Intrauterine Contraceptive Device (IUCD) - Complete Overview

What is an IUCD?

Types of IUCDs

First Generation - Non-Medicated (Inert) IUDs

• Double-S shaped polyethylene device
• Non-toxic, non-tissue-reactive, extremely durable
• Contains barium sulphate for X-ray visibility
• Has a nylon "tail" that projects into the vagina for position checking and easy removal
• Available in 4 sizes: A, B, C, D (D = largest)
• Larger sizes (C, D) are more suitable for multiparous women
• Advantage: does NOT need replacement (permanent unless removed)
• Disadvantage: higher side-effect rate (pain, bleeding) vs. copper devices

Second Generation - Copper-Bearing IUDs

• Copper-7 (Gravigard) - shaped like the numeral 7
• Copper T-200 - T-shaped, 200 mm² copper surface

In India's National Family Welfare Programme: Cu-T-200B was used historically; Cu-T-380A was introduced in 2002 as the standard.

• Lower expulsion rate
• Lower incidence of side-effects (pain, bleeding)
• Easier to fit even in nulliparous women
• Better tolerated by nulliparae
• Increased contraceptive effectiveness
• Effective as post-coital contraceptives if inserted within 3-5 days of unprotected intercourse (99% reduction in pregnancy risk)
• Effective life of at least 5-10 years

Third Generation - Hormone-Releasing IUDs

• T-shaped device filled with 38 mg of progesterone (natural hormone)
• Releases 65 mcg/day locally
• Effective life: 1 year (needs annual replacement)
• Direct local effect on endometrium, cervical mucus, and sperm

• T-shaped device releasing 20 mcg levonorgestrel/day
• Pregnancy rate: 0.2 per 100 women (very low)
• Fewer ectopic pregnancies than copper devices
• Associated with decreased menstrual blood loss and fewer bleeding days vs. copper
• Effective life: 5-10 years (Mirena approved for 8 years in US, up to 10 years in some guidelines)
• Particularly valuable where anaemia from heavy bleeding is a concern
• Also used therapeutically for menorrhagia, endometriosis, and fibroid-related bleeding

Mechanism of Action

Effectiveness

• Theoretical effectiveness is slightly less than oral/injectable hormonal contraceptives
• However, because IUDs have much higher continuation rates than pills or injections, the overall effectiveness in practice is comparable or superior
• Copper devices are more effective than Lippes Loop, with fewer expulsions
• LNG-IUS has the lowest failure rate of any IUD (~0.2/100 women-years)

Indications

• Women who desire long-term, highly effective, reversible contraception
• Women who cannot or do not want to use hormonal contraception (copper IUD option)
• Women seeking emergency contraception within 5 days of unprotected intercourse (copper Cu-T-380A)
• Women with menorrhagia or dysmenorrhoea (LNG-IUS is therapeutic)
• Women with endometriosis (LNG-IUS)
• Women with endometrial hyperplasia - in select cases (LNG-IUS protective effect)
• Postpartum women (can be inserted immediately postpartum or post-caesarean)
• Perimenopausal women wanting long-acting contraception
• Breastfeeding women (copper IUD is non-hormonal; LNG-IUS has minimal systemic effect)
• Women who need contraception but have difficulty with daily compliance (pills)

• Has borne at least one child
• No history of pelvic inflammatory disease
• Normal menstrual periods
• Willing to check the IUD tail periodically
• Has access to follow-up and treatment of potential problems
• Is in a monogamous relationship

Contraindications

Absolute Contraindications

1. Suspected or confirmed pregnancy
2. Active pelvic inflammatory disease (PID) - current or within 3 months
3. Vaginal/uterine bleeding of undiagnosed aetiology
4. Cancer of the cervix, uterus, or adnexa; other pelvic tumours
5. Previous ectopic pregnancy (especially for copper IUD)
6. Known allergy to copper or Wilson's disease (for copper IUDs specifically)
7. Septic abortion in the past 3 months

Relative Contraindications

1. Anaemia (copper IUD can worsen blood loss)
2. Menorrhagia (copper IUD may worsen; LNG-IUS is actually beneficial here)
3. History of PID since last pregnancy
4. Purulent cervical discharge / STI
5. Distortions of the uterine cavity - congenital malformations, fibroids (especially submucous)
6. Coagulopathies (ITP, von Willebrand disease)
7. Previous uterine perforation or recent uterine surgery
8. Nulliparity (relative - smaller copper devices can still be used)
9. Multiple sexual partners (increased STI/PID risk)
10. Immunosuppression / HIV (increased infection risk)
11. Unmotivated patient (less suitable candidate for continuation of use)

Side-Effects

1. Menstrual Disturbances (most common)

• Increased menstrual blood loss (menorrhagia) - most common with inert and copper IUDs; average 40-50% increase in blood flow
• Prolonged menstruation - longer duration of bleeding
• Intermenstrual bleeding - spotting between periods
• Dysmenorrhoea - increased period pain, especially in the first few months
• Note: LNG-IUS causes the opposite - reduced bleeding and amenorrhoea over time

2. Pain

• Insertion pain - cramping during and immediately after device insertion
• Lower abdominal pain/pelvic cramps - may persist for weeks after insertion
• More common in nulliparous women

3. Expulsion

• Partial or complete expulsion of the device from the uterus, particularly in the first year
• Higher with larger inert devices and with devices used in nulliparous women
• Copper devices have a lower expulsion rate than inert IUDs
• May go unnoticed - patient advised to regularly check the tail string

4. Pelvic Inflammatory Disease (PID)

• Risk is highest in the first 20 days post-insertion (from insertion-related contamination)
• Long-term risk relates to the patient's own STI risk (multiple partners), not the IUD itself
• Can lead to subfertility if not treated promptly

5. Ectopic Pregnancy

• If pregnancy occurs despite an IUD in place, a higher proportion are ectopic (~50%)
• The absolute risk of ectopic pregnancy is LOW (since IUDs prevent most pregnancies)
• The LNG-IUS has the lowest risk of ectopic pregnancy among IUDs
• Copper IUD does NOT prevent ectopic pregnancies as effectively as it prevents intrauterine ones

6. Uterine Perforation

• Uncommon but serious complication (~1 in 1,000 insertions)
• Usually occurs at the time of insertion
• Can be partial (myometrium) or complete (into peritoneal cavity)
• Requires surgical retrieval if complete perforation

7. Pregnancy with IUD In Place

• Increased risk of: spontaneous miscarriage, septic abortion, preterm labour
• IUD should be removed if strings are visible (reduces risk of complications)
• If IUD is left in place and pregnancy continues: risk of premature rupture of membranes, chorioamnionitis, preterm birth

8. Lost/Missing Threads

• Strings may ascend into the uterine cavity or break
• Requires ultrasound or hysteroscopy for localization

9. Hormonal Side-Effects (LNG-IUS specific)

• Irregular spotting and breakthrough bleeding in the first 3-6 months
• Headaches
• Breast tenderness
• Mood changes / depression (less common; systemic absorption is low)
• Acne (rare due to minimal systemic levels)
• Amenorrhoea (20% at 1 year, 50% at 5 years - often seen as a benefit)
• Ovarian cysts (functional) - occur in ~7% but mostly resolve spontaneously

10. Other

• Actinomyces-like organisms on cervical smear (associated with long-term IUD use; significance uncertain)
• Partner discomfort from strings (can be trimmed)
• Vaginal discharge (foreign body reaction)

Timing of Insertion

• Best time: During menstruation or within 10 days of the first day of a period - cervical canal is slightly dilated, pregnancy is excluded, insertion is technically easier
• Postpartum: Can be inserted immediately (within 48 hours) or after 4-6 weeks postpartum
• Post-abortion: Can be inserted immediately after a complete first-trimester abortion
• Emergency contraception use: Copper IUD inserted within 5 days of unprotected intercourse (99% effective)

Duration of Use

Summary Comparison Table