Intrauterine Contraceptives

Intrauterine methods of contraception (IUC) include the copper intrauterine device Cu-IUD and the levonorgestrel releasing intrauterine system LNG-IUS. IUC is considered to be a long acting reversible method of contraception (LARC);¹ with licensed duration of use between 3 and 10 years (Tables 1 and 2). There are a number of Cu-IUDs available and they vary in size, shape, copper content and duration of use. Most consist of a plastic frame with copper wire wound around the stem and some may have copper on the arms of the device. The LNG-IUS  consists of an elastomere frame with a reservoir on the stem containing levonorgestrel. With both Cu-IUD and LNG-IUS, threads protrude through the cervical canal into the upper vagina to permit easy removal. Once inserted, effectiveness of IUC does not rely on user adherence and so typical failure rates are much higher than the shorter acting methods of contraception such as the progestogen only injectable and the combined oral contraceptive pill that rely on the user to receive injections every 3 months, or taake a daily pill, respectively.² In addition to routine contraception the Cu-IUD can also be used for emergency or contraception.

Although IUC is the most widely used method of reversible contraception globally, uptake varies throughout the world.³ Worldwide use was estimated to be 14% in 2007, although this rises in some countries with rates as high as 37% in Eastern Asia.³ High income countries such as the UK, however, have much lower rates of use of IUC (6% using a Cu-IUD and 2% using a LNG-IUS in 2008/09).⁴ Differences in policy, availability of the method, cost, provider beliefs and user perceptions about the method may influence the variations in use.⁵

A Cochrane systematic review that compared the efficacy of the different Cu-IUDs⁶ concluded that T-shaped Cu-IUDs with copper on the transverse arms (banded devices) are the most effective. Cu-IUDs that contain at least 380 mm² of copper and have the longest duration of action are recommended as they are most effective and reduce the risk of complications associated with reinsertion.⁷ In the UK these are the Copper T380A^®, TT380 slimline^® and T-safe 380A^®. Clinicians may also choose one device over the other depending on availability within their setting, length of the uterine cavity (Table 1) and width of the inserter.

Table 1 Copper IUDs available in the UK (adapted from Lader D. Contraception and sexual health 2008/9. A report on research using the ONS Omnibus survey produced by the office for National Statistics, 2009 available at www.statistics.gov.uk⁴)

The intrauterine ball is a new frameless Cu-IUD that is not yet licensed for use. Once fitted, it takes on a three dimensional spherical form inside the uterus. A small study following 15 women for 1 year after insertion found no perforations, expulsion, malpositions, complications or pregnancies with this new device.⁸ Clearly, however, large studies of longer follow-up are needed to determine the safety and effectiveness of this device.

There are currently two LNG-IUS devices available (Table 2). The 52 mg LNG-IUS (Mirena^®) is licensed for 5 years for contraceptive use and releases around 20 µg levonogestrel per day which drops to 10 µg per day by 5 years.⁹ A 13.5 mg LNG-IUS, (known as Jaydess^® in Europe and Skyla^® in USA) , is licensed for 3 years for contraceptive use (Table 2).¹⁰ For the first 24 days the 13.5 mg LNG-IUS releases 14 µg levonogestrel. After 3 years this decreases to 5 µg per day. The 13.5 mg LNG-IUS also differs from the 52 mg LNG-IUS, in that the insertion device for the former is slightly narrower and the frame is shorter (Table 2). The 13.5 mg LNG IUS also has a silver band at the proximal end, which is designed to facilitate visualization using ultrasound and to distinguish it from the 52 mg LNG-IUS.

Table 2. Levonogestrel (LNG)  intrauterine systems available (adapted from Faculty of Sexual and Reproductive Health Care. Intrauterine Contraception. http://www.fsrh.org/admin/uploads/CEUGuidanceIntrauterineContraceptionNov07.pdf. 2007.)

Although the manufacturers have recommended duration of use for Cu-IUD and LNG-IUS, there is some evidence that efficacy of IUC extends beyond these limits.⁸ A randomized study of the 52 mg LNG-IUS and Copper T380 Ag IUD found that no pregnancies occurred in years 6 and 7 of use.¹¹

Both the Cu- IUD  and LNG-IUS works primarily by inhibiting fertilisation due to the toxic effect of copper ions on ova and sperm or LNG effects on sperm penetrability and transport.¹² Both Cu-IUD and LNG-IUS  also prevent implantation; the Cu-IUD  exerts a local inflammatory reaction in the endometrium and the LNG induces endometrial atrophy.¹² LNG also causes thickening of the cervical mucus which prevents sperm from entering the uterus, although it is not known how quickly such changes are established. With the 52 mg LNG-IUS, serum levels of LNG are detectable but  much lower than peak levels observed with other LNG containing contraceptives and most women (80%) will continue to ovulate with the 52 mg LNG-IUS.¹³

IUC is extremely effective since it does not rely on user compliance once fitted. IUC also has the benefit of being reversible. At 1 year it is even more effective than female sterilization.¹⁴ Overall there is no difference in pregnancy rates between users of the 52 mg LNG-IUS and the IUDs containing >250 mm² copper.¹⁵ Pregnancy rates for Cu-IUDs with copper content >300 mm² at 1 year are between 0.1% and 1%.¹⁴ A large retrospective Finnish study of 52 mg LNG-IUS users reported pregnancy rates of 0.1% at 1 year and 0.5% at 5 years.¹⁶ The 13.5 mg LNG -IUS has a compatible reported pregnancy rate of 0.9% at 3 years.¹⁷

A history should be taken from women requesting IUC to determine their suitability for the method and the need for further investigations. Additional investigations (e.g. pelvic ultrasound and endometrial sampling) may be indicated in women with abnormal menstrual bleeding patterns prior to insertion of IUC.⁷ Women at risk of sexually transmitted infections (STI) should ideally be screened for these prior to insertion .⁷

The World Health Organization system for determining medical eligibility criteria (MEC) for contraceptive use has been adapted for use in the UK by the Faculty of Sexual and Reproductive Healthcare (FSRH) and by the CDC in the USA.^{18, 19, 20} Using evidence based systematic reviews, conditions are categorized into one of four categories (Table 3). Table 4 summarizes conditions where use of IUC would not be recommended (MEC 4) according to the MEC of the World Health Organization from 2009.¹⁸

Table 3  Medical Eligibility Criteria for contraceptive use. Adapted from WHO¹⁸

Provision of a method to a woman with a category 3 condition, requires careful clinical judgment since use of that method is not recommended unless there is no acceptable alternative.

Table 4 Medical Eligibility Criteria 4 conditions and intrauterine contraceptive (IUC) use, adapted from WHO¹⁸

Healthcare professionals may be reluctant to offer IUC to nulliparous women or adolescents owing to beliefs it will be difficult or carry higher risks.²¹ However, there is in fact little evidence to support this common misconception and the evidence that does exist is reassuring.²² The World Health Organization (WHO), Faculty of Sexual and Reproductive Healthcare UK and American College of Obstetricians and Gynecologists all support use of IUC in young women and nulliparous women.^{18, 19, 20}

Heavy menstrual bleeding

Probably the most notable noncontraceptive benefit of the 52 mg LNG-IUS is that of reducing heavy menstrual blood loss. It is more effective than oral treatments such as norethisterone (a progestogen), the combined oral contraceptive pill, and tranexamic acid (ann antifibrinolytic), at reducing menstrual blood flow and improving quality of life.²³ It also appears to be comparable in effectiveness to endometrial ablation but is more cost-effective than both endometrial ablation and hysterectomy at 2 years.²³

The 13.5 mg LNG-IUS, is not licensed for use as a treatment for heavy menstrual bleeding. Whilst it does reduce menstrual bleeding and amenorrhea rates improve with time, the amenorrhea rate at 3 years of use was significantly less than that observed with the 52 mg LNG-IUS in a randomized controlled trial (12.7% vs 23.6%).²⁴

Dysmenorrhea

The 52 mg LNG-IUS may also be used to treat primary dysmenorrhea²⁵ and dysmenorrhea associated with endometriosis and adenomyosis.^{26, 27, 28} There is evidence from a Cochrane review that fitting an 52 mg LNG-IUS at the time of surgery reduces the time between recurrences of painful periods in women with endometriosis.²⁹

It is possible that this may be partly due to an effect of LNG absorbed from the uterus, since a small study of 11 women with rectovaginal endometriosis showed both symptom improvement and reduction in size of endometriotic lesions using ultrasound over 1 year of 52 mg LNG-IUS use.³⁰

Endometrial protection

The 52 mg LNG-IUS affords endometrial protection against the proliferative effects of unopposed estrogen therapy (i.e. as part of hormone replacement therapy) and is licensed for this purpose in the UK.^{9, 31} Amongst breast cancer patients taking tamoxifen (an antiestrogen), use of the 52 mg LNG-IUS has also been associated with a reduced incidence of endometrial polyps.³² Whilst there is some evidence that it also prevents and causes regression of endometrial hyperplasia, there is still insufficient evidence to support its routine use for the treatment or prevention of endometrial hyperplasia in high risk groups including women using tamoxifen.³²

Whether women choose to use the Cu-IUD or LNG-IUS may depend on their perceptions about the benefits, side-effects and risks of the method. Poor counselling may ultimately result in poor uptake or high discontinuation. Higher discontinuation rates will also make IUC less cost-effective. Qualitative research shows that women often lack accurate knowledge about IUC, often rely on information about contraception from friends and family and often hold negative misconceptions about IUC.³³ This highlights the need for good information provision about IUC to dispel misconceptions and inform about the benefits of the method.

Bleeding pattern

The most common causes for discontinuation of IUC are pain and menstrual bleeding patterns.^{34, 35} Although some women will have normal bleeding patterns following insertion of LNG-IUS others will experience longer and more frequent bleeding episodes.³⁶ The cause of this unscheduled bleeding is not fully understood. However, women can be advised that a reduction in menstrual blood loss and an increase in amenorrhea rates can be expected over the first year of use with the 52 mg LNG-IUS.⁷ Although most women welcome lighter or absent periods^{37, 38} for others it may be an unwanted side-effect. A large Finnish study found that women who had received quality information about side-effects in advance of their fitting, in particular on absent menstruation, were more satisfied with their IUS at follow-up.³⁹

Spotting, light bleeding, prolonged bleeding and heavy bleeding are common in the first 3–6 months of using the Cu-IUD.⁴⁰ However, this should settle with time. There is some evidence that addition of a nonsteroidal anti inflammatory drug or antifibrinolytic (tranexamic acid) may reduce menstrual blood loss with the Cu-IUD.⁴¹

Hormonal side-effects

Hormonal side-effects associated with the LNG-IUS are likely to decrease with time. Although the manufacturers for the LNG-IUS list acne, breast tenderness, mood disturbance and headaches as common side-effects),⁹ a systemic review failed to demonstrate any differences in side-effect profile between the 52 mg LNG-IUS and Cu-IUD.⁴² The side-effect profile of the 13.5 mg LNG-IUS has been reported to be similar to the 52 mg LNG-IUS.²⁴ Effects of hormonal contraception on libido are difficult to study as there several factors that influence libido and robust studies are lacking. Existing evidence fails to show that the LNG-IUS has negative effects on libido. Again a causal relationship between weight and hormonal contraception is difficult to establish. Weight gain has been reported with both Cu-IUD and LNG-IUS, although this does not appear to differ between these methods.⁴³

Ectopic pregnancy

Women using IUC should be informed that their overall risk of ectopic pregnancy is much reduced compared with women who are using no contraception. The risk of ectopic pregnancy for 52 mg LNG-IUS users has been reported as 0.01 per 100 women years (95% CI 0.00–0.003) and 0.07 per 100 women years 95% CI 0.02–1.78) for Cu-IUD users.⁴⁴ There are relatively few data on the 13.5 mg LNG-IUS. However, the absolute risk of ectopic pregnancy  in a phase III trial of the 13.5 mg LNG-IUS was 0.10 per 100 women years (CI 0.02–0.29).¹⁷

Although the absolute risk of ectopic is low with IUC use, if a pregnancy does occur with IUC in situ then the ‘relative’ risk of that pregnancy being ectopic is higher. In a multicountry European prospective study (EURAS), approximately 20% of all pregnancies occurring in women with IUC were ectopic pregnancies.⁴⁴

Perforation

Overall the perforation rates with IUC are low with reported rates of up to two perforations per 1000 insertions.⁷ Factors associated with an increased risk of perforation have been reported to include relative inexperience of the clinician inserting the IUC,⁴⁵ breastfeeding and being less than 6 months postpartum,^{46, 47, 48, 49} fewer pregnancies⁴⁷ and more abortions.⁴⁷ Although there is evidence of increased perforation rates in breastfeeding women, breastfeeding is not a contraindication to IUC,¹⁸ but the clinician should be alert to signs and symptoms of perforation. There does not appear to be a significant difference in perforation rates between devices. In particular a Cochrane review concluded that there were no significant differences in perforation rates between framed and nonframed Cu-IUDs.⁵⁰

Expulsion

It is reported that 1 in 20 IUC devices will be expelled and that this is most likely to happen in the first 3 months after insertion.¹ In general, similar expulsion rates are reported for both the Cu-IUD and LNG-IUS.⁷ Retrospective studies have reported that the risk of Cu-IUD expulsion (but not LNG-IUS) is higher amongst nulliparous compared to parous women.^{51, 52} There is no evidence that expulsion rates differ depending on use of menstrual protection (tampons, pads or menstrual cups).⁵³

Infection

The overall risk of pelvic inflammatory disease (PID) following insertion of IUC is low. A large retrospective cohort study⁵⁴ found the risk of PID within the first 90 days of fitting was 0.54%. However, PID is more likely immediately following insertion, six fold increased risk in the first 3 weeks, and in women at risk of STIs.⁷ The UK FSRH guidance suggests screening women at risk of STIs for chlamydia, gonorrhea, HIV and syphilis, and offering prophylactic antibiotics (at to cover chlamydia) to women at high risk of infection if insertion needs to be done before results of tests are known (for example, emergency Cu-IUD fitting).⁷

Timing

IUC can be fitted at any point in the cycle provided there is no risk of pregnancy. A Cu-IUD will be effective immediately for contraception. It is less clear how long the LNG-IUS takes to become effective. However, the Summary of Product Characteristics, WHO, UK and USA guidance advise that no additional precautions are required if the IUS is fitted on day 1–7 of the cycle and 7 days of additional precautions are recommended if fitted out with this time.^{7, 18, 19, 20}

Postabortion

Observational studies from a number of countries have shown that women who choose an IUC, immediately postabortion have a significantly reduced risk of another abortion in the subsequent year or two compared to counterparts choosing other methods.⁵⁵ Most women will ovulate within the first month after their abortion and so are at risk of pregnancy again if initiation  of effective contraception is delayed.⁵⁶ WHO recommend that a Cu-IUD or IUS can be inserted immediately after abortion so long as the clinician is sure the woman is no longer pregnant.⁵⁷

Clinicians can be reassured that fitting IUC immediately postabortion is safe and they should be encouraged to promote this method to women. A large randomized controlled trial (>500 women) from the USA showed that women who had a Cu-IUD fitted immediately after surgical abortion (first trimester) had similar low complication rates compared with women who had delayed insertion (2–6 weeks later).⁵⁸ In particular, there were no perforations, low rates of pelvic infection (2%) and expulsion rates in both groups were similar (~5%) at 6 months. Continuation rates in the immediate insertion group were higher at 6 months and the only pregnancies that occurred were in the delayed insertion group in women who had failed to return for IUC. The risk of expulsion may be slightly higher if the device is fitted immediately after a late first trimester or mid trimester surgical abortion compared with early first trimester insertion.⁵⁹

Sometimes it is not possible to fit IUC immediately after early medical abortion, for example if the woman chooses to have the abortion at home. Evidence shows that insertion of IUC within 1 week of early medical abortion (<9 weeks) does not increase the risk of expulsion and perforation compared with delayed insertion (at 3–4 weeks).^{59, 60} The clinician needs to exclude an ongoing pregnancy. Insertion of the Cu-IUD does not adversely impact upon duration or heaviness of bleeding postabortion, but women who choose a LNG-IUS postmedical or surgical abortion can benefit straight away with reduced bleeding.^{59, 60} It is also possible that insertion of IUC soon after medical abortion maybe easier than at a later stage, since the cervix may be slightly dilated.

There are no studies looking at immediate insertion of IUC after mid trimester medical abortion. Women who, for whatever reason, are having a delayed insertion of their IUC should be offered a bridging method of contraception to use until insertion of their chosen IUC can take place.

Postpartum

Inserting IUC immediately postpartum compared with delayed insertion is likely to be more convenient and less painful for women. With the constraints and pressures of having a new baby, women may be less likely to attend for IUC at a later date.⁵⁹ A Cochrane review found there to be no increased risk of perforation or infection when IUC was fitted immediately after delivery (within 10 minutes of placental delivery) compared with women who had interval insertion 6–8 weeks later.^{61, 62} Expulsion rates in women having immediate insertion have been reported as high as 24–38%^{62, 63, 64} but this should be weighed up against the benefits of immediate insertion.

Insertion of IUC at the time of cesarean section (placement directly into the cavity before closing the uterus) has also been shown to be safe and convenient for  women. Insertion at this time may also be relatively easier for the clinician compared to insertion weeks later through the narrow cervix. In addition, the risk of expulsion appears low when the device is fitted at the time of cesarean section delivery.⁶⁵

Observational studies have shown that for women choosing a Cu-IUD, the bleeding associated with insertion can be masked by lochia during the puerperium and women choosing the LNG-IUS can benefit from reduced menstrual bleeding in the weeks following childbirth.⁶⁶

Although there are theoretical concerns about the effects of the low dose of progestogen released into breast milk from the LNG-IUS on the neonate, the available evidence to date regarding all progestogen only methods of contraception and breastfeeding is reassuring. A recent systematic review of studies on progestogen only contraception and breastfeeding mothers showed that the effects on breastfeeding, composition of milk, infant health and growth were consistently reassuring.⁶⁷

Practical procedure

It is important that clinicians are adequately trained in fitting IUC and maintain this competency. Higher perforation rates are reported amongst clinicians who fit fewer than ten devices over a 6 month period.⁶⁶ In the UK the Faculty of Sexual and Reproductive Health advise that for recertification of their competency clinicians must therefore fit a minimum of 12 IUCs of at least two different devices over a 12 month period.⁷ In addition, the FSRH advise that clinicians should attend regular updates in resuscitation so they are equipped to deal with any emergencies that occur during the procedure. A chaperone/assistant should be present for the procedure and informed consent obtained prior to fitting the device. A bimanual pelvic examination should be performed on all women prior to IUC insertion. This allows the clinician to assess the size, position and mobility of the uterus. There is no evidence to suggest that cleansing/washing the cervix prior to insertion prevents infection. If a ‘no touch’ technique (i.e. anything that is inserted into the uterus is held by the handle only) is used for insertion then sterile gloves are not required. Tissue forceps (for example vulsellum) applied to the cervix will stabilize the cervix and straighten the uterine angle. This in turn should make the insertion easier and reduce the risk of perforation. A uterine sound should then be passed to measure the uterocervical length, since knowing this length helps the clinician place the device appropriately at the fundus, and may reduce the risk of perforation.

Ease of insertion and pain relief

Anticipated pain at the time of the procedure may be a barrier to the use of IUC for some women. Nulliparous women and those who have never had a vaginal birth, tend to find the insertion procedure more painful.⁶⁸ However, women can be advised that approximately half of women report little or no pain.⁷ A nonrandomized prospective study found that insertions were more difficult in women with shorter uterine lengths and steeper flexion gradient of the uterus.⁶⁹

A Cochrane review found no differences between the Cu-IUDs studied in terms of ease of insertion or pain at time of insertion.⁷⁰ However, in a randomized phase II study clinicians reported easier insertion and participants reported less painful insertion when using the narrower and smaller framed 13.5 mg LNG-IUS compared with the 52 mg LNG-IUS.²⁴

There is no good evidence that topical local anesthetic gel improves pain.⁷¹ However, paracervical and intracervical administration of local anesthetic has been shown to be associated with lower pain scores and may also be useful if dilation of the cervix is required or if a difficult insertion is anticipated.^{72, 73} Other interventions that have been studied to ease the pain associated with insertion include bladder filling (to straighten the uterine axis),⁷⁴ the use of misoprostol (to dilate the cervix)⁷¹ and nonsteroidal anti-inflammatory drugs (NSAIDs) (as analgesia) prior to fitting.⁷⁵ None of these measures have been found to reduce the pain associated with insertion.

Bleeding

When abnormal bleeding patterns occur with IUC pregnancy, STIs and gynecological causes should be considered and excluded. Pelvic examination, pregnancy testing and STI testing should be considered. In addition ultrasound and/or endometrial biopsy (especially in women over the age of 45) should also be considered if abnormal bleeding is persistent or is associated with other features such as pain/dyspareunia.⁷⁶ If no underlying cause is found, then women can continue with the method if they choose to do so. There is no good evidence to support the use of any additional medications for unscheduled bleeding with the LNG-IUS such as tranexamic acid (antifibrinolytic) or NSAID.^{76, 77} However, a Cochrane review found that NSAIDs and tranexamic acid may help pain and bleeding associated with the Cu-IUD.⁴¹ A woman with heavy periods with the Cu-IUD in situ may also consider changing to the LNG-IUS.

‘Lost’ threads

Most clinicians will advise women to either examine themselves or attend a clinician for an examination to check threads are still present within 6 weeks of insertion of the device. While ‘lost’ threads may indicate pregnancy, expulsion or perforation, it is often the case that the threads are retracted in the cervical canal or uterus.

A pregnancy test should be performed and emergency contraception/alternative contraception provided whilst the patient is waiting for an ultrasound to confirm that the device is in situ in the uterus. If the device is confirmed to be in situ and needs to be removed/replaced, then thread retrievers or forceps can be used by an experienced clinician. Occasionally hysteroscopy may be required to remove the device if threads cannot be retrieved.

Perforation

Uterine perforation can present in a number of ways. Sometimes the clinician will suspect perforation has happened at the time of fitting the device and in this situation the procedure should be abandoned and the woman monitored until stable. Around 30% of women⁷⁸ will have no symptoms of perforation and the diagnosis will be made due to the detection of lost threads, pregnancy or symptoms. Women may notice mild lower pelvic pain or change in bleeding pattern or give a history of painful insertion.^{78, 79}

If perforation is suspected, the woman should be managed as for ‘lost threads’ as above and if the ultrasound shows no evidence of a device in the uterus, then a plain abdominal X-ray should be performed. If perforation is confirmed (i.e. device visible on X-ray but not seen in the uterus with ultrasound) then the woman should be referred for laparoscopic retrieval.  Alternative contraceptive cover should also be provided.

Nonfundal device placement

There is concern that a nonfundally placed IUC may not provide optimal contraceptive cover or may be at higher risk of expulsion. Unfortunately, there is no good evidence to support or refute this concern. The clinician should manage such cases on an individual basis along with the woman's preference.

Pregnancy

In women who become pregnant with IUC in situ, an ultrasound scan should be conducted to exclude ectopic pregnancy. It is generally advisable that IUC should be removed before 12 weeks' gestation in view of the a greater risk of miscarriage, preterm delivery, septic abortion and chorioamnionitis if the device is left in situ.⁷ Although there is a theoretical concern about teratogenicity if a pregnancy is exposed to the LNG-IUS, to date no birth defects have been reported in the small number of cases exposed.⁹

Pelvic infection

A systematic review concluded that there were no differences in clinical or laboratory outcomes in IUC users with PID who had their IUC removed compared with women who had their device left in situ.⁸⁰ The FSRH, UK advise that routine removal of IUC is not necessary in cases of PID but should be considered if there is no response to treatment.⁷ If the IUC is removed, then the clinician should provide oral emergency contraception if required (i.e. due to recent unprotected sex).

Actinomyces-like organisms

Actimomyces-like organisms (ALOs) in the reproductive tract of women are commonly identified through cervical screening programs in women with and without IUC. The role of ALOs in infection in IUC users is not clear. If a woman with an IUC has ALOs but has no symptoms of infection, then the device can generally be left in situ.⁷ An IUC can also safely be removed and immediately reinserted in women with ALOs.⁸¹ However, if ALOs are present and a woman with an IUC has symptoms of infection then removal of the device and penicillin based antibiotics given.⁸² In addition, it is advisable to test women with symptoms of pelvic infection for STIs.

Women may have concerns surrounding the effects of IUC, on their fertility.⁸³ Evidence suggests that the Cu-IUD and the LNG-IUS do not cause a delay in return to fertility or increase the risk of infertility^{1, 84} and women should be advised of this.

The Cu-IUD can also be used as emergency contraception (EC). It is the most effective method of EC available (failure rate 1 in 1000) and should be offered to all eligible women.⁸⁵ The device can then be used as ongoing contraception or removed once pregnancy has been excluded. Since the blastocyst will implant between 6 and 10 days after fertilization,⁸⁶ an emergency Cu-IUD should be fitted no more than 5 days after the unprotected sex or 5 days after predicted ovulation in order to avoid disrupting an implanted pregnancy.⁸⁵ There is no evidence that the LNG-IUS is effective as EC and should therefore not be used for this purpose.

IUC is highly effective, safe, well tolerated and cost-effective. However, the importance of counselling women about possible side-effects and risks cannot be underestimated. Clinicians also need to remain up to date with current guidance and regularly fit devices in order to provide their patients with the best standard of care.

IUC can reduce the number of unintended pregnancies for women but unfortunately it remains an unpopular method of contraception in high income countries. More needs to be done to improve the uptake of these methods especially amongst young women at risk of unintended pregnancy. Provision of high quality accurate information to women on IUC, that dispels myths and provides information on benefits is important.^{33, 87} In addition, emphasis should be placed on removing the cost barrier⁵⁵ of these methods and ensuring that providers are up to date with recommendations for use of IUC and are trained and funded to provide these methods to women.