This document provides a comprehensive overview of intrauterine contraception (IUC), detailing its types, mechanisms of action, effectiveness, contraindications, and counseling principles. It discusses copper (cu-IUD) and levonorgestrel (LNG-IUD) devices, their insertion techniques, complications, and follow-up care. Additionally, it covers indications for IUD removal and future developments in IUD technology.

1. CU-IUD AND PP-IUD

2. INTRODUCTION
• Intrauterine contraception (IUC) is a long acting reversible
contraceptive(LARC), highly effective, reversible method of contraception.
• Cost effective
• Fertility returns immediately after removal.
• Safe for women who are breastfeeding.
• Two categories-
 Copper intrauterine devices (Cu-IUDs)
 Levonorgestrel intrauterine devices (LNG-IUDs).

3. CU-T
•Small, flexible plastic frame containing
copper impregnated with barium sulphate.
•Currently there are 2 types of Cu IUCDs
available under the national programme.
CU-T 375 CU-T 380
A
Effective for
5 years
Effective for
10 years

4. CUT 380 A CuT 375

5. Copper IUCD 380 A

6. Copper IUCD 375

8. • Forms biological foam in cavity- contains strands of fibrin, phagocytic cells and proteolytic
enzymes.
• Forms prostaglandins in cavity -causes smooth muscle contraction and inflammation.
• Cu ion - greater inflammatory response
• Change the surface morphology of cells , especially of microvilli of ciliated cells.
• Changes the intrauterine environment
• Decrease sperm motility and function by altering the uterine and tubal fluid environment,
thus preventing sperm from reaching the fallopian tubes and fertilizing the egg – prevents
fertilization .
• The device stimulates foreign body reaction in the endometrium that releases macrophages
and prevents implantation
MECHANISM OF ACTION

9. EFFECTIVENESS-
• Contraceptive effectiveness of IUDs is high and is not affected by enzyme-inducing
drugs or weight/body mass index (BMI).
• Contraceptive failure rates -0.6%–0.8% in the first year of use for the Cu-IUDs.
• Highly effective emergency contraception (EC) that can be retained to provide
ongoing contraception.

10. DURATION OF USE-
•Used for contraception for 5 or 10 years (device dependent).
•If ≥40 years old, can be used for contraception until menopause.
•Fertility returns promptly after an IUCD is removed.

11. TIMING OF INSERTION
Can be inserted
anytime-
Interval IUCD
Emergency
contraception
Postpartum Post Abortion
-not pregnant
-anytime preferably post
menstrually
if inserted within 5 days
after the first episode of
unprotected sexual
intercourse (UPSI) that
cycle, or within 5 days of
the earliest expected date
of ovulation.
- Post Placental
- Immediate post
partum
- Trans caesarean
- Delayed /Interval post
partum
• After Surgical Abortion:
Immediately or within 12
days of an abortion
procedure
• After Medical Method of
Abortion: Around day 15
of MMA (follow up/ 3rd
scheduled visit for medical
method of abortion)

12. ABSOLUTE CONTRAINDICATIONS
• Pregnancy
• Puerperal sepsis
• Immediate placement post septic abortion
• Unexplained vaginal bleeding
• Uterine anomalies that distort the anatomy
• Uterine fibroids that distort the shape of the uterus
• Current PID or history of PID in past 3 months
• Current purulent cervicitis or infection with gonorrhea or chlamydia
• Known pelvic tuberculosis
• Cervical cancer awaiting treatment
• Wilson’s disease

13. RELATIVE CONTRAINDICATIONS
•Excessively heavy periods or marked dysmenorrhea
• Small uterine cavity

14. SIDE EFFECTS
•Menstrual changes: There may be increase in the duration/amount of
menstrual bleeding or spotting or light bleeding during the first few days or
months after insertion. These usually subside with symptomatic treatment
• Discomfort or cramps during insertion and for the next few days which
subsides in due course

15. PRINCIPLES OF FP COUNSELLING
• Privacy and confidentiality
• Respectful, non-judgmental, accepting and caring attitude
• Simple, culturally appropriate and in easy language for patient to
understand
• Good verbal and non-verbal interpersonal communication skills
• Brief, simple and specific information
• Patient should be able to ask questions and express any concerns
• Voluntary informed decision making by the patient

16. BENEFITS OF FAMILY PLANNING COUNSELLING
• Increases acceptance of the methods
• Enhances continuation of methods
• Dispels misconceptions/ rumors
• Increases patient satisfaction
Counselling helps the patient to make voluntary decisions and
increases compliance.

17. TIMING OF COUNSELLING
IUCD in Interval Period:-
• During visit to the health facility
• During home visits by ASHA

18. IUCD in Post Partum period:-
 Postpartum period-
•During antenatal visits
•At the time of admission/ early labour
•Within 48 hours of delivery
 Post Abortion Period-
•On confirmation of pregnancy, if the woman wants MTP
• Before initiating the abortion procedure
•After completion of abortion for the woman

19. COUNSELLING
• General FP Counselling- to choose what , why , when and how.
• Method specific counselling- Effectiveness ,Health benefits and advantages ,Side
effects, health risks and complications and when to return for follow up.
• Follow up Counselling- satisfaction ,any problems or concerns

20. POST INSERTION COUNSELLING
• Follow-up visits - after 6 weeks or first menstruation.
• Any time if any warning sign or if the IUCD is expelled
• Warning signs -
P: Period related problems or pregnancy symptoms
A: Abdominal pain or pain during intercourse
I: Infections or unusual vaginal discharge
N: Not feeling well, fever, chills
S: String problems

21. ASSESSMENT FOR ELIGIBILITY
1. Clinical assessment – Clinical history, physical examination( general, systemic and pelvic).
2. Assessment for PPIUCD-
First Assessment Second Assessment Insertion
• Any distorted uterine cavity
(uterine septum, fibroid uterus,
etc.)
• Acute purulent discharge
• High risk of exposure to STIs
like Gonorrhoea or Chlamydia
• Malignant or benign
trophoblastic disease
• AIDS and neither clinically well
nor on antiretroviral therapy
Rule out
• Chorioamnionitis
• Postpartum endometritis
or puerperal sepsis
• More than 18 hours from
rupture of membranes to
delivery of the baby
• Unresolved postpartum
hemorrhage • Extensive
genital trauma
If patient is
eligible

22. INSERTION TECHNIQUES

23. PRE INSERTION PREPARATION
•Patient Preparation
•Provider preparation
•Visualization of the cervix
•Cleaning of the cervix and vagina
•Grasping the anterior lip of cervix
Grasping the anterior lip of cervix with
vulsellum

24. LOADING OF IUCD 380 A
•‘No Touch Technique’ – for Interval IUCD
or PAIUCD
•IUCD 375 is pre-loaded
•Check the contents of the packet
•Partially open the packet
•Place the white plunger rod in the clear
insertion tube
Placing plunger rod in insertion
tube.

25. •Bend the “arms” of the “T” downward
Positioning IUCD and bending arms of T

26. •Pull the insertion tube
away from folded arms
of the T
•Push the folded arms of
the T into the insertion
tube
Inserting folded IUCD arms in insertion tube

27. •Set the cervical guard/ blue length-
gauge to the appropriate
measurement
•Align the cervical guard/blue
length-gauge and folded arms of
the T so that they are both in a
“horizontal” position
•Remove the loaded IUCD from the
package
IUCD fully loaded in insertion tube

28. INSERTION OF IUCD
•Insert the sterile uterine sound
•Advance the sound into uterine cavity, and STOP when slight resistance is felt
•Determine the angle/ direction and length of the uterine cavity
•Hold the loaded IUCD with one hand
•Insert the loaded IUCD
•Gently advance loaded IUCD into the uterine cavity

29. IUCD-While holding vulsellum and plunger rod stationary
Withdraw the insertion tube downwards
Release of IUCD arms -‘Withdrawal technique’
Remove the white plunger rod
To ensure that arms of ‘T’ are high in fundus of the uterus, gently push the insertion
tube upwards again
Use sharp curved scissors to cut the strings at 3 to 4 cm from the cervical opening
and remove the insertion tube from the cervical canal

30. PPIUCD INSERTION (POST PLACENTAL: WITHIN 10
MIN OF DELIVERY)
•The anterior lip of the
cervix to be held with
ring forceps or sponge
holding forceps
•Grasp the IUCD

31. •Insert PPIUCD in lower uterine cavity
•Advance IUCD in uterine cavity
•High fundal placement of IUCD
•release the IUCD at the fundus.
•Slowly remove PPIUCD insertion forceps
•Examine the Cervix

32. POSTPARTUM IUCD INSERTION WITHIN 48
HOURS OF DELIVERY
•Ask to empty her bladder.
•Abdominal examination- for level and tone
•Insert IUCD using PPIUCD insertion forceps
•Examine the cervix following insertion
•Between 48 hours and6 weeks after birth:IUCD insertion is not recommended
during this period because the uterus is softer and more vascular than in its non-
pregnant state and is susceptible to an increase in perforation and overall
complication rate.

33. INTRA-CAESAREAN INSERTION OF IUCD
•Counsell for PPIUCD before the caesarean procedure
•After delivery of the baby and placenta and
evaluation for PPH but prior to closure of uterine
incision.
•Either manually or using sponge holding forceps
•Hold IUCD between the middle and index fingers of
the hand and pass it through the uterine incision
•IUCD strings can be pointed towards lower uterine
segment but should NOT be pushed through the
cervical canal.
Holding the IUCD
between middle and
index finger

34. POST-INSERTION COUNSELLING
•There may be increase in duration/ amount of menstrual bleeding or spotting
•Discomfort or cramps
•Spontaneous expulsion
•IUCD does not protect against STIs/ HIV
•Can be removed anytime (Except for PPIUCD insertion, when IUCD removal should
be delayed till at least 6 weeks after insertion

35. INSERTION TECHNIQUES
•If the insertion is correct, strings will not be seen at the cervix at
postpartum.
•Even in cesarean section, there is no need to push the strings into the
cervix.
•The strings follow the lochia and can be seen at the cervix by about
6 weeks.
• In about 50 % of the patients, strings will not be seen at the cervix. Hence,
one follow-up at 6 weeks with the provider is mandatory.
•If at 6 weeks the strings are long, or the partner can feel strings, it can be
trimmed.
•If the strings cannot be seen, ultrasonography can be done to reassure the
patient about the placement of IUCD

36. COMPLICATIONS
Pelvic infection
Uterine perforation
(1–2 per 1000
insertions in the
general population)
Cramping and
bleeding
Expulsion

37. FOLLOW UP VISITS
•First follow up visit is mandatory and has to be done at 6 weeks or after next
menstrual periods
•Subsequent visits should be after 3 months and 6 months
•Anytime if she is experiencing problems
•Follow up home visits can be done by ANM supported by ASHA or AWW
•Follow-up Care- Assessing for menstrual changes ,infection and expulsion

38. IUCD REMOVAL
Indications for IUCD removal -
• Woman wants another child
• IUCD needs to be replaced
• Medical reasons (e.g. pregnancy, heavy menstrual bleeding)
• Woman wants to switch to another method
• Menopause
• Evidence of IUCD displacement
• Personal reasons

39. IUCD should not be removed if-
• Infection is present
• Between 48 hours and 6 weeks post-delivery
Procedure-
• Clean the cervix and vagina at least two times
• Hold the anterior lip of cervix with a vulsellum
• Grasp the strings of the IUCD with an artery forceps and apply traction, gently
pulling the strings

40. Grasping the IUCD threads

41. FUTURE OF IUD ( UNDER INVESTIGATION)
Veracept- novel nitinol frame
low dose copper IUD (175
mm2 )
Intrauterine balls with
copper pearls- copper pearls
are strung on a memory alloy
nitinol wire. Size 12-18mm in
diameter, area 300 to 380
mm2.

42. MISSING THREAD
• Rule out pregnancy
• Probe the cervical canal using sterile long artery forceps to locate the
strings, and gently draw them out so that they can be seen protruding into
the vaginal canal.
• If the strings are not located in the cervical canal refer the woman for an
ultrasound (or X ray, if ultrasound is unavailable) to help determine whether
the IUCD is still in place, is malpositioned, or has been expelled.

43. PREGNANCY WITH CU T INSITU
Possible Symptoms/ Signs :-
• Missed menstrual period
• Other symptoms/ signs of pregnancy
• Missing strings
• Strings which are shorter or longer than expected

44. MANAGEMENT OF PREGNANCY WITH IUCD
• Confirm pregnancy and its duration.
• Rule out ectopic pregnancy
• When ectopic pregnancy has been ruled out, and if the pregnancy is in the
first trimester
Counsel the woman - the benefits and risks of removal ,the risk of abortion.
If the woman requests for removal- proceed with immediate removal if the
strings are visible and the pregnancy is in the first trimester.
If the strings are not visible, do an ultrasound to determine whether the
IUCD is still in the uterus or has been expelled. If the IUCD is still in place, do
not try to remove it.
If the woman declines removal, provide antenatal care

45. REFERENCES:-

46. REFERENCES:-
Berek & Novak's Gynecology - Wolters Kluwer
Gabbe's Obstetrics Essentials: Normal and Problem Pregnancies
Reference Manual for IUCD Services- National health Mission.