Intrauterine Contraceptive Device (IUCD)

There are 150 million users of the intrauterine contraceptive device (IUCD) worldwide. The majority are in China. They are ideal for a woman in her forties, with children. Recent evidence suggests that the latest banded copper IUCDs are better than the combined oral contraceptive and as effective as reversible sterilisation,^1,2

Evidence suggests that IUCDs are not intrinsically responsible for PID,³ and the greatest risk of PID is within 20 days of insertion. Practically this means that elective insertions, or re-insertions should be preceded by:

• Verbal screening to assess patients risk of sexually transmitted disease (STD)
• In high prevalence populations, i.e. most UK under 25s, DNA based screening for chlamydia
• Recent history of purulent discharge should prompt referral to genito-urinary medicine (GUM) clinic for thorough investigation prior to insertion.
• Detection of chlamydia should also prompt GUM referral
• The cervix should be thoroughly cleansed, with swabs, pre-insertion
• A post-insertion check within the first 3 weeks should detect women with infection
• Blind prescription of appropriate antibiotic is appropriate in emergency insertion. Screening should still be carried out, to allow contact tracing.

• Absolute, permanent:
  • Very distorted uterine cavity, or cavity depth less than 5.5cm
  • Allergy to known constituent
  • Wilson's disease-in copper bearing devices
  • Previous history of bacterial endocarditis after prosthetic valve replacement
• Absolute, temporary:
  • Suspicion of pregnancy
  • Undiagnosed, irregular genital tract bleeding
  • Significant infection
  • Significant immunosuppression
  • Malignant trophoblastic disease
• Relative- usable with caution:
  • Nulliparous, young age
  • Definite history of pelvic infection
  • High risk of STD
  • Known HIV infection
  • Structural heart disease, with risk of endocarditis
  • History of ectopic pregnancy
  • Patient has prosthesis which could be compromised by blood born infection
  • 2 days to 4 weeks post-partum
  • Benign trophoblastic disease
  • Severe cervical stenosis
  • Fibroids or congenital abnormality of uterus, but no marked distortion of the cavity
  • After endometrial ablation or resection

Insertion of a copper, banded IUD prevents conception in 98%⁵of women if:

• It is inserted up to 5 days after first episode of unprotected sex
• It is inserted up to 5 days after the earliest calculated ovulation date. To be precise 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, 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 it is not suitable for all women, because of the reasons above, it should be offered when:

• Efficacy is the womans main priority
• When exposure occurred more than 72 hours ago, or there have been multiple exposures
• When it is to be retained as a long-term method of contraception
• When there is contraindication to hormonal methods

• Lost Threads:
  • Always consider the woman with lost threads to be either already pregnant, or at risk of being so
  • Determine whether patient is pregnant
  • Explore cervix with narrow artery forceps, under direct vision. Gently open and close jaws and withdraw. The majority of threads will be found with this procedure.
  • If unsuccessful consider ultrasound to establish position or proceed to exploration of uterine cavity with retriever hook. Needs appropriate analgesia, e.g. mefenamic acid 500mg.
  • If still unsuccessful, refer for ultrasound, hysteroscopy or laparoscopy if extra-uterine
  • If pregnant with IUCD in-situ and wishing to proceed to full-term, gentle removal in the first trimester has been found to halve the miscarriage rate⁶
  • If patient elects for termination of pregnancy, the IUD can be removed at time of surgery.
• Nulliparous patient:
  • This is not a contraindication in itself, and is acceptable with carefully selected and screened patients.
  • As they have optimum fertility a banded copper T 380-A is the device of choice.
  • An IUCD may be the method of choice if hormonal contraception is contraindicated
• Actinomyces-like Organisms:
  • This may be reported on the cervical smear report of an asymptomatic woman
  • Call patient for consultation and bi-manual examination
  • Look for pain, dyspareunia, tenderness or signs of an adnexal mass. If positive arrange ultrasound and urgent gynaecology referral.
  • Discuss with microbiologist and remove device. Send for culture.
  • If there are no positive findings at examination, you can either ( after discussing with the patient) remove the device and inform patient of symptoms to watch for. Do not start treatment. Repeat the smear and examination in 3 months.
  • The alternative is to leave the device in-situ and having supplied written information on what to look for, advise the woman to have a further check in 6 months time. Cervical screening to proceed at normal intervals.
  • Keep meticulous records of the consultations
• Pre-menopausal Removal:
  • As fertility returns immediately, woman should have alternative arrangements available, if desired
  • The removal should be timed to minimise pregnancy risk i.e pre-ovulation.
  • The Faculty of Family Planning and Reproductive Health Care states that any device sited in a woman over 40 years, can be safely left in situ until the menopause, even though it is unlicensed for that duration.⁷