IUCD Insertion Technique

An intrauterine device (IUD) or 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. In the UK, an estimated 5% of the contraception population use IUCDs.¹
Insertion should only be undertaken by a trained family planning professional who fits at least one IUCD/IUS per month.²

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 device; LNG IUS - Mirena®³

• 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 (Chlamydia trachomatis and Neisseria gonorrhoea) 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.¹

Postpartum insertion

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. 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.
Expulsion of the device is more common for insertions after 48 hours post-delivery.¹

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.⁴

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

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

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 white inserter rod into 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 so allow the inserter rod arms to adopt the T position (2cm approx.)
• Slowly advance the insertion tube to ensure correct positioning before removing the insertion rod
• Cut the threads to a length of 3cm approx 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 to 2cm from the back of the cervix
• Release the arms by pulling back the slider and advance 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 2-3cm approx and note the length

• An IUCD (or advice on how to obtain one) should be offered to all women attending for 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.⁷
• 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® emergency contraception 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 contraindication to insertion is risk of STI.⁵

The IUS is not suitable for emergency contraception.⁸

Instruct patient how to feel the threads, and advise 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 patient is feeling well enough to leave.
Arrange follow-up in 6 weeks. This visit should be used to check for infection, perforation or expulsion.² Threads may need to be shortened, if felt by the partner. Further follow-up at least annually or sooner, if required.