When is copper Intrauterine Device (IUD) insertion recommended for a breastfeeding female in the postpartum period?

Copper IUD Insertion Timing for Breastfeeding Postpartum Women

The copper IUD can be safely inserted at any time during the postpartum period in breastfeeding women, including immediately after delivery of the placenta (within 10 minutes), between 10 minutes and 4 weeks postpartum, or at 4 weeks or later postpartum. 1

Immediate Postplacental Insertion (within 10 minutes of placental delivery)

• Copper IUD insertion immediately after placental delivery is classified as Category 1 (no restriction for use) by the US Medical Eligibility Criteria for Contraceptive Use 1
• Immediate insertion offers the advantage of guaranteed contraception before hospital discharge 1
• Insertion can be performed following either vaginal or cesarean delivery 1
• No additional contraceptive protection is needed after copper IUD insertion 1

Early Postpartum Insertion (10 minutes to <4 weeks)

• Copper IUD insertion between 10 minutes and 4 weeks postpartum is classified as Category 2 (advantages generally outweigh risks) 1
• This timing is safe and effective but has a higher expulsion rate compared to interval insertion 2

Interval Insertion (≥4 weeks postpartum)

• Copper IUD insertion at 4 weeks or later postpartum is classified as Category 1 (no restriction for use) 1
• This timing has the lowest expulsion rates (approximately 2% compared to 10% with immediate insertion) 2, 3

Special Considerations for Breastfeeding Women

• The copper IUD is an excellent choice for breastfeeding women as it:
  • Contains no hormones that might affect milk production 4
  • Can be safely used in breastfeeding women without restrictions 4
  • Does not interfere with breastfeeding establishment 1

Important Contraindications

• The copper IUD should not be inserted in women with:
  • Puerperal sepsis (Category 4 - unacceptable health risk) 1
  • Unexplained vaginal bleeding 1
  • Distorted uterine cavity 1
  • Wilson's disease (copper is contraindicated) 1

Expulsion Risk Considerations

• Expulsion rates are higher with immediate postpartum insertion (approximately 10%) compared to interval insertion (approximately 2%) 2, 5
• Despite higher expulsion rates, 6-month continuation rates are higher with immediate placement (80%) compared to interval insertion (50%) 1, 2
• Expulsion rates are lower when copper IUDs are placed during cesarean delivery compared to vaginal postplacental insertions 2, 5
• High fundal placement reduces the risk of expulsion 2, 5

Follow-up Recommendations

• Women should be counseled on how to check for IUD strings and detect expulsions 5
• A follow-up visit 4-6 weeks after insertion is recommended to check for proper IUD placement 6
• Women should be informed that the copper IUD does not protect against sexually transmitted infections 1

Clinical Pearls

• The copper IUD can also be used as emergency contraception if inserted within 5 days of unprotected intercourse 1
• No additional contraceptive protection is needed after copper IUD insertion, regardless of timing 1
• The copper IUD is a first-line contraceptive for women with a history of thromboembolic disease for whom estrogen is contraindicated 4