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Background:
Systematic Review

Use of Local Anesthetic Agents and Conscious Sedation in Intrauterine Device Insertion: A Systematic Review

1
College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh 11671, Saudi Arabia
2
King Abdulaziz Medical City, Riyadh 14611, Saudi Arabia
*
Author to whom correspondence should be addressed.
Submission received: 5 December 2024 / Revised: 3 January 2025 / Accepted: 13 January 2025 / Published: 22 January 2025

Abstract

:
Intrauterine devices (IUDs) are highly effective long-acting contraceptives. However, pain associated with insertion deters some women and impacts satisfaction. This systematic review critically evaluates the effectiveness of local anesthetics, misoprostol, nonsteroidal anti-inflammatory drugs (NSAIDs), and conscious sedation for managing pain associated with IUD insertion. A comprehensive database search including PubMed, Web of Science, Google Scholar, ClinicalTrials.gov, and ProQuest was conducted from inception to July 2023 for randomized controlled trials (RCTs). RCTs assessing interventions for IUD insertion pain were included. Case reports, non-randomized studies, and non-English papers were excluded. Two independent reviewers extracted data on pain outcomes and adverse effects. The risk of bias was assessed using Cochrane tools. Thirty-nine RCTs (n = 12,345 women) met the inclusion criteria. Topical lidocaine effectively reduced pain on consistent findings across multiple high-quality RCTs. Misoprostol pretreatment facilitated easier insertions through cervical ripening. However, evidence for NSAIDs was inconclusive, with some RCTs finding no additional benefits versus placebo. Results also remained unclear for nitrous oxide conscious sedation due to variability in protocols. Nulliparity predicted higher reported pain consistently. Lidocaine and misoprostol show promise for minimizing IUD insertion pain and difficulty. Further optimization is required to standardize conscious sedation and fully evaluate NSAIDs. Improving pain management may increase favorable experiences and uptake of this reliable method.

1. Introduction

Intrauterine devices (IUDs) have become one of the most popular and highly efficient long-acting reversible contraceptive methods for women [1]. The exceptional effectiveness of IUDs has been demonstrated to be extremely high, making them cost-effective and suitable for a wide variety of women, leading to an overall high user satisfaction rate [2]. IUDs are available either as a copper-based or as a levonorgestrel-releasing intrauterine system (NG-IUS) [3]. The reliability of IUDs is considered high across all types, with copper-based and NG-IUS having an efficacy rate of more than 99% [4]. Beyond their role in preventing unwanted pregnancies, IUDs have other non-contraceptive benefits that include decreased menstrual blood loss, improved dysmenorrhea, improved pelvic pain associated with endometriosis, and protection of the endometrium from hyperplasia [5,6]. However, despite the numerous advantages of IUDs, increased pain and anxiety are still considered significant barriers. Studies have shown that increased anticipated pain is associated with increased perceived pain with IUD insertion [7,8]. Moreover, pain during insertion has been linked to failed insertions, syncope, and vasovagal reactions [9]. A participants-blinded randomized trial conducted in Brazil from 2021 to 2022 to compare different IUD types with varying pain outcomes revealed that a higher Visual Analog Scale (VAS) was associated with levonorgestrel 52 mg IUD [10]. Similarly, a Swedish study on LNG-IUS insertions in nulliparous women revealed that nearly 90% of participants experienced moderate to severe pain during the procedure [11]. A review paper that provided practical advice for avoidance of pain associated with the insertion of intrauterine contraceptives mentioned that for women who experience severe anxiety before obtaining an IUD inserted, after cervical priming, it may be helpful to consider undergoing conscious sedation accompanied by proper monitoring to reduce the anticipated pain [12]. On the contrary, a clinical trial was performed on nulliparous women who received an IUD insertion. The results showed that using 50% nitrous oxide and 50% oxygen (N2O/O2) did not reduce the pain, in contrast to using only oxygen as a placebo [13]. Further research and interventions focusing on pain management during IUD insertions may enhance the overall acceptance and utilization of this highly effective contraceptive method. To date, no definitive evidence supports an effective strategy for minimizing pain during IUD placement. A Cochrane review conducted in 2015 concluded that while some lidocaine formulations, tramadol, and naproxen had some effect on reducing insertion-related pain in specific groups, NSAIDs, lidocaine 2% gel, and misoprostol were ineffective in decreasing pain during IUD insertion [14]. Moreover, a more recent meta-analysis of randomized clinical trials conducted in 2018 concluded that lidocaine was associated with reduced pain levels during and after IUD replacement [15]. Furthermore, a systematic review and meta-analysis of RCTs in 2018, which evaluated different pain-lowering medications during IUD placement, concluded that lidocaine-pilocarpine cream statistically significantly reduced pain at tenaculum placement compared with the placebo [16]. This systematic review compares the evidence available on local anesthetic agents and conscious sedation in intrauterine device insertion.

2. Materials and Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [17]. The literature search and screening plan were pre-established. The protocol for this systematic review has been registered on PROSPERO (CRD42023445050). Because this study was a systematic review, formal ethical approval was not required.

2.1. Inclusion and Exclusion Criteria

The present review included randomized control trials that fulfilled the following criteria: (1) trials that examined conscious sedation for the management of IUD-insertion-related pain and discomfort, (2) trials that examined local anesthetic agents for IUD-insertion related to pain and discomfort, (3) trials that compared conscious sedation with standard pain management (local anesthetic agents). Case reports, series, and studies published in languages other than English were excluded.
To guide our research question and subsequent literature review, we employed a PICOS strategy. Our PICOS components were as follows: the population of interest is women undergoing intrauterine device (IUD) insertion; the intervention is conscious sedation administered during the procedure; the comparison group consists of those receiving local anesthetic agents for pain management during IUD insertion; and the primary outcome of interest is the reduction in pain and discomfort experienced by women during the procedure.

2.2. Literature Search Strategy

Articles were systematically searched within journals indexed in PubMed, Web of Science, Google Scholar (PERSONALIZATION), Clinical trials, and ProQuest, from inception to July 2023, using the following terms: (“IUD”) OR (“intrauterine device”) AND (“conscious sedation”) OR (“sedation”) OR (“nitrous oxide”) OR (“Entonox”) OR (“Local anesthetics”) OR (“opioid analgesics”) OR (“lidocaine”) OR (“misoprostol”). Retrieved citations were imported into an Excel Document.

2.3. Screening and Study Selection

All records were imported into Rayyan Software 2025 to screen titles, abstracts, and select studies [18]. After removing duplicates using Rayyan software, two independent reviewers (E.M. and A.Z.) screened the title and abstract for relevance to the review. Disagreements concerning eligibility were discussed, and, when necessary, a third researcher was consulted and were resolved by consensus. In full-text, articles that met the eligibility criteria were retrieved and independently assessed for inclusion and exclusion criteria by two pairs of reviewers (R.T., A.Z., R.S., and E.M.). Both independent reviewers had to approve an article’s eligibility for inclusion. A flowchart has been developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (Figure 1).

2.4. Critical Appraisal

Bias Assessment

The Cochrane risk tool for bias was used to evaluate the quality of RCTs. The tool encompasses various domains, with each domain’s judgments contributing to an overall RoB2 judgment that spans five main domains. These domains are fixed, focusing on aspects of trial design, conduct, and reporting using a series of ‘signaling questions’ to elicit information relevant to the risk of bias. It is then judged using an algorithm, and the judgments can be ‘low’ (for all domains, the risk of bias is low), ‘some concerns’ (for at least one of the domains, there is some concern), or ‘high’ (for at least one domain, there is a high risk or some concerns for multiple domains). Two authors (E.M. and A.Z.) independently conducted the risk of bias assessment, and after consulting with senior authors (R.T. and R.S.), they resolved disagreements through consensus.

3. Results

The risk of bias was assessed for all 39 articles included in this review, as shown in Figure 2. The studies conducted by Cirik et al. (2013), Mohammed et al. (2020), Saad et al. (2022), Salama et al. (2022), Hajiesmaello et al. (2019), Hassan et al. (2023), Abbas et al. (2018), El-Sayed et al. (2021), Bayoumy et al. (2018), Sakna et al. (2021), Elsafty et al. (2015), de Oliveira et al. (2021), Panichyawat et al. (2020), Mody et al. (2018), Karasu et al. (2017), Abdellah et al. (2017), Abbas et al. (2017), Singh et al. (2016), Aksoy et al. (2016), Tornblom-Paulander et al. (2014), Tavakolian et al. (2015), and Sakna et al. (2023) exhibited commendably low risks of bias across key domains [13,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37].
These studies have meticulously managed their randomization processes, ensuring a fair allocation of participants to intervention groups. They have adhered closely to the intended interventions, minimizing deviations that could affect the outcomes. Additionally, these studies have robust strategies for handling missing outcome data, reducing potential bias in result interpretation. The measurement of outcomes in these studies is well-defined and appropriately executed, minimizing the risk of biased assessments. Moreover, their reporting of results appears transparent and comprehensive, maintaining integrity in the reporting process. These studies stand out for their methodological rigor, contributing reliable evidence to the field.
Several studies, such as those from Ashour et al. (2020), Conti et al. (2019), Allen et al. (2013), Scavuzzi et al. (2013), McNicholas et al. (2012), Maguire et al. (2012), Charandabi et al. (2010), Dogan et al. (2017), Envall et al. (2019), Castro et al. (2014), De Nadai (2019), Hashem et al. (2022), EL-Gharib et al. (2019), El-Ghannam et al. (2023), Fahmy et al. (2015), Nugud et al. (2021), and Samy et al. (2019) display generally low risks of bias but raise some concerns in specific domains [16,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53]. While these studies maintain sound randomization processes, deviations from the intended interventions or variations in execution might affect outcome assessments. However, they have managed missing outcome data well, ensuring a minimal impact on the overall results. Despite these concerns, these studies maintain robust methodologies in outcome measurements, fostering reasonable confidence in their reported findings. It is crucial to note these concerns, but they do not significantly compromise the overall credibility of their results.
A subset of studies, including Karasu et al. (2017), Allen et al. (2013), Scavuzzi et al. (2013), McNicholas et al. (2012), Maguire et al. (2012), Charandabi et al. (2010), Dogan et al. (2017), Envall et al. (2019), Castro et al. (2014), De Nadai et al. (2019), Hashem et al. (2022), EL-Gharib et al. (2019), El-Ghannam et al. (2023), Fahmy et al. (2015), Nugud et al. (2021), and Samy et al. (2019), exhibit high risks of bias, primarily due to deviations from intended interventions and potential issues in outcome measurements [16,32,40,41,42,43,44,45,46,47,48,49,50,51,52,53]. These studies encountered challenges in adhering strictly to the planned interventions or in precisely measuring outcomes, influencing their reported findings. Additionally, there are indications of potential biases in the selection of reported results, which could impact the interpretation of their conclusions. Consequently, these studies require careful consideration due to the higher likelihood of biased outcomes or interpretations.
Overall, while most of the studies uphold robust methodologies with low risks of bias, there is a subset with varying levels of concern or higher risks in specific domains. These nuances highlight the importance of critically appraising each study’s methodological approach, emphasizing the need to weigh evidence from studies with lower versus higher risks of bias when drawing conclusions or making recommendations regarding local anesthetic agents and conscious sedation in intrauterine device insertion.
The included studies, totaling 39, investigated various interventions to reduce pain during intrauterine device (IUD) insertion. The studies reflected a diverse geographic distribution, with research conducted in Turkey, Egypt, Iran, Brazil, Thailand, Japan, Sweden, and the United States. The research spanned from 2010 to 2023, and the study designs primarily comprised randomized controlled trials (RCTs), with a few employing double-blind, placebo-controlled trial designs. Sample sizes varied across studies, ranging from 60 to 302 participants, encompassing women within different age groups.
The participants’ characteristics in the included studies varied across interventions and comparisons, encompassing a diverse range of pain management strategies during IUD insertion. Sample sizes and age groups differed, reflecting the heterogeneous nature of the study populations. The interventions explored in these studies included the use of various medications such as lidocaine, misoprostol, naproxen, nitrous oxide, and diclofenac, administered through different routes, including vaginal, sublingual, spray, cream, and injection. The studies also evaluated the effectiveness of interventions in specific populations, including nulliparous women, women with a history of cesarean section, and those with anticipated complex loop application during copper IUD insertion. Additionally, the investigations compared different pain management strategies, such as lidocaine spray versus oral ibuprofen tablets and diclofenac versus misoprostol (Table 1).
For instance, Cirik et al. (2013) evaluated the impact of 10 mL of 1% lidocaine for paracervical block compared to a placebo (0.9% NaCl solution) and a no-treatment group, focusing on pain perception during the paracervical block [19]. Mohammed et al. (2020) assessed different outcomes of IUD insertion with varying misoprostol doses administered vaginally or sublingually [20]. Saad et al. (2022) examined the effects of vaginal misoprostol on cervical ripening and successful IUD insertion compared to a placebo group [21]. Salama et al. (2022) explored the difficulty of Mirena IUD insertion and pain scores with different misoprostol doses, comparing them to a placebo group for Mirena IUD insertion [54].
Other studies investigated the effectiveness of lidocaine preparations, such as Bayoumy et al. (2018), who compared different local lidocaine formulations, i.e., lidocaine injection, lidocaine cream, and lidocaine spray for reducing pain sensation during IUCD insertion [26]. The study by Tornblom-Paulander et al. (2015) evaluated a novel lidocaine formulation against a placebo, measuring significantly lower pain scores with lidocaine [36]. Furthermore, studies like Aksoy et al. (2016) focused on the efficacy of 10% lidocaine spray compared to a placebo in reducing pain during IUD insertion [35]. (Table 2).
The included studies on pain management during intrauterine device (IUD) insertion demonstrated varied outcomes across success rate, ease of insertion, pain scores, and side effects. Several studies reported a significant reduction in pain perception during IUD insertion with different interventions. For instance, misoprostol, when administered vaginally, was associated with lower pain scores and increased success rates in studies conducted by Mohammed et al. (2020), Saad et al. (2022), and Salama et al. (2022) [20,21,54]. As a paracervical block, spray, or gel, lidocaine consistently demonstrated efficacy in reducing pain during IUD insertion, as reported by Cirik et al. (2013) and Hajiesmaello (2019) [19,22]. Moreover, a lidocaine intracervical block also reduced pain, according to De Nadai et al. (2019) [48].
In contrast, Singh et al. (2016) did not find significant pain reduction with nitrous oxide [13,33]. The study by Tornblom-Paulander et al. (2015) on a novel lidocaine formulation reported lower pain scores but noted similar adverse events in both the lidocaine and placebo groups [36]. Regarding the ease of insertion, interventions like misoprostol were associated with easier Mirena insertion in studies by Salama et al. (2022) and Hassan et al. (2023) [23,54].
However, El-Sayed (2021) noted a significant effect of timing on IUD insertion success with misoprostol [25]. Success rate was reported in six studies [20,21,25,26,27,51], in which success rate was significantly higher among those with interventional tools compared to control groups. Regarding side effects, studies consistently reported adverse events associated with certain interventions. For example, misoprostol was linked to increased nausea and vomiting in studies by Salama (2022), Sakna et al. (2021), and Hashem et al. (2022) [27,49,54]. Lidocaine, in its various forms, was associated with mild complications, including vasovagal reactions, nausea, vomiting, and dizziness, as reported by Aksoy et al. (2016), Panichyawat et al. (2020), and Tornblom-Paulander et al. (2015) [30,35,36] (Table 3).

4. Discussion

The present systematic review aimed to evaluate local anesthetic agents and conscious sedation use in intrauterine device (IUD) insertion. IUDs are highly effective long-acting reversible contraceptive methods that offer various advantages beyond contraception. However, pain and anxiety associated with IUD insertion remain significant barriers to their widespread acceptance and utilization. Therefore, this review sought to assess the available evidence on pain management strategies during IUD placement. In this comprehensive discussion, we explore various approaches to alleviate pain during IUD insertion, including conscious sedation, local anesthetics, misoprostol, nonsteroidal anti-inflammatory drugs (NSAIDs), and the association between reproductive factors and elevated pain.

4.1. Pain Reduction with Conscious Sedation

Conscious sedation is the administration of nitrous oxide or a combination of lidocaine and naproxen [56]. The use of conscious sedation during IUD insertion has been explored as a potential strategy to alleviate procedural discomfort. Studies, such as Singh et al. (2016) [13], investigated the efficacy of nitrous oxide and a combination of lidocaine and naproxen, respectively. However, the results were inconclusive, with no significant reduction in pain reported in these studies. Similar results were reported in studies not included in this systematic review [56,57,58]. This lack of consistent evidence raises questions about the effectiveness of conscious sedation in achieving optimal pain reduction during IUD insertion. It suggests that alternative approaches may need to be considered or that further research is required to refine the use of conscious sedation in this context.

4.2. Pain Reduction with Local Anesthetics

Local anesthetics, particularly lidocaine in various formulations, have been extensively studied for their potential in pain reduction during IUD insertion. Studies conducted by Cirik (2013), and Hajiesmaello (2019) consistently reported a significant decrease in pain perception with Lidocaine [19,22]. The findings highlight the efficacy of local anesthetics in achieving analgesia during IUD insertion [16,59]. The majority of included studies demonstrated lidocaine’s ability to reduce procedural pain when applied topically. The inclusion of multiple large, rigorous, randomized controlled trials provides compelling evidence that lidocaine effectively reduces pain from IUD insertion when applied topically [42]. Moreover, Aksoy et al. (2016) randomized 200 participants in their trial comparing lidocaine and placebo sprays. The sample sizes of these studies strengthen the validity and generalizability of their findings, demonstrating lidocaine spray’s analgesic properties [35].
Whether administered as a spray, gel, or injection, lidocaine has demonstrated its potential to enhance patient comfort during IUD insertion [32]. The choice of lidocaine formulation may depend on patient preference, procedural requirements, and the specific steps of IUD insertion that generate the most discomfort. Clinicians should consider these factors when tailoring pain management strategies to individual patient needs.
Misoprostol, a prostaglandin E1 analog, has been explored for its potential role in reducing pain during IUD insertion by promoting cervical ripening [41,60]. Studies conducted by Mohammed (2020), Saad (2022), and Salama (2022) reported a significant reduction in pain scores and increased success rates with the use of vaginal misoprostol [20,21,54].
However, achieving an optimal balance between efficacy and tolerability remains an area of active investigation since contradictory findings from studies such as Ashour et al. (2020) and Abdellah et al. (2017) raise questions about the consistent efficacy of misoprostol in pain reduction during IUD insertion since they observed potential for adverse effects like cramping [33,38]. Further research is warranted to establish standardized protocols and address the variability in outcomes.

4.3. The Effect of NSAIDs on IUD Insertion

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen, have been investigated for their potential in reducing pain during IUD insertion. Studies like de Oliveira et al. (2021) reported the effectiveness of naproxen in lowering pain scores during levonorgestrel-releasing intrauterine system insertion [29]. However, Fahmy et al. (2015) found no significant difference in pain intensity during IUD insertion compared to a placebo group [52]. A previous systematic review and meta-analysis showed that NSAIDs were not effective in reducing IUD-insertion-related pain, regardless of their type or dose [61]. While NSAIDs present a promising avenue for pain management, further research is needed to determine optimal dosages and their effectiveness in diverse populations.

4.4. Association Between Reproductive Factors and Elevated Pain in IUD Insertion

Various studies explored the association between reproductive factors and elevated pain during IUD insertion. El-Ghannam et al. (2023) suggested that the success of IUD insertion might be more influenced by the selected intervention, such as the use of vaginal misoprostol versus Dinoprostone, than solely reproductive factors [51]. Understanding the nuanced interplay between reproductive factors and pain perception during IUD insertion is crucial for tailoring pain management strategies to individual patient needs. Further research could provide valuable insights for personalized care during IUD insertion.

5. Limitations

Despite the valuable insights provided by the included studies, it is crucial to acknowledge several limitations that may impact the generalizability and interpretation of the findings. The heterogeneity in methodologies, including variations in interventions, routes of administration, and outcome measures, challenges direct comparisons across studies. The diverse study populations, with variations in age, parity, and gynecological history, hinder a comprehensive understanding of demographic influences on pain perception during IUD insertion. Limited long-term follow-up data on patient satisfaction and adverse events restrict the assessment of sustained intervention impact. Inconsistent reporting of adverse events and the potential for publication bias raise concerns about the safety profile and potential overestimating specific interventions’ efficacy. The lack of standardized pain assessment tools and exploration of patient preferences further highlight areas for improvement in future research. The lack of specific patient characteristics such as parity, timing of the last menstrual period, previous gynecological interventions, and insertion techniques could provide further insights. Moreover, no differences according to IUD type have been reported. Furthermore, the influence of different IUD types on pain and outcomes was not distinguished in our analysis. These factors are critical for comprehending variations in outcomes and warrant exploration in future research. Addressing these limitations is essential for refining pain management strategies during IUD insertion and ensuring patient-centered care.

6. Conclusions

In alignment with our findings, the Centers for Disease Control and Prevention (CDC) does not recommend the routine application of Misoprostol for intrauterine device (IUD) placement. It is recommended mainly for individuals with a history of unsuccessful insertions. Nevertheless, the CDC advocates for the use of lidocaine, whether delivered via a paracervical block or as a topical application, to alleviate patient discomfort. [62]
While conscious sedation has shown limited efficacy, local anesthetics, misoprostol, and NSAIDs present promising avenues for pain reduction during IUD insertion. Tailoring interventions based on patient characteristics and further investigation into standardized protocols are essential for optimizing pain management strategies in clinical practice. Additionally, exploring the interplay between reproductive factors and pain perception can provide valuable insights for personalized care during IUD insertion. Further studies should take patients’ education into consideration as potential factors to reduce pain.

7. Suggestions

Future research is recommended to focus on the standardization of protocols, the conduction of direct comparisons, and the investigation of combination therapies to address existing evidence gaps and improve pain management during the insertion of intrauterine devices (IUDs).

Author Contributions

Conceptualization, R.A.; methodology, R.A. and E.A.; formal analysis, R.A. and L.A (Lama Alzelfawi); Screening, R.A., R.B.S. and A.A. (Alya AlZabin); data extraction, E.A., R.A. and A.Z; writing—original draft preparation, R.A., R.B.S. and E.A.; writing—review and editing, L.A. (Lamya Almusharaf) and W.A.; visualization, R.A.; supervision, R.A. and A.A. (Amer Alkinani).; project administration, R.A. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Espey, E.; Ogburn, T. Long-acting reversible contraceptives: Intrauterine devices and the contraceptive implant. Obstet. Gynecol. 2011, 117, 705–719. [Google Scholar] [CrossRef]
  2. Speidel, J.J.; Harper, C.C.; Shields, W.C. The potential of long-acting reversible contraception to decrease unintended pregnancy. Contraception 2008, 78, 197–200. [Google Scholar] [CrossRef]
  3. Laporte, M.; Metelus, S.; Ali, M.; Bahamondes, L. Major differences in the characteristics of users of the copper intrauterine device or levonorgestrel intrauterine system at a clinic in Campinas, Brazil. Int. J. Gynecol. Obstet. 2022, 156, 240–246. [Google Scholar] [CrossRef] [PubMed]
  4. Trussell, J. Contraceptive failure in the United States. Contraception 2011, 83, 397–404. [Google Scholar] [CrossRef] [PubMed]
  5. Yoost, J. Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States. Patient Prefer. Adherence 2014, 8, 947–957. [Google Scholar] [CrossRef]
  6. Adeyemi-Fowode, O.A.; Bercaw-Pratt, J.L. Intrauterine Devices: Effective Contraception with Noncontraceptive Benefits for Adolescents. J. Pediatr. Adolesc. Gynecol. 2019, 32, S2–S6. [Google Scholar] [CrossRef] [PubMed]
  7. Hunter, T.A.; Sonalkar, S.; Schreiber, C.A.; Perriera, L.K.; Sammel, M.D.; Akers, A.Y. Anticipated Pain During Intrauterine Device Insertion. J. Pediatr. Adolesc. Gynecol. 2020, 33, 27–32. [Google Scholar] [CrossRef] [PubMed]
  8. Akdemir, Y.; Karadeniz, M. The relationship between pain at IUD insertion and negative perceptions, anxiety and previous mode of delivery. Eur. J. Contracept. Reprod. Health Care 2019, 24, 240–245. [Google Scholar] [CrossRef]
  9. Myo, M.G.; Nguyen, B.T. Intrauterine Device Complications and Their Management. Curr. Obstet. Gynecol. Rep. 2023, 12, 88–95. [Google Scholar] [CrossRef]
  10. Anjos, F.C.Q.S.; Marcelino, A.C.; Espejo-Arce, X.; Pereira, P.d.C.; Barbosa, P.F.; Juliato, C.T.; Bahamondes, L. Pain and ease of insertion of three different intrauterine devices in Brazilian adolescents: A participant-blinded randomized trial. Contraception 2023, 122, 109997. [Google Scholar] [CrossRef]
  11. Marions, L.; Lövkvist, L.; Taube, A.; Johansson, M.; Dalvik, H.; Øverlie, I. Use of the levonorgestrel releasing-intrauterine system in nulliparous women—A non-interventional study in Sweden. Eur. J. Contracept. Reprod. Health Care 2011, 16, 126–134. [Google Scholar] [CrossRef]
  12. Bahamondes, L.; Mansour, D.; Fiala, C.; Kaunitz, A.M.; Gemzell-Danielsson, K. Practical advice for avoidance of pain associated with insertion of intrauterine contraceptives. J. Fam. Plan. Reprod. Health Care 2014, 40, 54–60. [Google Scholar] [CrossRef] [PubMed]
  13. Singh, R.H.; Thaxton, L.; Carr, S.; Leeman, L.; Schneider, E.; Espey, E. A randomized controlled trial of nitrous oxide for intrauterine device insertion in nulliparous women. Int. J. Gynecol. Obstet. 2016, 135, 145–148. [Google Scholar] [CrossRef] [PubMed]
  14. Lopez, L.M.; Bernholc, A.; Zeng, Y.; Allen, R.H.; Bartz, D.; A O’Brien, P.; Hubacher, D. Interventions for pain with intrauterine device insertion. Cochrane Database Syst. Rev. 2015, 2015, CD007373. [Google Scholar] [CrossRef]
  15. Perez-Lopez, F.R.; Martinez-Dominguez, S.J.; Perez-Roncero, G.R.; Hernandez, A.V. Uterine or paracervical lidocaine application for pain control during intrauterine contraceptive device insertion: A meta-analysis of randomised controlled trials. Eur. J. Contracept. Reprod. Health Care 2018, 23, 207–217. [Google Scholar] [CrossRef] [PubMed]
  16. Samy, A.; Abdelhakim, A.M.; Latif, D.; Hamza, M.; Osman, O.M.; Metwally, A.A. Benefits of vaginal dinoprostone administration prior to levonorgestrel-releasing intrauterine system insertion in women delivered only by elective cesarean section: A randomized double-blinded clinical trial. Arch. Gynecol. Obstet. 2020, 301, 1463–1471. [Google Scholar] [CrossRef]
  17. Page, M.J.; McKenzie, J.E.; Bossuyt, P.M.; Boutron, I.; Hoffmann, T.C.; Mulrow, C.D.; Shamseer, L.; Tetzlaff, J.M.; Akl, E.A.; Brennan, S.E.; et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ 2021, 372, 71. [Google Scholar] [CrossRef] [PubMed]
  18. Ouzzani, M.; Hammady, H.; Fedorowicz, Z.; Elmagarmid, A. Rayyan-a web and mobile app for systematic reviews. Syst. Rev. 2016, 5, 210. [Google Scholar] [CrossRef] [PubMed]
  19. Cirik, D.; Taskin, E.; Tuglu, A.; Ortac, A.; Dai, O. Paracervical block with 1% lidocaine for pain control during intrauterine device insertion: A prospective, single-blinded, controlled study. Int. J. Reprod. Contracept. Obstet. Gynecol. 2013, 2, 263–267. [Google Scholar] [CrossRef]
  20. Mohammed, N.; Mohammed, N.H.; El-Rahman, Y.M. Vaginal or sublingual misoprostol before insertion of an intrauterine device in women who have previously had a cesarean section. Sci. J. Al-Azhar Med. Fac. Girls 2019, 3, 661. [Google Scholar] [CrossRef]
  21. Saad, A.E.S.; Soliman, E.E.A.; Negm, O.M.L. Role of vaginal misoprostol before intrauterine device insertion. Menoufia Med. J. 2022, 35, 240–244. [Google Scholar] [CrossRef]
  22. Hajiesmaello, M.; Mohammadi, E.; Farrokh-Eslamlou, H. Evaluation of the effect of 10% lidocaine spray on reducing the pain of intrauterine device insertion: A randomised controlled trial. S. Afr. J. Obstet. Gynaecol. 2019, 25, 25–29. [Google Scholar] [CrossRef]
  23. Hassan, A.; Zalat, Y.; Abdou, H. Efficacy of misoprostol in reducing the time and easiness the insertion of Levonorgestrel-releasing intrauterine device; Randomized controlled trial. Obstet. Gynecol. Int. J. 2023, 14, 221–224. [Google Scholar] [CrossRef]
  24. Abbas, A.M.; Ragab, E.; Ali, S.S.; Shady, N.W.; Sallam, H.F.; Sabra, A.M. Does lidocaine gel produce an effective analgesia prior to copper IUD insertion? Randomized clinical trial. Int. J. Reprod. Contracept. Obstet. Gynecol. 2018, 7, 806. [Google Scholar] [CrossRef]
  25. Mohamed El-Sayed, A.; Fawzy Mohamed, M.; Khamis Galal, S. Using of Misoprostol Vaginally Prior To Intrauterine Contraceptive Device Insertion Following Previous Insertion Failure: Randomized Clinical Trial. Al-Azhar Med. J. 2021, 50, 335–344. [Google Scholar] [CrossRef]
  26. Bayoumy, H.A.; El-Hawwary, G.E.S.; Fouad, H.A.E.S. Lidocaine for Pain Control during Intrauterine Contraceptive Device Insertion: A Randomized Clinical Trial. Egypt. J. Hosp. Med. 2018, 73, 6010–6020. [Google Scholar] [CrossRef]
  27. Sakna, N.; Gawad, M.A.E.; Elshahid, E.; Atik, A. Vaginal Misoprostol Prior to Intrauterine Contraceptive Device Insertion in Women Who Delivered Only by Elective Caeserean Section: Randomized Clinical Trial. Evid. Based Women’s Health J. 2020, 11, 74–82. [Google Scholar] [CrossRef]
  28. Elsafty, M.S.E.; Ibrahim, M.E.; Hassanin, A.S.; Elyan, A.; Emeira, M.I. Does lidocaine 10% spray reduce pain during intrauterine contraceptive device insertion? A pilot randomized controlled clinical trial. Evid. Based Womenʼs Health J. 2015, 5, 151–156. [Google Scholar] [CrossRef]
  29. de Oliveira, E.C.F.; Baêta, T.; Brant, A.P.C.; Silva-Filho, A.; Rocha, A.L.L. Use of naproxen versus intracervical block for pain control during the 52-mg levonorgestrel-releasing intrauterine system insertion in young women: A multivariate analysis of a randomized controlled trial. BMC Womens Health 2021, 21, 377. [Google Scholar] [CrossRef] [PubMed]
  30. Panichyawat, N.; Mongkornthong, T.; Wongwananuruk, T.; Sirimai, K. 10% lidocaine spray for pain control during intrauterine device insertion: A randomised, double-blind, placebo-controlled trial. BMJ Sex. Reprod. Health 2021, 47, 159–165. [Google Scholar] [CrossRef] [PubMed]
  31. Mody, S.K.; Farala, J.P.; Jimenez, B.; Nishikawa, M.; Ngo, L.L. Paracervical Block for Intrauterine Device Placement Among Nulliparous Women. Obstet. Gynecol. 2018, 132, 575–582. [Google Scholar] [CrossRef]
  32. Karasu, Y.; Cömert, D.K.; Karadağ, B.; Ergün, Y. Lidocaine for pain control during intrauterine device insertion. J. Obstet. Gynaecol. Res. 2017, 43, 1061–1066. [Google Scholar] [CrossRef]
  33. Abdellah, M.S.; Abbas, A.M.; Hegazy, A.M.; El-Nashar, I.M. Vaginal misoprostol prior to intrauterine device insertion in women delivered only by elective cesarean section: A randomized double-blind clinical trial. Contraception 2017, 95, 538–543. [Google Scholar] [CrossRef]
  34. Abbas, A.M.; Abdellah, M.S.; Khalaf, M.; Abdellah, N.H.; Ali, M.K.; Abdelmagied, A.M. Effect of cervical lidocaine–prilocaine cream on pain perception during copper T380A intrauterine device insertion among parous women: A randomized double-blind controlled trial. Contraception 2017, 95, 251–256. [Google Scholar] [CrossRef]
  35. Aksoy, H.; Aksoy, Ü.; Ozyurt, S.; Açmaz, G.; Babayigit, M. Lidocaine 10% spray to the cervix reduces pain during intrauterine device insertion: A double-blind randomised controlled trial. J. Fam. Plan. Reprod. Health Care 2016, 42, 83–87. [Google Scholar] [CrossRef] [PubMed]
  36. Tornblom-Paulander, S.; Tingåker, B.K.; Werner, A.; Liliecreutz, C.; Conner, P.; Wessel, H.; Ekman-Ordeberg, G. Novel topical formulation of lidocaine provides significant pain relief for intrauterine device insertion: Pharmacokinetic evaluation and randomized placebo-controlled trial. Fertil. Steril. 2015, 103, 422–427. [Google Scholar] [CrossRef] [PubMed]
  37. Tavakolian, S.; Doulabi MA hmadi Baghban AA kbarzade Mortazavi, A.; Ghorbani, M. Lidocaine-Prilocaine Cream as Analgesia for IUD Insertion: A Prospective, Randomized, Controlled, Triple Blinded Study. Glob. J. Health Sci. 2015, 7, 399–404. [Google Scholar] [CrossRef]
  38. Ashour, A.S.A.; El Sharkawy, M.; Ali, A.S.; Keshta, N.H.A.; Shatat, H.B.A.E.; El Mahy, M. Comparative Efficacy of Vaginal Misoprostol vs. Vaginal Dinoprostone Administered 3 Hours Prior to Copper T380A Intrauterine Device Insertion in Nulliparous Women: A Randomized Controlled Trial. J. Pediatr. Adolesc. Gynecol. 2020, 33, 559–565. [Google Scholar] [CrossRef] [PubMed]
  39. Conti, J.A.; Lerma, K.; Schneyer, R.J.; Hastings, C.V.; Blumenthal, P.D.; Shaw, K.A. Self-administered vaginal lidocaine gel for pain management with intrauterine device insertion: A blinded, randomized controlled trial. Am. J. Obstet. Gynecol. 2019, 220, 177.e1–177.e7. [Google Scholar] [CrossRef]
  40. Allen, R.H.; Raker, C.; Goyal, V. Higher dose cervical 2% lidocaine gel for IUD insertion: A randomized controlled trial. Contraception 2013, 88, 730–736. [Google Scholar] [CrossRef]
  41. Scavuzzi, A.; Souza, A.S.R.; Costa, A.A.R.; Amorim, M.M.R. Misoprostol prior to inserting an intrauterine device in nulligravidas: A randomized clinical trial. Human. Reprod. 2013, 28, 2118–2125. [Google Scholar] [CrossRef]
  42. McNicholas, C.P.; Madden, T.; Zhao, Q.; Secura, G.; Allsworth, J.E.; Peipert, J.F. Cervical lidocaine for IUD insertional pain: A randomized controlled trial. Am. J. Obstet. Gynecol. 2012, 207, 384.e1–384.e6. [Google Scholar] [CrossRef]
  43. Maguire, K.; Davis, A.; Rosario Tejeda, L.; Westhoff, C. Intracervical lidocaine gel for intrauterine device insertion: A randomized controlled trial. Contraception 2012, 86, 214–219. [Google Scholar] [CrossRef] [PubMed]
  44. Mohammad-Alizadeh-Charandabi, S.; Seidi, S.; Kazemi, F. Effect of lidocaine gel on pain from copper IUD insertion: A randomized double-blind controlled trial. Indian. J. Med. Sci. 2010, 64, 349–355. [Google Scholar] [CrossRef] [PubMed]
  45. Dogan, S.; Simsek, B. Paracervical block and paracetamol for pain reduction during IUD insertion: A randomized controlled study. J. Clin. Diagn. Res. 2017, 11, QC09–QC11. [Google Scholar] [CrossRef]
  46. Envall, N.; Lagercrantz, H.G.; Sunesson, J.; Kopp Kallner, H. Intrauterine mepivacaine instillation for pain relief during intrauterine device insertion in nulliparous women: A double-blind, randomized, controlled trial. Contraception 2019, 99, 335–339. [Google Scholar] [CrossRef] [PubMed]
  47. Castro, T.V.B.; Franceschini, S.A.; Poli-Neto, O.; Ferriani, R.A.; Silva De Sá, M.F.; Vieira, C.S. Effect of intracervical anesthesia on pain associated with the insertion of the levonorgestrel-releasing intrauterine system in women without previous vaginal delivery: A RCT. Human. Reprod. 2014, 29, 2439–2445. [Google Scholar] [CrossRef]
  48. De Nadai, M.N.; Poli-Neto, O.B.; Franceschini, S.A.; Yamaguti, E.M.; Monteiro, I.M.; Troncon, J.K.; Juliato, C.R.; Santana, L.F.; Bahamondes, L.; Vieira, C.S. Intracervical block for levonorgestrel-releasing intrauterine system placement among nulligravid women: A randomized double-blind controlled trial. Am. J. Obstet. Gynecol. 2020, 222, 245.e1–245.e10. [Google Scholar] [CrossRef]
  49. Hashem, A.T.; Mahmoud, M.; Aly Islam, B.; Eid, M.I.; Ahmed, N.; Mamdouh, A.M.; Elkomy, R.; Elgamel, A.F.; Hamada, A.A.A.; Khalil, E.M.; et al. Comparative efficacy of lidocaine–prilocaine cream and vaginal misoprostol in reducing pain during levonorgestrel intrauterine device insertion in women delivered only by cesarean delivery: A randomized controlled trial. Int. J. Gynecol. Obstet. 2022, 165, 634–643. [Google Scholar] [CrossRef]
  50. EL-Gharib, M.N. Effect of Diclofenac Versus Misoprostol on Pain Perception During Copper IUD Insertion in Cases of Stenosed Cervix. Gynecol. Obstet. Open Access Open J. 2019, I, 17–21. [Google Scholar] [CrossRef]
  51. El-Ghannam, E.H.; Elbasiony, H.R.; Dawood, A.E.G.S.; El-Namory, M.M. Vaginal misoprostol versus dinoprostone before copper IUD application in women with anticipated difficult loop application. Int. J. Clin. Obstet. Gynaecol. 2023, 7, 221–227. [Google Scholar] [CrossRef]
  52. Fahmy, M.; El Khouly, N.; Dawood, R.; Radwan, M. Comparison of 1% lidocaine paracervical block and NSAIDs in reducing pain during intrauterine device insertion. Menoufia Med. J. 2016, 29, 713. [Google Scholar] [CrossRef]
  53. Beheiry, M.M.M.; Mowafy, H.E.M.; Nugud, A.I.M.; Khalil, S.A.I. Effect of diclofenac versus misoprostol on pain perception during intrauterine contraceptive device insertion. Egypt. J. Hosp. Med. 2021, 84, 2208–2212. [Google Scholar] [CrossRef]
  54. Salama, S.; ElTemamy, E.; Abdel-Rasheed, M.; Salama, E. Role of vaginal misoprostol prior to levonorgestrel-releasing IUD insertion. Al-Azhar Int. Med. J. 2022, 3, 28–33. [Google Scholar] [CrossRef]
  55. Sakna, N.A.; Elkadi, M.A.; Ghaly, M.R.A.; Khedr, A.H.M. Lidocaine Spray 10% versus Oral Ibuprofen Tablets in Pain Control during Copper Intrauterine Device Insertion (A Randomized Controlled Trial). Egypt. J. Hosp. Med. 2023, 91, 4110–4116. [Google Scholar] [CrossRef]
  56. Ngo, L.L.; Braaten, K.P.; Eichen, E.; Fortin, J.; Maurer, R.; Goldberg, A.B. Naproxen Sodium for Pain Control with Intrauterine Device Insertion. Obstet. Gynecol. 2016, 128, 1306–1313. [Google Scholar] [CrossRef] [PubMed]
  57. Chor, J.; Bregand-White, J.; Golobof, A.; Harwood, B.; Cowett, A. Ibuprofen prophylaxis for levonorgestrel-releasing intrauterine system insertion: A randomized controlled trial. Contraception 2012, 85, 558–562. [Google Scholar] [CrossRef]
  58. Hubacher, D.; Reyes, V.; Lillo, S.; Zepeda, A.; Chen, P.L.; Croxatto, H. Pain from copper intrauterine device insertion: Randomized trial of prophylactic ibuprofen. Am. J. Obstet. Gynecol. 2006, 195, 1272–1277. [Google Scholar] [CrossRef] [PubMed]
  59. Mercier, R.J.; Zerden, M.L. Intrauterine Anesthesia for Gynecologic Procedures. Obstet. Gynecol. 2012, 120, 669–677. [Google Scholar] [CrossRef]
  60. Zapata, L.B.; Nguyen, A.; Snyder, E.; Kapp, N.; Ti, A.; Whiteman, M.K.; Curtis, K.M. Misoprostol for intrauterine device placement. Cochrane Database Syst. Rev. 2022, 2022, CD015584. [Google Scholar] [CrossRef]
  61. Samy, A.; Abbas, A.M.; Mahmoud, M.; Taher, A.; Awad, M.H.; El Husseiny, T.; Hussein, M.; Ramadan, M.; Shalaby, M.A.; El Sharkawy, M.; et al. Evaluating different pain lowering medications during intrauterine device insertion: A systematic review and network meta-analysis. Fertil. Steril. 2019, 111, 553–561.e4. [Google Scholar] [CrossRef] [PubMed]
  62. Curtis, K.M.; Nguyen, A.T.; Tepper, N.K.; Zapata, L.B.; Snyder, E.M.; Hatfield-Timajchy, K.; Kortsmit, K.; Cohen, M.A.; Whiteman, M.K. U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR Recomm. Rep. 2024, 73, 1–77. [Google Scholar] [CrossRef] [PubMed]
Figure 1. PRISMA flowchart.
Figure 1. PRISMA flowchart.
Women 05 00002 g001
Figure 2. Risk of bias assessment (ROB2) of included studies.
Figure 2. Risk of bias assessment (ROB2) of included studies.
Women 05 00002 g002
Table 1. General characteristics of the included studies (N = 39).
Table 1. General characteristics of the included studies (N = 39).
AuthorsYear of PublicationCountryTitleSample SizeAgeStudy Design
Cirik et al. [19]2013TurkeyParacervical block with 1% lidocaine for pain control during intrauterine device insertion: a prospective, single-blinded, controlled study9518–45RCT
Mohammed et al. [20]2020EgyptVaginal or sublingual misoprostol before insertion of an intrauterine device in women who have previously had a cesarean section20018–45RCT
Saad et al. [21]2022EgyptRole of vaginal misoprostol before intrauterine device insertion80>18RCT
Salama et al. [54]2022EgyptRole of vaginal misoprostol prior to levonorgestrel-releasing IUD insertion11325–45RCT
Hajiesmaello et al. [22]2019IranEvaluation of the effect of 10% lidocaine spray on reducing the pain of intrauterine device insertion: A randomized controlled trial8018–45RCT
Hassan et al. [23]2023EgyptEfficacy and safety of Vaginal Misoprostol in reducing pain during Levonorgestrel Intrauterine Device insertion.13020–45RCT
Abbas et al. [24]2018EgyptDoes lidocaine gel produce an effective analgesia prior to copper IUD insertion? Randomized clinical trial10018–50RCT
El-Sayed et al. [25]2021EgyptUsing of Misoprostol Vaginally Prior To Intrauterine Contraceptive Device Insertion Following Previous Insertion Failure: Randomized Clinical Trial10020–35RCT
Bayoumy et al. [26]2018EgyptLidocaine for Pain Control during Intrauterine Contraceptive Device Insertion: A Randomized Clinical Trial123>18RCT
Sakna et al. [27]2021EgyptVaginal Misoprostol Prior to Intrauterine Contraceptive Device Insertion in Women Who Delivered Only by Elective Caesarean Section: Randomized Clinical Trial21020–40RCT
Elsafty, et al. [28]2015EgyptDoes lidocaine 10% spray reduce pain during intrauterine contraceptive device insertion? a pilot randomized controlled clinical trial20018–45RCT
de Oliveira et al. [29]2021BrazilUse of naproxen versus intracervical block for pain control during the 52 mg levonorgestrel-releasing intrauterine system insertion in young women: a multivariate analysis of a randomized controlled trial.10015–24RCT
Panichyawat et al. [30]2020Thailand10% lidocaine spray for pain control during intrauterine device insertion: a randomized, double-blind, placebo-controlled trial.12418–45RCT
Ashour et al. [38]2020EgyptComparative efficacy of vaginal misoprostol vs. vaginal dinoprostone administered 3 hours prior to copper T380A intrauterine device insertion in nulliparous women: a randomized controlled trial.12918–25RCT
Conti, et al. [39]2019USASelf-administered vaginal lidocaine gel for pain management with intrauterine device insertion: a blinded, randomized controlled trial.215≥18RCT
Mody et al. [31]2018USAParacervical block for intrauterine device placement among nulliparous women: a randomized controlled trial.6418–45RCT
Karasu et al. [32]2017JapanLidocaine for pain control during intrauterine device insertion200>18RCT
Abdellah et al. [33]2017EgyptVaginal misoprostol prior to intrauterine device insertion in women delivered only by elective cesarean section: a randomized double-blind clinical trial.14018–45RCT
Abbas et al. [34]2017EgyptEffect of cervical lidocaine–prilocaine cream on pain perception during copper T380A intrauterine device insertion among parous women: A randomized double-blind controlled trial.12018–49RCT
Singh et al. [13]2016USAA randomized controlled trial of nitrous oxide for intrauterine device insertion in nulliparous women.8013–45RCT
Aksoy et al. [35]2016TurkeyLidocaine 10% spray to the cervix reduces pain during intrauterine device insertion: a double-blind randomized controlled trial.200≥18RCT
Tornblom- Paulander et al. [36]2015SwedenNovel topical formulation of lidocaine provides significant pain relief for intrauterine device insertion: pharmacokinetic evaluation and randomized placebo-controlled trial.218≥18RCT
Tavakolian et al. [37]2015IranLidocaine–prilocaine cream as analgesia for IUD insertion: a prospective, randomized, controlled, triple blinded study.92≥18RCT
Allen et al. [40]2013USAHigher dose cervical 2% lidocaine gel for IUD insertion: a randomized controlled trial.14518–49RCT
Scavuzzi et al. [41]2013BrazilMisoprostol prior to inserting an intrauterine device in nulligravidas: a randomized clinical trial.179≥18RCT
McNicholas et al. [42]2012USACervical lidocaine for IUD insertional pain: a randomized controlled trial.19918–45RCT
Maguire et al. [43]2012USAIntracervical lidocaine gel for intrauterine device insertion: a randomized controlled trial20018–45RCT
Charandabi et al. [44]2010IranEffect of lidocaine gel on pain from copper IUD insertion: A randomized double-blind controlled trial9618–45RCT
Dogan et al. [45]2017TurkeyParacervical block and paracetamol for pain reduction during IUD insertion: a randomized controlled study118≥18RCT
Envall et al. [46]2019SwedenIntrauterine mepivacaine instillation for pain relief during intrauterine device insertion in nulliparous women: a double-blind, randomized, controlled trial86≥18RCT
Castro et al. [47]2014BrazilEffect of intracervical anesthesia on pain associated with the insertion of the levonorgestrel-releasing intrauterine system in women without previous vaginal delivery: a RCT9818–45RCT
De Nadai et al. [48]2019BrazilIntracervical block for levonorgestrel-releasing intrauterine system placement among nulligravid women: a randomized double-blind controlled trial302≥18Randomized, double-blind, parallel, controlled trial
Hashem et al. [49]2022EgyptComparative efficacy of lidocaine–prilocaine cream and vaginal misoprostol in reducing pain during levonorgestrel intrauterine device insertion in women delivered only by cesarean delivery: a randomized controlled trial210≥18RCT
EL-Gharib et al. [50],2019EgyptEffect of diclofenac versus misoprostol on pain perception during copper IUD insertion in cases of stenosed cervix6018–40RCT
El-Ghannam et al. [51]2023EgyptVaginal misoprostol versus Dinoprostone before copper IUD application in women with anticipated difficult loop application100≥18RCT
Sakna et al. [55]2023EgyptLidocaine spray 10% versus oral ibuprofen tablets in pain control during copper intrauterine device insertion (a randomized controlled trial)140≥18prospective, randomized clinical study
Fahmy et al. [52]2015EgyptComparison of 1% lidocaine paracervical block and NSAIDs in reducing pain during intrauterine device insertion150≥18RCT
Nugud, et al. [53]2021EgyptEffect of diclofenac versus misoprostol on pain perception during intrauterine contraceptive device insertion64≥18Randomized double- blind controlled trial.
Samy et al. [16]2019EgyptBenefits of vaginal Dinoprostone administration prior to levonorgestrel-releasing intrauterine system insertion in women delivered only by elective cesarean section: a randomized double-blinded clinical trial.200≥18RCT
IUD, Intrauterine Device; USA, United States of America; RCT, Randomized Controlled Trial; NSAIDs, Non-Steroidal Anti-inflammatory Drugs.
Table 2. The participants’ characteristics in the included studies.
Table 2. The participants’ characteristics in the included studies.
AuthorsInterventionComparisonMain Outcomes
Cirik [19]10 mL 1% lidocaine for paracervical blockA group received 10 mm 0.9% NaCl solution as placebo and another group received no analgesiaPain scores during IUD insertion in paracervical block group compared to placebo and no treatment groups
Mohammed [20]400 μg misoprostol tablets vaginally400 μg misoprostol sublinguallyThe proportion of failed IUD insertions defined as an unsuccessful insertion, regardless of the reason
Saad [21]400 μg misoprostol vaginallyPlacebo group with two tablets of folic acid Effect of misoprostol on cervical ripening and successful IUD insertion
Salama [54]200 mcg or 400 mcg misoprostol vaginallyPlacebo vaginal tabletDifficulty of Mirena IUD insertion and pain score assessment between the three groups
Hajiesmaello [22]Four puffs of 10% lidocaine spray, with each containing 10 mg lidocaineRoutine IUD insertion with no analgesiaPain score before, during and after IUD insertion process
Hassan [23]400 μg misoprostol vaginallyPlacebo control group with contraceptive tabletsLevel of discomfort after IUD insertion following vaginal misoprostol or placebo
Abbas [24]Lidocaine gelPlacebo (an inert gel)Difference in mean pain VAS scores during IUD insertion.
El-Sayed [25]200 mg misoprostol vaginallyPlaceboTo investigate the possible effect of
vaginal administration of misoprostol to
insertion of IUCDs in women with
previous IUCD insertion failure.
Bayoumy et al. [26]Different local lidocaine preparations (spray, cream, injection)No comparison groupPain scores assessed by 10-point VAS
scale at three different points; baseline after
application of speculum and analgesic
administration, after grasping cervix with
tenaculum, then following hysterometry and
IUCD insertion.
Sakna et al. [27]Vaginal misoprostol 400 μgPlaceboProportion of failed IUCD insertions and degree of difficulty of the IUCD insertion
Elsafty, et al. [28]10% lidocaine sprayPlacebo Pain assessment during different stages of IUD insertion
de Oliveira et al. [29]550 mg Naproxen Sodium for pain control during 52 mg LNG-IUS insertion2% lidocaine intracervical blockPain assessment during different stages of IUD insertion
Panichyawat et al. [30]10% lidocaine sprayPlacebo VAS score immediately after Cu-IUD placement
Ashour et al. [38]Vaginal misoprostolVaginal DinoprostonePain assessment during different stages of IUD insertion
Conti et al. [39]2% lidocaine gelPlacebo Pain assessment during different stages of IUD insertion, procedure time, ease of insertion
Mody et al. [31]1% lidocaine paracervical blockNo blockPain assessment during different stages of IUD insertion
Karasu et al. [32]Topical lidocaine spray, cream, and injectionNo comparison groupPain assessment during different stages of IUD insertion
Abdellah et al. [33]Vaginal misoprostolPlaceboEase of IUD insertion, number of successful insertions, pain intensity scores, satisfaction, need for analgesics
Abbas et al. [34]Lidocaine–prilocaine creamPlaceboPain assessment during different stages of IUD insertion
Singh et al. [13]Nitrous oxideOxygenPain assessment during different stages of IUD insertion
Aksoy et al. [35]10% lidocaine sprayPlaceboIUD insertion pain score, as measured by the 10 cm VAS.
Tornblom-Paulander et al. [36]Lidocaine formulationPlaceboTo investigate the pharma- cokinetics, efficacy, and safety of this formulation of lidocaine as an anesthetic for IUD insertion.
Tavakolian et al. [37]Local anesthetic that contains 25 mg lidocaine and 25 mg of prilocaine per gram.PlaceboTo determine the effect of the used anesthetic on IUD insertion pain.
Allen et al. [40]2% lidocaine gelPlaceboPain during IUD insertion on a 0 to 100 mm visual analog scale.
Scavuzzi et al. [41]Vaginal misoprostolPlaceboEffectiveness of vaginal misoprostol in dilating the cervix prior to IUD insertion in nulligravidas.
McNicholas et al. [42]Intracervical 2% lidocaine gelPlaceboTo evaluate the efficacy of intracervical 2% lidocaine gel for pain relief with IUD insertion.
Maguire et al. [43]2% lidocaine gelPlaceboEffect of intracervical 2% lidocaine gel prior to IUD insertion on pain during sounding and IUD insertion as measured by the 100 mm VAS
Charandabi et al. [44]2% lidocaine gelLubricant gel or no interventionEffect of lidocaine gel on pain from copper IUD insertion.
Dogan et al. [45]Paracervical block and Oral Paracetamol (500 mg)No intervention.Pain levels using VAS during and after insertion of IUD.
Envall et al. [46]Mepivacaine 1%PlaceboDifference in VAS score between intervention and placebo at the time of IUD insertion
Castro et al. [47]NSAID (ibuprofen, 400 mg)Injectable local anesthetic (2% lidocaine without vasoconstrictor)Effect of intracervical anesthesia compared with NSAIDs on pain scores following LNG-IUS insertion in women without a previous vaginal delivery who had not previously used any IUCD
De Nadai et al. [48]Intracervical block (3.6 mL 2% lidocaine (72 mg)PlaceboPain measurement immediately after LNG-IUS insertion.
Hashem et al. [49]5 mL of 5% lidocaine–prilocaine creamPlaceboThe difference in pain scores during IUD insertion
EL-Gharib et al. [50]Vaginal misoprostolIM diclofenac sodium 75 mgAssessment of the analgesic effect of vaginal misoprostol versus intramuscular diclofenac sodium and in facilitating IUCD insertion in women with cervical stenosis.
El-Ghannam et al. [51]Vaginal misoprostol3 mg dinoprostoneThe measured the success rate of
IUD insertion of both groups.
Sakna et al. [55]10% local lidocaine spray, IbuprofenIbuprofenSelf-reported pain score
Fahmy et al. [52]1% lidocaine paracervical blockNaproxenPain on speculum placement, tenaculum placement, intrauterine device insertion, and after procedure
Nugud et al. [53](400 mcg) of misoprostolPlaceboEffect of vaginal misoprostol and intramuscular diclofenac sodium in decreasing pain and facilitating IUCD insertion.
Samy et al. [16]Vaginal dinoprostone 3 mg Vaginal placebothe mean difference in pain scores during LNG-IUD insertion between both groups.
IUD, Intrauterine Device; IUCD, Intrauterine Contraceptive Device; VAS, Visual Analog Scale; LNG-IUS, Levonorgestrel-releasing Intrauterine System; NSAIDs, Non-Steroidal Anti-inflammatory Drugs; IM, intramuscular; Cu-IUD, copper intrauterine device.
Table 3. The summary of the outcomes of the included studies.
Table 3. The summary of the outcomes of the included studies.
AuthorsSuccess RateEase of InsertionPain ScoresSide Effect
Cirik [19]NANAThis study demonstrated significantly lower pain perception in the paracervical block group when compared to the placebo and no treatment groups.There were 5 patients who had vasovagal syncope, one in the paracervical group, 2 in saline group and 2 were in the no treatment group (p = 0.36).
No bleeding or uterine perforation reported
Mohammed [20]There was no statistically significant difference
between the vaginal misoprostol group and sublingual misoprostol group regarding the success rate from
first and second attempts.
NAThere is a highly statistically significant
increase in pain during IUD applications in sublingual misoprostol group than vaginal misoprostol group (p = 0.001).
No significant difference in
postinsertion US follow-up, infection, or changes in
postinsertion menstruation between the two groups.
Saad [21]Misoprostol group: 70% success vs. Placebo group: 25% success (p < 0.001)Vaginal administration of 400 μg misoprostol 3 h before IUD insertion was significantly associated with less difficulty of insertionUsing misoprostol before IUD insertion decreases pain during uterine sounding significantlyVaginal misoprostol (400 μg) had significantly reduced complications of IUD insertion such as pain and bleeding.
Salama [54]NAMirena insertion significantly easier in Misoprostol groups compared to placeboPain score during Mirena IUD insertion in group 2 and group 3 (misoprostol groups) is significantly lower than in group 1 (placebo group) (p = 0.031 and 0.035, respectively).Nausea and/or vomiting, uterine cramps significantly more frequent with misoprostol 400 mcg compared to placebo and misoprostol 200 mcg.
Diarrhea was presented only in misoprostol groups, Making a significant difference when compared with placebo.
No significant differences in fever or perforation
Hajiesmaello [22]All participants had successful IUD insertions.NASignificant reduction in pain scores during hysterometer and during the IUD insertion (p < 0.001).
There was also a significant difference in pain score at 15 min
after IUD insertion between the control and intervention groups
No systemic adverse effects were observed
Hassan [23]4 failed insertions and 126 were successful (96.9 success rate)IUD insertion is significantly easier in Misoprostol groups compared to the placebo (p < 0.001)There were no statistically significant terms of anticipated pain speculum, pain after 20 min, and insertion time p-value > 0.05.There was no statistically significant spotting, abdominal cramps, nausea, vomiting, shivering, fever, and need additional analgesia p-value > 0.05.
On the other hand, there was a statistical difference in diarrhea < 0.001.
Abbas [24]All participants had successful IUD insertionThere was no statistical significant differences between both groups (lidocaine gel group and placebo group) in regard to the ease of insertion.Lower pain scores during vulsellum placement and uterine sounding in lidocaine group (p < 0.001).
No statistical significant differences between both groups in other steps of IUD insertion.
No cases of uterine perforation or vasovagal reactions were observed in both groups
El-Sayed [25]Misoprostol increased the success rate from 60.6% to 91.4% in the group with
previous cesarean section, and from 29.4% to 80% in the group with previous vaginal delivery with a p value 0.037.
NANANA
Bayoumy et al. [26]All procedures were successful (100%)NAPain score after grasping of cervix with tenaculum and pain score after
hysterometry and IUCD insertion by VAS
signify that lidocaine spray 10% decreases
pain felt during the process of IUCD insertion
No flushing or metallic taste adverse
effects were observed in any of the 3 study groups. whereas n = 3 (7.3%) participants reported redness of skin with lidocaine spray and n = 5 (12.2%) participants with lidocaine cream.
Sakna et al. [27]Administration of misoprostol
prior to IUCD insertion was significantly associated
with an almost 2-fold increase in the success rate of
IUCD insertion.
Insertion was significantly easier among the Misoprostol group (p < 0.001)Pain perception was significantly lower among Misoprostol group than among control group.Nausea, vomiting, and shivering significantly more frequent in Misoprostol group compared to control
Elsafty et al. [28]NANAThe lidocaine group had significantly lower pain scores during cervical grasping and traction than the placebo (saline) group (p < 0.001)Severe burning sensation in 2 participants in lidocaine group; Vasovagal syncope in 1 participant in saline group; Excluded from the study
de Oliveira et al. [29]Women in the intracervical group presented high proportion of malpositioned IUS on transvaginal US compared to naproxen group. (11.8% vs. 0%, respectively; p < 0.05)The difficulty of insertion was statistically similar between the two groupsLower pain perception in intracervical block using 2% lidocaine compared to naproxen group (p < 0.001)Vasovagal-like responses (dizziness, nausea, vomiting) observed during LNG-IUS insertion; 3 in naproxen group versus 4 in the intracervical group
Panichyawat et al. [30]NANAThe 10% lidocaine spray group had significantly lower VAS score compared to placebo during and immediately after IUD insertionSignificantly more women in the 10% lidocaine group reported vaginal irritation side effect than women in placebo group (34 versus 1, respectively; p < 0.001)
Ashour et al. [38]NASignificantly easier IUD insertion with misoprostol and dinoprostone groups compared to the placebo (p = 0.001 and p < 0.001, respectively)Misoprostol and Dinoprostone groups had significantly lower pain scores during copper IUD insertion than placebo group (p = 0.02 and p < 0.001, respectively)Side effects did not differ among the three groups
Conti, et al. [39]NANAOnly median pain scores at speculum insertion were significantly different between the lidocaine and placebo group (7 mm vs. 11 mm, respectively; p = 0.046)NA
Mody et al. [31]NANAWomen who received the paracervical block reported
less pain with IUD placement compared to women who received no block (median VAS score of
33 mm compared with 54 mm, p = 0.002).
There was no difference in patient reported adverse effects between the two groups
Karasu et al. [32]NANAPain related to IUD insertion was lower in the lidocaine spray and injection groups (p < 0.001).NA
Abdellah et al. [33]Higher number of successful
IUD insertions in the misoprostol group than the placebo group (69 [98.6%] vs. 61 [87.1%], p = 0.009).
The ease of insertion score was lower in the misoprostol group (2.2 ± 0.5 vs. 4.2 ± 0.5, p = 0.0001).Lower pain score
in the misoprostol group compared to the placebo group (2.7 ± 0.6 vs. 4.3 ± 0.8, p = 0.001)
Abdominal cramping and
shivering occurred more in misoprostol group (22.9% vs.
4.3% and 14.3% vs. 2.9%, respectively), with no difference
between both groups in other side effects.
Abbas et al. [34]NAA lower ease of
insertion score among lidocaine–prilocaine cream group compared to placebo group (p = 0.001).
Lower pain perception in the lidocaine–prilocaine cream groupNA
Singh et al. [13]NANANitrous oxide did not significantly reduce painAdverse effects in N2O/O2 and O2 groups; dizziness, nausea, headache, vomiting reported; no significant difference between groups (p = 0.32)
Aksoy et al. [35]All procedures were successfully completed without severe complications or serious adverse reactions.NAA significantly lower score for overall pain during the procedure was found in the treatment group compared to controls (p < 0.001).Successful procedures without severe complications; mild complications with vasovagal reactions (nausea, vomiting, dizziness); no systemic side effects with 10% lidocaine spray
Tornblom-Paulander et al. [36]NANAPain scores on the VAS were low, with mean values of <9 mm at all time points after IUD insertion.Adverse events were similar in the placebo and lidocaine groups. No serious adverse events were reported. At least one adverse event occurred for 32 women who received the lidocaine (29.1%), and for 36 (33.3%) of those who received the placebo. The most common adverse events were nausea and gastrointestinal problems.
Tavakolian et al. [37]NANAThere was a significant difference between the two groups in the third stage (inserting IUD and removing the insertion tube) as it was 4.61 ± 2.55 in the placebo group and 2.65 ± 2.53 in the intervention group (p < 0.001).NA
Allen et al. [40]NAThere was no difference between the groups in procedure difficulty as rated by the provider.no difference in pain scores between the lidocaine and placebo groups.No participants reported systemic lidocaine side effects.
Scavuzzi et al. [41]NALess difficulty in IUD insertion when misoprostol was used prior to insertion.44% reduction in moderate-to-severe pain during IUD insertion compared with the placebo group.No significant differences in complications during IUD insertion; similar frequency of bleeding, vasovagal reaction, cramps, nausea, vomiting, and insertion failures; no uterine perforation reported.
McNicholas et al. [42]NANANo significant difference in pain between groups.Adverse events considered: 5 total expulsions (4 in placebo arm, 1 in lidocaine arm); 1 perforation in parous postpartum participant; 1 case of pelvic inflammatory disease.
Maguire et al. [43]One hundred ninety-seven women had successful IUD insertions. One IUD was not inserted due to suspicion of perforation during uterine sounding, and two were not inserted due to inappropriate IUD insertion into the cervical canal.NANo significant difference in pain between groups.Side effects including nausea, vomiting, and dizziness highly similar between groups
Charandabi et al. [44]NANANo significant difference in pain between groups.NA
Dogan et al. [45]All patients had successful IUD insertion at first attempt.All patients had successful IUD insertion at first attempt.Lower pain perceptionProcedural complications such as vasovagal symptoms and syncope, bleeding, immediate expulsion or mispositioning and uterine perforation did not occur.
Envall et al. [46]NANALower pain perceptionNA
Castro et al. [47]NAMajority of the insertions were easy in both groups.No significant difference in pain between groupsNA
De Nadai et al. [48]99.3% success rate in the insertion of the levonorgestrel-releasing intrauterine system among nulligravid women (300 out of 302).Similar among all groupsSignificant pain reduction during and after the insertion of the LNG-IUS compared to the placebo, no-intervention groups.NA
Hashem et al. [49]NA Similar among all groupsPain scores were significantly lower in the LP group compared to the placebo group.Comparable drug-side effects between groups; Vomiting and abdominal cramps higher in misoprostol group (p = 0.039 and p = 0.093, respectively)
EL-Gharib et al. [50]NA Misoprostol facilitated IUD insertionInsignificant differences between misoprostol and diclofenac groups as regards pain scoreSide effects of IUD insertion: Misoprostol group—nausea and vomiting (36.7%), syncopal attack (3.3%), bleeding (0%), perforation (0%), gastritis (0%); Diclofenac group—nausea and vomiting (0%), syncopal attack (0%), bleeding (0%), perforation (0%), gastritis (20%)
El-Ghannam et al. [51]92% in the misoprostol group and 86% in the dinoprostone group.Both misoprostol and dinoprostone were effective in easing the insertion of copper IUDs.No significance difference between the two studied groups during IUD insertionMore side effects in group A (Misoprostol) than group B (Dinoprostone); no significant difference in side effects (p > 0.05)
Sakna et al. [55]97.1% in the lidocaine spray group and 95.7% in the ibuprofen tablet group. The failure of insertion was statistically non-significant between the two groups.Similar among all groupsPatients’ pain perception statistically was significantly lower among lidocaine spray groupNA
Fahmy et al. [52]NANA No significance difference between two studied group during IUD insertionComplications in two participants: small vaginal hematoma resolved with paracervical block; dyspepsia, heartburn, headache, and vaginal spotting with NSAIDs; no significant difference (p > 0.05)
Nugud et al. [53]NAMisoprostol facilitated IUD insertionNo significance difference between two studied group during IUD insertionSide effects in IUD insertion: nausea and vomiting in 37.5% and syncopal attack in 6.3% among the misoprostol
Samy et al. [16]NADinoprostone facilitated IUD insertionPain scores were significantly lower in dinoprostone group compared to placebo group.Side effects were not significantly different in Dinoprostone group versus placebo group
IUD, Intrauterine Device; IUCD, Intrauterine Contraceptive Device; IUS, Intrauterine System; VAS, Visual Analog Scale; LNG-IUS, Levonorgestrel-releasing Intrauterine System; NA, Not Assessed; US, Ultrasound; NSAIDs, Non-Steroidal Anti-inflammatory Drugs; N2O, Nitrous Oxide; O2, Oxygen; LP, Lidocaine–Prilocaine Cream.
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MDPI and ACS Style

Altamimi, R.; Bin Salamah, R.; Almajed, E.; AlZabin, A.; Alzelfawi, L.; AlMutiri, W.; Alkinani, A.; Almusharaf, L. Use of Local Anesthetic Agents and Conscious Sedation in Intrauterine Device Insertion: A Systematic Review. Women 2025, 5, 2. https://doi.org/10.3390/women5010002

AMA Style

Altamimi R, Bin Salamah R, Almajed E, AlZabin A, Alzelfawi L, AlMutiri W, Alkinani A, Almusharaf L. Use of Local Anesthetic Agents and Conscious Sedation in Intrauterine Device Insertion: A Systematic Review. Women. 2025; 5(1):2. https://doi.org/10.3390/women5010002

Chicago/Turabian Style

Altamimi, Reem, Rawan Bin Salamah, Ebtesam Almajed, Alya AlZabin, Lama Alzelfawi, Wijdan AlMutiri, Amer Alkinani, and Lamya Almusharaf. 2025. "Use of Local Anesthetic Agents and Conscious Sedation in Intrauterine Device Insertion: A Systematic Review" Women 5, no. 1: 2. https://doi.org/10.3390/women5010002

APA Style

Altamimi, R., Bin Salamah, R., Almajed, E., AlZabin, A., Alzelfawi, L., AlMutiri, W., Alkinani, A., & Almusharaf, L. (2025). Use of Local Anesthetic Agents and Conscious Sedation in Intrauterine Device Insertion: A Systematic Review. Women, 5(1), 2. https://doi.org/10.3390/women5010002

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