again.
So wait at least two, three, four weeks
for that tract to close down
before another attempt is made
at an IUD insertion, and by
the way when she comes back
for that additional attempt,
it may be more successful
if it's done with ultrasound done
at the same time as the IUD insertion,
just to make sure that there's
not a repeat perforation.
Now what are some of the things you can do
to prevent a perforation from happening?
Always always, with every IUD insertion,
to a bimanual exam beforehand
to detect anti-flection, retro-flection,
and particularly if it's extreme,
taking that into account as
you're doing the insertion.
Second is to always use the
tenaculum to give you traction,
to straighten out the uterine axis.
Careful hand positioning of
the sound and the inserter,
and particularly with the sound
that means holding it like a dart.
You don't wanna hold
the sound in such a way
that you can apply lots of pressure,
push it right through the internal os
and potentially through the fundus.
Instead you protect yourself
by holding the sound like a dart,
and you might even brace your
fingers against the speculum,
and that prevents you from going too deep.
Consider using a plastic sound, routinely.
And the reason for that is that
an OBGYN in Salt Lake
City, Utah, Dave Truck,
did a study of women who
had had a hysterectomy,
the uterus had come out of the body,
and then with that, those
uterine pathology samples,
what he did was to look at how
much pressure was necessary
to cause a perforation
through that excised uterus
with either a metal
sound or a plastic sound.
With a metal sound it took
a fair amount of pressure,
with a plastic sound it
was almost impossible.
So we know that plastic
sounds will usually bend
before they'll actually
cause a perforation.
Next is never use the IUD
inserter to sound the patient.
This one's really important,
a shortcut that many clinicians take.
'Cause they say, I don't
wanna sound the patient,
it hurts her, it takes too much time,
I will just use the Bayer inserter
or the Paragard inserter,
IUD inserter, as the sound,
and that way I can skip the
step of doing the sound.
Not a good idea for two reasons.
Number one is because of
the fact that oftentimes
the inserter is just not rigid enough
to successfully use as a sound.
Number two, what if she sounds
to under five centimeters,
in maybe a nulliparous adolescent.
Or what if she sounds to 16 centimeters
in a grand multipara?
Well, those are women who are not
considered to be candidates for an IUD.
Remember the depth of the uterus has to be
at least five or five
and a half sonometers,
the upper limit is somewhere
around 10 or 12 sonometers,
and let's say for example
you sounded someone
with the IUD inserter,
she sounded to four,
and you couldn't do the insertion,
you now have an $800 sound.
So only open the package
after the patient has been
successfully sounded, and
she knows she fits within
the criteria for doing an IUD insertion.
Next is don't use the
white stabilizing rod
as a plunger with copper IUDs.
The stabilizing rod is intended to hold
the bottom of the IUD in place
while you withdraw the tube,
not to plunge it into
the endometrial cavity.
And if you're finding a lot of resistance
at the internal os as
we talked about earlier,
again a cervical block with
the use of an os finder device
or cervical dilation is really
the best guarantee you have
of trying to avoid causing a perforation.
Other thoughts are to move
slowly and intentionally,
try to avoid a circumstance
where you're pushing
with lots of pressure
through the internal os,
because once you get
through, you'll have momentum
that may keep your instrument going.
And then also once you've
passed through the internal os,
just stop, pause for a
second, the muscle will relax,
and then you can intentionally
proceed to the fundus
in a more controlled fashion,
in such a way that
you'll avoid perforation.
You'll feel resistance when
the sound touches the fundus,
and of course that's always a signal
to stop advancing the sound at that point.
And remember that even
though we sound first
and then we set the flange on either
a levonorgestrel IUD or a copper IUD,
that once you put the inserter in,
ideally if you've done
your measurements correctly
the flange should hit the
cervix at the very same time
that the tip of the
instrument hits the fundus.
But that's not always the case.
So if you feel the fundus and the flange
isn't against the cervix, stop.
Or alternatively, if the
flange hits the cervix
and you don't feel the fundus,
also stop in that circumstance.
Whichever one hits first,
either the flange on the cervix
or the instrument at the
fundus, then go ahead and stop.
All right, let's go to our
next patient who's Rosa.
She's a 50 year old
gravida three para three
and her complaint is, I
can't feel the string.
And I know this is one
that you see fairly often.
So her IUD that was
inserted eight years ago,
she remembers it has a T shape,
but she's not sure whether it
was copper or levonorgestrel.
She hasn't been able to feel the string
for at least two months,
but before that she checked
irregularly and thought
she felt the string.
On your exam the string is not present
at the external cervical os.
So what are the possibilities?
So this is something I had
to deal with very frequently
at the complex contraception clinic,
particularly when I was teaching
our residents and fellows.
The question is, when you cannot see
an IUD string on a patient,
there are five possibilities
for what that could be.
And you really need to
think about each one of them
as you begin the workup.
So possibility one is
that the IUD is in place,
you just can't see the string.
That's because the string
is coiled in the canal
or in the endometrial cavity,
or maybe the string was short or broken
or had been cut at some point.
So the idea is there you
just can't see the string.
Second is that she may have
had an unnoticed expulsion,
the IUD fell out.
Third possibility is that she's pregnant.
Now, if she has an intrauterine pregnancy,
as the uterus gets bigger,
it pulls the IUD upward
toward the fundus, and the
string gets shorter and shorter
and finally you can't
see the strings at all.
Number four and five are due to
mal-positioning of the
IUD after a perforation.
So one is embedment of the IUD
into the muscle of the uterus,
and the IUD is so stuck
in the wall of the uterus
that you can't see the strings.
And then the final one again
following a perforation
is a translocation, where
that IUD was inadvertently
put through the uterine wall
into the abdominal cavity.
Translocations happen
in two circumstances.
One is about half occur right at
the same time that the IUD is inserted.
The other half of
translocations are IUDs that are
initially embedded in
the wall of the uterus,
and then over time they work their way,
the IUD works its way
through the uterine wall
into the abdominal
cavity, just like a sliver
would work its way out of your skin.
So those are the five possibilities.
So think of each of those possibilities
as you're working up a
patient for a missing string.
And again I'm gonna emphasize the fact
that that tractive muscle of
the uterus is not the problem.
Perforation is not the issue.
It's the abnormal position of the IUD,
either in being embedded
in the uterine muscle
or the abdominal cavity,
which is the problem.
All right, so how are we gonna
manage those possibilities?
(coughs) Excuse me.
So, I'm gonna show you the algorithms
for the workups in just a moment,
but let's say for example
that an ultrasound shows
that the IUD is exactly
where it should be,
but the string is coiled up inside.
Well, if the patient wants
to continue with that IUD,
there is absolutely no
reason to remove it.
So let's say for example
she's had a Mirena in for for three years,
it has a five or even
a seven year lifespan.
There's absolutely no
reason to remove the Mirena
and put in a new one just
because she can't see the string.
As long as you've proved that it's
within the endometrial cavity
based on the ultrasound.
Now the patient might
ask, well, how do I know
that it doesn't fall out at
some point in the future?
And the answer is is that,
you don't have to do this,
but the patient can choose to
have a once a year ultrasound
just to show that the Mirena
or her IUD is in the right place
until the lifespan of that IUD is up.
On the other hand, if she
has an IUD in her uterus
and can't see the string
and she says look,
I wanna get pregnant or I was
planning on having my IUD out,
then we can do an office
extraction of the IUD,
I'll also tell you about how to do that
in just a few minutes.
All right, the next
possibility is an expulsion,
and as I had mentioned to
you, the rate of expulsion
is somewhere between two and 10%.
The risk of expulsion is
related to the provider's skill
at getting the IUD up in the
fundus at the time of placement
and not too far down within
the endometrial cavity.
The patient's age,
where younger women are
more likely to expel.
Parity, where multiparous
women are more likely to expel,
and uterine configuration,
so a woman who has a submucous fibroid
is more likely to expel, as well.
And then the time since insertion,
most expulsions happen
within the first six months
after an IUD is placed.
Probably not related so much
to the timing of the insertion
unless it's a postpartum
or post-abortion insertion of an IUD.
Oftentimes the way that
an expulsion is diagnosed
is a woman who comes in and is pregnant.
She's late for her menstrual period,
maybe has pregnancy symptoms.
The string isn't seen,
and then on further workup
she has no IUD in her body,
so she expelled the IUD,
and its presenting complication
was the fact that she was pregnant.
However, partial
expulsion might be present
with pelvic pain, cramps,
intermenstrual bleeding.
Partial expulsion means
that the stem of the IUD
is stuck in the cervical
canal so that it's not
in the endometrium
working the way it should,
it is literally stuck in the canal,
and that causes intense
cramps, pelvic pain,
intermenstrual bleeding,
usually painful intercourse
for the patient, and
definitely painful intercourse
for the partner if his
penis is bumping into
the stem of the IUD, which
is now at the external os.
And then the other thing that may show up,
partial expulsion, is that the IUD string
is much longer than it
had been previously,
sometimes it will literally come
down to the vaginal introitus.
So the next possibility,
we've covered so far the IUD in situ
and the possibility of
asymptomatic expulsion.
The third possibility is
if she's actually pregnant.
And you'll see in a
moment when we talk about
the stepwise workup, that
early on in the patient
with a patient with a missing IUD string,
we have to do a pregnancy test.
If the pregnancy test is positive,
then of course the next step
is to find out where she's pregnant.
Is this an IUP or an ectopic.
The reason for that is that
IUDs don't fail very often.
And, women who use IUDs
have a much lower rate
of ectopic pregnancies than
women in the general population.
Both IUDs prevent ectopic pregnancies.
However, when an IUD fails,
there's a higher likelihood
that that pregnancy
is in the fallopian tube
than it is in the uterus.
And what's typically quoted
is that somewhere around
25 to 50% of IUD failures
with subsequent pregnancies
are in fact tubal pregnancies
or ectopic pregnancies.
So, step one, woman with
a missing IUD string,
positive pregnancy
test, get an ultrasound.
If there's a possibility of ectopic,
then that's managed appropriately.
On the other hand if she does
have an intrauterine pregnancy
then the next question
is, your IUD failed,
you have an intrauterine pregnancy,
do you plan to continue
your pregnancy or not.
If a woman is planning on
having a pregnancy termination,
it's best not to remove the
IUD, and to await her procedure.
Because if you take the IUD out,
that actually could trigger a miscarriage.
So if she's gonna have
a pregnancy termination
a few days later, just wait until
the time of the termination
and the IUD can be
taken out at that point.
If on the other hand the woman says
all right, I understand I'm pregnant,
I want to continue with my pregnancy.
If you can see the strings,
then it's better to try to remove the IUD
just by gently pulling on the strings.
On the other hand, if the
strings are not visible,
do not attempt any type of removal.
Just because of the fact that there's
almost no way to avoid
interrupting the pregnancy
by instrumenting the uterus
when the IUD is in place.
However, if she continues the
pregnancy with an IUD in place
she is at increased
risk for a miscarriage,
in both first and second trimester,
as well as preterm birth.
On the other hand there is no
greater risk of birth defects.
So remember that that IUD which
is in the uterus as it grows
is outside of the amniotic
sac, it's kind of pinned,
between the amniotic sac
and the uterine wall.
So it's not as if the
baby is going to be born
with an IUD in its hand,
because the IUD is
outside of the yolk sac.
All right, so, next
possibility is a translocation.
As I mentioned, a translocation is when
the IUD is in the abdominal cavity.
Do they always have to come out?
And the answer is that
copper IUDs have caused
a lot of scarring and
reactivity within the cavity.
More adhesions or scar tissue,
and therefore whenever
we make that diagnosis
they should be extracted by laparoscopy.
The levonorgestrel IUDs are less reactive,
they're less likely to cause scarring
or mal-obstruction or a
problem with the bladder,
but most experts still
recommend laparoscopic removal,
or retrieval of a levonorgestrel
IUD once it's diagnosed.
Now this final thing to
mention is embedment.
So that's when an IUD is stuck
in the muscle of the uterus.
The way we make that diagnosis
is that the string is
usually missing at the os,
we try to remove the
IUD, we try to extract it
with the forceps I'll
show you in just a minute.
We tug and tug and tug on the IUD
and it just won't come out.
That's because of the fact that
it's buried in the uterine wall.
Or we may do special imaging and realize
that the IUD is buried
in the uterine wall.
Now whenever we diagnose
an embedment by either way,
a failed office extraction
or through imaging,
we do wanna remove it,
because that embedment can
progress to a translocation.
Again, with uterine contractions the IUD
will naturally work its way
into the abdominal cavity
rather than back to the right place,
and therefore we wanna remove
it before it actually converts
from an embedment into a translocation.
One of the things that'll really help
to find out where the IUD is embedded
is what's referred to as advanced imaging,
either a 3D ultrasound
or a pelvic CT scan.
Because it's gonna help direct us to
what her correct treatment is
to remove the embedded IUD.
Might be through a hysteroscope.
It might be through a laparoscope,
or, rarely, it's actually a laparotomy.
Now, why so many alternatives?
The answer is, because
the IUD can be embedded
in so many different places.
I love this slide because
it shows very clearly
why we need to know the position
of the embedded IUD before it's removed.
So if you look at examples A1
and A2 where there's basically
an arm that's embedded in the myometrium,
or if you look D1 or D2 where the stem
is buried into the myometrium.
For the most part, those
IUDs, at least A1, A2, and D2
can be removed through a hysteroscope.
That might even be done
as an office procedure.
On the other hand, D1
and C1 have to be removed
by laparoscopy, because you
have better access to the IUD
trans-abdominally with the laparoscope
than you do with a hysteroscope.
And the worst circumstance at all is D,
where you can see that
the entirety of the IUD
is completely buried in myometrium,
and you couldn't get that
either with a hysteroscope
or a laparoscope, and therefore
the woman would have to have
a procedure in that case, a laparotomy,
in order to make an incision
in the uterine muscle
and take that IUD out.
And the important thing is
that a regular 2D ultrasound
will not show you that kind of detail.
That's why you either need
a CT scan or a 3D ultrasound
in order to be able to find
exactly where that IUD is.
All right, so let's
kind of finish up this,
and we'll have one more case
and then your questions.
So, how do you manage the patient then
who has a missing IUD string?
The first thing is, it may
just be coiled up in the canal.
Use a brush sampler,
what's often referred to
as a cider brush, just
put it in the canal,
spin it like a spaghetti fork, remove it,
that may be enough to sweep
the string out of the canal.
If it's not, you need to know
if the patient's pregnant.
So perform an office
urinary pregnancy test.
If it's positive, the next
stop is to get an ultrasound
to see if this is an
intrauterine pregnancy
or an ectopic pregnancy.
If the pregnancy test is negative,
then if you have office ultrasound
it's best to ultrasound the patient next.
If you do not see any
IUD at all in the uterus,
on ultrasound, it could be
because she has a translocation.
So send the patient to diagnostic imaging
to get an abdominal film called a KUB.
However, if you see the IUD in the uterus,
then we go to the last
step, number four is,
does she wanna continue with the IUD.
And if she does, she can continue use
for the rest of the lifespan of that IUD.
If not, we can attempt to extract it.
Oops, wrong direction.
Okay, so this basically is an algorithm
that tells you what I just explained
if you have an ultrasound in your office.
So no string in the canal,
pregnancy test negative,
office ultrasound is done.
Over on the left side,
if the IUD is present
and she wants it retained, just leave it.
If she wants it removed,
we're gonna try to
extract it in the office.
Most of the time we're successful.
Some of the time we tug on the
IUD and we can't get it out.
In which case she has an embedment.
And then sometimes we
program the endometrium
to try to remove the IUD
and we can't find it.
Then we go over to the right side.
So if the IUD does not show
up on ultrasound, in uterus,
then the next step is to get a KUB.
A KUB looks at all of
the abdominal cavity.
If it cannot see the
radiopacity of the ultrasound,
it's not in her body, it's
been expelled, end of story.
On the other hand, if the KUB
shows that it's in her pelvis,
then we ask the radiologist
to do a formal ultrasound.
If it's present in the uterus
it means it's probably embedded,
and we go to the next step of doing
the 3D ultrasound or the CT scan.
On the other hand, if
it's present on the KUB
and absent in the endometrial cavity,
then we know it's translocated
and she'll go to laparoscopy.
The next algorithm is
similar but not identical,
it's what you would do
in the case of having
no office ultrasound.
I won't read that to you,
because I more or less explained it.
Now, how do you actually
go about removing an IUD
in the office where you
can't see the strings.
Pregnancy test is negative,
you're not able to sweep the
stings out with a cider brush.
Get consent for a uterine
instrumentation procedure,
do a bimanual exam, we've
already talked about
probing that canal for the strings.
Apply tenaculum,
do a cervical block if you know how,
it is considered to be
optional but it is recommended.
Then you choose an extraction device.
And I'd rather show you
the extraction devices.
So this one is called an
Emmett thread retriever.
It's a little like a Christmas tree.
You put that through the internal os,
you spin it like a spaghetti fork,
and either one of the arms or the string
will be caught on one of those notches
and you can take the IUD out.
Now, until very recently
these were not available
in the United States.
They are currently available
and can be ordered.
Just Google them in the United States
and you'll be able to find these.
All right, here's another
variant of a thread retriever.
This is the one that we use
at San Francisco General,
it's called an alligator forceps.
Some of them are relatively more thick,
others are very narrow,
we prefer the narrow ones.
But you can see that the value
of us is that the fulcrum,
basically the grasping
end of this forceps,
is at the very end.
So what you do is put the
tenaculum on, pull down,
very gently put the alligator forceps
through the canal through the internal os.
Then open the forceps, close it,
turn 90 degrees, and then withdraw it.
What you're trying to
find is either the string,
the stem, or an arm.
And the way you do this is you
start by opening and closing
the forceps just right
through the internal os
in the lower uterine segment.
Because you don't wanna do
a lot of probing around,
it's painful and can be dangerous.
But each time you insert the
forceps go a little higher,
a little higher, open,
close, twist, take it out.
And in my experience about half the time
you'll grasp the string, and
the other half of the time
you'll grasp an arm or the stem,
and then you'll be able to remove it.
Now there are times where you grasp,
tug and tug, and it just won't come.
In that circumstance you're
dealing with an embedment,
you should stop there.
Okay, now the last part of this is that
at any point doing realtime
ultrasound may help
to show you where the IUD is.
If the alligator forceps or
the Emmett thread retriever
don't help, you can
actually use a metal hook
or an aluminum hook like a crochet hook,
which you use just very
gently and move it along
the anterior wall and the posterior wall.
Those were mainly used back in the days
of Lissy's Loops but they
may help occasionally.
And then finally if you feel the IUD
but it just won't come out, just stop.
Desist, get that 3D ultrasound or CT scan,
and show exactly where the embedment is.
All right, one last topic,
and then we'll wrap up
and take some questions,
I'm gonna skip over this slide.
I already explained most of it already.
But let me mention one more
thing about IUD removal,
'cause this comes up in our…
Complex contraception
clinic every now and then.
What about a patient who
is going through menopause,
and she says, you know, I
don't really need this anymore
for pregnancy, what should I do?
Well if you can see
the strings, remove it.
On the other hand, if you
don't see any strings visible,
then you really need to weigh the risks
of instrumenting her uterus.
If you ultrasound her, the
IUD is present in her uterus,
she doesn't need it for
birth control anymore,
what you have to counsel her about is
what's the risk of leaving
it for the rest of your life?
Maybe a little postmenopausal bleeding,
probably not pelvic actinomycosis,
versus the risk of removal which is pain
and the possibility of perforation.
And in our experience in
San Francisco General,
for postmenopausal women when
you know the IUD is in place
but the strings are coiled up inside,
more often than not we just leave it.
And if it's a tail-less
IUD, a stainless steel coil
which by design has no tail,
those are not inserted in the
United States, only in China,
then we advise the woman
just to leave that in place
unless she insists upon its removal.
Now let me tell you just
about the last few slides
and then I'll stop.
As I mentioned, PID in an IUD
user is very very uncommon,
it's no more likely than women
in the general population.
But there are two guidelines
that tell us what to do
in women who develop PID
when they use an IUD.
The first is from the selected
practice recommendations,
you'll see a link to getting this
in the materials for the webinar.
Basically what the selective
practice recommendations say
in the chapter on IUDs is, if
a woman has PID with an IUD
in place, use one of the
CDC antibiotic regimens,
but you do not need to
remove the IUD immediately
if the woman needs ongoing contraception.
However, have her come
back in two or three days.
If she has no improvement in the PID,
then continue antibiotics and
consider removal of the IUD.
'Cause there are some
patients where the IUD
inhibits the ability of the body
to deal with the infection
and you take it out.
But that's only in women
who fail antibiotic therapy.
And if a woman wants
to discontinue the IUD,
what we typically do is
start antibiotics first,
wait a day or two,
and then have her come
back for the IUD removal.
Just so that removing the
IUD in the face of infection
doesn't cause any kind
of bacterial shower.
But for the most part,
we leave the IUD in place
when we're treating PID.
Now if you flip it around and look at
the CDC STD treatment guidelines,
they basically say the same thing.
If an IUD user is diagnosed with PID,
you do not need to remove the IUD.
Treat consistent with
the PID recommendations
in the CDC STD treatment guidelines.
Have the patient come back
two or three days later,
if she's no better
consider removing the IUD.
And the treatment outcomes are really no,
treatment outcomes I mean by treating PID,
are no different if you
take the IUD out or not.
So there's no reason to take the IUD out
unless the woman has not
responded to therapy.
I'm gonna skip this
slide on actinomycoses,
you can read that, I will just
go to the last one which is,
what if a woman has a vaginal infection
and has an IUD in place?
You diagnose her with trichomoniasis
or bacterial vaginosis.
Obviously that IUD
removal is not necessary
in that circumstance, either.
Whoops, wrong way.
So, I am going to stop at
that point, it is one oh one,
and I'd be happy to take
any questions you have,
either on the topics that I discussed
in regard to IUDs or things
that I didn't mention
in the context of complications
where you'd like to ask a question.
Hang on a minute, this isn't dead air,
we have a number of people
who are typing. (laughs)
So I'll read the first question
once the question has been typed
and I see it in my chat box.
I am not a very fast
typer either. (chuckles)
Yeah, hi, it says, do
you know who manufactures
the reusable set of three os
finders that you mentioned.
You know, I apologize, I don't
have that at my fingertips
Jenna, but if you just do
as a search term os finders
on your computer, you will
find a number of companies,
I even think there was
one of the companies
that has them available on Amazon.
You do not need to have a prescription
or have a physician order
or that sort of thing
to be able to buy them.
But I know that when I helped to buy them
for San Francisco General a few years ago
I just Googled it and found two or three
different companies that made them.
They're not very expensive.
We like the ones that could
be sterilized and reusable
rather than the disposable
ones, but both are available.
All right, next question is for Karen.
How long after a chlamydia infection
is diagnosed and treated
would you place an IUD?
All right, so the answer is,
if we're strictly talking about
a cervical chlamydia infection,
we're not talking about chlamydial PID,
I would say within 48 hours, basically.
We know that when we use
Azithromycin to treat chlamydia
that it works fairly
quickly, and there's a small
but reasonable amount of
evidence which says that
once you've treated the
chlamydia appropriately,
that within 48 hours it
should be entirely dead,
and that it would be reasonable to do
an IUD placement in that circumstance.
Now it is a little different
in a woman who's been treated for PID,
and in fact, that very issue is dealt with
in the CDC selected
practice recommendations.
There we have very little data,
but the recommendation is to wait
somewhere between four and six weeks
after PID has been fully treated
before a woman has an IUD insertion.
But if it's strictly
lower tract chlamydia,
I would say either chlamydia or gonorrhea,
once it's been treated, that
within a few days afterwards
that a patient should be
able to have her IUD placed.
All right, that was Karen.
And yeah, PDPD, patient
delivered partner therapy
was given at the time of her chlamydia
diagnosis and treatment
so that's wonderful.
All right, next from Samantha.
And that is, if a patient
has a PAP that's high SIL,
would you wait to do an IUD insertion.
Okay, her full question just came in.
So if a patient has a pap that's high SIL,
would you wait to insert her IUD
until after her colposcopy and treatment.
You know Samantha,
there's not a hard and
fast rule about that.
In the past we said if a woman
was diagnosed with high SIL
that we should not do an IUD placement,
that she should wait until she's treated,
until after she's treated, rather,
because of the fact that the treatment,
whether it's a cryotherapy or a LEEP,
or a comb for that matter,
has some likelihood
that the IUD string is going to fracture.
And it has no effect at all on the fact
that the IUD is not
gonna make high SIL worse
or more difficult to treat
or any of that kinda stuff,
it's really all about the
treatment fracturing the string.
The reality is though
that we can do some things
before we do a cryo or before we do a LEEP
where we push the string up
the canal, do the procedure,
and then try to bring the string back down
where we avoid that problem.
So I think you can go either way.
I think if a patient has
a diagnosed high SIL,
doesn't want to take any risk at all
about her string fracturing,
then she can go ahead
and have her treatment
with the cryo or with the LEEP
and then delay the IUD insertion.
But on the other hand,
if the patient really wants
to have an IUD inserted
or on the other hand if
she already has an IUD,
you can absolutely do the cryo or the LEEP
with the IUD in place, try to
tuck the string up the canal,
and by the way, what if the string breaks?
No big deal, it just
means that once a year
you do an ultrasound to make sure
that the IUD hasn't fallen out.
So it's actually not a problem
at all if the IUD is in place
at the time that she's
treated and the string breaks.
Any more questions?
All right, okay, there you go.
– [Renee] All right, if
there are no more questions.
Conclude for the afternoon.
Thank you everyone for participating,
we hope to see you at our next webinar,
and thank you Dr. Policar for
your amazing presentation.
– [Dr. Policar] Sure thing.
– [Renee] We want to remind everybody
to be on the lookout for the
evaluation in your email,
or click the link in the web links box,
or copy down the URL and
complete that for us,
it takes less than two minutes.
Thank you, and enjoy the rest of your day.
– [Dr. Policar] Okay, Renee?

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