Intrauterine Contraceptives (IUCD and IUS) - Management

An intrauterine contraceptive device (IUCD) is a small device made of plastic, sometimes with added copper or added slow-release progestogen, that is placed into the uterus as an effective method of contraception. Jaydess® and Mirena®, the levonorgestrel-releasing intrauterine systems (LNG-IUS), are both classed as an IUS, not an IUCD. Mirena® is also licensed for the treatment of menorrhagia.

This article covers the theory related to the practicalities of inserting these devices. It is not a substitute for practical training: insertion of intrauterine devices should only be undertaken by an appropriately trained family planning professional who maintains competence by fitting at least one IUCD/IUS per month and attending regular updates in managing emergencies.

In the Americas, IUCDs are used by well below 10% of women of reproductive age. In the UK their use is between 11.3 and 12.1%^[1] .

Intrauterine contraceptive types

There are two types of intrauterine contraceptives available for use in the UK:

• Copper-releasing devices: these include T-Safe® 380A (banded), Multiload® 250, Flexi-T® 300, GyneFix® (banded).
• Levonorgestrel-releasing intrauterine system (LNG-IUS): Mirena® and Jaydess®.

Indications,contra-indications and side-effects of each device are listed in the respective separate Intrauterine Contraceptive Device and Intrauterine System articles.

Choice of device

• After counselling, most women can choose between IUCD and IUS.
• If a woman chooses an IUCD then the device with the longest duration of use and lowest failure rate should be used first-line: namely the TCu380S (TT380 Slimline® or T-Safe TCu380A QuickLoad®).
• If the uterus sounds to 6.5 cm or less then a device with a shorter stem or a frameless device may be used.
• There is no evidence suggesting a different choice in nulliparous women.

Timing of IUCD/IUS insertion

• Copper-containing IUCDs (Cu-IUCDs) may be inserted at any time in the menstrual cycle, as long as pregnancy can reasonably be excluded (see 'Excluding pregnancy', below). Documenting a negative pregnancy test may be sensible, if possible.
• The LNG-IUS (Mirena® or Jaydess®) can be fitted at any time in the cycle as long as pregnancy can be reasonably excluded.
• The IUS is ideally inserted between day 1 and day 7 of the menstrual cycle^[2] . If it is fitted at any other time condoms are advised for the first seven days of use.
• Whilst postpartum contraception is a licensed indication for the Cu-IUCD, pregnancy beyond five days following unprotected sexual intercourse (UPSI) is an absolute contra-indication to the copper device, and any pregnancy is an absolute contra-indication to use of the LNG-IUS^[3] .
• Insertion towards the end of the menstrual period, or just after it, is often more comfortable for the patient.

Excluding pregnancy

Pregnancy may be reasonably excluded if the woman meets any of the following criteria^[4] :

• Has not had intercourse since last normal menses.
• Has correctly and consistently used a reliable method of contraception.
• Is in day 1-7 of the menstrual cycle.
• Is day 1-7 following termination or miscarriage (although ideally the intrauterine device would be inserted within 48 hours).
• Is fully breastfeeding, amenorrhoeic and within six months of delivery.

Postpartum insertion

• UK medical eligibility criteria state that risks generally outweigh benefits if postpartum insertion occurs between 48 hours and four weeks^[3] . This reflects an increased rate of uterine perforation due to the softness of the postpartum uterus. Expulsion of the device is more common for insertions after 48 hours post-delivery.
• Beyond four weeks postpartum, benefits outweigh risks, even if the woman is breastfeeding (there is no increased copper level in breast milk) and in post-caesarean section mothers.

Post-termination insertion^[2]

• 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.
• There is no evidence of an increased perforation rate 48 hours to four weeks after termination. However it is recommended that insertion in this period be done only by an experienced operator.

Emergency contraception^[5]

• An IUCD (or advice on how to obtain one) should be offered to all women attending for emergency contraception (EC) even if presenting within 72 hours of UPSI.
• IUCDs with banded copper on the arms and containing at least 380 mm²of copper have the lowest failure rates for EC and should be the first-line choice, particularly if the woman intends to continue the IUCD as long-term contraception.
• Ideally, an emergency IUCD should be fitted at first presentation, but insertion can be offered later, at the woman's convenience. In this case, oral Levonelle® EC should be given in the interim.
• A Cu-IUCD can be inserted up to five days after the first episode of UPSI. If the timing of ovulation can be estimated, insertion can be beyond five days of UPSI, as long as it does not occur beyond five days after the estimated date of ovulation. The only relative contra-indication to insertion is risk of STI.
• The IUS is not suitable for EC.

Pre-insertion counselling

Before the device is fitted, patients should be offered advice on the following:

• Mode of action: a Cu-IUCD primarily prevents fertilisation and the IUS predominantly prevents implantation.
• Failure rates (1-2% at five years)^[2] . See also the separate Intrauterine Contraceptive Device article.
• Perforation risk (0-2 per 1,000 insertions)^[6] .
• Expulsion risk (1 in 20)^[2] .
• No delay in return to fertility post-removal, although there may be a delay in return of regular menses post-IUS.
• Six-fold increase in the chance of pelvic infection in the three weeks post-insertion^[4] .
• Irregular bleeding and sometimes pain are common for the first 3-6 months of IUCD use. These can be managed, and if they are discussed at counselling then women are more likely to anticipate them and seek help, rather than removal, if they occur. Irregular bleeding and spotting often continue for the first six months of IUS use, although oligomenorrhoea or amenorrhoea are usual within a year.
• Hormonal side-effects from the IUS are uncommon and rarely a reason to discontinue
• The insertion procedure may be uncomfortable; oral analgesia prior to insertion may be helpful
• STI screening: a clinical history is required prior to insertion, to assess the individual sexual health risk for each woman.
• Examination and testing for STIs - Chlamydia trachomatis and Neisseria gonorrhoeae - may then be offered and performed, if appropriate.
• Testing for any STIs should be offered in women who request it.

Insertion^[7]

Preparation

• Obtain informed consent. Oral consent is acceptable.
• Offer a chaperone.
• An appropriately trained assistant should be present (to monitor the patient and assist in an emergency).
• Basic risk assessment includes gathering information about previous intrauterine procedures. Patients who have had previous adverse events during insertion are more likely to have them again.
• Pulse rate and blood pressure should be documented.
• The need for pain relief during insertion should be discussed with the patient
• Non-steroidal anti-inflammatory analgesia can be taken one hour previously: there is no evidence of significant reduction in pain associated with insertion, although it may aid post-insertion discomfort.
• Many operators use local anaesthetic gel on the cervix. There is evidence that this reduces pain associated with tenaculum placement.
• Routine antibiotic prophylaxis is not recommended pre-insertion. However, for women at increased risk of STIs, in whom testing has not been completed, prophylactic antibiotics are advised.
• Antibiotic prophylaxis is no longer recommended for women at risk of endocarditis - eg, those who have had previous endocarditis or who have a prosthetic heart valve or valvular heart disease. This does not mean that there is no risk, and the woman's cardiologist should be consulted.
• For women with symptomatic pelvic infection, treatment should be given prior to insertion, which should be postponed until symptoms resolve.
• Cervical cleansing should be performed with antiseptic solution.
• A 'no-touch' sterile technique should be adopted.
• A pelvic examination should be performed prior to inserting the device, to assess the size, shape, position and mobility of the uterus.
• Assessment of uterine length/distance by sound measure.
• Forceps (tenaculum) are used to stabilise the cervix during insertion and reduce perforation.
• Some operators offer cervical anaesthesia for the procedure.
• Insertion may be offered under general anaesthesia to patients who cannot tolerate the procedure.
• Documentation should be made in the case notes of pre- and post-insertion counselling, the procedure, the type of device inserted, and any adverse events.

Procedure: copper-releasing devices

Most IUCDs will have a leaflet within the box, describing insertion, with diagrams:

IUCD in position

• The blue flange must be aligned with the IUCD arms at the uterine distance.
• Insert the white inserter rod into the insertion tube at the opposite end to the arms of the IUCD.
• Insert the IUCD into the uterus until the flange reaches the back of the cervix.
• Pull back the inserter tube to allow the inserter rod arms to adopt the T position (2 cm approximately).
• Slowly advance the insertion tube to ensure correct positioning before removing the insertion rod.
• Cut the threads to a length of 3 cm approximately and note the length.

Procedure: IUS

The IUS has a leaflet within the box, outlining the process. Make sure you are familiar with this.

• Align the arms of the device horizontally.
• Draw the device into the insertion tube by pulling both threads of the device.
• The flange should be set to the correct uterus depth.
• Holding the slider, the IUS is inserted into the cervix.
• Slowly advance the insertion tube until it reaches a distance of 1.5-2 cm from the back of the cervix.
• Release the arms by pulling back the slider and advance the inserter until the flange touches the cervix.
• Release the device by pulling the slider down whilst holding the inserter in position.
• Remove the inserter.
• Cut the threads to a length of 2-3 cm approximately and note the length.

Problems associated with insertion

Insertion failure

• Pain during insertion is associated with a higher failure rate.
• Other factors relate to the experience of the doctor.
• Difficulties include problems passing the sound or IUCD through the cervix and immediate expulsion.
• Age and time since last delivery increase the problems.
• Nulliparous women are more likely to experience failed insertion, as the cervix is often more tightly closed and the procedure more painful/less well tolerated. However, one Swedish study suggested comparable rates of insertion failure in nulliparous and parous women.

Syncope

• Syncope may be experienced at insertion secondary to vagal stimulation from the cervix.
• Bradycardia is more common in nulliparous women.

Suspected perforation at insertion

• The rate of perforation in experienced operators is low: 0-2.3 per 1,000 insertions, with lower rates for the IUS than for the IUCD^[6] .
• The risk of perforation, whilst still small, is significantly increased in lactating women.
• Symptoms are most commonly of abdominal pain (which is usually mild) associated with lost threads and abnormal bleeding.
• Most perforations are not recognised at the time of insertion and are discovered when there is a shortening or disappearance of strings, or a pregnancy.
• Some patients are asymptomatic and the situation may be discovered only because the threads are lost.
• More severe pain can occur, and severe complications have been described including damage to viscera and peritonitis.
• The device cannot be considered effective if perforation has occurred, so pregnancy is a further complication.
• Perforation rates are greatest during the postpartum period.

If perforation is suspected at the time of insertion, stop the procedure and check vital signs. If these are altered then monitor until stable. Ultrasound or plain abdominal film to locate the device should be arranged as soon as possible (copper devices have flexible side arms containing barium sulfate which is visible on X-ray).

Copper ions are inflammatory, and there are reports of IUCDs eroding into the bladder or gastrointestinal tract. It is therefore recommended that the IUCD be retrieved as soon as possible.

Vasovagal collapse/cervical shock

• Abandon the procedure, lower the head and/or raise the legs.
• The IUCD/IUS may need to be removed.
• An assistant should monitor vital signs.
• Ensure a clear airway.
• Oxygen and suction as required.
• Consider use of atropine 0.6 mg/ml IV for persistent bradycardia.
• Consider use of adrenaline (epinephrine) 1:1000 IM (1 mg/nl) for management of anaphylaxis.
• Automated external defibrillator (AED) should be available.
• Arrange ambulance transfer if there is no swift improvement.

Problems occurring after insertion

Cramping

This is common for the first 24-48 hours and does not usually persist beyond this.

Expulsion

• This can occur immediately. It is more likely where the procedure is less well tolerated and in nulliparous women, but is also related to the skill of the operator.
• Overall it occurs in 1 in 20 women, most commonly in the first three months during menstruation^[2] : the patient may be unaware that expulsion has taken place.
• Expulsion is more common with copper devices, younger patients and nulliparous patients.
• Expulsion is most likely to occur in the first 72 hours post-insertion, and may in some cases relate to a widened cervical os.

Infection

• The risk of pelvic inflammatory disease (PID) in association with a Cu-IUCD is related to the insertion.
• The risk is more than six times higher than baseline for the first 20 days post-insertion, then returns to normal baseline levels after this.

Lost threads^[4]

• If threads are not visible, or if they are but the stem of the device is palpable, the woman should be advised to use condoms or abstain from intercourse until the site of the device (if present) can be determined.
• Perform a speculum examination to ensure the device is not in the posterior fornix.
• Determine whether the woman is already pregnant.
• With consent, explore the lower part of the endocervical canal with narrow artery forceps: threads which have been drawn a little way up are usually found by this method.
• An experienced operator may, after appropriate analgesia (eg, mefenamic acid 500 mg) explore the uterine cavity with a retriever hook.
• Hormonal emergency contraception may be indicated.
• Ultrasound should be arranged to locate the device.
• If ultrasound does not locate the device and there is no definite history of expulsion then abdominal X-ray should be performed to look for an extrauterine device.
• Expulsion should not otherwise be assumed.
• Hysteroscopy can be helpful if ultrasound is equivocal.
• Surgical retrieval of an extrauterine device is advised.

Management of ongoing problems

See the separate Intrauterine Contraceptive Device article, which discusses management of problems which may be associated with IUCD use, and the separate Intrauterine System article which discusses management of problems which may be associated with IUS use.

Post-insertion advice

Instruct the patient on how to feel the threads, and advise her to seek medical advice if she is unable to feel them. It may be sensible to check they are present:

• Before the first episode of sexual intercourse.
• After her next menses.

Check the patient is feeling well enough to leave.

Arrange follow-up for six weeks' time. This visit should be used to check for infection, perforation or expulsion. Threads may need to be shortened, if felt by the partner. Further follow-up should occur at least annually or sooner, if required.

Make sure that the woman is aware of when the IUCD/IUS needs to be checked and when it will need to be changed.

Documentation

It is advised that the following documentation be kept for IUCD/IUS insertion:

Medical history and clinical assessment

• Age.
• Menstrual history (including date of last menstrual period).
• Previous contraception used (including difficulty in IUCD/IUS insertion).
• Obstetric history (including ectopic pregnancy).
• Past medical history (relevant cardiovascular disease, past gynaecological history/cervical surgery, including treatment to the cervix, history of STIs and PID, relevant medical history and conditions, allergies).
• Coital history.
• Sexual history to identify risk of STIs.

Information advice and counselling

• Contraceptive choices discussed.
• Risks/benefits/uncertainties discussed.
• Mode of action and efficacy of IUCD/IUS, choice of device and duration of use.
• Effects on bleeding pattern.
• Risk of spontaneous expulsion and perforation.
• Risk of post-insertion pelvic infection.
• Explanation of insertion procedure, consent obtained, leaflets given, including manufacturer's patient information.
• Thread check and teaching.

Details of insertion procedure

• Name of assistant.
• Any tests undertaken.
• Bimanual examination and speculum findings.
• Analgesia/local anaesthesia if used.
• Allis forceps application, uterine sounding/uterocervical length, use of 'no-touch' technique, problems encountered, if any, and actions taken.
• Type of device inserted/removed and date for removal.

Post-insertion follow-up advice

• Other treatment if any (eg, antibiotics; special instructions if any, such as postcoital IUCD).
• Follow-up if there are any problems or threads cannot be felt.
• Details of removal.
• Reason for removal.
• Coital history (since last menstrual period) to identify risk of pregnancy post-removal.
• Alternative contraception method advised/provided, if any.
• Technique of removal used; problems encountered, if any, and actions taken.

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