Intrauterine Contraceptive Device (IUCD)

tracey2408 Jadeycakes Lauren1610 256 Users are discussing this topic

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

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

The copper-containing 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. Worldwide, earlier models with lower effectiveness are no longer produced.

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.

NEW - log your activity

  • Notes Add notes to any clinical page and create a reflective diary
  • Track Automatically track and log every page you have viewed
  • Print Print and export a summary to use in your appraisal
Click to find out more »

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 pill (COCP) even at 1 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.

There are 150 million users of the IUCD worldwide. Use is higher in less developed countries (14.5%) and lower in developed countries (7.9%).[2] 

  • 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.
  • Many factors determine efficacy in individual women, including sexual activity, age and parity.
  • Failure rates for most devices are low (1-2% at 5 years).
  • Cochrane reviews have extensively examined data relating to failure rates.
  • One Cochrane review concluded that the TCu380A and TCU380S appeared to be more effective than other copper IUCDs.[3] 
  • The frameless GyneFix® has comparable failure rates to the TCu380A although the effectiveness may be compromised by a slightly increased rate of expulsion.[4] 
  • Over 12 years of use the models with less surface area of copper have higher failure rates.
  • All copper IUCDs are licensed for at least 5 years of use and some are recommended for longer use.
  • 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 copper-containing IUCD is inserted when a woman is 40 years or over it can be retained and will remain effective until the menopause is confirmed.[6]
  • 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[5]

Device Copper (mm2) Duration
Copper-sleeved devices:    
TCu380S
Recommended first choice for all women opting for Cu IUCD.
380 10
TT 380® Slimline
Marketed as a replacement for the Ortho Gynae® T380 which is no longer available in the UK.
380 10
TCu380A QuickLoad®
Replacement for the TCu380A (T-Safe® 380A) which is no longer available in the UK.
380 10
Mini TT 380® Slimline
Can be used when the uterine cavity is less than 6.5 cm on sounding.
380 5
Flexi-T® 380
There are limited data on the Flexi-T®. Unlike other banded devices, it therefore cannot be recommended for 10 years of use.
380 5
Copper in stem only:    
Ancora® 375 Cu 375 5
Cu-Safe® T300 300 5
Load® 375 375 5
Neo-Safe® T380 380 5
UT 380 Short®
Can be used when the uterine cavity is less than 6.5 cm on sounding.
380 5
Nova-T® 380 380 5
Novaplus T 380® Cu (mini and normal sizes) 380 5
Novaplus T 380® Ag (mini and normal sizes) 380 5
Neo-Safe® T380 380 5
Multiload® Cu375
Can be used when the uterine cavity is less than 6.5 cm on sounding.
375 5
Multi-Safe® 375 375 5
Multi-Safe® 375 Short Stem
Can be used when the uterine cavity is less than 6.5 cm on sounding.
375 5
Flexi-T® 300
Can be used when the uterine cavity is less than 6.5 cm on sounding.
300 5
Flexi-T® 380 380 5
Frameless copper devices:    
GyneFix®
Can be used when the uterine cavity is less than 6.5 cm on sounding.
330 5

Contraception

  • For most women seeking contraception the copper IUCD is a safe option.
  • Any copper IUCD sited in a woman aged over 40 years, can be safely left in situ until the menopause, even though it is unlicensed for that duration.[5][7]
  • 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 separate article Contraception and Special Groups).[1] 
  • 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 (see 'Side-effects', below) 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:

  • It is inserted up to 5 days after a first episode of unprotected sex.
  • It is inserted up to 5 days after the earliest calculated ovulation date:
    • An IUCD can be inserted more than 5 days after unprotected sex, if the woman presents up to 5 days after the earliest date that ovulation could have occurred in that cycle.
    • For a woman with a regular 4-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.

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

  • Efficacy is the woman's main priority.
  • Exposure occurred 72 hours ago to 5 days ago, including multiple exposures within this period.
  • It is to be retained as a long-term method of contraception.
  • When there is contra-indication to hormonal methods.
  • See separate article Intrauterine Contraceptives (IUCD and IUS) - Management for details on choice of device.

NB: the IUS is NOT suitable for emergency contraception.

Absolute contra-indications

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 3 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 3 months.

Pregnancy

  • Current pregnancy.
  • Between 48 hours and 4 weeks postpartum. World Health Organization (WHO) medical eligibility criteria state that risks generally outweigh benefits if postpartum insertion occurs between 48 hours and 4 weeks.[9] Beyond 4 weeks postpartum, benefits outweigh risks, even if the woman is breast-feeding (there is no increased copper level in breast milk).

Uterine factors

  • Uterine abnormality distorting the uterine cavity - eg, fibroidsbicornuate 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

Other factors

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

Relative contra-indications - usable with caution

  • 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 does not routinely recommend the use of antibiotic prophylaxis for genitourinary procedures.[10][11] 
  • History of ectopic pregnancy.
  • Patient has a prosthesis which could be compromised by blood-borne infection.
  • 2 days to 4 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 4 weeks post termination: the chances of expulsion post 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.[5]

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 2 weeks.

Use in adolescents

  • There are little data regarding safety, efficacy and acceptability in adolescents.[2]
  • 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 looked at case reports of use in teenagers suggested that continuation rates are high and pregnancy rates low, although none addressed the CuT380A.[12]

Use in nulliparous women

  • The copper IUCD is a recommended form of contraception for nulliparous women.[2]
  • The length, width and depth of the uterus tend to be smaller in nulliparous women.
  • In one Mexican study the continuation rate of the Copper T-380A® was particularly low in this group at less than 30%, discontinuation being mainly for pain and bleeding.[13]
  • This study suggested that expulsion and discontinuation rates might be improved by using a short-stemmed device in nulliparous women.

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

Altered or abnormal bleeding

  • Prolonged, heavier and more painful periods are common after insertion of a copper 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.[5]
  • 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.
  • 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.

Evidence suggests that the IUCD does not delay return to fertility after removal.[5]

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 7 days, at other times.
  • Where the IUCD is to be exchanged, intercourse should be avoided for the previous 7 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 7 days before the procedure in case re-insertion is not possible.
  • When switching to the COCP, remove after 7 consecutive pills.
  • When switching to the depot or implant progestogen methods, remove the IUCD after 7 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.
 

IUCD - gold standard is the banded T-Safe copper 380A®.

IUS - Mirena® or Jaydess®

Method of action

Prevents fertilisation and inhibits implantation.

Prevent mplantation mainly.
Duration of action

5-10 years if contains 380 mm copper.

Until no longer requires contraception.

Mirena® is effective for 5 years or until contraception is no longer required.

Jaydess® is effective for 3 years.

Failure rate

1-2% over five years for most devices[5] 

Evidence suggests that the latest copper-banded IUCDs are better than the COCP and as effective as sterilisation.

Expulsion in less than 1 woman in 20 per 5 years.

Risks

PID incidence is less than 1% if there is low risk for STI.

Perforation incidence is less than 1 per 1,000.

Ectopic pregnancy risk is 1 in 20, if pregnant with IUCD in situ.

60% request removal within 5 years due to bleeding, pain or hormonal problems.

PID risk is less than 1%, if there is low risk for STI.

Perforation risk is less than 1 per 1,000.

Ectopic pregnancy risk is 1 in 20, if pregnant with IUS in situ.

Query increased risk of acne.

Effect on menses Increased menstrual loss and dysmenorrhoea.

Irregular bleeding and spotting for first 6 months.

Oligomenorrhoea or amenorrhoea likely if these persist for 1 year.

Lesser chance of amenorrhoea with Jaydess®.

Return to fertility No delay. No delay.
Advice given at fitting

Pain and discomfort last a few hours, followed by light bleeding for a few days.

Watch for signs of perforation.

Follow-up should be in 3-6 weeks.

Return if concerned.

Check threads.

Pain and discomfort last a few hours, followed by light bleeding for a few days.

Watch for signs of perforation.

Follow-up should be in 3-6 weeks.

Return if concerned.

Check threads.

Further reading & references

  1. Long-acting reversible contraception; NICE Clinical Guideline (2014)
  2. Long-term safety, efficacy, and patient acceptability of the intrauterine Copper T-380A contraceptive device; Int J Womens Health. 2010; 2: 211–220. Published online Aug 9, 2010
  3. Kulier R, Helmerhorst FM, O'Brien P, et al; Copper containing, framed intra-uterine devices for contraception. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD005347.
  4. Kulier R, O'Brien PA, Helmerhorst FM, et al; Copper containing, framed intra-uterine devices for contraception. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005347.
  5. Intrauterine Contraception; Faculty of Sexual and Reproductive Healthcare (2007)
  6. Penney G, Brechin S, de Souza A, et al; FFPRHC Guidance (January 2004). The copper intrauterine device as long-term contraception. J Fam Plann Reprod Health Care. 2004 Jan;30(1):29-41; quiz 42.
  7. Newton J, Tacchi D; Long-term use of copper intrauterine devices. A statement from the Medical Advisory Committee of the Family Planning Association and the National Association of Family Planning Doctors. Lancet. 1990 Jun 2;335(8701):1322-3.
  8. Emergency Contraception; Faculty of Sexual and Reproductive Healthcare (2011)
  9. Medical eligibility criteria for contraceptive use, 4th edition; World Health Organization, 2009
  10. Wilson W, Taubert KA, Gewitz M, et al; Guidelines for the prevention of infective endocarditis: : a guideline from the American Heart Association J Am Dent Assoc. 2007 Jun;138(6):739-45, 747-60.
  11. Prophylaxis against infective endocarditis: Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures; NICE Clinical Guideline (March 2008)
  12. Deans EI, Grimes DA; Intrauterine devices for adolescents: a systematic review. Contraception. 2009 Jun;79(6):418-23. doi: 10.1016/j.contraception.2008.12.009. Epub 2009 Feb 7.
  13. Otero-Flores JB, Guerrero-Carreno FJ, Vazquez-Estrada LA; A comparative randomized study of three different IUDs in nulliparous Mexican women. Contraception. 2003 Apr;67(4):273-6.

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.

Original Author:
Dr Hayley Willacy
Current Version:
Peer Reviewer:
Prof Cathy Jackson
Document ID:
464 (v5)
Last Checked:
02/04/2014
Next Review:
01/04/2019