• Intrauterine Devices
• Intrauterine Systems

Congratulations are due to the authors for producing much-needed guidelines.1 These are necessarily a consensus owing to the lack of quality studies on pharmacological interventions. Since 2009 I have provided a referral service for intrauterine device (IUD) problems, and currently manage 400–500 referrals per year for failed insertion or removal, or a history of severe pain and/or vasovagal syncope (VVS). Women referred are motivated to persevere with this method despite a bad experience. There are no data to indicate how many women are put off by a poor experience and rule out this method of contraception and/or menstrual control. In my experience, concerns around the fitting are the main barrier to improving the overall low uptake of intrauterine methods in the UK. I would strongly echo the consensus that the setting, confidence and technique of the provider, and particularly the presence of an assistant skilled at addressing anxiety, are key to the overall experience.

There are six points where I differ from Bahamondes et al.'s recommended practice.

1. I am fortunate to have an electric lithotomy couch but rarely use the leg supports, usually only where access to the cervix is particularly difficult. My preferred position is sitting on a stool with wheels at the side of the couch rather than with the woman at the end of …