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 |
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 |
No |
Following abortion of miscarriage |
Post-surgical abortion or surgical management of miscarriage: ideally insert at the time of the procedure
|
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 |
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 |
Consider PT and EC. Bridge |
|
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 |
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 |
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.