Intrauterine Contraceptive Device

This article refers to copper-containing intrauterine contraceptive devices (Cu-IUCDs). For information on Mirena® and Jaydess®, the levonorgestrel-releasing intrauterine systems (LNG-IUS), see the separate Intrauterine System (IUS) article. For information regarding IUCD and IUS insertion, see the separate Intrauterine Contraceptives (IUCD and IUS) - Management article.

Description

The Cu-IUCD is a long-acting reversible contraceptive (LARC). It is typically T-shaped or frameless and is anchored to the myometrium at the fundus. The amount of copper in the device and the type of frame (structure) can affect the effectiveness of different models. The T- shaped models with a surface area of 380 mm² of copper have the lowest failure rates. Earlier models with lower effectiveness are no longer produced worldwide.

The addition of small quantities of silver to the core prevents fragmentation of the copper, extending the lifespan and efficacy. In some countries the addition of other noble metals such as gold is used for the same effect.

Cost-effectiveness

The National Institute for Health and Care Excellence (NICE) advises that all currently available LARC methods (IUCDs, the IUS, injectable contraceptives and implants) are more cost-effective than the combined oral contraceptive (COC) pill even at one year of use.^[1] IUCDs, the IUS and implants are also more cost-effective than the injectable contraceptives. NICE also advises that increasing the uptake of LARC methods will reduce the numbers of unintended pregnancies. It is important that women should be advised of LARC methods when seeking contraception.

Although IUCDs are used by large numbers of women, global distribution of their use is uneven. In a few countries, including China and most of Central Asia, IUCDs constitute at least half of all contraceptive use.^[2] In Northern Africa and the Middle East, they represent about a quarter of all use, and in parts of Europe, about a fifth. In the Americas, IUCD use is generally well below 10%. In the UK their use is between 11.3 and 12.1%.^[3]

Mode of action

• The primary mode of action is through setting up a cytotoxic inflammatory reaction in the endometrium, which is spermicidal.
• The copper concentration in cervical mucus is also substantial and inhibits sperm motility.
• The copper devices may also prevent implantation if fertilisation occurs. However, the studies suggesting this were of older devices with lower copper content, and there is no clear evidence that modern devices allow fertilisation to occur.
• The postcoital use of copper devices utilises this post-fertilisation contraceptive effect.

Effectiveness

• Many factors determine efficacy in individual women, including sexual activity, age and parity.
• Cumulative pregnancy rates for IUCDs with copper content >300 mm²are noted as being between 0.1% and 1% after the first year of use and around 2.2% for the TCu380A after 12 years.^[4]
• A Cochrane review has concluded that the TCu380A and TCu380S appear to be more effective than other Cu-IUCDs.^[5]
• The frameless GyneFix® has comparable failure rates to the TCu380A and has been shown to have an improved continuation rate compared to framed devices.^[6]
• Over 12 years of use the models with less surface area of copper have higher failure rates.

Duration of action

• All Cu-IUCDs are licensed for at least five years of use and some are recommended for longer use.^[4]
• The TCu380A is effective for up to 12 years of use and licensed for 10 years.
• The TCu380S (TT 380® Slimline and T-Safe® 380A QuickLoad) is licensed for 10 years of use.
• In the UK it is widely accepted that if a Cu-IUCD is inserted when a woman is 40 years or over it can be retained and will remain effective until the menopause is confirmed.

Choice of device

• Longer-acting devices are generally preferred, as this reduces the risks associated with removal and re-insertion (perforation, infection, expulsion).
• Short-stemmed devices can be used if the uterine cavity is less than 6.5 cm at sounding.

Types of device currently available in the UK^[7]

Indications

Contraception

• For most women seeking contraception, the Cu-IUCD is a safe option.
• Any Cu-IUCD sited in a woman aged over 40 years, can be safely left in situ until the menopause; however, it is only licensed for 10 years use.
• It can be appropriate for many other women, including those who traditionally offer contraceptive challenge, such as obese women, women with diabetes or epilepsy, women with migraine and women with contra-indications to oestrogen (see the separate Contraception and Special Groups article).
• Advantages as a contraceptive method include:
  • Rapid return of fertility post-removal.
  • Convenience (long-lasting method that is independent of intercourse).
  • No hormonal content.
• Disadvantages include heavier and more painful menstruation and the discomfort of fitting.
• Fitting an IUCD is technically a little less difficult than an IUS, as the IUS has a larger diameter than other IUCDs.

Emergency contraception^[8]

Insertion of a copper-banded IUCD prevents conception in 98% of women if:

• Unprotected sexual intercourse (UPSI) occurred before insertion and there is a risk of pregnancy, a Cu-IUCD can safely be inserted up to five days after the first episode of UPSI or within five days of the earliest expected time of ovulation.
• For a woman with a regular four-week cycle, this means that an IUCD can be inserted up to and including day 19 of her cycle, regardless of when the unprotected sex took place following her last period. However, LMP must be accurately known and cycles must be regular in order to make the estimation.

Although not suitable for all women, the Cu-IUCD should be offered as a postcoital contraceptive when:

• Efficacy is the woman's main priority. The Cu-IUCD is more effective than emergency hormonal contraception, with a failure rate of considerably lower than 1%.^[9]
• Exposure occurred up to five days ago, including multiple exposures within this period.
• It is to be retained as a long-term method of contraception.
• There is contra-indication to hormonal methods.

See the separate Intrauterine Contraceptives (IUCD and IUS) - Management article for details on choice of device.

NB: the IUS is NOT suitable for emergency contraception.

Contra-indications

Absolute contra-indications^[10]

There are few absolute evidence-based contra-indications and they fall into five categories: infection, pregnancy, uterine factors, gynaecological cancers and adverse reactions to copper.

Infection

• History of pelvic inflammatory disease (PID) or purulent cervicitis, although it may be inserted three months after infection, if there are no signs of persisting infection.
• Recent exposure to sexually transmitted infection (STI).
• Septic abortion or postpartum endometritis in the previous three months.

Pregnancy

• Current pregnancy.
• Between 48 hours and four weeks postpartum. UK medical eligibility criteria (UKMEC) state that risks generally outweigh benefits if postpartum insertion occurs between 48 hours and four weeks. Beyond four weeks postpartum, benefits outweigh risks, even if the woman is breastfeeding (there is no increased copper level in breast milk).^[10]

Uterine factors

• Uterine abnormality distorting the uterine cavity - eg, fibroids, bicornuate uterus.
• Uterus less than 5.5 cm in length on sounding.
• The device may be expelled, but may also be less effective (eg, if placed in one horn of bicornuate uterus).

Gynaecological cancers

• Ovarian, cervical or endometrial cancer.
• Malignant trophoblastic disease.
• Undiagnosed irregular vaginal bleeding/suspicion of genital malignancy.

Adverse reactions to copper
Copper allergy or Wilson's disease.

Other factors

• Previous history of bacterial endocarditis after prosthetic valve replacement.
• Significant immunosuppression.

Relative contra-indications - usable with caution^[10]

• Nulliparous, young age (see under 'Special groups', below).
• Definite history of pelvic infection.
• High risk of STI.
• Known HIV infection.
• Structural heart disease, with risk of endocarditis. The American Heart Association and NICE recommend discussion with the patient's own cardiologist but do not routinely recommend the use of antibiotic prophylaxis for genitourinary procedures.
• History of ectopic pregnancy.
• Patient has a prosthesis which could be compromised by blood-borne infection.
• Two days to four weeks postpartum.
• Benign trophoblastic disease.
• Severe cervical stenosis.
• Fibroids or congenital abnormality of uterus, but no marked distortion of the cavity.
• After endometrial ablation or resection.
• Between 48 hours and four weeks post-termination: the chances of expulsion following insertion are slightly increased in this period. It is recommended that the IUCD/IUS should only be inserted at this time if the patient is at risk of pregnancy and finds no other method acceptable and the operator is experienced.

Post-termination insertion

• Insertion after termination of pregnancy is safe and practical. It can often be a convenient time to perform the procedure and may avoid some discomfort. Expulsion rates are marginally increased.
• Insertion following terminations of pregnancy of more than 14 weeks of gestation are usually postponed for two weeks.

Special groups

Use in adolescents

• There are little data regarding safety, efficacy and acceptability in adolescents.
• Women aged under 20 years are more likely to request removal due to pain and bleeding, or to experience expulsion, although discontinuation rates of all methods of contraception are higher in this age group.
• There is no evidence to suggest that infection rates at insertion are any higher in adolescents.
• A systematic review which looked at case reports of use in teenagers suggested that continuation rates are high and pregnancy rates low, although none addressed the TCu380A.^[6]

Use in nulliparous women

• The Cu-IUCD is a recommended form of contraception for nulliparous women.
• The length, width and depth of the uterus tend to be smaller in nulliparous women.
• Continuation rates of the TCu380A can be particularly low in this group; discontinuation being mainly for pain and bleeding.

Complications^[7]

For complications associated directly with the insertion process, including perforation, expulsion and lost threads, see the separate Intrauterine Contraceptives (IUCD and IUS) - Management article.

Altered or abnormal bleeding

• Prolonged, heavier and more painful periods are common after insertion of a Cu-IUCD, and are the most common reason for discontinuation of the device.
• For women using an IUCD, non-steroidal anti-inflammatory drugs can be used to treat spotting, light bleeding or prolonged menses. Thrombolytics such as tranexamic acid may be used for menorrhagia.
• Heavy bleeding should make the clinician consider the possibility of early pregnancy at the time of insertion.
• Menstrual bleeding and pain are the most common reasons for early discontinuation of intrauterine contraception.
• Abnormal bleeding beyond the first six months after insertion requires investigation for gynaecological pathology.

Pelvic infection

• This is most strongly related to the insertion procedure and to the background risk of STIs.
• There is a sixfold increase in risk of PID in the first 20 days following insertion.
• If pelvic infection is suspected in a woman using an IUCD/IUS then antibiotics should be started.
• The device does not need to be removed unless symptoms fail to resolve within 72 hours.
• Women should be followed up and their partners treated where appropriate. Sexual health risk assessment and counselling should be offered.

Actinomyces-like organisms

• Actinomyces-like organisms (ALOs) are commensals of the female genital tract and have been identified in women with and without intrauterine contraception.
• Their role in infection in women using intrauterine contraception is not clear.
• If ALOs are seen on a swab or smear, removal of the device is not indicated if the woman is asymptomatic.^[7]
• If symptoms of pelvic pain occur in conjunction with the presence of ALOs, other causes of infection should be considered and removal of the device may be advisable.

Pregnancy

• Ectopic pregnancy must be excluded although most pregnancies will be intrauterine.
• Ectopic pregnancy is increased relative to normal pregnancies where copper devices are used. However, there is no absolute increase in risk.
• Women who become pregnant must be counselled regarding the increased risk of second-trimester miscarriage, infection and preterm delivery if the device remains in situ, and that removal reduces these outcomes but is associated with a small risk of miscarriage.
• If threads are visible or retrievable in the endocervical canal, the device should be removed up to 12 weeks of gestation.
• In other cases the device should be sought at delivery or termination and, if not detected at this time, an abdominal X-ray performed to ensure it is not extrauterine.

Removal and return of fertility

Evidence suggests that the IUCD does not delay return to fertility after removal.

Where pregnancy is desired

The IUCD can be removed at any time.

Where pregnancy is not desired

• The IUCD should be removed with menstruation or, if there has been no unprotected sexual intercourse in the previous seven days, at other times.
• Where the IUCD is to be exchanged, intercourse should be avoided for the previous seven days in case re-insertion fails.
• Where removal is at the end of the licensed duration use: remove at any time in the menstrual cycle. If pregnancy is to be avoided, remove in the first few days after the onset of menstruation or advise condoms or abstinence from sexual intercourse for at least seven days before the procedure in case re-insertion is not possible.
• When switching to the COC pill, remove after seven consecutive pills.
• When switching to the depot or implant progestogen methods, remove the IUCD after seven days of use of the new method.

Postmenopausal removal

If inserted after the age of 40 years, the IUCD can continue to be used and will remain effective for contraception until the menopause is confirmed.

Summary of main points

Dr Mary Lowth is an author or the original author of this leaflet.