• intrauterine devices
• family planning service provision
• general practice

As a general practitioner and intrauterine device (IUD) fitter for over 13 years now I applaud looking at new ways to reduce the pain of IUD insertion as described in Vincent and Sewell's letter in the October 2012 issue of the Journal,1 and recently I have also looked into the possibility of getting some Entonox^® in our practice for IUD fitting. For most women the experience of having an IUD fitted is unpleasant and crampy but tolerable. For some women, however, the procedure is excruciatingly painful. The reasons for the variation are many but are usually fairly unpredictable, and so in my opinion pain relief of some sort should be given routinely to everyone being fitted with an IUD.

The method of pain relief I use – and which I'm sure is fairly standard in most clinics – is simply lidocaine gel local anaesthetic (an unlicensed use, I believe). For many years I believed that this was barely significant in its effects other than as a lubricant and the placebo effect of telling the patient I was using local anaesthetic jelly. It didn't seem to have much of an effect and I wondered if there was much point in using it at all.

The trouble is, in our ever increasingly busy clinics, we pop the jelly in and perhaps think we have waited long enough for it to work, and as time is pressured we get on and insert the IUD. I am fairly sure this a commonplace practice, and it's certainly how I was taught.

Now I have started to wait a full (timed) 3 minutes after insertion of the jelly into the canal and on the surface of the cervix before attempting to fit the IUD, and I believe this has made a big difference to the amount of pain experienced by my patients. [NB. We use lidocaine 2 g in a pre-filled 6 ml syringe with a quill so we can be sure of reaching into the canal.]

After the jelly is introduced and the clock is started we say “We are going to wait a full 3 minutes for the local anaesthetic to work so you can just relax for now”, and then we all chat about something or other, usually the patient's toenail colour or their escape from childcare or whether they have a day off, and so on. It's amazing the range of conversations you can have in 3 minutes and it's also surprising how long 3 minutes really is when you are timing it!

I believe that this is time well spent. Who knows whether it's the effects of the lidocaine or the conversation and subsequent relaxation of the patient immediately prior to IUD insertion? But I do know that since I have adopted this much more precise practice I have hardly had anyone feel faint, and had no one jumping off the bed in agony. I will still consider using Entonox because there are always a few women whose pain will not be tolerable with lidocaine gel alone; but for those clinicians using this method, do make sure you time a full 3 minutes before sounding the canal. I am convinced that if we all did this then IUD fitting generally would be a lot less painful for the patient.