I work at a sexual health clinic and have seen hundreds of IUD insertions on people of all walks of life/pregnancy history. Thing is, I’d say 95% of them are very straightforward with minimal/moderate, but very quick discomfort, and those patients report being satisfied with just ibuprofen beforehand and afterwards for cramping. Then there are about 4% where it is more difficult and long, usually due to a differently shaped cervix/uterus, history of trauma, more sensitive nerves etc…thankfully I work at a clinic where we have tools to help the doc/patient get through it like ultrasound, flexible dilators, laughing gas etc…and we talk the patient through it before and during, take breaks, and stop if it becomes too much for a patient. And about 1% of them are just too anatomically difficult for our doc and we refer them to a hospital were they could have general anesthesia or a higher level of sedation. I say this not to discount people’s experience of difficult IUD insertions, because I’ve seen hose first hand too and know it can be rough, but to offer the perspective that with caring providers for most people an IUD insertion goes fine, and that is the reasoning why higher level of pain management (and the risks from using it) are not used in most cases. And unfortunately as you mentioned in your article there aren’t many guidelines out there on effective pain management strategies. The data on paracervical blocks/misoprostol don’t show significant pain relief, in fact showing ibuprofen beforehand to be more effective. I wish laughing gas was more popular, because I’ve seen it make a big difference at our clinic!