Frequently Asked Questions (FAQs) about Intrauterine Devices (IUDs)

General Information About the IUD
Q1. What are IUDs?
Q2. How does the IUD work?
Q3. Will the IUD cause discomfort to a woman's partner during sex?
Q4. What types of IUDs are available?
Q5. How much does the IUD cost?

IUD Effectiveness
Q6. How effective is the IUD?
Q7. How soon after insertion is the IUD effective?
Q8. What are the chances of getting pregnant while using copper IUD?
Q9. Does the chance of getting pregnant increase after having an IUD in for five years if it has not been replaced?

Advantages and Disadvantages
Q10. What are the advantages of the IUD?
Q11. What are the disadvantages of the IUD?

Who Can Use the IUD?
Q12. Who can use IUDs?
Q13. For whom are IUDs a good contraceptive option?
Q14. Can nulliparous women receive IUDs?
Q15. Can a woman be too young or too old to use an IUD?
Q16. Can a woman with diabetes use an IUD?
Q17. Who should not have an IUD inserted?

IUD Insertion
Q18. When can an IUD be inserted?
Q19. Must an IUD be inserted only during a woman's menstrual period?
Q20. Should antibiotics be given before IUD insertion to prevent infection?
Q21. Is there a need for a routine pre-exam (a separate visit) before IUD insertion?
Q22. Can a woman get an IUD just after she has a baby?
Q23. When can an IUD be inserted postpartum?
Q24. Can an IUD be inserted immediately after abortion?
Q25. In what postabortion situations should IUDs not be inserted?
Q26. Can IUDs be safely inserted by trained nurses and midwives?

Follow-Up After Insertion
Q27. What is the appropriate follow-up schedule after IUD insertion?

Removing an IUD
Q28. Is there a need for a "rest period" with IUDs after a certain period of use?
Q29. Are there medical reasons for removal of an IUD?
Q30. Should an IUD be removed if the partner complains about the string?

Return to Fertility After IUD Removal
Q31. Will the IUD prevent a woman from having babies after it is removed?

Side Effects, Complications, and Risk of Infection
Q32. What are the complication warning signs for IUD users?
Q33. Does the IUD increase the risk of ectopic pregnancy?
Q34. What are the possible reasons for missing strings?
Q35. Can the IUD travel from the woman's uterus to other parts of her body, such as her heart or her brain?
Q36. What are the common side effects of IUDs?
Q37. If a woman complains of heavier menses or bleeding between menses, is there a medical basis for the IUD to be removed?
Q38. Do IUDs cause PID?
Q39. Does the IUD protect against STIs/HIV?

Sources

General Information About the IUD

Q1. What are IUDs?

An IUD is a safe, easy to use, reversible, effective, long-term method of contraception. The IUD is a small, flexible device made of plastic. .It is inserted into a woman’s uterine cavity through her vagina.

Q2. How does the IUD work?

IUDs work mainly by preventing fertilization. The copper-bearing IUDs interfere with fertilization and make the uterus a “spermicidal environment.” The sperm are killed or impaired and cannot reach the egg. IUDs that contain progestin cause thickening of the cervical mucus, which stops sperm from entering the uterus.

Q3. Will the IUD cause discomfort to a woman’s partner during sex?

Generally, no. Sometimes a man can feel the strings. If this bothers him, cutting the strings shorter should solve the problem. The woman should be told beforehand, however, that this will mean she will not be able to feel the strings to check her IUD, and removing her IUD may be more difficult. A man may feel discomfort during sex if the IUD has started to come out through the cervix. If a woman suspects this, she should see a doctor or nurse immediately.

Q4. What types of IUDs are available?

There are basically two types of IUDs: copper or hormone-releasing. Copper IUDs have copper wire and/or sleeves around the plastic frame. The copper T-380A (TCu 380A) is widely used. The only hormone-releasing IUD contains levonorgestrel, the same synthetic progestin found in many oral contraceptive pills.

Q5. How much does the IUD cost?

IUDs are very low cost both for programs and for clients. For programs, the commodity cost of IUDs is significantly less than of most other contraceptive methods (USAID 2005 cost for the Copper T IUD is $1.77). Other programmatic costs include training services and related expendable supplies. For clients the cost of the IUD is dependent on her country context and whether she receives the method through the private or public sector. However, generally, the cost of an IUD is roughly equal to or less than the cost of pills or injectables after two years of use.

IUD Effectiveness

Q6. How effective is the IUD?

The IUD is more than 99% effective, making it one of the most effective contraceptive methods.

Q7. How soon after insertion is the IUD effective?

It is effective immediately; the woman can have sex as soon as she wants. The client should be told that there might be some bleeding or spotting during the first few days after insertion. She should not worry if this happens.

Q8. What are the chances of getting pregnant while using the copper IUD?

The chance of getting pregnant while using the copper IUD is extremely small, 0.6 to 0.8 pregnancies per 100 women in first year of use (one in every 125 to 170).

Q9. Does the chance of getting pregnant increase after having an IUD in for five years if it has not been replaced?

The chance of getting pregnant does not increase with time of use. Evidence from the World Health Organization (WHO) study has confirmed excellent efficacy for at least 12 years. (Readers should be aware that the United States Food and Drug Administration (FDA) has only labeled the copper IUD as effective for only 10 years. Note that some of the documents within the IUD Toolkit may cite the effectiveness of the IUD as 10 years; however, the IUD Toolkit guidance is that it is “effective for at least 12 years”).

Advantages and Disadvantages

Q10. What are the advantages of the IUD?

The advantages are as follows:

Highly effective (99% +) and extremely safe
Reversible (fertility restored immediately after removal)
May be used safely by lactating women and by those who are immediately postpartum
Good choice for women with contraindications for oral contraceptives
Can be used by HIV-positive women or by women at risk of HIV
Long duration of use (at least 12 years for TCu 380A)
Only one visit needed for insertion; minimal follow-up is required, either after menstruation or within the first three to six weeks after insertion
The client does not have to use any other method at the time of sexual intercourse (IUD is coitally independent), which allows her privacy and control over her fertility
Synthetic hormones, such as those found in oral contraceptives and injectables, are non-existent in the copper IUD; this allows women to maintain their natural hormonal levels
Does not interact with medications the client may use
Highly acceptable with good continuation rates
Economical

Q11. What are the disadvantages of the IUD?

The disadvantages are as follows:

Dependent on a trained provider for insertion and removal
Some pain, cramping, minor bleeding when inserted in the uterus
For the copper IUD, clients may experience heavier or longer menstrual periods, increased cramping, and bleeding or spotting, which is fairly common in the first three months after insertion
Serious complications require immediate attention and good back-up medical services
If standard infection prevention practices are not followed, insertion may put client at risk of infection
If the client has a current chlamydial or gonococal infection, IUD insertion may place client at risk of pelvic inflammatory disease (PID) and subsequent infertility; an IUD should not be inserted in the presence of such infections
Like all other contraceptives other than male and female condoms, the IUD does not protect against sexually transmitted infections (STIs), including HIV

Who Can Use IUDs

Q12. Who can use IUDs?

Women of any parity, women of all ages, and women who are HIV-positive, have high blood pressure, or have any of a wide variety of medical conditions that sometimes preclude hormonal contraception.

Q13. For whom are IUDs a good contraceptive option?

IUDs are an appropriate choice for a client who:

Wants to delay her first pregnancy for more than one or two years
Wants to space her pregnancies two or more years apart
Has completed childbearing and does not want a permanent method (sterilization)
Wants a long-term, easily reversible method (IUDs have an excellent rate of return to fertility)
Wants an effective method
Is breast-feeding (IUDs do not affect lactation)
Is immediately postpartum (from delivery of placenta to 48 hours) and wants an effective method that will not interfere with breast-feeding. IUDs do not affect lactation and may be inserted immediately after the placenta or within first 48 hours postpartum. This procedure requires a specially trained provider.

Q14. Can nulliparous women receive IUDs?

IUDs generally can be used by nulliparous women. However, a woman who has not had children is slightly more likely (up to 10%) to expel the IUD because her uterus is small. This causes no harm, but if the IUD is expelled the woman will no longer be protected against pregnancy.

Q15. Can a woman be too young or too old to use an IUD?

There is no minimum or maximum age, as long as the woman is medically eligible for an IUD and she is properly counseled about the advantages and disadvantages of the IUD. An IUD should be removed from the woman after menopause—at least one year after her last menstrual period.

Q16. Can a woman with diabetes use an IUD?

Yes, IUDs are safe for women with diabetes. Women with diabetes are at greater risk of many infections, however. They should see a nurse or doctor if they notice possible signs of STIs or other types of infections, particularly just after IUD insertion.

Q17. Who should not have an IUD inserted?

Women who have the following conditions:

Currently pregnant
Infection after childbirth or abortion
Unexplained vaginal bleeding
Cervical, endometrial, or ovarian cancer
Current PID or STI (purulent cervicitis)
Distorted uterine cavity (incompatible with IUD insertion)
Malignant gestational trophoblastic disease (rare)
Known pelvic tuberculosis (rare)

IUD insertion

Q18.When can an IUD be inserted?

The IUD may be inserted at any time during the menstrual cycle, at the user's convenience, when it is reasonably sure that she is not pregnant. Under current guidance, copper IUDs can be inserted through the first 12 days of the menstrual cycle, or any other time as long as it is reasonably sure the client is not pregnant. It can also be inserted after childbirth and after abortion (provided the uterus is not infected).

Q19. Must an IUD be inserted only during a woman’s menstrual period?

An IUD can be inserted at any time during her menstrual cycle if it is reasonably sure that the woman is not pregnant. During her period may be a good time because she is not likely to be pregnant, and insertion may be easier for some women. It is not as easy to see signs of infection during menstruation; however, some providers like to insert the IUD midway through the menstrual cycle because the mouth of the cervix is a little wider.

Q20. Should antibiotics be given before IUD insertion to prevent infection?

It is not necessary to give antibiotics before IUD insertion. When IUD insertion is done correctly, there is little risk of infection for healthy women, and antibiotics are not necessary for IUD insertion. In any case, most recent research suggests that antibiotics do not significantly reduce the risk of PID.

Q21. Is there a need for a routine pre-exam (a separate visit) before IUD insertion?

There is no medical need for a routine pre-exam or separate visit before IUD insertion. It may be difficult for a woman to make two visits, and she may be at risk of pregnancy during this interval without any protection. Assessing a client’s STI risk by medical history and physical examination is recommended before IUD insertion. If at all possible, handle all counseling and screening on the same day as the insertion.

Q22. Can a woman get an IUD just after she has a baby?

Yes, a woman can get an IUD inserted after she has a baby. The IUD can be inserted after a vaginal delivery or through the abdominal incision after a cesarean section (surgical delivery). The IUD has to be inserted by a properly trained health care provider.

Q23. When can an IUD be inserted postpartum?

An IUD may be inserted:

Immediately after delivery (within 10 minutes of expulsion of the placenta), or after a C-section (special training required)
Prior to hospital discharge (up to 48 hours after delivery)
As early as four to six weeks postpartum when the woman comes for routine postpartum care and also requests an IUD

Q24. Can an IUD be inserted immediately after abortion?

The IUD may be inserted immediately a spontaneous or induced abortion (or anytime after an abortion as long as the woman is not pregnant), except in women with pelvic infections or those who have had septic abortion (see below).

Q25. In what postabortion situations should IUDs not be inserted?

IUDs should not be inserted in the following situations:

Confirmed or presumptive diagnosis of infection (sign of unsafe or unclean induced abortion, signs and symptoms of sepsis or infection, or inability to rule out infection), do not insert an IUD until risk of infection has been ruled out or infection has fully resolved (approximately three months).
Serious trauma to the genital tract (uterine perforation, serious vaginal or cervical trauma, chemical burns); do not insert an IUD until trauma has healed.
Hemorrhage and severe anemia; IUDs are not advised until hemorrhage or severe anemia is resolved. However, progestin-releasing IUDs can be used with severe anemia (they decrease menstrual blood loss).
Postabortion IUD insertion after 16 weeks gestation requires special training of the provider for correct fundal placement; if this is not possible, delay insertion for six weeks.

Q26. Can IUDs be safely inserted by trained nurses and midwives?

IUDs (including immediate postpartum and post-abortion insertion) can be safely inserted by nurses and midwives, as well as other paramedical providers who are appropriately trained according to relevant national or institutional standards.

Follow-Up After Insertion

Q27. What is the appropriate follow-up schedule after IUD insertion?

One routine follow-up visit is recommended at first menses or three to six weeks after insertion. No further routine follow-up is recommended, except for removal. A client should return anytime she has problems or concerns.

Removing an IUD

Q28. Is there a need for a "rest period" with IUDs after a certain period of use?

No rest period is needed if a woman wants a new IUD when an old one has expired. There is less risk of pelvic infection if the expired IUD is removed and the new IUD is inserted during the same procedure. Requiring the woman to make two visits may also put her at risk of pregnancy during the interval in between removal and insertion.

Q29. Are there medical reasons for removal of an IUD?

IUD removal is indicated if:

The woman requests removal
The woman develops symptoms of contraindications
The effective life of the IUD is reached (the IUD is effective for at least 12 years of use, with FDA approval for 10 years)

Q30. Should an IUD be removed if the partner complains about the string?

It is not necessary to remove the IUD if the partner complains about the string.

Explain to the woman and/or her partner what the partner is feeling and recommend they try again.
Describe to the client her other options (and their disadvantages): The string can be cut short so that it does not protrude from the cervical os (opening of the cervical canal). Inform the woman that she will not be able to check to make sure the IUD is in place by feeling for the string and that, at the time of IUD removal, narrow forceps will be needed to remove the IUD (this entails a small additional infection risk). If a string is cut, record in the chart, and tell the woman where the string is located for future removal.
Offer to remove the IUD if the above options are not acceptable.

Return to Fertility After IUD Removal

Q31. Will the IUD prevent a woman from having babies after it is removed?

In general, no. A woman can become pregnant immediately after her IUD is removed, and there is no significant risk of infertility associated with IUD use. However, a woman who has an STI when her IUD is inserted is at increased risk of PID, which can cause infertility. The presence of an STI at the time of insertion, rather than the IUD itself, is the main risk factor for PID and possible infertility.

Side Effects, Complications, and Risk of Infection

Q32. What are the complication warning signs for IUD users?

These five signs are the warning signs of infection or IUD failure (expulsion or pregnancy). If a client notices any of these signs, she should see her health care provider. The PAINS acronym is a helpful way to remember warning signs for IUD users:

Period is late, abnormal spotting, or bleeding
Abdominal pain during intercourse
Infections (or unusual vaginal discharge)
Not feeling well or presence of fever or chills
Strings are missing, shorter, or longer than usual

Q33. Does the IUD increase the risk of ectopic pregnancy?

IUDs do not increase the risk of ectopic pregnancy. The IUD protects against all pregnancies, including tubal implantation or ectopic pregnancies. IUD users are therefore less likely to experience an ectopic pregnancy than sexually active women using no contraceptive method. In the unlikely event of pregnancy in an IUD user, that pregnancy is more likely to be ectopic than would be a pregnancy in a non-user. Still, pregnancy for an IUD user is far more likely to be normal than ectopic: only an estimated one in every 13 to 16 pregnancies, or six percent to eight percent, is ectopic.

Q34. What are the possible reasons for missing strings?

Reasons for missing strings include:

The IUD might have been expelled during her menses/period (even if she did not see it come out).
If she is experiencing a lot of pain (or experienced a lot of pain during insertion), it could mean the IUD has perforated the uterus.
In either case, the client should return to the clinic for follow-up.

Q35. Can the IUD travel from the woman’s uterus to other parts of her body, such as her heart or her brain?

Very rarely, the IUD may come through the wall of the uterus and rest in the abdomen. This is probably due to a mistake during insertion and not due to slow movement through the wall of the uterus. The IUD does not travel to other parts of the body.

Q36. What are the common side effects of IUDs?

Common side effects include:

Cramping, discomfort, pain
Increased spotting and bleeding
In 10 percent or fewer cases, expulsion of IUD

Q37. If a woman complains of heavier menses or bleeding between menses, is there a medical basis for the IUD to be removed?

Not necessarily. Women should be informed that menses are normally heavier with the copper IUD and that intermenstrual bleeding may occur, especially in the first few months. Give nutritional advice on the need to increase the intake of foods containing iron.

For mild to moderate bleeding and pain in the first month after insertion, with no evidence of clinically apparent pelvic infection, and if the woman wants to keep the IUD, a short course of a nonsteroidal anti-inflammatory agent other than aspirin (e.g., ibuprofen) may be given.
Bleeding generally decreases over time. If bleeding is heavy or the woman is anemic, treatment using oral iron can improve hemoglobin levels. If bleeding or pain is severe, or if the client wishes to discontinue use, remove the IUD. If prolonged or heavy bleeding seems to be abnormal, the client should be evaluated and treated as appropriate.
A possible gynecological problem needs to be excluded.
If pelvic infection is diagnosed, remove the IUD and treat with antibiotics. (In the case of mild uterine tenderness without any other evidence of pelvic infection, broad spectrum antibiotics or chemotherapeutics may solve the problem; use clinical judgment regarding whether or not to remove the IUD.)

Q38. Do IUDs cause PID?

The IUD does not cause PID. However, in the presence of existing infection like gonorrhea or chlamydia, IUDs can increase the risk of PID, primarily in the first month after insertion.

Q39. Does the IUD protect against STIs/HIV?

The IUD, like many other contraceptive methods, does not provide protection against STIs/HIV. To protect against STIs/HIV, condoms should be used during every act of intercourse.