Insertion. advice and aftercare following insertion

Warning

Insertion

Discussion

IUC discussion and assessment is essential to ensure the method and procedure will be safe for the individual, that they make an informed choice about their contraception options and are able to give informed consent. Discussion may be at the time of the procedure, or at a prior appointment, depending on local service pathways and the urgency of the IUC insertion. Discussion and assessment  may be undertaken face-to-face, via telephone or virtual appointment, or by self-assessment and signposting to patient resources. Women can be encouraged to watch an eight minute information film produced by Lothian Sexual Health available  at https://www.lothiansexualhealth.scot/contraception/iud-ius/

When can an IUC be inserted 

A Cu-IUD can be inserted at any time during the menstrual cycle providing that pregnancy can be reasonably excluded (see Box 1). Recommendations for starting or switching to a Cu-IUD can be found in Table 2 and Table 3.

The Cu-IUD can be used for EC if inserted within 5 days of the first episode of UPSI that cycle, or within 5 days of the earliest expected date of ovulation (see emergency contraception protocol)

Box 1: Criteria for reasonably excluding pregnancy

Healthcare practitioners can be reasonably certain that an individual is not currently pregnant if any one or more of the following criteria are met and there are no symptoms or signs of pregnancy:
They have not had intercourse since the start of their last normal (natural) menstrual period, since childbirth, abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease.
They have been correctly and consistently using a reliable method of contraception. (For the purposes of being reasonably certain that an individual is not currently pregnant, barrier methods of contraception can be considered reliable providing that they have been used consistently and correctly for every episode of intercourse.)
They are within the first 5 days of the onset of a normal (natural) menstrual period. They are less than 21 days postpartum (non-breastfeeding individuals).*
They are fully breastfeeding, amenorrhoeic and less than 6 months’ postpartum.*
They are within the first 5 days after abortion, miscarriage, ectopic pregnancy or uterine evacuation for gestational trophoblastic disease.
They have not had intercourse for >21 days and have a negative high-sensitivity urine pregnancy test (able to detect human chorionic gonadotrophin (hCG) levels around 20 mIU/ml).

Table 1: Starting Cu-intrauterine contraception (no recent hormonal contraception) [from FSRH Clinical Guideline: Intrauterine contraception (March 2023)]

 Current Situation

Timing of insertion of Cu-IUD

Additional Precautions required

No recent hormonal contraception and no recent pregnancy

Any time in a natural menstrual cycle if reasonably certain the individual is not
pregnant* or at risk of pregnancy (unless qualifies for use as EC)

No

Cu-IUD within licensed duration of use

Any time 

Ideally abstain/use condoms for 7 days prior to change in case new device cannot be inserted.

Cu-IUD past licensed duration of use

Any time in a natural menstrual cycle if reasonable certain the individual is not pregnant* or at risk of pregnancy (unless qualifies for use as EC)

No

Post partum (vaginal birth or Caesarian section, breastfeeding or non-breast feeding

Within 48 hours after childbirth or from
4 weeks after childbirth if it is
reasonably certain the individual is not pregnant* or at risk of pregnancy (unless criteria for use as EC apply)

No

Following abortion of miscarriage

Post-surgical abortion or surgical management of miscarriage: ideally insert at the time of the procedure
Post-medical abortion or miscarriage: IUC can be inserted any time after
expulsion of pregnancy

 

No

Following use of oral emergency contraception

 

Within the first 5 days (120 hours) following first UPSI in a natural menstrual cycle or within 5 days after
the earliest estimated day of ovulation

No

If there has been UPSI in this natural menstrual cycle that occurred >5 days ago AND it is >5 days after the earliest estimated date of ovulation (or date of ovulation cannot be estimated), a Cu-IUD cannot be inserted until pregnancy can be excluded by a high-sensitivity pregnancy test taken ≥21 days after last UPSI

Condoms or bridging contraception until
Cu-IUD can be inserted

UPSI (unprotected sexual intercourse)

*See Box 1 for how to exclude pregnancy.

Table 2: Switching to Cu-IUD from a hormonal contraceptive method

Current Situation

Timing of insertion

Additional Precautions required

CHC use

At any time if CHC has been used correctly (or criteria for use as EC are met)

No

POP 

At any time if POP has been used correctly (or criteria for use as EC are met)

N0

ENG implant within 3 years after insertion

Any time

No

ENG implant in situ for

3-4 years

Any time if PT negative

Repeat PT 21days after last UPSI

ENG implant in situ for >4 years and no UPSI in the last 21 days

Any time if PT negative

Yes (7 days)

ENG implant in situ for >4 years and UPSI in the last 21 day

 

If PT negative AND all UPSI that has taken place in the last 21 days was within the last 5 days, Cu-IUD can be inserted as EC

No

Cu-IUD cannot be inserted if
any UPSI occurred between
5 and 21 days ago

Consider PT and EC. Bridge
with alternative contraception
until pregnancy can be
excluded by a high-sensitivity
PT taken ≥21 days after last
UPSI

Progestogen-only injectable (DMPA) ≤14 weeks post-injection

Any time

No

Progestogen-only injectable (DMPA) >14 weeks post-injection and no UPSI since 14 weeks

Any time

No

Progestogen-only injectable (DMPA) >14 weeks post-injection

 AND

 UPSI since 14 weeks post-injection, all of which took place ≥21 days ago

Any time if PT negative

No

Progestogen-only injectable (DMPA) >14 weeks post-injection

 AND

UPSI since 14 weeks post-injection, some of which took place within the last 21 days

If PT negative AND all UPSI that has taken place in the last 21 days was within the last 5 days, Cu-IUD can be inserted as EC

No

Cu-IUD cannot be inserted if
any UPSI occurred between
5 and 21 days ago

Consider PT and EC. Bridge with alternative contraception until pregnancy can be excluded by a high-sensitivity PT taken ≥21 days after last UPSI

52 mg LNG-IUD in situ for < 8 years

OR

19.5 mg LNG-IUD in situ for < 5 years

OR

13.5 mg LNG-IUD in situ for < 3 years

Any time

 

No

 

52 mg LNG-IUD in situ for >8 years†

AND

no UPSI within the last 21 days

OR

19.5 mg LNG-IUD in situ for >5 years AND no UPSI within the last 21 days

 OR

 13.5 mg LNG-IUD in situ for >3 years AND no UPSI within the last 21 days

Any time if PT negative on day of replacement

No

52 mg LNG-IUD in situ for >8 years† AND UPSI within the last 21 days

OR

 19.5 mg LNG-IUD in situ for >5 years AND UPSI within the last 21 days

OR

13.5 mg LNG-IUD in situ for >3 years AND UPSI within the last 21 days

 

 

If PT negative AND all UPSI
that has taken place in the
last 21 days was within the
last 5 days, Cu-IUD can be
inserted as EC

No

If PT negative any UPSI occurred between 5 and 21 days ago Cu-IUD cannot be inserted. 

Consider PT and EC. Bridge with alternative contraception until pregnancy can be excluded by a high-sensitivity PT taken ≥21 days after last UPSI

CHC, combined hormonal contraception; Cu-IUD, copper intrauterine device; DMPA, depot medroxyprogesterone acetate; DRSP, drospirenone; EC, emergency contraception; ENG, etonogestrel; HFI, hormone-free interval; IUC, intrauterine contraception; LNG-IUD, levonorgestrel intrauterine device; POP, progestogen-only pill; PT, pregnancy test; UPSI, unprotected sexual intercourse. *See Box 1 for how to exclude pregnancy. †Recommendations for the 52 mg LNG-IUD insertion relate to devices inserted before age 45 years. If replacing a 52 mg LNG-IUD with a Cu-IUD that has been in situ for >8 years but was inserted after age 45 years, follow guidance for replacing a 52 mg LNG-IUD that has been in situ for < 8 years

Insertion Checklist

Intrauterine contraception pre-insertion checklist for the minimum criteria that should be met prior to insertion.   

The clinician inserting the intrauterine contraception (IUC) should ensure that (as a minimum) the following criteria are met prior to insertion:
Individual assessed as medically eligible
Checked there are no indications for IUC to be inserted in an alternative setting/service
Checked there are no allergies to IUC content or local anaesthetic
Checked it is a suitable time to insert and any requirement for additional contraception/follow-up pregnancy testing
Considered and offered sexually transmitted infection (STI) testing and/or cervical screening as appropriate
Individual advised about:
Different IUC types available
Contraceptive effectiveness and time to effect (including need for additional contraception and/or follow-up pregnancy test)
Duration of use (for contraception and other indications)
Potential bleeding patterns
Other potential side effects and risks
Insertion procedure and associated risks including: pain, infection, expulsion, perforation, failure, ectopic pregnancy, non-visible threads
Analgesia options and option to stop at any time during the procedure
Signs/symptoms that require review
How and when to check threads
Removal procedure
Individual given opportunity to ask questions and to reflect on new information and return for procedure or alternative at another time if they wish
Type of IUC device confirmed with patient and assistant
Expiry date on IUC and analgesia checked
Suitably trained assistant present
Appropriate equipment available (e.g. resuscitation equipment, appropriate examination couch/lighting, range of speculum sizes, analgesia options)

Training: Clinicians offering IUC insertion should hold the appropriate FSRH Letter of Competence in Intrauterine Techniques or have achieved equivalent recognised competencies and show evidence of recertification/reaccreditation.

Immediate postpartum intrauterine contraception (PPIUC) technique is different to standard IUC insertion and should only be performed by those who have trained in this technique.

All staff involved with IUC insertion should undergo training and regular updates in resuscitation.

Informed consent: Informed consent for undertaking an IUC procedure should be obtained in line with local policy

Assistants and Chaperones: A chaperone should be offered for all intimate examinations. The chaperone’s role is to support the patient.  An appropriately trained assistant should be present during all cervical instrumentation procedures. The assistant can also fill the role of a chaperone if trained. The assistant should support the individual during the IUC procedure and monitor the patient for any signs of pain or distress.

Check the device has not expired: Prior to inserting an IUC, check it has not expired. If an expired device is inadvertently inserted, inform the individual of the error and offer the option of retaining the device or having it removed and replaced. The expiry date relates to the microbiological sterility of the device. Risk of infection from loss of microbiological sterility could well be lower than the risk of infection if the device is replaced again when Intrauterine contraception. Manage the error according to local clinical governance policies and for more information refer to FSRH Clinical Guideline: Intrauterine contraception (March 2023, Amended July 2023)

Practical aspects of IUC insertion

Examination: A bimanual pelvic examination should be performed on all individuals prior to inserting IUC to allow the clinician to assess the position, size, shape and mobility of the uterus.

Measurement of pulse rate and blood pressure: Routine measurement of pulse rate and/or blood pressure before, during and/or after IUC procedures is not required but can be considered on a case-by-case basis, guided by the clinical picture.

Cervical cleansing: Cleansing the vulva, vagina or cervix prior to IUC insertion is not required.

Sterile gloves: There is no requirement to use sterile gloves when inserting IUC if a ‘no touch’ technique is used.

Pain associated with IUD insertion

Individuals should be advised that most IUC insertions are associated with mild-to-moderate pain or discomfort, but that pain can range from none to severe. Analgesia options should be discussed and offered to individuals having IUC inserted. Referral processes should be in place for circumstances where an individual requests an analgesia option that the clinician is unable to provide.

Clinicians should support and encourage users to tell them if they are experiencing pain or discomfort and reassure them that the procedure can be paused or stopped at any time.

Post-procedure analgesia NSAIDs such as ibuprofen can reduce pain after IUC insertion and can be offered to individuals who experience pain after insertion of an intrauterine method.

Emergency management for problems at IUC insertion

IUC insertion can trigger a vasovagal response. Drugs and equipment required for resuscitation must be available, accessible, clearly labelled, adequately maintained and their location known to all staff. Recommended drugs required for resuscitation are:

  • Adrenaline 500mcg IM (0.5ml of 1:1000) (two doses if needed)
  • Atropine 500 or 600 mcg IV/IM (two doses if needed) for the treatment of symptomatic bradycardia

Locally agreed risk management policies for the treatment of emergencies should be in place and take into account national recommendations.

Documentation

Clinicians inserting or removing IUC should document the procedure and consultation in line with local policy and protocol and notify (where applicable and with consent) other relevant healthcare providers (e.g. primary care) of the type of device, date of insertion and recommended duration of use.

Advice and Aftercare following insertion

After IUC insertion, individuals should be given information on the device inserted, including the name of the device, its mode of action, duration of use and time to become effective. The manufacturer’s booklet/card will usually be given to the patient.

Where IUC has been inserted outside of product licence information about how and when to perform a pregnancy test should be given.

With the exception of PPIUC, routine post-insertion check-ups with a clinician are not required. However, individuals who have had an IUC inserted should be advised they can seek review at any time if they have concerns, cannot locate their threads, or wish to change their method of contraception. They should be given information on who to contact and how.

Due to the increased risk of expulsion or long or non-visible threads with PPIUC, routine IUC check-ups are recommended when IUC has been inserted within 48 hours of a vaginal or caesarean birth. These check-ups are undertaken 4–6 weeks post-insertion and IUC users should be advised where this will take place, in line with local PPIUC pathways.

lUC users should be advised to feel for their threads within the first 4–6 weeks after insertion and then at regular intervals (e.g. monthly or after menses) and if they have any concerns suggestive of IUC displacement (e.g. change in bleeding pattern, new-onset pelvic pain).  Clinicians should explain how to feel for IUC threads and that users should seek review if threads are not palpable, thread length becomes shorter or longer, or the stem of the device is felt. Clinicians should explain that any of these changes could mean the IUC is incorrectly sited and therefore effectiveness cannot be guaranteed. The individual should be advised to abstain or use an alternative method of contraception until the IUC position is confirmed, and if there has been any recent, condomless sex they should seek advice as emergency contraception may be required.

In addition to seeking review if there are concerns when they check their threads, individuals should be advised to seek urgent review if they have:

  • Symptoms of pelvic infection (e.g. change in vaginal discharge, pelvic pain and intermenstrual/ postcoital bleeding)
  • Concerns regarding their bleeding pattern
  • A positive pregnancy test.

Women can be encouraged to watch a 4 minute video produced by The West of Scotland Managed Clinical Network for Sexual Health for women who have recently had a IUD inserted which gives advice on what to expect, how to check for threads and when to seek advice.

https://sexualhealthdg.co.uk/iuc.php

Advice about use of menstrual cups, discs and tampons

Evidence suggests that there could be increased risk of expulsion associated with menstrual cup use. With many different brands available, users should be advised to follow the manufacturer’s instructions, including any special considerations for IUC users. With any of these methods, care should be taken not to dislodge the IUC by accidently pulling the IUC threads when removing the menstrual device and, where applicable, users should be advised to ensure they release any suction from the menstrual device prior to removal.

Some clinicians advise avoiding tampons and menstrual cups for up to several weeks after IUC insertion, citing increased risk of expulsion or infection. There are not robust studies to inform effect of use of tampons on risk of expulsion.

There is no clear evidence of increased risk of infection associated with use of tampons, menstrual cups/discs or intercourse in the days or weeks after IUC insertion.

Advice for individuals requiring magnetic resonance imaging

Individuals requiring magnetic resonance imaging (MRI) with a device containing a metallic component should inform their MRI department so that local guidelines can be followed. The limited published evidence suggests that it is safe for an individual with a Cu-IUD to undergo MRI at a strength of 1.5 Tesla (T) or 3 T and therefore removal of the device would not normally be necessary unless the area of interest is very close to the position of the device (this could result in some imaging artefacts). Cu-IUD inserted outside of the UK may contain different metals and might not be MRI safe. Advice should be sought from the local radiology department. Devices containing stainless steel (e.g. the Chinese ring) are not MRI safe and should be
removed prior to MRI.

 

Editorial Information

Last reviewed: 31/08/2023

Next review date: 30/09/2025

Author(s): West of Scotland Managed Clinical Network in Sexual Health Clinical Guidelines Group .

Version: 10.1

Approved By: West of Scotland Managed Clinical Network in Sexual Health