Clinical Management Contraindications to IUD use listed by the World Health Organization include pregnancy, puerperal sepsis, PID, or STDs current or within the past 3 months, endometrial or cervical cancer, undiagnosed genital bleeding, uterine anomalies, and fibroid tumors that distort the endometrial cavity (87). Infection with HIV is not considered a contraindication for IUD use. No increase in pelvic infection, female-to-male transmission, or viral shedding was found among HIV-1 infected women (89,90). Copper allergy and Wilson’s disease are contraindications to the use of copper IUDs.
IUDs are appropriate for long-term contraception in most women given their ease of use, high efficacy, and favorable side effect profile. Nulliparous women, adolescents, women undergoing a first or second trimester surgical abortion, women with a recent medical abortion, and women immediately postpartum should all be considered candidates for IUDs (91). There is renewed interest in postpartum and postabortal insertion of IUDs. In both circumstances, the woman is clearly no longer pregnant, she may be highly motivated to accept contraception, and the setting is convenient for both the woman and the provider (92,93). Postpartum and postabortal insertions are safe. Complications are not increased by comparison to interval insertion. The only disadvantage is that the expulsion rate is higher. In comparing postpartum to interval insertion, all the women requesting postpartum IUD received the device, but many women scheduled for interval insertion did not return. When surveyed at 6 months postpartum, more women who had postpartum insertion were wearing IUDs than were those who had scheduled for interval insertion (94). Goodman and colleagues found many fewer repeat abortions among women followed after postabortal IUD insertion compared to a cohort of women choosing non-IUD methods of contraception after an induced abortion (94).
At the contraceptive visit, the patient’s history is obtained and a physical examination, screening for Neisseria gonorrhoeae and chlamydia in high-risk women, and detailed counseling regarding risks and alternatives are provided. The IUD usually is inserted during menses to be sure the patient is not pregnant, but it can be inserted at any time in the cycle if pregnancy can be excluded (95). The copper-T380A IUD can be inserted within 5 days of unprotected intercourse for 100% effective emergency contraception.
There are limited data on effective treatment of pain during IUD insertion. One randomized nonblinded study suggested a benefit with 2% lidocaine gel applied to the cervical canal 5 minutes before insertion. Other techniques such as paracervical block were not evaluated. Premedication with oral prostaglandin inhibitors such as ibuprofen is strongly advised, although evidence of its benefit with modern IUDs is limited (96).
Antibiotic prophylaxis is not beneficial, probably because the risk of pelvic infection with IUD insertion is so low. A large randomized trial of 1,985 patients receiving either oral azithromycin or placebo found no difference in rates of IUD removal during the first 90 days after insertion and no difference in rates of salpingitis (97). These women were screened for STDs only by self-history. Screening for gonorrhea and chlamydia at the time of insertion is recommended for adolescents, but it is not necessary to wait for the results before insertion because patients with positive results have no adverse effects if treated promptly (98). PID, puerperal sepsis, or postabortion sepsis within the past 3 months are considered contraindications and patients with purulent cervicitis should be tested and treated before insertion.
The technique of insertion is as follows: 1.
The cervix is exposed with a speculum. The vaginal vault and cervix are cleansed with a bacteriocidal solution, such as an iodine-containing solution.
2.