An intrauterine contraceptive device (IUCD) is a small device made of plastic or copper that is placed into the uterus as an effective method of contraception.
Insertion should only be undertaken by a trained family planning professional who fits at least one IUCD/IUS per month.
In the UK, an estimated 5% of the contraception population use IUCDs.
There are two types of IUCD available for use in the UK:
- Copper-releasing devices: includes T Safe® 380A (banded), Multiload® 250, Flexi-T300®, GyneFix® (banded)
- Levonorgestrel-releasing intrauterine system (LNG-IUS): Mirena®
Timing of IUCD insertion
- Counselling should be provided for women considering an IUCD.
- A clinical history is also required to assess the individual sex health risks for each woman. Examination and testing for sexually transmitted infections (STIs) - Chlamydia trachomatis and Neisseria gonorrhoeae - may then be offered and performed, if appropriate.
- A pelvic examination should be performed prior to inserting the device to assess the size, shape, depth and position of the uterus.
- IUCDs can be inserted at any time in the menstrual cycle, if pregnancy can reasonably be excluded. Documenting a negative pregnancy test may be sensible, if possible.
- Routine antibiotic prophylaxis should not be offered pre-insertion.
World Health Organization (WHO) medical eligibility criteria state that risks generally outweigh benefits if postpartum insertion occurs between 48 hours and 4 weeks. This reflects an increased rate of uterine perforation. Expulsion of the device is more common for insertions after 48 hours post-delivery.
However, after 4 weeks, benefits outweigh risks, and this is applicable to breast-feeding (there is no increased copper level in breast milk) and post-Caesarean section mothers.
Insertion after an abortion is safe and practical. It can often be a convenient time and may avoid some discomfort from the procedure. Expulsion of the device is marginally increased.
Contra-indications to IUCD insertion
- History of pelvic inflammatory disease, although it may be inserted 3 months after infection, if there are no signs of persisting infection
- History of ectopic pregnancy
- Copper allergy or Wilson's disease (copper bearing devices only)
- Septic abortion or postpartum endometritis in the previous 3 months
- Uterine abnormality affecting cavity, eg fibroid
- Exposure to sexually transmitted diseases
- Undiagnosed irregular vaginal bleeding/suspicion of genital malignancy
In addition, the hormone-bearing (levonorgestrel) IUS is contra-indicated in:
- Lost threads (see companion record)
- Ectopic pregnancy
- Uterine perforation
- Abnormal uterine bleeding
- Non-steroidal anti-inflammatory analgesia 1 hour previously.
- Cervical cleansing with antiseptic solution.
- 'No-touch' sterile technique.
- Assessment of uterine length/distance by sound measure.
- Forceps (tenaculum) are used to stabilise the cervix during insertion and reduce perforation.
Most IUCDs will have a leaflet within the box, describing insertion, with diagrams:
- 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.
- 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 IUCD 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.
- 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 unprotected sexual intercourse (UPSI). IUCDs with banded copper on the arms and containing at least 380 mm2 of copper have the lowest failure rates 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 Levonelle® EC should be given in the interim.
- A copper IUCD can be inserted up to 5 days after the first episode of UPSI. If the timing of ovulation can be estimated, insertion can be beyond 5 days of UPSI, as long as it does not occur beyond 5 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.
Instruct the patient 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 6 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.
Further reading & references
- Revised guidance for health professionals on the provision of contraceptive services for under 16s, Dept of Health (2004)
- Amy JJ, Tripathi V; Contraception for women: an evidence based overview. BMJ. 2009 Aug 7;339:b2895. doi: 10.1136/bmj.b2895.
- No authors listed; Female contraception over 40. Hum Reprod Update. 2009 May 20.
- Contraception - IUS/IUD, Clinical Knowledge Summaries (March 2011)
- Long-acting reversible contraception, NICE Clinical guideline (October 2005)
- The copper intrauterine device as long-term contraception, Faculty of Family Planning and Reproductive Health Care, Royal College of Obstetricians and Gynaecologists (January 2004)
- Summary of Product Characteristics (SPC) - Mirena®; Summary of Product Characteristics (SPC) - Mirena® (levonorgestrel intrauterine system), Schering Health Care Limited, electronic Medicines Compendium. Updated April 2009
- Kapp N, Curtis KM; Intrauterine device insertion during the postpartum period: a systematic review. Contraception. 2009 Oct;80(4):327-36. Epub 2009 Aug 29.
- Grimes D, Schulz K, Stanwood N; Immediate postabortal insertion of intrauterine devices. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD001777.
- World Health Organization; Medical eligibility criteria for contraceptive use - 3rd edition; Copper IUD for emergency contraception
- Johnson BA. Insertion and removal of intrauterine devices. American Family Physician; January 2005
- Emergency Contraception, Faculty of Family Planning and Reproductive Health Care (2006)
- The levonorgestrel-releasing intrauterine system (LNG-IUS) in contraception and reproductive health, Faculty of Family Planning and Reproductive Health Care, RCOG (April 2004)
|Original Author: Dr Hayley Willacy||Current Version: Dr Hayley Willacy|
|Last Checked: 20/04/2011||Document ID: 2346 Version: 23||© EMIS|
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.