Types

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®^[3]

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.^[2]

Postpartum 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.^[2][4]

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.

Postabortal insertion

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.^[5]

In addition, the hormone-bearing (levonorgestrel) IUS is contra-indicated in:

• Acute liver disease, jaundice or liver carcinoma
• Breast carcinoma

Adverse effects

• Cramping
• Lost threads (see companion record)
• Ectopic pregnancy
• Expulsion
• Infertility
• Uterine perforation
• Abnormal uterine bleeding

Insertion^[7]

Preparation

• 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.

Copper-releasing devices

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.

IUS

• 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.

Emergency contraception

• 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.^[8]
• 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.^[6]

The IUS is not suitable for EC.^[9]

Post-insertion

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.^[1] Threads may need to be shortened, if felt by the partner. Further follow-up should occur at least annually or sooner, if required.