Intrauterine contraception

• Faculty of Sexual & Reproductive Healthcare •

Clinical assessment

• A clinical history (including sexual history) should be taken as part of the routine assessment for intrauterine contraception to assess suitability for use of the method.
• Women at higher risk of sexually transmitted infections (STIs) (i.e. aged <25 years, or >25 years with a new sexual partner or more than one partner in the last year, or if their regular partner has other partners) should be tested for Chlamydia trachomatis (as a minimum) in advance of insertion. If results are unavailable before insertion then prophylactic antibiotics (at least to cover C. trachomatis) may be considered

N.B. There is no indication to test or treat other lower genital tract organisms or delay insertion in asymptomatic women attending for insertion of intrauterine contraception

Points to cover when counselling patients

Health care professionals should counsel women to enable them to choose an intrauterine method based on medical eligibility and the woman’s preference

• Mode of action of a copper-bearing intrauterine device (Cu-IUD) is primarily to prevent fertilisation, and the levonorgestrel-releasing intrauterine system (LNG-IUS) is to prevent implantation
• Failure rates at 5 years’ use are low: less than 2% for Cu-IUDs (copper content 380 mm2) and less than 1% for the LNG-IUS
• Uterine perforation is uncommon (up to 2 per 1000 insertions)
• Expulsion occurs in around 1 in 20 women. It is most common in the first year of use and particularly within 3 months of insertion
• Risk of ectopic pregnancy is reduced when using intrauterine contraception when compared to using no contraception
• There is no delay in return to fertility after removal of intrauterine contraception
• There is a six-fold increase in risk of pelvic infection in the 20 days following insertion of intrauterine contraception, but risk is the same as in the non-IUD-using population thereafter
• Bleeding and pain are common causes of discontinuation. Spotting, light bleeding, heavy or prolonged bleeding are common in the first 3–6 months of Cu-IUD use. Irregular bleeding and spotting are common in the first 6 months after insertion of the LNG-IUS. By 1 year after LNG-IUS insertion, amenorrhoea or oligomenorrhoea is usual
• Hormonal side-effects can be due to due to systemic absorption of progestogen, but few women discontinue use of the LNG-IUS for this reason and discontinuation rates are not significantly different from Cu-IUD users
• Insertion procedure and likely discomfort during and after intrauterine contraceptive insertion should be discussed with women and oral analgesia can be advised before insertion

Timing of insertion

• A Cu-IUD can be inserted at any time in the menstrual cycle if there is reasonable certainty that the woman is not pregnant. A Cu-IUD will provide immediate contraceptive protection
• The LNG-IUS can be inserted at any time in the menstrual cycle if there is reasonable certainty that the woman is not pregnant and the clinician is reasonably certain there has been no risk of conception. Unless the LNG-IUS is inserted within the first 7 days of the menstrual cycle, condoms or abstinence is advised for 7 days after insertion

Procedures for insertion

• Clinicians who insert intrauterine contraceptive methods should be appropriately trained, maintain competence, and attend regular updates in dealing with emergencies
• Emergency equipment must be available in all settings where intrauterine contraception is being inserted and local referral protocols must be in place for women who require further medical input
• An appropriately trained assistant should be present during insertion of intrauterine contraception
• A bimanual pelvic examination should be performed before inserting intrauterine contraception:
  • cleansing the ectocervix prior to insertion of intrauterine contraception has no proven benefit
  • a ‘no-touch’ technique can be used when sounding the uterine cavity and inserting intrauterine contraception.If a ‘no-touch’ technique is used sterile gloves are not required
  • the cervix should be stabilised with an appropriate forceps to allow assessment of the length of the uterine cavity and to ensure fundal placement of the device
• The case notes should include appropriate documentation on pre- and post-insertion counselling, the insertion procedure, and the type of device inserted

Ongoing management

• Women should be given information (oral and written) about the device inserted and duration of use
• Women should be instructed on how to check for the intrauterine contraceptive and its threads, and advised that if they are unable to feel the threads it may be that the device has been expelled. Alternative contraception should then be used until medical advice is sought
• Women should be advised to seek medical help at any time if they develop symptoms of pelvic infection, pain, persistent menstrual abnormalities, missed period, non-palpable threads, or if they can feel the stem of the device
• A follow-up visit after the next menses or 3–4 weeks after insertion is recommended. Annual follow-up is not routinely recommended and women should attend if problems arise at any time

N.B. Intrauterine methods do not protect against STIs and, therefore, women at higher risk of STIs (i.e. those aged <25 years, or aged >25 years with a new sexual partner or more than one partner in the last year, or if their regular partner has other partners) should be advised to use condoms in addition to the intrauterine method

Choice of device

• After counselling most women can choose between a Cu-IUD or the LNG-IUS since this choice is usually determined by the likely effects on menstrual bleeding pattern and duration of use
• If a woman chooses a Cu-IUD then a device with the lowest failure rate and longest duration of use should be used first-line—the TCu380S (TT380 Slimline® or T-Safe TCu380A QuickLoad®) is the suggested device of choice
• If at insertion the TCu380S cannot be inserted because the cervical os is too tight another 380 mm2 Cu-IUD is appropriate
• If the uterine length at sounding is less than 6.5 cm, Cu-IUDs with a shorter stem or a frameless device may be used
• There is no evidence comparing the use of different devices in nulliparous women and the TCu380S is the preferred IUD for these women also
• A Cu-IUD inserted at age 40 years or over or an LNG-IUS inserted at age 45 years or over can be retained until 1 year after the last menstrual period if the woman is aged over 50 years (and for 2 years if she is aged under 50 years) or until contraception is no longer required
• For the full version of the recommendations and good practice points, please see guidance at www.fsrh.org

full guidelines available from…
Faculty of Sexual & Reproductive Healthcare
http://www.fsrh.org

FSRH Clinical Guidance. Intrauterine contraception (November 2007).
November 2007