Table 2. Summary of the 19 articles included in the review.

N: Sample size; IUD: intrauterine device; EMLA: eutectic mixture of local anesthetics; cc: cubic centimeter

Authors	Study Design	Sample	Study Aim	Specialty	Findings	Recommendations	Limitations
Brima (2015) [7]	Analytical Cross-sectional Study	N = 89	Compare the expected and actual pain experienced with the placement of IUD, and to evaluate if these are associated with personal circumstances or impacted their satisfaction with the procedure.	Camberwell Sexual Health Clinic based at King’s College Hospital, London	Expectation of pain prior to the IUD insertion was high for all women, but for those who have had vaginal deliveries their expected pain was significantly higher than actual pain. When comparing women who had not had a previous vaginal delivery with those who have, actual pain experienced was much higher.	Assessing the participants anxiety before the placement of the IUD. Additional research on types of pain management strategies for IUD placements.	The use of a more objective numerical scale versus a visual analog scale (VAS) or a tool that requires administration by the researcher to the patient. The small convenience sample.
Bednarek (2015) [8]	Randomized Controlled Trial	N = 202	Evaluate the effectiveness of 800mg ibuprofen in reducing pain with intrauterine device (IUD) insertion among US women.	Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR	Mean and median pain scores did not differ between placebo and ibuprofen when nulliparous and parous women were analyzed independently.	Concentrate on alternate strategies to reduce pain and improve satisfaction with IUD insertion among nulliparous women. Assess pain and drug absorption at different time points.	The study failed to enroll the number of participants it had originally estimated. It also did not address pain in the hours after placement. Only one time point was evaluated for drug absorption.
Tavakolian (2015) [9]	Triple Blind Clinical Trial	N = 92	Evaluate the efficacy of a eutectic mixture of local anesthetics (EMLA; that contain 25mg lidocaine and 25mg prilocaine) at reducing pain during IUD insertion at multiple points during the procedure	Department of Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran	Use of EMLA cream significantly reduced pain at multiple points during the IUD insertion procedure. Patients in both the experiment and control group found hysterometer insertion as the most painful part of the procedure.	Expand the use of EMLA cream during IUD insertion procedures	Demographic data was presented as mean values instead of the raw number of participants that fit into each category. This obfuscates exactly who can benefit from using this method. Unclear if one or more clinicians performed the IUD insertion procedure.
Hylton (2020) [11]	Randomized Controlled Trial	N = 69	Determine whether use of cold compress on abdomen during IUD insertion reduces pain	University gynecology clinic Adults	No reduction in IUD insertional pain with cold compress	Consider perceptions of pain and in those with pain before procedure Assess role of both tenaculum placement and diameter of device placed in procedure-related pain as well as approaches to transpose anxiety-related to IUD insertion	Lack of documented tenaculum placement Lack of confirmation of timing of cold compress application Did not stratify BMI (which may have affected impact of cold compress) Did not stratify for parity or delivery type
Miles (2019) [15]	Randomized Controlled Trial	N = 160	Evaluate oral naproxen and intrauterine instillation of lidocaine for analgesia with intrauterine device (IUD) as compared to placebo	Walter Reed National Military Medical Center outpatient obstetrics and gynecology clinics	Naproxen with or without intrauterine lidocaine does not reduce pain with IUD placement	Include separate arm with no intervention (instillation of saline, usage of 18-gauge Angio catheter) other than IUD insertion, limit subjects to nulliparous women	Possible alternative treatment modalities other than IUD insertion, study not randomized to type of IUD
Aksoy (2016) [18]	Randomized Controlled Trial	N = 200	Study the effectiveness of 10% lidocaine spray to the cervix in reducing pain during IUD insertion.	Department of Obstetrics and Gynecology, Kayseri Education and Research Hospital, Kayseri 38010, Turkey	Lidocaine 10% spray is shown to be effective in lowering pain levels during IUD insertion when compared to placebo.	Perform a larger scale study involving other types of topical anesthetics in order to assess lidocaine effectiveness and optimal dosage.	Lack of a non-treatment group in addition to the treatment and placebo groups. The study also did not assess pain levels after the IUD is inserted. Finally, the study was only conducted in parous women, excluding nulliparous women.
Mody (2018) [19]	Randomized Controlled Trial	N = 64	Determine if a 20-cc buffered 1% lidocaine paracervical block could reduce pain during IUD placement	University of California, San Diego and Planned Parenthood of the Pacific Southwest	The 20-cc buffered 1% lidocaine paracervical block was able to decrease pain during the IUD placement, with uterine sounding, and 5 minutes after the placement. The overall perception of pain was lower when a block was administered compared to when no block was given at all.	Expanding the generalizability of the population by increasing the diversity in the age, education level and race of the participants to represent the national population.	The study had a lack of diversity when it came to education, age and race of the participants. In addition, not all types of IUDs where included, such as the LNG-52 mg IUD (Liletta®).
Ngo (2015) [20]	Randomized Controlled Trial	N = 67	Evaluate intramuscular ketorolac compared to placebo saline injection for pain control with IUD placement	University of California San Diego Women's Health Clinics	Ketorolac does not reduce pain with IUD placement but does reduce pain at 5 and 15 minutes after placement	Additional studies on efficacy of naproxen during and after IUD placement, larger sample size	Study was not powered to detect pain score differences less than 2.0cm or subgroup analysis by parity or other subgroups like IUD type, small sample size, participants were not followed past 15 minutes of injection to minimize clinic flow interruptions, unblinded staff administering study forms (could have caused bias), ketorolac may not be available in all clinics, painful intramuscular injection
Hunter (2020) [21]	Randomized Controlled Trial	N = 93	Identify factors that are associated with anticipated pain with IUD insertion in young women and adolescents	Three academic family planning clinics	Black race was only factor found to be associated with higher levels of anticipated pain	Recommend providers discuss with all women their anticipated pain, anxiety, pain management preference, and actual pain when undergoing IUD placement. Additional training in racial disparities and racial sensitivity.	Difference in anticipated pain between minority populations can be complex and multifactorial. Study population was only young adults therefore may not be generalizable to older populations. Secondary analysis which limited analysis to previously recorded data.
Fouda (2016) [22]	Randomized Controlled Trial	N = 90	Determine if diclofenac in combination with 2% lidocaine gel can reduce pain scores during the IUD insertion procedure.	Department of Obstetrics and Gynecology at Cairo University, Egypt.	Participants receiving diclofenac and lidocaine gel combo had lower pain scores during tenaculum application and IUD insertion. Pain scores were lower in women with previous vaginal deliveries compared to those who got a C-section.	Conduct additional research with both nulliparous and multiparous women as participants and have 1 or 2 gynecologists perform the insertions. Consider the diclofenac and lidocaine combo as a step in the pain management protocol.	None of the participants were nulliparous. 8 gynecologists completed the procedures, so it could have resulted in different experiences with different gynecologists. Only one type of IUD was used in the study, so the results may be different with other IUDs.
Chaves (2021) [23]	Prospective Single Cohort Study	N = 413	Compare pain scores during the insertion of a levonorgestrel releasing intrauterine system in women who have never given birth, women with previous vaginal delivery and women with previous cesarian delivery	Family Planning Service, Department of Obstetrics and Gynecology, Hospital das Clinicas of the Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil	Nulligravidas women had the highest mean pain scores among the three groups and nulligravidas women and women who had undergone elective cesarian delivery mostly classified their pain as moderate or severe.	Further investigating the differences in pain response among nulligravidas women, women with only vaginal deliveries and women with only cesarian deliveries and evaluating the impact that pain management can have among the groups	Risk of informational bias due to both gynecologist and resident physicians collecting data. The clinician performing the procedure was not blinded to what group a participant belonged to, creating possibility of bias. The study also did not take into consideration the role of past experiences such as obstetric history and sexual abuse.
Lambert (2020) [24]	Randomized Controlled Trial	N = 66	Compare pain reduction between "slow" and "cough" techniques for tenaculum placement	University gynecology clinic Adults	Neither method is superior for pain reduction or provider satisfaction	Larger study to demonstrate clinically significant differences in experience of pain	Unmeasured confounders such as anxiety level and use of anxiolytics
Bastin (2019) [25]	Prospective Observational Study	N=281 direct method; N =254 standard method	Compare the pain experienced using the direct method vs the standard method of IUD placement	General practitioner, gynecologist, and midwives	Less pain with insertion using the direct method of insertion vs the stand method of insertion. Additionally, using the direct method led to fewer adverse effects up to 6 months post insertion	Further studies to examine the contraceptive efficacy of IUDs placed with the direct method.	Study was observational and not a randomly controlled trial. Direct method group tended to utilize more drug-free strategies introducing a possible confounding variable.
Speedie (2016) [26]	Randomized Controlled Trial	N =100	Compare the single-toothed tenaculum to the Littlewoods forceps in regard to pain and ease of use during the IUD insertion procedure.	Community Sexual and Reproductive Healthcare Clinic in the United Kingdom.	No difference in pain scores during insertion and 5 minutes post-insertion. There was a difference 10- minute post-insertion; however, the scores were very low by 10 minutes with either forceps. No difference in the ease of use, with both being easy to use.	Either one of the forceps is an effective and appropriate tool for the insertion procedure, so the type of forceps might not be considered a factor when creating a pain management protocol. A new study with a larger sample size should be considered.	The study had a low sample size of only 100 participants. Some participants (30%-36% of participants in each arm) had already taken oral analgesia prior to the procedure (this was corrected for but did not mention how).
de Oliveira (2021) [27]	Randomized Controlled Trial	N = 100	Compare the effectiveness of 550 mg of naproxen sodium and lidocaine 2% intracervical block in lowering pain during IUD insertion.	Family Planning Service, Department of Obstetrics and Gynecology, Hospital das Clínicas of Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil	Lidocaine 2% intracervical block was found to be significantly more effective than 550mg of naproxen sodium in lowering pain during IUD insertion in young women.	double-blind study and match physician’s skill levels.	The medication option used was not blinded to either the physicians performing the procedure or the patients. In addition, physicians' experience levels were not the same, meaning most of them were residents, which could interfere with the pain levels.
Crawford (2017) [28]	Randomized Controlled Trial	N =72	Evaluate if oral ketorolac provides effective pain relief during placement of an IUD for contraception.	OhioHealth Riverside Methodist Hospital, Columbus, OH, USA	Oral ketorolac given 40 to 60 minutes prior to IUD insertion is effective in reducing pain during IUD deployment, overall pain, and pain 10 minutes after IUD placement.	Evaluate pain at different points of the procedure. Collect adverse effect data or post procedure pain medication use. Increase generalizability by utilizing more sites.	Lacked observation 30 and 60 minutes after procedure to consider the peak analgesic effects. LNG-releasing IUD was not available at the participating offices at the time of the study and thus application to this device may not be consistent with the devices studied. As this trial was completed at one site, this limits generalizability
Ashour (2020) [29]	Randomized Controlled Trial	N =129, N=43 Misoprostol, N = 43 dinoprostone	Compare the effect of Misoprostol vs dinoprostone vs placebo administration with IUD placement and its relative pain scale and ease of insertion	Family planning clinic of a tertiary referral hospital Cairo, Egypt	There was less pain and increase of ease in women who was administered Misoprostol and dinoprostone versus those who received the placebo	Further studies are needed to look at the side effects of these medications as prostaglandin analogs	This study only accounted for 2 prostaglandin analog and one type of IUD. (Copper T380A)
Torky (2017) [30]	Quasi-Experimental ( Prospective Multicentre Non-Randomised Comparative Study)	N = 420, N= 140 Lidocaine Gel, N= 140 Lidocaine Spray, N = 140 Placebo	Compare the effects of lidocaine gel vs spray on the perceived pain of IUS insertion	Air force Specialized hospital (New Cairo, Egypt), University Hospital (Giza Egypt), Al-Galaa Teaching hospital (Cairo, Egypt)	There was no significance with the use of lidocaine spray nor gel in comparison to the placebo in regard to IUD insertion. But there was significance when it came to pain during cervical traction.	Timing and dose should be considered for the application of analgesic for the optimal pain relief for IUD insertion.	This study was conducted in three different hospitals, participant number was not noted from how many participated from each respective hospital.
Elkhouly (2017) [31]	Randomized Controlled Trial	N = 200	Compare the use of Lidocaine, Misoprostol, and an NSAID to reduce pain during IUD insertion and the advantages of using one drug over another	Outpatient clinic of Menoufia University Department of Obstetrics and Gynecology	Similar mean pain scores during the IUD insertion procedure and 15 mins after in the groups who were administered an analgesic and the placebo group.	Additional research on perceived vs actual pain during IUD insertion, the effect of pain management when the insertion is performed by an inexperienced clinician and the use of pain management drugs when the procedure is performed without the use of a tenaculum	Researchers did not take into consideration whether the insertion was done in a routine or emergency setting, the position of the uterus in each participant, the experience level of the practitioner performing the procedure, and perceived pain of each participant. The clinicians performing the procedure were also not blinded creating the risk of bias when conducting the insertion