• Explaining the procedure to the client and responding to her questions and concerns. This helps the client relax, making insertion easier and less painful.
• Infection-prevention procedures including use of high-level disinfected instruments and cleaning of the cervix with a water-based antiseptic such as chlorhexidene gluconate or an iodophor (for example, Betadine®). This minimizes the chances of uterine infection following insertion. Particularly useful is the no-touch technique, which includes loading sterile packaged IUDs in their inserters while both IUD and inserter are still in the sterile packaging (614) (see sidebar, Infection Prevention for IUD Insertion and Removal).
• Speculum examination and bimanual pelvic examination. The speculum exam should come first, to check for signs of genital tract infection. The bimanual exam determines the size, position, consistency, and mobility of the uterus and identifies any tenderness, which might indicate infection (614). A retroverted uterus—that is, bent backward—requires special care during insertion (449).

• Sounding of the uterus slowly and gently to determine its depth and direction. This reduces the risk of perforating the uterus, which usually occurs because the sound or IUD is inserted too deeply or at the wrong angle (7, 63, 190, 395, 437).
• Careful and slow technique during all phases of sounding and insertion. This reduces the client's discomfort and minimizes the chances of uterine perforation, cervical laceration, and other complications (57, 62, 63, 123).
• IUD placement high in the uterus (that is, at the fundus). This minimizes expulsions, accidental pregnancies, and possibly bleeding (71, 269, 332, 382).
• Following the manufacturer's instructions for insertion. Most IUDs are inserted by the withdrawal technique: The inserter tube, loaded with the IUD, is inserted to the depth indicated by sounding. Then the inserter tube is withdrawn while the inner plunger is held steady. This leaves the IUD in position. Then the plunger is withdrawn (591).

Health care providers should never use force to insert an IUD. Instead, the provider may ask the client to return during her menstrual period, when insertion may be easier, or refer her to a more experienced provider, who may use dilators, with or without paracervical anesthesia, if the cervical canal is narrow. Cervical dilation does not increase the risk of later expulsion (55). Insertion failures are rare—2 to 8 per 1,000 attempted insertions—and are usually due to excessive pain or to the larger size of inserter used with some types of IUDs (63).

Many currently available IUDs are supplied in individual sterile packages with a sterile inserter. The packaged TCu-380A has a shelf-life approved by the US Food and Drug Administration of seven years. The copper on IUDs may become discolored in the packaging, but the IUD can still be used. It is still sterile, and the IUD will still be effective. If the package is damaged, however, the IUD and inserter may no longer be sterile, and it is best to discard them (36, 191, 213). Copper and plastic IUDs should never be boiled or autoclaved because heat deforms them (436).