An intrauterine device (IUD) is a highly effective, long-acting reversible contraceptive method placed directly inside the uterus. These small, T-shaped devices prevent pregnancy by either releasing hormones or copper. The question of whether IUD placement is possible often arises for people who have been told they have a “tilted uterus.” The definitive answer is that, in most cases, an IUD can be safely and successfully inserted, but the procedure requires specific, careful adjustments by the healthcare provider.
What It Means to Have a Tilted Uterus
A tilted uterus, medically termed a retroverted uterus, is a common anatomical variation, not a medical condition or abnormality. The uterus is typically positioned in an anteverted state, meaning it tilts forward over the bladder toward the abdomen, which is the orientation found in 70 to 80% of individuals. A retroverted uterus, by contrast, tilts backward toward the rectum and the spine, an orientation present in about 20 to 30% of women.
This backward tilt can be present from birth due to genetic factors or it may develop later in life. Acquired retroversion can result from conditions like endometriosis, which causes scar tissue or adhesions that pull the uterus backward, or from the stretching of supporting ligaments after childbirth. For the majority of people, this difference in positioning causes no symptoms and is often only discovered during a routine pelvic examination or ultrasound.
Navigating IUD Insertion with a Tilt
The primary challenge during IUD insertion in a retroverted uterus is the misalignment between the vaginal canal and the uterine cavity. The backward tilt creates a sharper angle between the cervix and the body of the uterus, which must be navigated to ensure the device is placed correctly at the top, or fundus, of the uterus. The procedure begins with a careful bimanual examination to accurately determine the exact angle, size, and depth of the uterine cavity before any instrument is passed.
The provider will then typically use an instrument called a tenaculum to gently grasp the cervix. For a retroverted uterus, the tenaculum is often placed on the posterior lip of the cervix, rather than the anterior lip used in a forward-tilted uterus. Applying gentle, steady traction with the tenaculum helps to straighten the cervical canal, momentarily aligning the cervix with the uterine body to facilitate a smoother path for the IUD inserter.
Following this, a sterile, flexible instrument called a uterine sound is carefully inserted to measure the depth and confirm the direction of the cavity. This step is especially important in a tilted uterus to reduce the risk of the IUD being placed incorrectly or causing perforation. In complex cases or when a severe tilt is present, the provider may elect to use real-time ultrasound guidance to visualize the entire process, which has been shown to reduce pain, complication rates, and the chance of insertion failure.
Efficacy and Monitoring After Placement
Once the IUD is successfully placed in the fundus of a retroverted uterus, its contraceptive efficacy is not compromised. The mechanism of action, whether hormonal or copper-based, functions locally within the uterine cavity regardless of the uterus’s physical orientation in the pelvis. Therefore, the pregnancy prevention rates remain consistently high, comparable to those of an anteverted uterus.
While the overall performance is similar, some studies suggest that a retroverted position may be associated with a slightly elevated, though still low, risk of IUD malposition or expulsion compared to a forward-tilted uterus. IUD expulsion is an uncommon event, generally occurring in about 2 to 10% of users in the first year, but careful placement is paramount to minimize this risk. Due to the anatomical variation, healthcare providers often recommend a close follow-up check soon after insertion to confirm the IUD remains correctly positioned high in the uterus.
Patients are still instructed to perform regular self-checks for the IUD strings, which are the only tangible sign that the device is in place. Because the cervix may be angled more toward the back, locating the strings can sometimes be slightly more challenging for the patient or provider during a routine exam. The backward tilt does not affect the IUD’s ability to remain within the uterine cavity, provided it was initially placed correctly.