Cervical priming with sublingual misoprostol prior to insertion of an intrauterine device in nulliparous women: a randomized controlled trial

TLDR

The copper IUD is a highly effective and safe contraceptive, yet insertion can be technically challenging in nulliparous women with a narrow cervix, and the optimal misoprostol regimen remains unclear. To evaluate whether sublingual 400 µg misoprostol plus diclofenac improves cervical priming and eases IUD insertion compared with diclofenac alone in nulliparous women. Cervical dilatation was assessed with Hegar pins before insertion, and insertion ease was evaluated by the investigator. Misoprostol significantly eased IUD insertion (19 % improvement, P = 0.039) without increasing pain or overall side effects, though it was associated with a higher incidence of shivering.

Abstract

The copper intrauterine device (IUD) is a highly effective and safe contraceptive method, also in nulliparous women. However, insertion of an IUD through a narrow cervix may be technically difficult. Misoprostol has been shown to be effective for cervical priming in non-pregnant women prior to hysteroscopy.Eighty nulliparous women requesting an IUD were randomly allocated to receive sublingually 400 microg misoprostol and 100 mg diclofenac (misoprostol group) or 100 mg diclofenac alone (control group) 1 h prior to IUD insertion. Cervical dilatation was measured prior to insertion using Hegar pins. Ease of insertion was judged by the investigator. Pain, bleeding and side effects were recorded at insertion and until follow-up performed one month later.Following treatment with misoprostol, insertion was significantly easier than in the control group [P = 0.039, difference 19.36%, confidence interval (CI) -0.013, 39.99]. Pain estimated on a visual analogue scale (1-10) showed no evidence of a difference between the groups. The overall distribution of side effects did not differ. However, shivering was more common in the misoprostol group (P = 0.0084, difference 23.27%, CI 6.64, 39.90).Misoprostol facilitates insertion of an IUD, and reduces the number of difficult and failed attempts of insertions in women with a narrow cervical canal. The optimal regimen of misoprostol remains to be defined.