IUD insertion and removal

An IUD is a small device placed inside the uterus that prevents pregnancy for between three and ten years depending on which one you choose, with nothing required of you in between. It is among the most effective contraception available and it is fully reversible. Most of what people want to know before booking is not about effectiveness, which is excellent, but about the insertion itself, how much it will hurt, what happens to their bleeding afterward, and what the real risks are. This page answers those directly.

The two kinds, and what actually separates them

Every IUD is a small flexible T-shaped frame sitting inside the uterus, with two thin threads passing through the cervix so it can be checked and later removed. Beyond that shared design there are two entirely different mechanisms, and choosing between them is mostly a question of what you want your periods to do.

Hormonal IUDs

These release levonorgestrel into the uterine cavity, thickening cervical mucus and thinning the lining. They come in several strengths: the 52 mg devices are approved for up to eight years of contraception, a 19.5 mg device for five, and a 13.5 mg device for three. The smaller devices have a slightly narrower insertion tube, which some people prefer if they have never been pregnant, though the comfort difference is modest. Because most of the hormone stays local, blood levels are far lower than with pills. The 52 mg devices are also approved to treat heavy menstrual bleeding and are often the first thing we offer for it.

The copper IUD

Copper is toxic to sperm and creates a local environment hostile to fertilization. There are no hormones at all, you keep ovulating, and the device works for at least ten years. It is also the most effective emergency contraception that exists, better than any pill, when placed within five days of unprotected sex. The trade-off is consistent and worth taking seriously: periods are typically heavier and cramps stronger, most noticeably in the first six months. If you already bleed heavily, this is the wrong device for you.

How effective, and for how long

Both types fail in fewer than 1 in 100 users per year, and cumulative failure across the full lifespan of the device stays under that threshold. What makes IUDs unusual is that typical-use effectiveness is essentially identical to perfect-use effectiveness, because there is nothing for you to do correctly. That single fact is why they outperform the pill in real life by a wide margin despite the pill being nearly as good on paper. Both work immediately, with one caveat: a hormonal IUD placed more than seven days after your period starts needs backup for a week, while a copper IUD protects from the moment it is in.

What insertion actually feels like, and what we do about it

Here is the honest version. Placement takes two to five minutes. A speculum is inserted, the cervix is cleaned, its position and the depth of the uterus are measured, and the device is passed through the cervical canal and released. The measuring step and the moment of release are the two points that hurt. For most people that is intense cramping, comparable to the worst of a bad period, lasting from fifteen seconds to a couple of minutes, then easing over the following hour. For a minority it is considerably worse, and there is no reliable way to predict who, though people who have never been pregnant and those with severe period pain tend to have a harder time.

For years the standard advice was to take ibuprofen beforehand and expect a pinch. That advice was wrong and has since been formally revised. We plan pain control with you before the appointment rather than improvising on the table, and the options genuinely differ in how much they achieve.

• Oral anti-inflammatories an hour beforehand, which help the cramping that follows insertion more than the insertion itself.
• A paracervical block, meaning injected local anesthetic around the cervix. This has the best evidence for reducing insertion pain and is available here to anyone who wants it.
• Topical lidocaine gel or spray on the cervix, milder than a block but helpful for some people and quick to apply.
• Misoprostol the night before in selected cases, such as a difficult previous insertion or a stenotic cervix, accepting that it causes cramping of its own.
• Anti-anxiety premedication, or scheduling under sedation, for severe procedural anxiety or a history that makes pelvic examination difficult.
• Stopping. If it is worse than you can tolerate we stop and reschedule with a different plan, and that is never treated as a problem.

Bring someone if you would like to, and eat beforehand, since fainting is uncommon but happens more often on an empty stomach. Plan a quiet afternoon, and expect cramping and light bleeding for a day or two afterward.

The first three to six months

This period determines whether people keep their IUD, and it is the part that gets undersold. With a hormonal IUD, expect irregular spotting and unpredictable light bleeding for three to six months as the lining thins. It does not mean anything is wrong and it is not permanent, but it is genuinely annoying and it is the most common reason for early removal. After that, most people bleed substantially less than before, and by one year roughly one in five has no periods at all. With a copper IUD, the first several cycles are heavier and crampier than your baseline, then usually settle somewhat while remaining heavier than they were.

We check in at six to eight weeks, partly to confirm the device sits where it should and partly so there is a scheduled moment to say something is not working. If bleeding is still disruptive at six months, that is a real problem with real options, including switching device type or removing it.

Pain with IUD insertion is real, it is measurable, and it is not something you are expected to absorb quietly to prove a point.

Removal, replacement, and getting pregnant afterward

Removal is far simpler than insertion. A speculum is placed, the strings are grasped, and steady traction folds the arms of the device upward as it comes through the cervix. It takes seconds and most people describe one brief cramp. You can have it removed at any time, for any reason, including because you changed your mind, and you do not need to wait for expiry or justify the decision. A new one can be placed at the same visit.

Fertility returns immediately with both types, and conception in the first cycle after removal is common, so use something else straight away if you are not ready. Occasionally the strings cannot be seen at a visit. This almost always means they have curled into the cervical canal and can be retrieved in the office with a narrow instrument. If not, an ultrasound confirms the device is still correctly positioned, and in the uncommon case where it is not, removal under hysteroscopy is straightforward.

The risks, at their actual frequency

Expulsion, where the device partially or completely comes out on its own, occurs in roughly three to five percent of users in the first year, most often in the first few months and most often during a period. It is more likely with heavy bleeding, severe cramping, or placement immediately after childbirth. That is why you are taught to feel for the strings, since a displaced device does not reliably prevent pregnancy.

Perforation, where the device passes partway or fully through the uterine wall at insertion, occurs in roughly one to two per thousand insertions, and the risk is higher while breastfeeding or within six months of delivery. It is usually recognized early and managed by removing the device, often laparoscopically. Pelvic infection risk is slightly raised in the first twenty days after placement and is under one percent overall; after that first month IUD users are at no greater risk than anyone else, and an IUD does not cause infertility. Pregnancy with an IUD in place is rare, but the chance that such a pregnancy is ectopic is higher than average, so a positive test with an IUD in place warrants a prompt visit. These are small numbers, and they are worth knowing rather than worth worrying about.