Insertion. advice and aftercare following insertion

Insertion

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/

When can LNG-IUD be inserted

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

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

Current Situation	Timing of insertion of LNG-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	Yes, for 7 days (unless inserted in the first 5 days† of the menstrual cycle)
Cu-IUD within licensed duration of use	Any time if no UPSI within the last 7 days (otherwise defer until no UPSI for 7 days)	Yes, for 7 days (unless inserted in the first 5 days† of the menstrual cycle)
Cu-IUD past licensed duration of use	Any time in a natural menstrual cycle if reasonably certain the individual is not pregnant* or at risk of pregnancy	Yes, for 7 days (unless inserted in the first 5 days† of the menstrual cycle)
Post partum (vaginal birth or Caesarian section, breastfeeding or non-breast feeding	Within 48hrs after childbirth	No
	From 4 weeks after childbirth certain that the individual is not pregnant* or at risk of pregnancy	Yes, for 7 days (unless inserted in the first 5† days of the menstrual cycle or criteria for LAM are met)
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	If an LNG-IUD is inserted after day 5† post abortion or miscarriage, additional precautions are required for 7 days
Following use of oral emergency contraception	Should not be inserted following administration of oral EC until pregnancy can be excluded by a high-sensitivity pregnancy test taken ≥21 days after last UPSI	Condoms or bridging contraception until LNG-IUD can be inserted

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 3: Switching to intrauterine contraception from a hormonal contraceptive method

Current Situation	Timing of insertion	Additional Precautions required
CHC use	Weeks 2 or 3 of CHC use (or subsequent weeks of continuous CHC use) or Day 1 of the HFI	No, providing CHC used correctly
CHC use	After day 1 of the HFI or in week 1 of CHC use	If no UPSI since the start of the HFI – use condoms for 7 days or restart/continue CHC until used correctly for 7 days after HFI OR If UPSI since the start of the HFI – restart/continue CHC use for 7 days
POP (traditional)	At any time if POP has been used correctly	Continue POP for 7 days or use condoms for 7 days
POP (desogestrel)	At any time if POP has been used correctly	No
POP – drospirenone	During HFI (placebo pills, days 25– 28) assuming prior correct use of active pills or Days 1–7 of active pills (taken correctly) after HFI	If no UPSI since start of the HFI – use condoms for 7 days OR If UPSI since the start of the HFI – restart/continue DRSP POP until 7 consecutive active pills taken
POP – drospirenone	Days 8–24 of active pills (taken correctly)	No
ENG implant within 3 years after insertion	Any time	No
ENG implant in situ for 3-4 years	Any time if PT negative	Yes (7 days) 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	LNG-IUD cannot be inserted until pregnancy can be excluded*	Consider PT and EC. Bridge with alternative contraception until pregnancy can be excluded by a high sensitivity PT taken ≥21 days after last UPSI

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

Current Situation	Timing of insertion	Additional Precautions required
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	Yes (7 days)
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	Yes (7 days)
Progestogen-only injectable (DMPA) >14 weeks post-injection AND UPSI since 14 weeks post-injection, some of which took place within the last 21 day	LNG-IUD cannot be inserted until pregnancy can be excluded	Consider PT and EC. Bridge with alternative contraception until pregnancy can be excluded by a high-sensitivity PT taken ≥21 days after last UPSI

Table 2: Switching to LNG-IUD from a hormonal contraceptive method (contd)

Current Situation	Timing of insertion	Additional Precautions required
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 Ideally abstain/use condoms for 7 days prior to change in case new device can not be inserted
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	Yes (7 days)
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	LNG-IUD cannot be inserted until pregnancy can be excluded	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; ENG, etonogestrel; HFI, hormone-free interval; IUC, intrauterine contraception; 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 >6 years but was inserted after age 45 years, follow guidance for replacing a 52 mg LNG-IUD that has been in situ for < 6 years

Insertion Checklist

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

Safe LNG-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 IUC 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 when Intrauterine contraception. Manage the error according to local clinical governance policies.

Pain associated with LNG-IUD insertion

LNG-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 LNG-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 IUD 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

Aftercare advice and follow-up

After 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 time to become effective. The manufacturer’s booklet/card will usually be given to the patient.

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

Except for 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.

LNG-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 LNG-IUD displacement (e.g. change in bleeding pattern, new-onset pelvic pain). Clinicians should explain how to feel for LNG-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 LNG-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 LNG-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

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 LNG-IUD by accidently pulling the LNG-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 LNG-IUD insertion.

Advice for individuals requiring magnetic resonance imaging

Individuals should inform their MRI department so that local guidelines can be followed.

Mirena®, Levosert® and Benilexa® contain no metallic, magnetic or conductive material and are safe at any magnetic field strength. Jaydess® and Kyleena® have a silver ring on their stem which should not prevent basic MRI scanning, however the MRI department will make this decision.

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

Reviewer name(s): George Laird.