Avocados as simulation tools for intrauterine device insertion and removal

Intrauterine device (IUD) placement is a technical skill well within a family physician’s skillset. Long-acting reversible contraception constitutes 14.3% of birth control used worldwide.¹ In a study of American family medicine residents, Schubert et al noted “nearly nine in 10 family medicine residents (88.7%) reported that they were ‘likely’ or ‘very likely’ to insert IUDs in their future family medicine practices.”² However, previous research showed residents in primary care had varying degrees of knowledge about IUD placement, despite acknowledging their importance in primary care.

In a study of 74 family medicine, obstetrics, pediatrics, and internal medicine residents 1 month prior to graduation, 73% reported receiving formal training in contraception, but only 16% felt able to insert an IUD independently.³ It can be argued a physician’s ability to discuss and recommend varying contraception options constitutes an important intersection between medical education, clinical care, and public health outcomes.³ As such, practising IUD placement during medical training is imperative for today’s family medicine residents and practising physicians.

The medical education and pedagogy of IUD placement has most often involved transparent plastic models resembling a coronal cross-section of a uterus. The problem with these simulation models is they neither resemble, nor produce, a comparable tactile sensation to a cervix and uterus. Further, transparent plastic models make it easy to visualize IUD insertion and deployment, which is not comparable to reality. As such, placement of an IUD in a patient may be stressful for both the clinician and the patient owing to the sensitive nature of the anatomy involved and unique manual technique required to master the procedure, regardless of whether plastic models were used for practice.

To prepare for IUD placement and removal during resident teaching rounds, we endeavoured to find a more realistic representation of a uterus, and discovered a fresh avocado satisfies this need. Avocados are relatively inexpensive, readily available in grocery stores, and, by consensus of the resident and faculty group, more similar to a uterus than plastic models due to their opacity and insertion sensation. An avocado’s stem can be removed to create a simulated cervix and its size is comparable to a uterus. The internal texture is consistent with endometrial tissue. Practising IUD placement and removal techniques on avocados was found to be helpful and practical. As such, this model can easily be used in clinical medical education, regardless of the type of IUD being inserted.

Other fruits have previously been used to simulate tenaculum placement on the cervix, with green bananas found to be most useful.⁴ Similarly, papayas were used to demonstrate paracervical blocks, endometrial biopsies, and uterine aspiration and curettage.⁵ Since this is a clean practice technique, fruit used to rehearse IUD placement and removal can be eaten afterward, if so desired, minimizing concerns about food waste.

Approach

Materials used included a moderately ripe avocado, a kitchen knife, paper tape or duct tape, a uterine sound, an IUD (authentic or trainer device), and scissors. None of these materials need be sterile for practice. The approximate total cost was $4.04 ($4.44 USD) per simulation (Table 1).

Table 1.

Estimated costs per student simulation as of time of submission

ITEM	COST
IUD practice insertion kit	Free from manufacturer (not available for sale)
Avocado	$1.25 ($0.85 USD)
Roll of paper tape or duct tape*	$2.79 ($3.59 USD)

IUD—intrauterine device.

^*One roll of tape can be used for multiple students.

Technique

The following technique is recommended:

1. Begin with a moderately ripe avocado. Using a kitchen knife, halve it lengthwise.

2. Remove the stem and pit (Figure 1).

3. Approximate both halves together and reattach them along the cut line using paper tape or duct tape. Leave a gap in the tape where the stem was removed (Figure 2).

4. Place a uterine sound through the opening left by removing the stem. Insert the sound until substantial resistance is felt, which corresponds to uterine wall resistance (Figures 3 and 4). Note the insertion depth and use it to determine the depth of IUD placement.

5. Remove the uterine sound.

6. Proceed with IUD placement (Figure 5) and cut the strings.

7. Remove IUD inside the avocado as would normally be done in situ using ring forceps.

Figure 1.

Materials required to simulate IUD placement: Materials shown include a moderately ripe avocado (pit and stem removed), a kitchen knife, tape, a uterine sound, an IUD insertion training device, and an authentic IUD.

Figure 2.

Preparing the avocado for intrauterine device insertion practice: After the avocado is cut in half, approximate both halves together and reattach them along the cut line using tape; leave a gap in the tape where the stem was removed.

Figure 3.

Avocado, with pit and stem removed, ready for uterine sound to be placed through the opening left by removing the stem

Figure 4.

Uterine sound inserted into avocado, showing insertion depth of 7 cm

Figure 5.

Insertion of intrauterine device into avocado

Conclusion

Family physicians, residents, and medical students are encouraged to try this easy and novel technique to gain practice with IUD placement and removal. It is more realistic than currently available models and, as such, increases confidence in a clinical setting.

We encourage readers to share some of their practice experience: the neat little tricks that solve difficult clinical situations. Praxis articles can be submitted online at http://mc.manuscriptcentral.com/cfp or through the CFP website (https://www.cfp.ca) under “Authors and Reviewers.”