We appreciate the author's interest in continuing the conversation about how best to reduce pain for patients undergoing intrauterine procedures.
Since the publication of our article,1 the American College of Obstetricians and Gynecologists has published a Clinical Consensus on Pain Management for In-Office Uterine and Cervical Procedures.2 The consensus recommendation for intrauterine device procedures states: “local anesthetic agents may reduce intrauterine device insertion.” The discussion in this Consensus regarding nonpharmacologic pain management interventions highlights a 2023 systematic review and meta-analysis of 7 RCTs involving 1,267 patients evaluating the use of transabdominal ultrasound during IUD insertion.3 This evidence is described as “promising,” reflecting both an improvement in pain scores (reduction in the Visual Analog Scale pain score of −1.91 [95% CI (−3.08, −0.73), P = .0010]) but also the limitations of this approach as it requires ultrasound equipment and a knowledgeable assistant. In addition, we note that there are now concerns about the validity of this meta-analysis as 4 of the 7 RCTs have been retracted, reducing the number of patients who could be included in analyses from 1,267 to 600.4–7
While ultrasound can be considered as one of many options to potentially reduce pain during IUD insertion, evidence for routine use to reduce pain is lacking. We encourage clinicians to discuss options for pain relief with each patient and through shared decision making determine the best plan of care.
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