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Comment on ‘Practical advice for avoidance of pain associated with insertion of intrauterine contraceptives’: authors’ response
  1. Luis Bahamondes, MD
  1. Professor of Gynaecology, Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil; bahamond{at}
  1. Diana Mansour, FRCOG, FFSRH
  1. Consultant in Community Gynaecology and Reproductive Healthcare, Newcastle Hospitals, Community Health, New Croft Centre, Newcastle upon Tyne, UK
  1. Christian Fiala, MD
  1. Director, Gynmed Clinic, Vienna, Austria and Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
  1. Andrew M Kaunitz, MD
  1. Professor and Associate Chair, Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
  1. Kristina Gemzell-Danielsson, MD
  1. Professor of Obstetrics and Gynecology and Department Chair, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden

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We thank Dr Pillai for her letter1 about our review article entitled ‘Practical advice of pain associated with insertion of intrauterine contraceptives’.2 We would like to make the following comments regarding the specific points Dr Pillai raised in her letter.

  1. Dr Pillai suggests that clinicians may wish to sit on a stool with wheels at the side of the couch rather than with the woman at the end of the couch. This still means that clinicians need to sit at the side of the couch, thereby twisting their backs when fitting an intrauterine contraceptive (IUC). This may be personal preference for some but not ideal for others. Many health care professionals (HCPs) prefer to sit in front of the woman for the reasons given in our review and electric lithotomy couches are not available in many clinics.

  2. We are aware that some HCPs do not use tenaculums to stabilise the cervix when fitting IUCs, however it is standard practice to recommend their use to avoid uterine perforation. However, using a tenaculum may induce pain, which could be avoided by an experienced HCP in cases where the cervix presents easily and the cervical canal is open and thus does not offer resistance to IUC insertion. We are also unaware of evidence supporting the routine use of ultrasound scanning when fitting IUCs with many HCPs unable to access this facility and, if implemented, this would greatly increase costs and reduce access to IUCs.

  3. We described atraumatic tenaculums that gently grip rather than puncturing the cervix. This can be achieved by gently holding the forceps rather than locking the handles together. Additionally we also suggested the use of Judd-Allis forceps.

  4. We agree with Dr Pillai's approach to finding the cervical canal but reiterate that routine use of ultrasound is not possible for many HCPs.

  5. We also agree with Dr Pillai's use of the os finder to open a partially stenosed external os and the suggestion to use tapered dilators to help dilate the internal os if available.

  6. We describe both intracervical and paracervical blocks in our review2 together with the advantages of using a dental syringe and needle. We agree that the latter could be given laterally at the base of the cervix or via the cervical canal. There is no strong evidence that lidocaine gel or intrauterine infusion of lidocaine works and we reference the key studies. Dr Pillai's advice regarding filling the uterine cavity with anaesthetic gel following IUC removal and prior to inserting a new one is interesting and merits further study.


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  • Competing interests None.

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