This chapter should be cited as follows: This chapter was last updated:
Nelson, A, Glob. libr. women's med.,
(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10394
May 2008


Intrauterine Contraceptives

Anita L. Nelson, MD
Professor, Harbor-UCLA Medical Center, 1000 Carson Street, Torrance, California 90509, USA


Intrauterine contraceptives (IUCs) provide top tier contraception that is convenient, long term, cost effective and rapidly reversible. Their efficacy compares favorably with permanent sterilization. Continuation rates are high of any hormonal method.1  Currently, there are two types of IUCs available in the United States: the copper T 380A intrauterine device (ParaGard® T 380A Intrauterine Copper Contraceptive, Duramed Pharmaceuticals Inc., Pomona, NY),2 and the levonorgestrel-releasing intrauterine system (Mirena®, Bayer HealthCare Pharmaceuticals Inc., Wayne, NJ).3

The copper T 380A intrauterine device (IUD) (Fig. 1) is a T-shaped device composed of a polyethylene frame measuring 36 mm by 32 mm with 176 mg of electrolytic copper wire wrapped around its vertical stem and two copper sleeves of 68.7 mg of copper, placed on each of the horizontal arms, for a total surface area of 380 ± 23 mm2 of copper. The device has a monofilament polyethylene string tied at the base of the stem to create two tail strings that aid in monitoring device’s position and in its removal. The frame contains barium sulfate to permit radiographic visualization. The copper T 380A IUD is Food and Drug Administration (FDA)-approved for 10 years of use, although clinical studies indicate high efficacy for at least 12 years4 and perhaps as long as 20 years.5

Fig. 1. The copper T 380A IUD (ParaGard® T 380A Intrauterine Copper Contraceptive, Duramed Pharmaceuticals Inc., Pomona, NY). (Photo courtesy of Duramed Pharmaceutical Inc.)

Fig. 2. The levonorgestrel-releasing IUS (Mirena®, Bayer HealthCare Pharmaceuticals Inc., Wayne, NJ). (Photo courtesy of Bayer HealthCare Inc.)

View video demonstrating the correct method of inserting Mirena

The levonorgestrel-releasing system (LNG-IUS)(Fig. 2) is also a T-shaped device with a polyethylene frame measuring 32 mm by 32 mm and containing barium sulfate for radiographic imaging. A reservoir of levonorgestrel mixed with polydimethylsiloxane EVA is molded around the vertical stem of the T. The sleeve is coated with a membrane that regulates the release of levonorgestrel (LNG) directly into the endometrium at a rate of 20 mcg per day initially and 14 mcg per day at the end of 5 years. The system is approved in the United States for 5 years of use, but it may protect against pregnancy for 7 years.6 Systemic absorption of LNG does occur. Because the daily release is only approximately 10% of the amount in an oral contraceptive containing 150 mcg of LNG, the mean plasma concentration is significantly lower than that seen with combined oral contraceptives, progestin-only pills or progestin implants.

Other IUCs may currently be used by women living in America. Inert plastic IUDs, such as the Lippes Loop and the Safety Coil, were used in the United States before 1985. Women with these devices may continue to use them as long as they are at risk for pregnancy, because the duration of use of plastic IUDs is unlimited. Other IUCs are available internationally, and women often obtain them before immigrating to the United States. The Multiload copper 375 IUD, Nova-T IUD, stainless steel rings, and other stringless IUDs can be obtained in Asia, and other copper IUDs are also available overseas. Newer, lower dose versions of the LNG-IUS are in clinical testing in the United States.


Worldwide, IUCs are used nearly 160 million women (15% of the world's women of reproductive age) making them the most popular method of reversible contraception.7 In Sweden and Germany, 15–20% of reproductive-aged, contracepting women select the IUC. In China, 49% of women use IUCs.8 In the United States, this effective, convenient, and cost-effective method of reversible birth control has been growing in popularity, but is still used by only 3% of contracepting women.9 In part, the under-utilization of IUCs in the United States results from the medicolegal issues created by the Dalkon Shield IUD.10 Other barriers that have been identified to more mainstream use of intrauterine contraception can be attributed to (1) incorrect beliefs that IUCs act as abortifacients; (2) concerns that an IUC may increase the risk for pelvic infection or increase legal liability; (3) physician inexperience with the modern IUCs11; and (4) lack of insurance coverage for IUCs despite their demonstrated cost effectiveness.12 


Both IUCs are in the top tier of contraceptive efficacy and are at least as effective as irreversible sterilization.13 The cumulative 5-year pregnancy rate with the LNG-IUS is less than 0.5%14 and is between 0.3–0.6% for the copper T 380A IUD.15, 16 The copper T 380A IUD is the most effective copper-bearing IUD in the world.17 The 10-year cumulative pregnancy rate for the copper T 380A is 1.9–2.2%. Extended use studies with that device report no pregnancies from 8–15 years18 from 8–20 years.5 The 10-year failure rate of the copper T 380A IUD is only a fraction of the typical use first-year failure rate of oral contraceptive pills;19 and is less that than the 10-year failure rate of some methods of tubal ligation.20, 21 No pregnancies occured in women who extended their use of the LNG-IUS to 7 years, used a second IUS for an additional 5 years, and a third one for 5 more years.22 Because IUCs act locally (see mechanisms of action), their efficacy is maintained even in women with Class III obesity. Efficacy after placement immediately following early pregnancy loss or postpartum is not well established, but failure rates have been reported to range from 0.7–9.5%.16


Modern IUCs are appropriate for women seeking reversible contraception, as well as by those who have completed their families.13 The 2004 WHO Medical Eligibility Criteria rate use of either IUC as being appropriate for the vast majority of nonpregnant women, even those women with serious medical problems.14 See Table 1. 

Table 1

World Health Organization WHO Medical Eligibility Criteria — Category 4 conditions14


Puerperal sepsis××
Immediate postseptic abortion××
Unexplained vaginal bleedingInitiationInitiation
Malignant gestational trophoblastic disease××
Cervical cancer (awaiting treatment)InitiationInitiation
Breast cancer (≤5 years) ×
Endometrial cancerInitiationInitiation
Uterine fibroids with distortion of the uterine cavity××
Distorted uterine cavityInitiationInitiation
PID ≤3 months××
Current purulent cervicitis, chlamydial infection or gonorrheaInitiationInitiation
Known pelvic tuberculosisInitiationInitiation

× indicates initiation or continuation.


The most important requirements for potential IUC candidates are that they do not currently have infection or carcinoma of the cervix or upper genital tract, that they do not have unexplained abnormal bleeding and that they do have an appropriately sized uterus which permits placement of the IUC. For women who have had breast cancer within the last 5 years and those with acute hepatitis, the LNG-IUS is contraindicated. According to the WHO criteria,14 none of the following is a contraindication to IUC use: smoking, seizure disorder, thyroid disease, valvular heart disease, venous thrombosis, diabetes, hypertension, heart disease, gallbladder disease, migraine, or HIV infection. Women with cancer on chemotherapy are in need of effective protection from pregnancy, which is provided by intrauterine contraceptives. While these WHO criteria are not intended to provide recommendations for individual patient care, they do have the advantage of being evidenced-based and being periodically updated. A recent review of the WHO MEC suggests re-evaluation of prohibition of LNG-IUS use by women with recent breast cancer.15

The WHO MEC recommendations often differ significantly from the product labeling. The package insert for the copper T 380A was significantly updated in 2005. The recommended patient profile was removed entirely. According to the current labeling, the copper T 380A may be used by nonpregnant women with a uterine cavity that measures 6–9 cm in depth, unless they have an absolute contraindication to use (Table 2).

Table 2

Copper T 380A IUD U.S. labeling contraindications 2


ParaGard® should not be placed when one or more of the following conditions exist:
1. Pregnancy or suspicion of pregnancy.
2. Abnormalities of the uterus resulting in distortion of the uterine cavity.
3. Acute pelvic inflammatory disease or current behavior suggesting a high risk for pelvic inflammatory disease.
4. Postpartum endometritis or postabortal endometritis in the past 3 months.
5. Known or suspected uterine or cervical malignancy.
6. Genital bleeding of unknown etiology.
7. Mucopurulent cervicitis.
8. Wilson's disease.
9. Allergy to any component of ParaGard®.
10. A previously placed IUD that has not been removed.


The copper T 380A IUD is not appropriate for women with copper allergies and is not recommended for women with copper storage defects (Wilson's disease). Labeling states that the copper T 380A IUD should not be used by women at high risk for sexually transmitted infections; however, in that situation, concurrent condom use may enable IUD use. A recent retrospective study of women with a history of STDs or active infections showed that both the IUCs were safe and effective.16 HIV-infected women are also appropriate candidates for IUCs.18

The product labeling for the LNG-IUS continues to be much more restrictive. The LNG-IUS package insert continues to provide both a recommended patient profile as well as an extensive list of contraindications (Table 3).

Table 3

LNG-IUS US labeling contraindications 3


Mirena® insertion is contraindicated when one or more of the following conditions exist:
1. Pregnancy or suspicion of pregnancy.
2. Congenital or acquired uterine anomaly including fibroids if they distort the uterine cavity.
3. Acute pelvic inflammatory disease or a history of pelvic inflammatory disease unless there has been a subsequent intrauterine pregnancy.
4. Postpartum endometritis or infected abortion in the past 3 months.
5. Known or suspected uterine or cervical neoplasia or unresolved, abnormal Pap smear.
6. Genital bleeding of unknown etiology.
7. Untreated acute cervicitis or vaginitis, including bacterial vaginosis or other lower genital tract infections, until infection is controlled.
8. Acute liver disease or liver tumor (benign or malignant).
9. Woman or her partner has multiple sexual partners.
10. Conditions associated with increased susceptibility to infections with microorganisms. Such conditions include, but are not limited to, leukemia, acquired immune deficiency syndrome (AIDS), and I.V. drug abuse.
11. Genital actinomycosis.
12. A previously inserted IUD that has not been removed.
13. Hypersensitivity to any component of this product.
14. Known or suspected carcinoma of the breast.
15. History of ectopic pregnancy or condition that would predispose to ectopic pregnancy.


The recommended candidate for LNG-IUS use on label is a parous woman who is in a stable, long term mutually monogamous relationship with no history or risk factors for pelvic inflammatory disease. Although the risk of ectopic pregnancy with the LNG-IUS is distinctly lower than the risk of ectopic pregnancy with unprotected intercourse, product labeling lists a history of ectopic pregnancy and risk factors for ectopic pregnancy as contraindications to LNG-IUS use (Table 3). LNG-IUS may be used in women whose uterine depth sounds to between 6 and 10 cm.

The WHO MEC guidelines have far fewer absolute contraindications of initiation or continuation of IUCs (Table 1). The MEC rates nulliparity as a 'condition where advantages of using the method generally outweigh the theoretical or proven risks', commenting only that women who have never been pregnant have higher expulsion rates. The product labeling for both of the IUCs do not list nulliparity as an absolute contraindication. However, it is recognized that placement of the IUC is more challenging through a nulliparous cervix and that expulsion rates are higher among nuliparous women than among parous women. In other countries, there are IUCs that are more specifically designed for use by nulliparous women and that are better tolerated than the IUCs currently available in the U.S.19

The real concern with IUD use in nulliparous women, however, has been a medicolegal one. If a woman with previously unproven fertility is unable to conceive after using an IUC, she may blame the IUC for her infertility rather than focusing on other more obvious causes. Clinical studies of IUC use by nulliparous woman have been reassuring. Hubacher20 found no higher risk for tubal infertility in nulliparous women who had previously used copper IUDs compared to control women with other causes of infertility or to pregnant controls. In this study, tubal infertility was not associated with duration of IUD use, the reason for IUD removal, or gynecologic problems relating to the use of the IUD. The only marker of increased tubal infertility was the presence of chlamydia antibodies. Similarly, Doll and colleagues21 measured the return to fertility in nulliparous women who stopped using different contraceptive methods and found that after 1 year, the former barrier method users had the highest fertility rate (54%), followed by former IUD users (39%) and prior oral contraceptive users (37%). However, long-term IUD users (longer than 78 months) had lower fertility rates than short-term users. The ACOG Committee on Adolescent Health has concluded that because adolescents contribute disproportionately to the epidemic of unintended pregnancy in this country, top tier methods, including IUCs and implants, should be considered as first-line choices for both nulliparous and parous adolescents.23

Selection between intrauterine contraceptives can be individualized on the basis of a woman’s fertility plans, her medical conditions, and her physical findings. Often, the copper IUD is selected because of its longer duration of action. However, the major factor in matching a particular woman to one of the available IUCs is the impact each IUC is expected to have on the woman’s menstrual bleeding. The copper IUD increases monthly menstrual blood loss by about 30%. On the other hand, the impact of the LNG-IUS on vaginal bleeding varies over time following insertion. During the first 3–4 months of use, women experience considerable unscheduled spotting and bleeding, but, with longer use, their menstrual blood loss decreases substantially. With prolonged use, many women become amenorrheic. Women who are looking for long-term contraception, who do not tolerate irregular bleeding, and those who do not tolerate hormonal side effects would be better served by using the copper IUD. Women who have anemia, heavy or prolonged menses, or dysmenorrhea may be better served by use of the LNG-IUS. Cost should also be considered. Even though it is approved for twice as long an effective useful life as the LNG-IUS, the copper T 380A IUD is less expensive.


The details of all the mechanisms of action of each of the IUDs have not been completely elucidated, but several experiments have unequivocally demonstrated that the IUD does not function as an abortifacient by disrupting an implanted pregnancy and does not act by blocking implantation. Segal and coworkers24 reported the absence of any detectable postovulatory human chorionic gonadotropin (hCG) in the sera of 30 IUD users during 30 months of use. Wilcox and colleagues25 found one episode of a transient elevation in hCG in the urine tests done during 107 IUD cycles compared to a substantial increase seen in 29% of cycles in women attempting pregnancy. Videla-Rivero et al26 found reassuringly negative levels of early chorionic activity in women using a variety of IUCs.

The primary action of the older, inert IUDs was the establishment of an intense foreign-body reaction within the endometrium, which is spermicidal.27 Tredway and associates28 found that, 15–30 minutes after artificial insemination, sperm was present in all of the tubal flushings of control women but in none of the tubal flushings of IUD users. Sagiroglu29 found that 2–16 hours after sexual intercourse, spermatozoa were phagocytized in the endometrial cavities of women with Lippes loop IUDs; no viable sperm were found there 18 hours after artificial insemination. Both El-Habashi and associates30 and Moyer and colleagues31 reported finding no sperm in the fallopian tubes of women with Lippes loop IUDs.

Copper intensifies this inflammatory endometrial response.32, 33 In addition, the copper ions released from the IUD directly reduce forward motility of sperm and block fertilization by interfering with acrosomal enzyme activation and by increasing intraperitoneal prostaglandin levels.32, 33, 34 Uterine washings yielded eggs in 4 of 115 controls, but in none of the 56 IUD users. Ova were less frequently recovered by flushing from the fallopian tubes of IUD users versus those of controls (39% versus 56%). In studies of ova obtained from women undergoing tubal sterilization after midcycle intercourse, none of the ova from the IUC group showed normal development under light microscopy, indicating successful fertilization, whereas 50% of the ova obtained from controls demonstrated normal postfertilization development.35 This was true when the ova were studied under light microscopy and when detailed evaluation of the ova was done under electron microscopy.27 Finally, IUD users have a significant reduction in their ectopic pregnancy rates, which is also consistent with the fact that the IUD inhibits fertilization.

The LNG-IUS also acts as a contraceptive. The main mechanism of action for the LNG-IUS is that the progestin thickens cervical mucus rapidly to prevent sperm entry into the upper genital tract.26 The LNG also slows tubal motility and reduces the ability of sperm to fertilize eggs. In a small percent of cycles, ovulation is blocked. Mandelin and coworkers36 reported that all LNG-IUS users had midcycle endometrial expression of glycodelin A, a uterine glycoprotein that inhibits sperm-egg binding and usually is absent during ovulation. The LNG also eventually induces endometrial atrophy, but this effect cannot contribute significantly to contraceptive efficacy, since the LNG-IUS works as well preventing pregnancies in first cycle of use as it does in later cycles when the endometrial changes are better established.37 It should be remembered that a blastocyst does not need any endometrium for implantation. Ectopic pregnancies comprise almost 2% of all pregnancies; there is no endometrium in the fallopian tubes. 


When used as directed, all modern methods of birth control are safer than pregnancy. In every age group from 15–44, the IUD has the lowest estimated mortality rates of any method of female contraception.38 The Centers for Disease Control (CDC) report that there have been no reported cases of maternal death as a result of a septic abortion in a pregnant woman with an in situ IUD since 1977.39 All previous reports of life-threatening septic abortion occurred in women with Dalkon Shield IUDs; there is no evidence that either of the modern IUCs increases the risk of septic abortion if pregnancy occurs. After years of monitoring clinical events associated with the modern IUCs, the CDC has concluded: 'women desiring long-term, effective contraception and their clinicians should be aware that currently marketed IUDs are highly effective and acceptable and are associated with a low risk for complications in women at low risk for STDs.'39

In a 7-year prospective international study of IUDs, including the copper T 380A, use of the IUD for more than 5 years did not increase the risk of pelvic infection, ectopic pregnancy, anemia, or abnormal Pap smears.40 Duration of IUD use did not affect subsequent pregnancy rates or pregnancy outcome. In the short term, however, there are acknowledged risks that must be discussed with the patient and minimized by careful patient selection and fastidious insertion technique (see below).



Consent Issues

Every patient considering contraception deserves to be informed about all of her birth control options and her own individualized risks and benefits with each method. Bachman and colleagues41 showed that women who received information about potential side effects prior to placement were the most satisfied with their experience with IUCs. It is strongly recommended that each patient sign a formal consent before IUC placement. The manufacturers’ brochures are useful in providing specific information about their products, in identifying potential patient contraindications, and in documenting the informed consent process for the medical record. Those brochures are also an excellent source of information for the patient, not only before she has an IUC placed, but also on an ongoing basis to guide her in follow-up care.

Timing of Insertion

Product labeling for the LNG-IUS advises that that system should be placed during the first 7 days of a normal cycle.3 This placement early in the cycle allows time for adequate hormone release to thicken the cervical mucus prior to ovulation. Exceptions are allowed for women switching from other hormonal methods. LNG-IUS replacement may be done immediately after removal of the first unit if the patient is still a candidate. 

On the other hand, labeling for the copper IUD allows for placement at any time during the normal menstrual cycle when pregnancy can be excluded.2 Traditionally, copper IUDs had been placed during menstruation, but White and colleagues42 demonstrated that expulsion rates in the first 3 months are highest when placement is performed during menses. They reported that the optimal time to place a non-hormonal IUD is during ovulation, when the cervical os is dilated and the myometrium is calmed by progesterone, but a significant reduction in early expulsion rates can be achieved by delaying placement until after cycle day 5. Jovanovic and coworkers43 found that infection was also reduced by avoiding placement during menses.

Women with oligomenorrhea or amenorrhea as a result of breastfeeding, DMPA or other drug use do not need to await menses for placement of either type of IUC. Once pregnancy is ruled out, the IUC placement can proceed. Although a survey by Andersson and colleagues44 raised concerns about an increased perforation rate when IUDs are placed in breastfeeding women, studies by Chi and colleagues45, 46 showed that breastfeeding women appear to be at no higher risk for IUC perforation or pain and are often good IUC candidates. Postpartum women in many countries have received IUCs immediately after delivery (within 10–15 minutes after the delivery of the placenta),47, 48 although an earlier WHO-sponsored multicenter study had concluded that this practice was associated with higher risk of expulsion and pregnancy.49 A pilot study of ultrasound-guided insertion of an LNG-IUS immediately following delivery of the placenta was associated with a 10% expulsion rate and demonstrated that the technique is feasible.50 In routine situations in the United States, however, an IUC is inserted after a term pregnancy only after the uterus is completely involuted (at least 6 weeks postpartum). On the other hand, after first trimester losses or termination, immediate IUC insertion is appropriate if there is no evidence of genital tract infection. A recent review by Grimes51 of studies of immediate postabortal insertion showed that the risk of expulsion and infection were low after first trimester losses; the expulsion rates were higher after second trimester abortions.

Patient Evaluation Before Insertion

On physical examination, it is important to assess uterine size, position, contour, mobility, and tenderness. An immobile or markedly angulated uterus is more susceptible to perforation. The patient should be clinically assessed for cervical infection. For those with an abnormal discharge, microscopic studies are needed. Because trichomoniasis is usually sexually transmitted, that diagnosis necessitates re-evaluation of the patient’s candidacy for an IUC. Cervical infection with either gonorrhea or chlamydia would preclude placement of an IUC until the woman is treated and can reduce her risk of acquiring subsequent STIs. In established patients thought to be at low risk for STIs, clinical evaluation of the cervix during the pelvic examination is acceptable to rule out such infections. In new patients or those with questionable risk factors, however, formal laboratory testing for cervical infection may be advisable. Screening at the time of IUC placement allows for more timely initiation of contraception. Women with positive test results have no adverse effects if they are promptly treated after the laboratory test results return.52, 53, 54

Antibiotic Prophylaxis and Premedication

Routine antibiotic prophylaxis before insertion is not warranted.55 One large randomized, placebo-controlled trial of azithromycin prophylaxis showed that the incidence of PID is very rare (1/1000 insertions) with or without antibiotics in women selected for IUD use following current medical and social screening protocols.56 Current American Heart Association guidelines for antibiotic prophylaxis make no recommendations for antibiotic use, even in woman who are at high risk for endocarditis.57

High dose nonsteroidal anti-inflammatory drugs (NSAIDs) can be offered up to 24 hours before IUC placement to women who have no contraindications to their use, but their efficacy in reducing discomfort associated with IUC placement has not been demonstrated. Interestingly, in a randomized trial of over 2000 first time IUC users, provision of 400 mg ibuprofen 45 minutes before insertion did not reduce pain scores compared to placebo, but median pain scores in both groups were 1.0 on scale of 0-10.58 NSAIDs may be offered to treat post-placement discomfort if it occurs.

Placement of 2% lidocaine gel along the cervical canal significantly lowered pain scores in one trial of 102 IUC insertions.59 Some investigators have found that pretreatment of women with potentially narrow endocervical canals with misoprostol 400 mg per vagina 4 hours prior to placement facilitates a more comfortable procedure, but formal follow-up studies of expulsion rates in these patients have not been published. Therefore, this is still considered an experimental intervention.

Placement Techniques

Each IUC has its own loading device and placement technique, which is described clearly in each of the manufacturer’s materials. Supervised instruction and experience with each type of IUC is advised before independent placement. The following general recommendations are germane to both IUCs:

  1. Aseptic technique is critical. Cleanse the upper vagina, the ectocervix, and the endocervical canal with an antiseptic agent.
  2. Local anesthesia may help reduce procedural pain. Many women benefit from the injection of local anesthetic at the tenaculum site. A paracervical block is helpful when cervical dilation is needed and for women prone to vasovagal reactions. Remember to wait at least 3–5 minutes after placing a paracervical block before proceeding with uterine sounding.
  3. A tenaculum is needed to straighten the cervicoisthmic angle and to stabilize the uterus during uterine sounding and IUC placement. Use of a small toothed tenaculum whose teeth do not overlap can reduce discomfort and post procedure bleeding.
  4. If cervical stenosis is encountered, gentle dilation with a plastic cervical dilator (e.g. cervical os finder) or slower dilation with laminaria placed 2–4 hours before insertion combined with a paracervical block will provide adequate dilation and does not increase the risk of expulsion after insertion.60
  5. The uterine sound should be advanced to the fundus being held as a pencil using only two fingers to apply forward pressure. This reduces the risk of uterine perforation. If there is any question that the patient may have a lesion distorting her endometrial cavity or preventing the IUC's arms from opening, or inhibiting the correct placement of the unit at the uterine fundus, the sound can be pivoted from side to side after it reaches the fundus to verify adequate endometrial space for the IUC. Women with excessively large or small or irregularly shaped endometrial cavities should select other methods of birth control.
  6. The IUC is placed following detailed manufacturer's instructions. Each IUC is ultimately placed at the uterine fundus and the insertion apparatus is withdrawn. This approach reduces the risk of perforation. Routine post-placement evaluation with an ultrasound is not necessary, but such imaging may be useful if there is any question of incorrect placement.
  7. The length to which the IUC tail strings are cut is individualized. The goal is to permit the strings to be tucked securely behind the patient's cervix. This will prevent coital discomfort for the partner (which can occur when the strings are too short) as well as introital irritation (which can result in women with pelvic relaxation if the strings are too long).
  8. The patient should be taught to check the tail strings each month after her menses, and advised regarding the signs and symptoms of possible IUC complications (e.g. pregnancy, expulsion, infection). A follow-up visit is arranged within 3 months after IUC placement. Routine follow up earlier is not necessary. Fundal positioning has been achieved with the modern techniques at the time of placement; no 'wandering' of the IUC is expected after placement. The purpose of the follow up visit is to detect silent partial expulsions, which rarely occur by 4 weeks, but are more likely to develop by 10–12 weeks.56 Since each of the manufactures will provide free replacement units for those units that need to be removed before 3 months, a 10 week visit will not only identify this problem on a timely basis, but will also reduce costs. Backup contraception is needed for 2 weeks only if the levonorgestrel IUS is not placed early in the menstrual cycle.

Potential IUC Placement Problems

Vasovagal reactions occur in less than 1% of women during the uterine sounding or during IUC placement. The risk of such reactions is higher in nulliparous women and cases where women experience moderate to severe pain with IUC placement.61 Usually women will respond to smelling salts and supportive measures but, if the patient's symptoms do not spontaneously resolve promptly, the instrument/IUC must be withdrawn. It is important to rule out other problems, such as perforation, which could provoke vasovagal symptoms. A paracervical block may be helpful in preventing recurrent vasovagal episodes for her with cervical manipulation in the future.

Uterine perforation is a relatively rare event, occurring in the United States in only 0.6 in 1000 insertions with the copper IUC.4 Current evidence supports the dictum that all perforations occur or are initiated at the time of IUC placement. Complete perforation at the time of placement should be suspected if there is a sudden, inappropriate loss of resistance to advancement of the instrument, when the uterine depth greatly exceeds expected uterine size, or when the patient reports severe pain during the procedure. Partial uterine perforation, which can ultimately result in complete perforation, occurs when one piece of the IUC is introduced into the myometrium. Three important variables have been associated with an increased the risk of perforation: (1) a markedly anteverted or retroverted uterus and/or lack of mobility of the uterus; (2) plunging technique of insertion; and (3) less experienced providers. Fortunately, the plunging technique used to insert older IUDs (e.g. Lippes Loop) has been replaced by the withdrawal technique for modern IUC placement.62

If there is any suspicion of perforation, the instrument and/or IUC should be gently withdrawn without delay.63 Fortunately, most acute perforations occur transcervically or in the midline of the posterior wall of the uterus, at a distance from the uterine arteries. After removal of the instrument or IUC in cases of suspected uncomplicated perforation, the patient should be closely observed for at least a few hours for signs or symptoms of internal hemorrhage. However, if there is any suspicion of internal organ damage (involving the bowel or vascular structures), surgical exploration is indicated.

Andersson and co-workers44 found that most perforations (72%) were diagnosed more than 1 month after insertion. The occurrence of an unexpected pregnancy led to the diagnosis in the majority (56%) of these cases. Most of the remaining cases (42%) were diagnosed as a result of failure to visualize the IUC tail strings during a routine follow-up pelvic examination. If a copper IUD is located in the peritoneal cavity, it should usually be removed. Appropriate treatment of the intraperitoneal LNG-IUS is less well defined. Although laparoscopy is the preferred surgical approach, its feasibility is reduced over time with the copper IUD, because that IUD tends to become encased in dense adhesions.62 There are case reports of bowel obstruction and organ perforation caused by intraperitoneal IUCs, but the risks of laparotomy may outweigh the benefits of surgical removal of the LNG-IUS because the overall risk of complications from perforated IUCs is low.63 The decision to operate must be made on a case-by-case basis; however, women with abdominal symptoms definitely require surgery.64


Not surprisingly, analysis demonstrates that patients who are well informed about potential side effects prior to placement are most likely to be more satisfied than less well informed women, whether or not they actually experience any problems.41, 65 Table 4 summarizes the significant clinical events that led to discontinuation of the copper IUD and the LNG-IUS in a comparative multicenter study.40 Cochrane analysis revealed that overall continuation rates with the 2 different IUCs are similar, although the timing of removal requests does differ.1

Table 4. Discontinuation rates at 7 years per 100 women in an extended use comparative trial.40


% Discontinuation

Copper T 380A














Overall menstrual problems






Ectopic pregnancy






Pregnancy-Related Events

If a woman becomes pregnant while using the IUC, it is recommended that the IUC be removed if she is in the first trimester, the IUC tail strings are visible, and the removal can be accomplished without difficulty. Such removal significantly reduces the risk of subsequent spontaneous and septic abortion. However, women who undergo early removal still have a higher risk of preterm delivery (i.e. before 37 weeks’ gestation).66

Women with IUDs without visible tail strings who become pregnant have twice the risk of preterm birth,67, 68 but apparently no increased risk for spontaneous abortion. The prevailing recommendation is to provide women information about early signs and symptoms of preterm labor and chorioamnionitis, but not to attempt to remove the IUD in those who desire to continue their pregnancies. There are small series of ultrasound-guided IUD removals69 and of hysteroscopic IUD removals70, 71 during the first trimester, but these procedures are still considered experimental.

There is no evidence that copper IUDs increase the risk of congenital anomalies in children exposed in utero to those devices.72 The IUD is generally implanted at the border of the placenta and is physically separated from the fetus by the amniotic sac. Despite the high intrauterine concentration of LNG, in the few pregnancies that have been reported with the LNG-IUS, there is no report of masculinizing effects on the fetus or of any other unexplained congenital anomalies.

The risk of ectopic pregnancy is significantly reduced with IUC use. Noncontraceptive users have a background ectopic pregnancy rate of 3.0 per 1000 woman-years. The risk of ectopic pregnancy with a copper IUD is lowered by a factor of 15, to a rate of 0.2 per 1000 woman-years.73, 74 Ectopic pregnancy rates with the LNG-IUS are also very low. Despite the fact that the IUCs decrease a woman’s overall risk for ectopic pregnancy, if a woman does become pregnant while using an IUC, an ultrasound study should be performed to localize the pregnancy because the risk of an ectopic implantation is approximately 4–50% (depending on the type of IUC). Past use of an IUC does not increase a woman’s overall subsequent risk for ectopic pregnancy.75, 76


Expulsion rates are highest in the first few months after placement and depend on insertion technique and timing of placement within the menstrual cycle.42 Overall, first-year expulsion rates with the copper T 380A are 5.7% among all users and 2.3% among parous women. After the first year, expulsion rates decline. Walsh and coworkers56 found the expulsion rate after 3 months to be 3.5%. Fewer than 10% of the expulsions were complete; most were partial expulsions. Many of these partial expulsions were clinically silent, so the authors recommended that a routine follow-up visit be scheduled at 3 months to detect this problem. The 5-year expulsion rate for the LNG-IUS has been shown to be 5.9%.77 A woman who has expelled one IUD has a 30% chance of expelling a subsequent IUD.78 The current recommendation is to remove IUCs located in the endocervical canal and those that are suspected of having relocated lower in the uterine cavity. If the woman is not pregnant, another IUC can be inserted immediately.

Petta and associates79 concluded that routine ultrasound screening for IUC placement is inappropriate. However, ultrasound can be used to identify the position of an IUC when dislocation is suspected because of elongated strings, thus avoiding unnecessary IUC removals. Faúndes and colleagues80 noted that IUCs appear on ultrasound to migrate into the correct position after insertion and move throughout the woman’s cycle, so that if the T is within 1–2 cm of the fundus midcycle, it can be assumed to be in the correct position.81


The risk of infection with IUC use was historically a significant concern that resulted in considerable medicolegal activity in the late 1970s and early 1980s, and, ultimately, led to the virtual loss of IUDs in the United States for many years. The risk of infection has been recognized to be very uncommon among users of modern IUCs. This difference in risk is due to the fact that the earlier infections were due to the unique properties of the Dalkon Shield and due to practice protocols that allowed IUD use by women at risk for STDs. The risk posed by the Dalkon Shield was caused by its polyfilament tail, which facilitated entry of vaginal pathogens into the endometrial cavity by wicking or capillary action through the interstices between the filaments in the tail string.82 Modern IUDs, which have monofilament tails, have eliminated this risk; when monofilament tails are cultured, no growth of either anaerobic or aerobic organisms is observed.83 Most studies have shown that IUDs with monofilament tails pose no higher risk for PID than stringless IUDs.84, 85, 86, 87

Appropriate selection criteria for IUC candidates and thorough screening for potential acute infections have significantly reduced the risk of infection among IUC users. In a study by Farley and associates,88 of 23,000 IUD users worldwide, PID risk varied by region but was inversely related to age and number of live births. In the Americas, the rates were the second lowest (1.3/1000 woman-years). Worldwide, Farley and coworkers88 noted that PID rates after 1980 were considerably lower than in previous years. Importantly, Buchan and colleagues89 found no statistically significant increase in the risk of PID in current users of medicated IUDs or in former IUD users from 1981–1989 in the Oxford–Family Planning Association study. In the United States, Lee and colleagues90 found that among women with one sexual partner (married or cohabiting), women who used IUDs had no statistically significant increase in the incidence of PID compared to those who used no method of birth control.

There is a transient increase in the risk for PID due to endometrial contamination at the time of insertion. In international studies, Farley and colleagues88 reported that PID developed at a rate of 9.7 per 1000 woman-years during the first 20 days after insertion reflecting the prevalence of STIs in many of their study sites.  This early infection risk supports the classic observations of Mishell and associates91 that the endometrial cavities of IUD users were contaminated by bacteria at the time of IUD insertion, but they were sterile 30 days after IUD insertion except in women who had developed clinical evidence of infection. A recent evaluation of the risk of PID attributable to the IUD in West Africa estimates the risk to be 0.075% or less than 1 woman in 1300.92

In studies from developed countries, the incidence of PID associated with IUC insertion has been reported to be about 1 per 1000 woman-years. No cases of PID were reported in a series of 975 Norwegian women inserted with IUDs.53 Interestingly, these women were tested for infection on the day of insertion and 5 of them tested positive for chlamydia. The researchers contacted the patients immediately, initiated treatment within 14 days, and no cases of clinical PID developed. In the study by Walsh and co-workers56 of antibiotic prophylaxis for IUD placement, the absolute incidence of PID in the first 3 months of use was approximately 1 in 1000. Those investigators also found that the incidence of removal in the first 3 months for reasons other than expulsion, such as increased bleeding or other possible indications of subclinical infection, was not altered by antibiotic prophylaxis. It has been suggested that the rates of infection could be lower with use of the LNG-IUS. In randomized multicenter trials, the discontinuation rates for PID were significantly lower in the LNG-IUS users compared to the Nova T users.77, 93 However, a study by Sivin and colleagues6 comparing the copper T 380A to the LNG-IUS failed to show any difference in PID rates by IUC type.

Tsanadis and colleagues83 demonstrated that routine culture of removed IUCs and treatment of women with positive cultures are not recommended in women who are asymptomatic for PID. If upper genital tract infection develops in an IUD user, treatment outcomes are not improved by IUC removal.94 The 2006 STD Treatment guidelines do not recommend that the IUC be removed, just that the patient be monitored closely for response to therapy.95

Other Infectious Issues

Pelvic actinomycosis is a very serious pelvic and abdominal infection characterized by widespread granulomatous diseases. However, it is a very rare condition with a prevalence estimated to be less than 0.001%.96

'Actinomyces-like organisms' are occasionally detected on routine Pap smears. However, this finding is not diagnostic of an infection with Actinomyces. Only half of those women test positive for that organism on cultures. Most of those who test positive are only colonized, not infected, with this gram-positive anaerobic bacterium. Actinomyces is normally found in the gastrointestinal tract, and it is also a normal vaginal organism.97 On careful examination, one study found that the Pap smears of one third of plastic IUD users had sulfur granules indicative of the presence of 'Actinomyces-like organisms', but copper IUD users had much lower rates of involvement (1–6%).98, 99, 100 On the other hand, Merki-Feld and colleagues101 reported that users of the Multiload Copper IUD had 20% incidence of Actinomyces-like organisms in Pap smears compared to 2.9% incidence reported in LNG-IUS users. The prevalence with Actinomyces increases with the duration of IUD use.102

If Actinomyces is detected on Pap smear in an asymptomatic woman with no signs of upper genital tract disease, there is no need to treat her with antibiotics or to remove her IUC. It is reasonable to follow her with routine Pap smears and pelvic examinations because identification of actinomyces in the cervix or vagina is not diagnostic of any disease and is not predictive of any disease.97 There has been no increase in adverse outcomes when no treatment is offered to women who are asymptomatically colonized with Actinomyces. In addition to this conservative approach, ACOG offers other management options for asymptomatic IUC users with actinomyces on Pap tests including an extended course of antibiotics, removal of the IUC and both measures, although no studies demonstrate resolution of PID risk with those interventions.96 At a minimum, the patient should be made aware of her colonization and given PID precautions. 

Joesoef and colleagues103 reported that, in a low-risk population, the rate of STDs in IUD users compared to users of other methods of contraception was not different, but that bacterial vaginitis was more common amount IUD users, even after controlling for age, education, douching practices, and STDs.

Menstrual Changes

Increased menstrual bleeding, often combined with cramping, is the most common medical reason for removing IUCs. On average, copper IUCs increase menstrual flow above baseline levels by 30% to 55, increase menstrual cramps, and extend the duration of menses by 1–2 days per cycle. In the first few months after insertion, spotting and cramping can also occur between menses. These changes prompt 4–15% of women to discontinue IUD use in the first year.104 Partial expulsion can cause this late onset bleeding problem and should be ruled out. However, once that has been ruled out, treatment with NSAIDs generally prevents the increase in blood loss following placement of an IUC.105, 106 NSAIDs should be started at the beginning of menses and continued through the heavy flow days (usually 3 days).

Because of the profound antiproliferative impacts that the LNG-IUS has on endometrial cells,107 on estrogen and progestin receptors in the endometrium,108 and on the basal lamina,109 virtually every woman who uses the LNG-IUS will experience pronounced changes in her menstrual cycling. Unscheduled bleeding is the most common reason for LNG-IUS discontinuation. Women should be counseled to expect more days of spotting and bleeding than bleeding-free days in the early months of use. However, after 4–6 months, women using the LNG-IUS experience significant reductions in their menstrual blood loss. At 12 months, 20% of women are amenorrheic. The remaining women average 0 days of bleeding and 1–3 days of spotting per month. Overall, at 1 year, women experience an 80% reduction in blood loss compared to baseline. Hemoglobin levels increase and dysmenorrhea decreases at 1 year. Counseling about each of these changes is important because unscheduled bleeding is not only the most common adverse side effect with LNG-IUS but is also the most common reason for LNG-IUS discontinuation.110

Hormonal Side Effects

There are no hormonal side effects with the copper IUDs. Circulating plasma concentrations of LNG with the LNG-IUS are 150–200 pg/mL. These levels are only 10% of the peak concentrations seen with levonorgestrel-only oral contraceptives and are consistently lower than those seen with LNG implants. Ovarian steroidogenesis is not substantially impacted; estradiol levels remain well within normal range for reproductive aged women, both for amenorrheic LNG users and for those experiencing menstrual bleeding. Other adverse events, such as mastalgia, headache, acne, nausea, nervousness, abdominal pain, vaginitis, back pain, depression, decreased libido, abnormal Pap smears, and sinusitis were reported by at least 5% of women using the LNG-IUS. Most of the hormonally-related events were concentrated in the first 3 months of use. Progestin slows atresia of ovarian follicles. In initial reports, 2% of women were diagnosed with persistent functional cysts that generally resolved spontaneously. In subsequent studies, 17.5% of women had cysts detected on ultrasound at 6 months and 21.5% had evidence of cysts at 12 months. Most (94%) women found to have these cysts were asymptomatic and resolved spontaneously.110, 111, 112 Alopecia has been reported in 0.33% of LNG-IUS users in one study.113 Weight gain attributable to LNG-IUS has not been reported.


Routine removal of IUCs is straightforward. The tail strings are grasped close to the external os with ring forceps or vaginal packing forceps. Gentle traction on the strings generally delivers the IUC with ease. An international multicenter study found that less than 2% of attempted removals were difficult.6

If a patient presents with missing strings, it is desirable to rule out pregnancy by history and, perhaps, with a pregnancy test. If examination reveals that the strings are curled up in the cervix, a cytobrush can be used to catch and straighten them. Alternatively, an endocervical speculum can be used to open the external os, allowing visualization of the canal. If the strings are not retrievable, ultrasound can localize the IUC to rule out expulsion or perforation. It should be noted that the sonographic appearance of the LNG-IUS is more subtle than that of other IUDs. Generally, it is best to locate the acoustic shadow of the IUS, which will help to define both ends of the device.114 If the device is intrauterine and tail strings cannot be repositioned, alligator forceps can be used by the experienced provider to explore the endometrial cavity with a series of opening, closing, and slight tugging motions to grasp any part of the device to remove it. IUD hooks are not recommended to remove T-shape IUCs. Real-time ultrasound imaging can also be used to guide the extraction procedure.

Embedment occurs more frequently with prolonged use of certain types of IUDs (e.g. Dalkon Shield, Lippes Loop). The problem can be suspected when the IUC does not deliver with a moderate amount of pulling on the strings or when the strings break where traction is placed on them. In this case, the alligator forceps can be used to grasp the device directly and rock it gently from side to side to release it from the endometrial lining. Embedded IUCs refractory to such manipulations can be removed hysteroscopically.


Patient satisfaction with the IUC is high. Surveys of current contraceptive users early in the 1990s found that IUD users rated their satisfaction higher than users of any other method; 96% of IUD users viewed their method favorably.115 This satisfaction is reflected in the annual continuation rates for the copper IUD. Continuation rates for IUDs in clinical trials were higher than those for oral contraceptives, condoms, or diaphragms. The greatest rate of IUD discontinuation occurred during the first 2 years of use. Every year after that, 8090% of women chose to continue to use the method. Earlier discontinuation rates are higher for LNG-IUS users, but the ultimate 5 years continuation rates for both IUCs are essentially equal. Many of the discontinuation decisions are made early in IUD use. Each of the manufacturers has a program of replacing any unit that is removed or lost within the first 3 months. This helps increase the cost effectiveness of this method.


Fertility returns rapidly after IUD removal, comparable to pregnancy rates after discontinuation of barrier methods or oral contraceptives.116 The cumulative pregnancy rate of the LNG-IUS ranges between 79% and 96% 12 months after removal.117, 118, 119 Wilson75 reported that first-year pregnancy rates were essentially the same for women who had (copper and inert) IUDs removed in order to conceive and for women who had IUDs removed because of complications (85.8% and 82.8%, respectively), and both were equivalent to expected fertility rates. Both groups also had comparably low ectopic pregnancy rates at one year (0.4% and 0.8%). There was no increase in the risk of spontaneous abortion or preterm labor among past IUC users compared to that for the general population.75 These findings were consistent with those of a similar study of former IUC users in Norway.120 Landmark studies in the mid 1980s found that monogamous women who had used only copper IUDs had no increase in the risk of tubal infertility compared to women who had never used IUDs (relative risk [RR], 1.1; confidence interval [CI], 0.52.7).121 Among women who had had multiple sexual partners, however, copper IUD users had a statistically significant higher risk of tubal infertility compared to those who never used IUDs (RR, 2.8; CI, 1.7 to 4.5; p < .0001).122 These findings reinforce the importance of careful patient selection.


Copper IUDs are extremely effective at preventing pregnancy when inserted within 5–7 days after unprotected intercourse. Several studies since 1979 have indicated that copper IUDs have a failure rate for emergency contraception of approximately 0.1%,123, 124, 125 which is significantly lower than that for emergency contraception with the levonorgestrel emergency contraceptive pills. In addition to the prolonged period for postcoital utilization and the high efficacy, copper IUDs have the advantage of providing extended contraceptive coverage after insertion. The LNG-IUS has not been tested for use as a postcoital contraceptive agent.


A recent meta-analysis of 10 studies found a 40% reduction in the risk of endometrial cancer.126 Hubacher and colleagues127 also analyzed the three articles exploring the possibility that IUDs may reduce the risk of cervical cancer, but none has shown a statistically significant reduction with the U.S. IUCs.

The noncontraceptive benefits of the LNG-IUS primarily to reduction in vaginal bleeding. In over 100 countries in which LNG-IUS is registered by an FDA-like agency, it is indicated for contraception and for the treatment of menorrhagia. Trials are under way in the United States to obtain that indication in this country also. Hubacher and colleagues127 reported in a literature review that average hemoglobin increases varied from as little as 0.5 g/dL after 2 years to 1.6 g/dL after 5 years. When idiopathic menorrhagia was treated with the LNG-IUS, blood loss was reduced by 79% to 93% by 1 year, and the number of days bleeding in these women was reduced by 50%.128 Extended use of the LNG-IUS (1213 years) resulted in a 60% rate of amenorrhea.22 In women with HIV infection using LNG-IUS, hemoglobin levels rose from 12.3 to 13.5 in one year of use.129 In a clinical trial comparing medical management to LNG-IUS use in women awaiting hysterectomy for menorrhagia, 64% of the LNG-IUS users canceled surgery compared to 9–14% of the women assigned to the medical intervention arm.130 Nagrani and colleagues131 reported 5-year follow-up of these women; 50% were still using the device and 67.4% avoided surgery. In a randomized trial of hysterectomy vs. LNG-IUS for women with menorrhagia, 58% of LNG-IUS women followed for 5 years avoided hysterectomy. The LNG-IUS is very effective in reducing blood loss suffered by women with bleeding diatheses.132 Overall costs for women in the LNG-IUS arm were consistently reduced.133 Menorrhagia resulting from uterine leiomyomata was reduced in one clinical study134 and in one case report,135 although the impact on fibroid size was variable. Adenomyosis-induced menorrhagia was also effectively treated by the LNG-IUS.136  The pain and bleeding associated with MRI diagnosed adenosis is also reduced by LNG-IUS.137 Overall, Stewart and colleagues128 found in a systematic review of the literature that the LNG-IUS is an effective treatment for menorrhagia and may prove to be cost effective. It has been noted that since the introduction of the LNG-IUS and endometrial ablation techniques in England, the number of hysterectomies done for menorrhagia has dropped by 64%.138

Other noncontraceptive benefits of the LNG-IUS reported in small studies include reduction in dysmenorrhea, not only in healthy users, but also in women with endometriosis.139, 140 Use of LNG-IUS, which is less costly and has fewer side effects than GnRH therapy, results in comparable improvement in quality of life in women with endometriosis. The LNG-IUS has been proven effective in managing women after conservative therapy for endometriosis.141 Endometrial implants in the rectovaginal space shrunk with LNG-IUS use.142 The LNG-IUS has been used as a progestin source for postmenopausal women using hormone therapy.143, 144, 145 This has strong appeal because the only organ in the menopausal woman using estrogen therapy that needs progestin is the uterus. In 96 countries, the LNG-IUS is approved to provide endometrial protection in women using postmenopausal estrogen therapy. Similarly, Gardner and colleagues146 demonstrated that the LNG-IUS protected against endometrial stimulation and polyp formation associated with tamoxifen use. Perino147 and Scarselli148 showed that the LNG-IUS can reverse endometrial hyperplasia. Söderström-Anttila and colleagues149 reported the success of using the LNG-IUS in oocyte donors during ovarian stimulation.


Intrauterine contraceptives offer the top tier protection against pregnancy with unsurpassed convenience. There is no method of birth control that is more cost effective.150 Side effects are minimal and patient satisfaction is high.40 Their record of safety has been well established over the last two decades, even in women who have very serious health problems. The amount of training needed to master placement and removal is minimal. Insurance coverage is increasingly available. Given all of these observations, it is clearly time to reassess and remove any of the barriers remaining to making intrauterine contraceptives first line methods for women seeking intermediate to long term contraception. Women who desire no future pregnancies should be evaluated for IUCs prior to being offered permanent procedures, because IUCs are safer, less expensive and no less effective than tubal sterilization.13 IUCs also preserve a woman's ability to change her mind in the future, and minimize post sterilization regret which affects 5.9% of women.151 In addition, IUCs offer noncontraceptive benefits not available from sterilization.

In the case of women with heavy menstrual bleeding, the appeal of the LNG-IUS in undeniable, particularly when compared to surgical procedures such as endometrial ablation. Women who are candidates for endometrial ablation almost always are candidates for the LNG-IUS. Women undergoing ablation almost always need to be provided a second procedure to sterilize them, since pregnancy following ablation has been shown to be potentially hazardous. Providing contraception and bleeding control in one easy office procedure is not only more cost effective, but preserves the woman's reproductive options and prevents post-sterilization regret.151




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