Intrauterine Device (IUD) Placement in India and UAE | Complete Patient Guide

• IDEAL CANDIDATES FOR IUD/IUS INSERTION:

• Women seeking long-acting reversible contraception (LARC) who prefer to avoid daily pill compliance or systemic hormonal exposure

• Women with heavy menstrual bleeding (HMB; defined as >80 mL blood loss per cycle or subjectively distressing blood loss) seeking the LNG-IUS as a first-line medical alternative to surgery

• Patients with endometriosis or adenomyosis seeking hormonal suppression of endometrial tissue with localised uterine delivery of levonorgestrel

• Patients with endometrial hyperplasia without atypia requiring progestogen therapy

• Women requiring oestrogen-only HRT who need endometrial protection via intrauterine progestogen

• Women who require emergency contraception (copper IUD insertion within 120 hours of unprotected intercourse)

• Breastfeeding mothers (copper IUD and low-dose LNG-IUS are both WHO Medical Eligibility Criteria Category 1 or 2 in lactating women)

• Nulliparous women (insertion is feasible with appropriate cervical preparation; not a contraindication)

• REQUIRED PRE-PROCEDURAL DIAGNOSTICS & WORKUP:

• Pelvic examination and bimanual assessment to determine uterine position (anteverted, retroverted, or mid-position) and size

• Transvaginal ultrasound (TVUS) to confirm uterine cavity dimensions, rule out uterine anomalies (e.g., septate uterus, fibroids distorting the cavity, polyps), and serve as real-time guidance during insertion if elected

• Cervical screening (Pap smear / HPV co-test) — must be up to date prior to insertion

• Sexually transmitted infection (STI) screening: endocervical swabs for Chlamydia trachomatis and Neisseria gonorrhoeae (NAAT-based testing); active cervicitis is a contraindication until treated

• Urine pregnancy test (day of procedure)

• Full blood count (FBC) in patients with HMB to assess for iron-deficiency anaemia

• Coagulation screen if history suggests bleeding disorder (e.g., von Willebrand disease workup — APTT, vWF antigen, vWF activity, Factor VIII)

• Sonohysterography or hysteroscopy if suspected intrauterine pathology requires characterisation prior to device placement

• CONTRAINDICATIONS (Absolute — WHO MEC Category 4):

• Confirmed or suspected pregnancy

• Unexplained abnormal uterine bleeding (prior to investigation)

• Distorted uterine cavity (large submucous fibroids, severe uterine anomalies that preclude correct placement)

• Active pelvic inflammatory disease (PID) or puerperal sepsis

• Active sexually transmitted infection (cervicitis due to gonorrhoea or chlamydia — until successfully treated)

• Cervical or endometrial cancer (uninvestigated or confirmed)

• Uterine cavity depth <6 cm (for standard adult devices)

• Gestational trophoblastic disease with persistently elevated beta-hCG (relative contraindication for LNG-IUS)

• Known copper allergy or Wilson's disease (contraindication specific to copper IUDs)

• Active liver disease or liver tumour (contraindication specific to LNG-IUS due to hepatic metabolism of levonorgestrel)

IUD insertion encompasses several clinical approaches and device types, selected based on the patient's indication, parity, uterine anatomy, and personal preference. The following outlines the complete spectrum available at GAF Healthcare's partner centres:

1. STANDARD COPPER IUD INSERTION (Non-hormonal, in-office procedure)

The copper IUD (most commonly Copper-T 380A, effective for 10–12 years, or Multiload Cu-375, effective for 5 years) is inserted using a narrow insertion tube (typically 3.5–4.4 mm outer diameter) passed through the cervical os into the fundal uterine cavity. The procedure takes 5–15 minutes under local anaesthesia (paracervical block) or without anaesthesia. A no-touch technique (Hicks technique) is employed at high-volume centres to minimise contamination risk. The strings are trimmed to 2–3 cm from the external cervical os to facilitate removal and self-monitoring.

2. LEVONORGESTREL-RELEASING INTRAUTERINE SYSTEM (LNG-IUS) INSERTION

The LNG-IUS (Mirena 52 mg / Kyleena 19.5 mg / Jaydess 13.5 mg) is inserted via a dedicated introducer system. The Mirena system uses a 4.4 mm outer diameter introducer tube; its mechanism of action is primarily local (intrauterine levonorgestrel concentrations are 1,000-fold higher than serum concentrations), making systemic side effects minimal compared to oral or injectable progestogens. Selection among formulations is guided by duration of use required, uterine cavity size (Kyleena and Jaydess have smaller frames, preferred for nulliparous patients or small cavities), and whether HMB treatment is the primary indication (only the 52 mg LNG-IUS is licenced for HMB management).

3. ULTRASOUND-GUIDED INSERTION (Advanced Technique)

Real-time transabdominal or transvaginal ultrasound guidance during insertion is the advanced standard of care offered at GAF Healthcare's partner JCI/NABH-accredited hospitals for:

• Nulliparous patients with cervical stenosis

• Patients with a retroverted or acutely anteflexed uterus

• Post-caesarean section patients with lower segment scarring

• Patients with submucosal fibroids requiring precise fundal placement

• Any case where the first unaided attempt is unsuccessful

Ultrasound guidance reduces the perforation rate from ~1–2/1,000 to <0.5/1,000 in experienced hands and confirms optimal fundal positioning immediately post-insertion.

4. HYSTEROSCOPY-ASSISTED IUD PLACEMENT (Minimally Invasive)

In patients with suspected or confirmed uterine cavity pathology (polyps, septa, small fibroids), office or operative hysteroscopy is performed immediately prior to IUD insertion. This allows direct visualisation, treatment of intrauterine pathology, and placement of the IUD under direct endoscopic view — a combined approach that maximises efficacy and safety. Modern slim-diameter hysteroscopes (Bettocchi office hysteroscope, 5 Fr operating channel; Storz Compact Hysteroscope) allow this to be performed without general anaesthesia in the outpatient setting.

5. IMMEDIATE POST-PLACENTAL AND POST-ABORTION IUD INSERTION

At GAF Healthcare's partner centres experienced in postpartum family planning, copper IUDs and LNG-IUS can be inserted within 10 minutes of placental delivery (post-placental) or immediately following first- or second-trimester medical or surgical abortion. Post-placental insertion carries a higher expulsion rate (~15–25%) compared to interval insertion (~5%), which is fully discussed with patients during informed consent. The clinical benefit of leveraging an already-dilated cervix often outweighs the expulsion risk for motivated patients.

6. CERVICAL PREPARATION PROTOCOLS

For nulliparous patients or those with cervical stenosis, pharmacological cervical priming is performed with:

• Misoprostol 400 mcg vaginally or sublingually (2–4 hours pre-insertion)

• Mifepristone 200 mg orally 24–48 hours prior (emerging evidence, particularly in nulliparous patients)

• Mechanical osmotic dilators (Dilapan-S or laminaria) in select complex cases

Paediatric/mini-sized IUDs (e.g., Flexi-T 300, Copper-T 200B, Gynefix frameless intrauterine copper implant) are alternatives for patients with a uterine cavity depth of 5–6 cm.

PRE-ARRIVAL & TELECONSULTATION (2–4 weeks before travel)

• GAF Healthcare coordinates a secure video consultation between the patient and the treating gynaecologist at the destination centre

• Upload and review of prior medical records: previous Pap smear results, STI screening, pelvic ultrasound reports, and menstrual history

• Determination of the optimal timing of insertion (preferably during the first 7 days of the menstrual cycle to confirm non-pregnant status and ease cervical access, though insertion can occur at any point in the cycle when pregnancy is excluded)

• Selection of device type (copper IUD vs. LNG-IUS formulation) and insertion technique (standard vs. ultrasound-guided vs. hysteroscopy-assisted)

• Prescription of pre-procedural cervical priming medication (misoprostol) or NSAIDs (ibuprofen 400–600 mg or naproxen 500 mg orally 1 hour before procedure) for pain management, dispatched or prescribed locally prior to travel

• GAF Healthcare initiates e-Medical visa (India) or entry/tourist visa (UAE) documentation support

DAY OF ARRIVAL (Day 0)

• Airport pickup arranged by GAF Healthcare dedicated coordinator

• Check-in to partner hotel or hospital-affiliated accommodation

• Briefing by GAF Healthcare patient coordinator; translation services confirmed

DAY 1 — PRE-PROCEDURE ASSESSMENT (Day of or day before insertion)

• In-person consultation with consultant gynaecologist

• On-site diagnostics (same-day turnaround): urine pregnancy test, pelvic examination, transvaginal ultrasound, STI swabs (NAAT), FBC if indicated

• Uterine sounding performed in clinic to measure cavity depth and confirm suitability

• Informed consent process: risks, benefits, alternatives, string check instructions, and expulsion warning signs discussed in detail

• Anaesthesia plan confirmed (paracervical block; oral analgesia; IV sedation for anxious or complex patients in selected centres)

DAY 1 OR DAY 2 — THE INSERTION PROCEDURE (Duration: 5–20 minutes)

• Patient positioned in dorsal lithotomy; bimanual examination repeated

• Cervix visualised with bivalve speculum; antiseptic (povidone-iodine or chlorhexidine) applied to ectocervix

• Tenaculum applied to anterior lip of cervix for traction and uterine straightening

• Paracervical block administered if elected (1% lidocaine, 5 mL bilaterally at 3 o'clock and 9 o'clock positions)

• Uterine sound passed to confirm cavity depth and direction

• IUD loaded into insertion tube and advanced to the fundus using the withdrawal/plunger technique; fundal placement confirmed with ultrasound

• Strings trimmed to 2–3 cm; speculum removed

• Patient monitored for 15–30 minutes post-insertion for vasovagal response, severe cramping, or abnormal bleeding

• Discharge with written aftercare instructions: expected light cramping and spotting for 24–72 hours; NSAIDs as needed; activity as tolerated; avoid penetrative sexual intercourse for 24 hours

DAY 2–3 — POST-PROCEDURE RECOVERY & OBSERVATION

• Follow-up clinical check (in-person or teleconsultation) at 24–48 hours to confirm absence of fever, excessive bleeding (>a heavy period), or severe pelvic pain

• GAF Healthcare coordinator available 24/7 for patient queries

• Transvaginal ultrasound at 48-hour check if any doubt about position

• Most patients resume normal activity, light work, and walking within 24 hours

• Avoidance of tampons and menstrual cups for the first menstrual cycle post-insertion to reduce expulsion risk

FIT-TO-FLY ASSESSMENT (Day 2–3)

• Patients are generally fit to fly within 24–72 hours provided:

(a) No signs of pelvic inflammatory disease (fever >38°C, purulent discharge, uterine tenderness)

(b) No suspected perforation

(c) Bleeding is manageable (≤heavy period flow)

(d) No vasovagal or haemodynamic instability

• Recommendation: long-haul flights (>6 hours) should be preceded by a confirmed 48-hour observation period and a clearance ultrasound

FOLLOW-UP (4–6 weeks post-insertion)

• First string check and device position confirmation: patient performs self-string check or attends a local gynaecologist at home country

• GAF Healthcare provides a comprehensive discharge summary, device insertion record, and referral letter for the patient's home-country gynaecologist

• Annual string check recommended thereafter; device replaced at recommended interval (5, 8, or 10–12 years depending on device type)