An IUD insertion is a brief in-office procedure that typically takes under five minutes once it begins, though the total appointment runs longer. A clinician uses a speculum to visualize the cervix, stabilizes it with a small clamp, measures the depth of the uterus, and then slides the folded device through the cervical canal into the uterine cavity using a thin applicator tube. The device’s arms spring open once released, and the clinician trims the attached strings before removing the instruments. The whole sequence sounds more involved than it feels for most people, but the details matter if you want to know what is actually happening at each step and why.
What Happens Before the Procedure Starts
You will likely be asked to schedule the appointment during or shortly after your period, not because insertion is impossible at other times, but because the cervix is slightly softer and more open during menstruation. Some providers also like the reassurance that you are not pregnant. Beyond scheduling, there is surprisingly little required preparation. You can eat and drink normally. Most providers recommend taking an over-the-counter painkiller like ibuprofen about 30 to 60 minutes beforehand.
One thing you probably do not need is misoprostol, a medication sometimes prescribed to soften and open the cervix before insertion. A randomized trial in women who had never given birth found no meaningful difference in pain during IUD placement between those who took misoprostol and those who took a placebo. The misoprostol group actually reported more nausea and cramping before the procedure even started.1PubMed. Effects of prophylactic misoprostol administration prior to intrauterine device insertion in nulliparous women Some providers still use it in select cases where they anticipate a tight cervix, but routine prescribing has fallen out of favor.
The Speculum and Cervical Stabilization
The first thing you feel is the speculum, the same duck-bill instrument used during a Pap smear. It holds the vaginal walls apart so the clinician can see the cervix clearly. This part is familiar if you have had a pelvic exam before, and it is more pressure than pain for most people.
Once the cervix is visible, the provider cleans it with an antiseptic solution and then applies a tenaculum, a narrow clamp that grips the cervix and holds it steady. This step steadies the cervix so the rest of the instruments can pass through the cervical canal in a straight line. Most people describe the tenaculum as a sharp pinch or cramp. It is often cited as one of the more uncomfortable moments of the whole procedure, and it is also one of the shortest.
Measuring the Uterus
Before the IUD goes in, the clinician needs to know the depth and direction of your uterine cavity. Traditionally, this is done with a uterine sound, a thin, flexible rod that is gently passed through the cervical canal until it reaches the top of the uterus. The measured depth, usually somewhere between six and nine centimeters, tells the provider whether the cavity is large enough for the device and helps them set the inserter to the right depth.
Sounding is the step that often catches people off guard. It causes a deep, crampy sensation as the rod moves through the internal cervical opening. It is brief, but some describe it as the single most intense moment of the procedure. Interestingly, there is growing debate among researchers about whether sounding is even necessary. A recent review found that the measurements produced by sounding are prone to error and may not provide objective benefit over ultrasound imaging, particularly with newer device designs.2PubMed Central. Is Sounding the Uterus Prior to Intrauterine Device Placement Still Relevant? Despite this, sounding remains part of the standard insertion protocol recommended by most IUD manufacturers, so you are still likely to encounter it.
How the Device Is Deployed
The IUD itself arrives folded flat inside a narrow plastic inserter tube, roughly the diameter of a drinking straw. The clinician slides this tube through the cervical canal to the depth measured during sounding. At the correct position, they pull back the outer sleeve of the inserter, which releases the IUD’s arms so they spring open into their T shape (or their specific configuration, depending on the brand). The provider then withdraws the inserter tube, leaving the device seated at the top of the uterine cavity.
The actual physical force required to place the device is modest. Measurements show that insertion forces range from about 1.5 to 6.5 newtons depending on the device, roughly the force you would use to press a key on a stiff keyboard.3International Journal of Women’s Health. Role of uterine forces in intrauterine device embedment, perforation, and expulsion The cramping you feel during deployment comes less from the force itself and more from the cervix being dilated by the tube and the uterus responding to a foreign object.
This step takes only a few seconds. Most people feel a strong cramp as the arms open and then a rapid easing of intensity as the inserter is removed.
Trimming the Strings and Wrapping Up
Every IUD has one or two thin plastic strings attached to its base. These hang down through the cervix into the upper vagina so the device can be checked and eventually removed. After releasing the IUD, the clinician trims the strings to about three to four centimeters outside the cervix.4Obstetrics and Gynecology Clinics of North America. Long-Acting Reversible Contraception (LARC) The strings are thin enough that you cannot feel them, though a partner sometimes can during sex. If the strings cause irritation, a provider can trim them shorter at a follow-up visit.
With the strings trimmed, the tenaculum is released and the speculum is removed. You might notice a small amount of spotting from the tenaculum site. Most clinicians will ask you to rest on the exam table for a few minutes to make sure you feel stable before you get dressed. The entire hands-on portion, from speculum in to speculum out, typically takes three to five minutes.
What the Pain Actually Feels Like and What Helps
Pain experiences during IUD insertion vary enormously, and this is one area where online discussions can create outsized anxiety. Some people describe mild cramping comparable to a period. Others report sharp, intense pain that fades within seconds of each step. The moments most commonly rated as the worst are the tenaculum placement and the sounding or device deployment, both of which involve passing something through the tight internal cervical opening.
A systematic review comparing multiple pain-lowering strategies found that lidocaine-prilocaine cream ranked highest for reducing pain both at tenaculum placement and during the actual insertion, followed by paracervical lidocaine injection.5PubMed. Evaluating different pain lowering medications during intrauterine device insertion: a systematic review and network meta-analysis Paracervical blocks involve several small injections of local anesthetic around the cervix. They add a minute or two to the procedure and have their own brief sting, but they numb the cervix for the steps that follow. Not every clinic routinely offers anesthesia for IUD insertion, so it is worth asking about your options ahead of time if pain is a concern.
More novel approaches are also being studied. A randomized trial found that wearing virtual reality goggles during the procedure significantly lowered both pain scores and anxiety symptoms compared to standard care.6Perspectives in Psychiatric Care. Easing the Experience: Virtual Reality as a Tool to Reduce Anxiety and Pain During IUD Insertion—A Single‐Blind Randomized Controlled Trial Distraction techniques like VR are not yet mainstream, but they point to how much of the pain experience is linked to fear and anticipation rather than the mechanical stimulus alone.
Vasovagal Reactions During Insertion
Some people feel lightheaded, nauseated, or faint during or immediately after IUD insertion. This is a vasovagal response, a reflex where the vagus nerve is stimulated and your heart rate and blood pressure temporarily drop. It is more common than most patient information leaflets suggest, and it is the main reason clinicians ask you to lie still for a few minutes afterward.
Research on vasovagal reactions during insertion found that people who have never given birth and those experiencing moderate to severe pelvic pain during the procedure are at the highest risk.7PubMed. Syncope and other vasovagal reactions at interval insertion of Lippes Loop D–who is most vulnerable? The reaction is almost always self-limiting, resolving within minutes with rest, legs elevated, and sometimes a cold cloth. Eating a snack and staying hydrated before your appointment helps. If you have a history of fainting during blood draws or medical procedures, let your provider know so they can take extra care with pacing and pain management.
How Rare Complications Happen
Uterine perforation, where the IUD or an instrument passes through the wall of the uterus, is the complication people worry about most. It is genuinely uncommon, occurring in roughly 1 in 1,000 insertions overall.8PubMed Central. Intrauterine devices and risk of uterine perforation: current perspectives Perforation can be partial, with the device embedded in the uterine wall, or complete, with it migrating into the abdominal cavity. Most partial perforations are identified at follow-up and managed without emergency surgery.
A large study of over 326,000 IUD placements found that the five-year cumulative incidence of perforation was about 0.6% overall, but the risk was not distributed evenly. Insertions done between four days and six weeks postpartum carried roughly 6.7 times the perforation risk compared to nonpostpartum insertions. Breastfeeding at the time of insertion further increased the risk by about 40% among postpartum individuals.9PubMed Central. Risks of Uterine Perforation and Expulsion Associated With Intrauterine Devices For people who are not recently postpartum, the five-year perforation rate was about 0.3%, which is very low.
Provider experience also matters. One study found that less experienced clinicians were associated with a higher rate of perforation, and that ultrasound performed both before and after insertion was more common among patients who did not experience perforation.10PubMed Central. Risk factors of uterine perforation when using contraceptive intrauterine devices This does not mean you need to interrogate your provider’s resume, but it does suggest that going to a clinic where IUD insertions are routine rather than rare is a reasonable precaution.
Expulsion and What Increases the Risk
Expulsion, where the IUD partially or completely slips out of position, is more common than perforation and usually less dangerous, though it does mean the device is no longer protecting you. Among the general population getting IUDs outside of the postpartum period, the strongest risk factor for expulsion is a history of heavy menstrual bleeding, especially if the diagnosis has been present over a long period.11PubMed Central. Demographic, Reproductive, and Medical Risk Factors for Intrauterine Device Expulsion Younger age, higher body weight, and having had four or more pregnancies also increased the risk in that analysis.
Expulsion rates are highest in the first few months after insertion. You check for it yourself by reaching into the vagina and feeling for the strings. If they feel longer than usual, shorter than usual, or you can feel the hard plastic base of the device, the IUD has moved and you should contact your provider. Three-dimensional ultrasound is especially good at catching subtle malpositions, including cases where one arm of the T has embedded in the uterine wall while the device is still technically in place.12PubMed Central. Ultrasonography of intrauterine devices
Postpartum Insertion Has Different Rules
If you are getting an IUD placed after giving birth, the timing makes a meaningful difference in how the procedure goes and what risks you face. There are three broad windows: immediate (within minutes of delivering the placenta), early (the first few weeks postpartum), and interval (six or more weeks after delivery).
Immediate postpartum insertion is done while you are still in the delivery room. Because the cervix is fully dilated, no speculum, tenaculum, or sounding is needed. The provider places the IUD into the large, soft uterus by hand or with a specialized inserter. The tradeoff is a higher expulsion rate. A meta-analysis found that expulsion occurred in about 10% of immediate postpartum placements, compared to roughly 2% for interval placements done at four or more weeks after delivery.13PubMed Central. Intrauterine Device Expulsion After Postpartum Placement: A Systematic Review and Meta-analysis
A large cohort study confirmed that the expulsion risk was highest for the immediate window (five-year cumulative incidence around 10.7%) and lowest for insertions at the six-to-fourteen-week mark (about 3.2%).14PubMed Central. Association of the Timing of Postpartum Intrauterine Device Insertion and Breastfeeding With Risks of Intrauterine Device Expulsion A randomized trial comparing early placement at about four weeks to standard interval placement at six or more weeks found that complete expulsion at six months was low in both groups, at 2% and 0% respectively, though partial expulsion was somewhat more common in the earlier group.15JAMA. Early vs Interval Postpartum Intrauterine Device Placement: A Randomized Clinical Trial
The clinical logic is that many people do not return for a six-week postpartum visit, so offering the IUD immediately or early prevents gaps in contraception even though the device is somewhat more likely to be expelled. Providers weigh this tradeoff on a case-by-case basis.
When Ultrasound-Guided Insertion Helps
Standard IUD insertion is done “blind” in the sense that the provider feels the anatomy rather than seeing it in real time. For most people, this works perfectly well. But certain situations make the standard approach trickier, and that is where ultrasound guidance comes in.
A study of 67 patients referred for transabdominal ultrasound-guided IUD insertion found that the most common reasons for referral included fibroids, unusual uterine position, a history of previous IUD expulsion, and limited tolerance of pelvic exams. Of those 67, 56 had the device placed successfully with ultrasound guidance. The cases that failed were due to patient discomfort, cervical stenosis, or the inability to remove and replace an existing device.16PubMed. Sonographically guided insertion of intrauterine device: Indications and results Ultrasound guidance allows the provider to watch the device travel through the canal on a screen, confirming correct placement in real time rather than relying on tactile feedback alone.
If you have been told you have a sharply tilted uterus, large fibroids near the cavity, or have had a previous IUD expelled, asking about ultrasound-guided placement is reasonable. Not every clinic has the equipment or the scheduling flexibility to offer it, but many gynecology and radiology departments can accommodate it. For people with anxiety about the procedure, the ability to watch the screen alongside their provider also serves as a form of reassurance and, informally, distraction.