Insertion. advice and aftercare following insertion

1. Discussion

This is essential to ensure individuals make an informed choice about their contraception options and can give informed consent. These 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/

2. When can a Cu-IUD 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)

Contraception After Pregnancy | CoSRH

Table 2: Starting Cu-IUD (no recent hormonal contraception) [from CoSRH Clinical Guideline: Intrauterine contraception (March 2023)]

UPSI (unprotected sexual intercourse)

*See Box 1 for how to exclude pregnancy.

Table 3: Switching to Cu-IUD from a hormonal contraceptive method

Table 3: Switching to Cu-IUD from a hormonal contraceptive method (contd)

Table 3: Switching to Cu-IUD from a hormonal contraceptive method (contd)

CHC, combined hormonal contraception; DMPA, depot medroxyprogesterone acetate; DRSP, drospirenone; 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. †Recommendations for the 52 mg LNG-IUD insertion relate to devices inserted before age 45 years.

Insertion checklist

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

Safe Cu-IUD Insertion

Training: Clinicians offering Cu-IUD insertion should hold the COSRH Letter of Competence in Intrauterine Techniques. Immediate postpartum intrauterine contraception (PPIUC) technique is different to standard Cu-IUD insertion and should only be performed by those who have trained in this technique.

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 Cu-IUD procedure and monitor the patient for any signs of pain or distress.

Check the device 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. Manage the error according to local clinical governance policies.

Pain associated with Cu-IUD insertion

Cu-IUD insertions can cause mild-to-moderate pain or discomfort. Analgesia options should be discussed, offered and documented. NSAIDs such as ibuprofen can reduce pain after Cu-IUD insertion.

Emergency management for problems at IUD insertion

Cu-IUD 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.  Follow locally agreed risk management policies for the treatment of emergencies.

Documentation

Clinicians inserting or removing Cu-IUDs 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 Cu-IUD insertion, individuals should be given information on the device inserted, including the name of the device, its mode of action, duration of use and that it will become effective immediately. The manufacturer’s booklet/card will usually be given to the patient.

Where a Cu-IUD 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. They should be advised to seek review at any time if they have concerns or cannot locate the coil threads. They should be given information on who to contact and how. Local pathways should be followed for PPIUC insertions and follow-up.

Cu-IUD users should feel for the 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 Cu-IUD displacement (e.g. change in bleeding pattern, new-onset pelvic pain).  Clinicians should explain how to feel for Cu-IUD 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. The individual should be advised to abstain or use an alternative method of contraception until the Cu-IUD position is confirmed, and if there has been any recent, condomless sex they should seek advice as emergency contraception may be required.

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

11. Advice about use of menstrual cups, discs and tampons

There could be increased risk of expulsion associated with menstrual cup use. Users should be advised to follow the manufacturer’s instructions. Care should be taken not to dislodge the Cu-IUD by accidently pulling the Cu-IUD threads when removing the menstrual device’

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 Cu-IUD insertion.

12. Advice for individuals requiring magnetic resonance imaging

Individuals should inform their MRI department so that local guidelines can be followed. Cu-IUD inserted outside of the UK may contain different metals (eg Chinese ring contains steel) and might not be MRI safe. Advice should be sought from the local radiology department.