Insertion, removal, advice, and documentation

NHS Dumfries & Galloway - RefHelp
NHS Dumfries and Galloway

Insertion

Timing of insertion

Circumstances

Timing of insertion

Additional precautions

All circumstances

Any time in the menstrual cycle if reasonably certain the woman is not pregnant or at risk of pregnancy (unless qualifies for use as emergency contraception).

No

Post partum including caesarian section and breast feeding

Any time after 4 weeks post partum and it is reasonably certain the woman is not pregnant or at risk of pregnancy (unless qualifies for use as emergency contraception).

No

Following abortion (all induced or spontaneous at less than 24 weeks gestation), ectopic pregnancy, or miscarriage

Post surgical abortion: ideally should be inserted at the end of the procedure.

Post medical abortion: can be fitted at any time after completion of the second part - i.e., after the passage of products of conception confirmed by clinical assessment and/or local protocols.
Note some services offering early medical discharge (products passed at home) opt to insert in those with a negative pregnancy test at the time of the follow up visit 2 to 3 weeks post abortion (provided no risk of further pregnancy since abortion unless qualifies for use as emergency contraception).

Post ectopic pregnancy and miscarriage: ideally should be inserted immediately after treatment for ectopic pregnancy or miscarriage.

No

Following administration of oral EC

Within the first 5 days (120 hours) following the first unprotected sexual intercourse (UPSI) in a cycle, or within 5 days from the earliest estimated day of ovulation.

Outside of the above criteria a Cu-IUD should not be inserted following administration of oral emergency contraception, until pregnancy can be excluded by a pregnancy test no sooner than 3 weeks after the last episode of UPSI.

No

 

 

 

Not applicable

All methods of contraception

A Cu-IUD can be inserted at any time if another reliable method of contraception has been used consistently and correctly, and it is reasonably certain the woman is not pregnant or at risk of pregnancy (except in those circumstances that would qualify for use as emergency contraception).

Also refer to local protocols since some services choose not to consider barrier methods as reliable contraception.

No

Ideally, when switching from a LNG-IUS to CU-IUD, additional contraceptive precautions are advised in the 7 days before changing incase the new device cannot be inserted.

A provider can be reasonably certain a woman is not currently pregnant if she has no symptoms or signs of pregnancy and meets any of the following criteria:

  • Has not had intercourse since last normal menses.
  • Has been correctly and consistently using a reliable method of contraception.
  • Is within the first 7 days of the onset of a normal period.
  • Is not breastfeeding and less than 4 weeks from giving birth.
  • Is within the first 7 days post-abortion or miscarriage.
  • Is fully or nearly fully breast feeding, amenorrhoeic, and less than 6 months postpartum.

NB. In addition to the conditions mentioned above, clinicians should also consider whether a women is at risk of becoming pregnant as a result of UPSI within the last 7 days.

 

The insertion procedure

Clinicians inserting IUC should hold the appropriate letter of Competence in Intrauterine Techniques, or have achieved the equivalent recognised competences and show evidence of recertification / reaccreditation.

 

Interventions that ease Cu-IUD insertion

  • Factors that predict pain during insertion include:
    • nulliparity or no history of vaginal delivery
    • anxiety
    • length of time since last pregnancy or last menses.
  • Oral analgesia prior to insertion is commonly recommended but evidence suggests oral ibuprofen at does up to 600mg has been shown not to reduce pain.
  • Local anesthetic block is not routinely required but maybe available.

 

Advice following insertion

  • Women should be informed what device has been inserted and when it needs to be removed / replaced. Clients should be given written information on the method.
  • Insertion of a Cu-IUD may cause pain and discomfort for a few hours and women should be informed about appropriate pain relief.
  • A routine follow up visit can be advised 3 to 6 weeks following insertion. This is not essential and it may be more important to advise women as to the signs and symptoms of infection, perforation, expulsion, pregnancy and returning if they have any problems.
  • Women should be informed of the symptoms of pelvic infection (for example pain, dyspareunia, abnormal discharge and fever) and advised as to how and where to seek medical help if these occur particularly in the first three to four weeks after insertion. Women should be informed about the use of additional precautions for protection from STIs and advised on the appropriate timings of STI testing after unprotected sexual intercourse.
  • Patients at increased risk of developing infective endocarditis should already be familiar with symptoms that may indicate infection. Any episode of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing.
  • Women should be informed about how to check for the presence of Cu-IUD threads and encouraged to do this regularly with the aim of recognising expulsion / perforation. If threads cannot be felt they should be advised to use additional contraception until they seek medical advice. Likewise if they can feel the stem of the Cu-IUD they should also seek medical advice and use additional contraception. Consideration may also have to be given to the use of emergency hormonal contraception.
  • Women should be advised to seek medical help (to exclude ectopic pregnancy) if they miss a period or develop abdominal pain.
  • In addition, women should be advised to seek medical assistance at any time if they develop persistent menstrual abnormalities as this may indicate the presence of an STI, pregnancy or gynaecological pathology.
  • Women should be informed about the use of additional precautions for protection from STIs and advised on the appropriate timings of STI testing after unprotected sexual intercourse.
  • Theoretically, since plastic, copper, and silver are not magnetic, no magnetic force should be experienced with magnetic resonance scanning (MRI). MRI centres may ask women to inform them if they have any metallic object in their body including a Cu-IUD. Some have polices stating the Cu-IUD should be removed prior to a MRI scan and the CEU suggests checking with the relevant radiology department. The CEU suggests that removal is not required when a magnetic field up to 3 Tesla is used.

Documentation

  • The patient record should be completed or updated as required.
  • Name of chaperone should be recorded.
  • Details of the insertion procedure including the name, batch number and expiry date of Cu-IUD inserted should be recorded.
  • Details of local anaesthetic used, if any, including batch number and expiry date should be recorded.
  • Permission should be sought as to whether the client’s GP can be notified.

Timing of removal / replacement of Cu-IUD

Reason for removal

Recommendation for removal

For a planned pregnancy

Offer pre pregnancy advice regarding lifestyle, diet, folic acid, rubella immunity, and vitamin D, then removal at any time in the cycle when the women is ready to conceive.

When removal is
within the licensed
duration of use and
alternative method is
chosen.

Women using a Cu-IUD can have their device removed up to day 3 after the
onset of menstruation without the need for additional precautions.
Women having a Cu-IUD removed after day 3 should be asked to avoid
intercourse or use another method of contraception for at least 7 days before
removal. Advise contraception thereafter.

When replacement is within the licensed duration of use

Advise condoms for at least 7 days before the procedure in case reinsertion is not possible.

When replacement is outwith the licensed duration of use

A Cu-IUD (containing at least 300mm2 of copper), inserted at or after the age of 40:

  • Can be retained until 1 year after the last menstrual period if this occurs when the woman is over the age of 50 years.
  • Can be retained until 2 years after the last menstrual period if this occurs when the woman is under the age of 50 years.

Women who wish replacement of a Cu-IUD outwith the licensed duration of use (excluding those detailed above) should have a pregnancy reliably excluded or fill the criteria for emergency contraception.

References

  1. FSRH Clinical Effectiveness Unit. FSRH Clinical Guideline: Intrauterine Contraception [Internet]. The Faculty of Sexual and Reproductive Healthcare; 2015 Apr [updated 2019 Sep; cited 2022 Oct 14]. Available from: https://www.fsrh.org/standards-and-guidance/documents/ceuguidanceintrauterinecontraception/
  2. National Institute for Health and Care Excellence. Long-acting reversible contraception [Internet]. [London]: NICE; 2005 [updated 2019 Jul; cited 2022 Oct 14]. (Clinical guideline [CG30]). Available from: https://www.nice.org.uk/Guidance/CG30
  3. National Institute for Health and Care Excellence. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures [Internet]. [London]: NICE; 2008 [updated 2016 Jul; cited 2022 Oct 17]. (Clinical guideline [CG64]). Available from: https://www.nice.org.uk/guidance/cg64
  4. FSRH Clinical Effectiveness Unit. FSRH Clinical Guideline: Contraception for Women Aged over 40 Years [Internet]. The Faculty of Sexual and Reproductive Healthcare; 2017 Aug [updated 2019 Sep; cited 2022 Oct 14]. Available from: https://www.fsrh.org/standards-and-guidance/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/

Editorial Information

Last reviewed: 01/06/2020

Next review date: 31/12/2023

Author(s): Janice Allan.

Version: 9.1