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Difficulty with Sounding or Placement

Particularly for new inserters, sounding the uterus may evoke some anxiety. Sounding provides reassurance that it is safe to place the IUC, reduces the risk of perforation, and sets the expectation for what a woman will feel during IUC placement. Consider the following tips:

  • Use a tenaculum prior to sounding.
  • If the sound cannot pass through the external os, consider using an os finder or small dilator to determine the route of the cervical canal.
  • If you encounter unexpected resistance, stop, repeat the bimanual, and re-attempt sounding, ensuring the sound follows the axis of the uterus.
  • When the sound reaches 3-4 cm or when slight resistance is felt, warn the woman she may feel discomfort as the internal os is passed.
  • Once in the uterus, use minimal force to measure the uterine cavity, and do not apply excessive force once the fundus is reached.

If the sound does not pass beyond 4-5 cm:

  • Repeat the bimanual exam to confirm the uterine axis.
  • Consider a paracervical block if discomfort is limiting sounding.
  • Consider dilation or using an os finder.
  • A false passage is possible, especially if there is resistance throughout sounding. Consider rebooking an appointment with the woman in 2 weeks for a second attempt, or refer her to a more experienced inserter.
  • Do not place the IUC as it is unlikely that the sound is in the uterus.
  • Do not use misoprostol as it does not improve ease of placement.

If the sound passes beyond 10 cm:

  • STOP. Do not place the IUC.
  • Migration of a correctly-placed device through a perforation caused by a uterine sound has been reported.
  • A perforation is possible and likely, particularly if an enlarged uterus is not appreciated on bimanual. If an enlarged uterus is suspected, consider the use of ultrasound to ensure correct placement.
  • Ensure the woman is not in excessive pain and discuss signs and symptoms requiring urgent care.
  • If a perforation occurred, a second attempt can be made after 6 weeks.
  • Consider ultrasound guidance if an IUD is placed in an enlarged uterus (sound>10 cm).

Difficult placement of IUC after correct sounding

  • Re-sound the uterus, paying attention to the uterine axis.
  • Consider the need for additional dilation, particularly for larger insertion tubes.
  • Consider a false passage.
  • Do not release the IUC if it is not inserted at least 6 cm into the uterus.

Failure to Unload

  • This occurs when, upon correct entry into the uterus, the IUC fails to release from the tube and is removed with the insertion tube.
  • You will observe that the strings do not appear to "move" into the tube as it is withdrawn. Rather, both move together.
  • The most common cause is a damaged insertion tube (kink in the plastic).
  • For an IUC with an obturator/plunger, reinsert the plunger and attempt to unload the IUC again. If there is resistance, stop. For a one-handed inserter, advance the slider to reload the IUC into the tube, adjust the inserterand attempt a second release.
  • If the IUC is withdrawn from the cervix, do not reinsert, as it has now touched the non-sterile vagina.
  • If available, consider a repeat placement with a backup device.

Some manufacturers offer a replacement program, which may require forwarding the expelled IUC to the manufacturer (save all components of package and unit to provide to manufacturer).

Costescu D. and Guilbert E. et al. Preceptorship Program - Module 4
Waddington A. and Reid R. More harm than good: the lack of evidence for administering misoprostol prior to IUD insertion. JOGC 2012;34(12):1177-79.