See also separate article Intrauterine System.

The intrauterine contraceptive device (IUCD) is a long-acting reversible contraceptive (LARC). The National Institute for Health and Clinical Excellence (NICE) advises that all currently available LARC methods (IUCDs, the intrauterine system (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 more cost-effective than the injectable contraceptives. They also advise 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; the majority are in China. They are ideal for a woman in her forties, with children.

Pre- and post-insertion pelvic inflammatory disease precautions

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

• Verbal screening to assess the patient's 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 a genitourinary 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 should detect women with infection.
• Blind prescription of an appropriate antibiotic is appropriate in emergency insertion.
• Screening should still be carried out to allow contact tracing.

Contra-indications^4,5

• Absolute, permanent:
  • Very distorted uterine cavity, or cavity depth less than 5.5 cm.
  • 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.
  • A 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.

Use as emergency contraception

Insertion of a copper-banded IUCD prevents conception in 98% of women if:⁶

• 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, 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 woman's main priority.
• Exposure occurred more than 72 hours ago, or there have been multiple exposures.
• It is to be retained as a long-term method of contraception.
• When there is contra-indication to hormonal methods.

Clinical scenarios

• Lost threads:
  • Always consider the woman with lost threads to be either already pregnant, or at risk of being so.
  • Determine whether the patient is pregnant.
  • Explore the cervix with narrow artery forceps, under direct vision. Gently open and close the 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 the uterine cavity with a retriever hook. This needs appropriate analgesia, e.g. mefenamic acid 500 mg.
  • If still unsuccessful, refer for ultrasound, hysteroscopy or laparoscopy if extrauterine.
  • 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 rate.⁷
  • If the patient elects for termination of pregnancy, the IUCD can be removed at the time of surgery.
• Nulliparous patient:
  • This is not a contra-indication 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 contra-indicated.
• Actinomyces-like organisms:
  • This may be reported on the cervical smear report of an asymptomatic woman.
  • Call the patient for consultation and bi-manual examination.
  • Look for pain, dyspareunia, tenderness or signs of an adnexal mass. If positive, arrange ultrasound and urgent gynaecological referral.
  • Discuss with a microbiologist and remove the device. Send for culture.
  • If there are no positive findings at examination, after discussing with the patient, you can either:
    • Remove the device and inform the 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. Cervical screening to proceed at normal intervals.
  • Keep meticulous records of the consultations
• Premenopausal removal:
  • As fertility returns immediately, the woman should have alternative arrangements available, if desired.
  • The removal should be timed to minimise pregnancy risk, i.e. pre-ovulation.
  • Any device 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.^7,8

Document references

1. Long-acting reversible contraception, NICE Clinical guideline (October 2005); (the effective and appropriate use of long-acting reversible contraception)
2. Intrauterine contraception, Faculty of Family Planning and Reproductive Health Care, Royal College of Obstetricians and Gynaecologists (November 2007)
3. Farley TM, Rosenberg MJ, Rowe PJ, et al; Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 1992 Mar 28;339(8796):785-8. [abstract]
4. UK Medical Eligibility Criteria for Contraceptive Use, Faculty of Family Planning and Reproductive Healthcare, Royal College of Obstetricians and Gynaegologists (2009)
5. Contraceptive Medical Eligibility Criteria, World Health Organization (WHO)
6. Emergency contraception, Faculty of Family Planning and Reproductive Health Care, Royal College of Obstetricians and Gynaecologists (2006)
7. The copper intrauterine device as long-term contraception, Faculty of Family Planning and Reproductive Health Care, Royal College of Obstetricians and Gynaecologists (January 2004)
8. 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.

Internet and further reading

• Contraceptive choices for young people, Faculty of Family Planning and Reproductive Health Care, Royal College of Obstetricians and Gynaecologists (March 2010)
• Contraception - IUS/IUD, Clinical Knowledge Summaries (March 2011)

Acknowledgements