Insertion. advice and aftercare following 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 

IUC 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 IUC can be found in Table 1 and Table 2.

Box 1: Critieria for reasonably excluding pregnancy

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

LAM (Lactation amenorrhoea method) UPSI (unprotected sexual intercourse)

*See Box 1 for how to exclude pregnancy. † Summary of Product Characteristics suggests this applies also to days 6 and 7 of a natural cycle.

Table 2: Switching to intrauterine contraception from a hormonal contraceptive method

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 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.   

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)

https://www.fsrh.org/standards-and-guidance/documents/ceuguidanceintrauterinecontraception

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 LNG-IUS 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.

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.

IUC 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

Mirena®, Levosert® and Benilexa® contain no metallic, magnetic or conductive material and are safe at any magnetic field strength. 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 Intrauterine contraception that it is safe for an individual with a Kyleena or Jaydess 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). IUC 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.