What are the contraindications, required pre‑insertion screening, timing considerations, potential side effects, and follow‑up recommendations for copper intrauterine device (IUD) use in women?

Copper IUD Use: Key Clinical Considerations

The copper IUD can be inserted at any time if it is reasonably certain the woman is not pregnant, requires no backup contraception after insertion, and is suitable for women of all ages including adolescents and nulliparous women. 1

Pre-Insertion Screening Requirements

Pregnancy Exclusion (Critical)

• Ruling out pregnancy is the single most important pre-insertion requirement because IUD placement during pregnancy carries serious risks including spontaneous abortion, septic abortion, preterm delivery, and chorioamnionitis 1
• Use a pregnancy checklist with 99-100% negative predictive value; if uncertainty exists, provide alternative contraception until pregnancy can be definitively ruled out 1
• A urine pregnancy test should be performed if there is any clinical uncertainty 1

STI Screening Considerations

• Screen for sexually transmitted infections, particularly Chlamydia trachomatis, before insertion 2
• The risk of pelvic infection is slightly elevated only during the first 3 months after insertion, with approximately 6 infections per 1000 woman-years 2
• Routine antibiotic prophylaxis is not necessary 2
• If active genital tract infection is present, postpone insertion until after treatment 2
• Women must be counseled that copper IUDs provide no protection against STDs 1

Physical Examination

• No pelvic examination is required to determine IUD eligibility 3
• Blood pressure measurement is not specifically required for copper IUD (unlike combined oral contraceptives) 3

Timing of Insertion

Standard Contraceptive Use

• Can be inserted at any time during the menstrual cycle if reasonably certain the woman is not pregnant 1
• Waiting for the next menstrual period is unnecessary when switching from another contraceptive method 1
• Timing relative to the menstrual cycle has minimal effect on long-term outcomes (continuation, expulsion, pregnancy rates) or short-term outcomes (pain, bleeding, immediate expulsion) 1

Emergency Contraception

• Most effective emergency contraception method available with <1% failure rate 4
• Must be inserted within 5 days (120 hours) of unprotected intercourse 1, 4
• Extended window: Can be inserted >5 days after intercourse if insertion occurs within 5 days of ovulation (when ovulation timing can be estimated) 1, 4
• Provides ongoing long-term contraception after emergency insertion 4

Postpartum Timing

• Can be inserted immediately postpartum 1
• Avoid insertion <4-6 weeks after delivery due to increased perforation risk (0.6-16 per 1000 insertions) 2

Postabortion Timing

• Can be inserted immediately after first-trimester abortion 1
• Higher perforation risk if inserted <4-6 weeks post-abortion 2

Contraindications

Absolute Contraindications

• Current pregnancy (Category 4) 4
• Puerperal sepsis 1
• Active pelvic infection or unexplained vaginal bleeding (postpone insertion) 2

Relative Considerations

• High risk for STIs at time of placement (Category 3) 4
• Pre-existing asymptomatic Chlamydia trachomatis infection increases early infection risk 2

Backup Contraception Requirements

No additional contraceptive protection is needed after copper IUD insertion 1—this is a key advantage over hormonal IUDs, which require 7 days of backup contraception if inserted >7 days after menstrual bleeding starts 1

Expected Side Effects and Discontinuation Reasons

Menstrual Changes

• Heavier menstrual bleeding is the most common side effect and may be associated with menstrual pain 2
• Bleeding and dysmenorrhea are the most common reasons for discontinuation 5

Insertion-Related Events

• Pain, bleeding, and syncope occur in <1.5% of insertions overall 2
• Uterine perforation occurs in 0.6-16 per 1000 insertions 2

Device-Related Events

• Expulsion occurs in 5-10% of cases within 5 years 2
• Expulsion recurs in approximately 30% of women who experience it once 2

Pregnancy-Related Risks

• Approximately 6 pregnancies per 1000 woman-years with copper IUDs 2
• TCu380A has the lowest pregnancy rate among copper IUDs 6, 7
• If pregnancy occurs with IUD in place: 25% result in live birth if device left in place vs. 90% if removed 2
• About 1 in 20 pregnancies occurring with an IUD in place is ectopic 2
• Overall ectopic pregnancy risk is lower in IUD users than in women using no contraception 2

Efficacy Comparison

• TCu380A is the most effective copper IUD, superior to MLCu375, MLCu250, TCu220, and TCu200 6, 7
• TCu380S shows slightly fewer pregnancies than TCu380A after the first year, though it has higher expulsion rates 6, 7
• Copper IUD efficacy is comparable to correctly used combined oral contraceptives, but more effective than incorrectly used oral contraceptives 2
• Fewer than 1 woman per 100 becomes pregnant in the first year of typical IUD use 1

Special Populations

Adolescents and Nulliparous Women

• Can be safely used in adolescents and nulliparous women 1
• The only additional concerns are more pain during insertion and slightly more frequent expulsions 2
• No evidence that any particular framed copper device is better suited for nulliparous women 6, 7

Medical Conditions

• First-line contraceptive for women with history of deep venous thrombosis, pulmonary embolism, or coronary events 2
• Safe in breastfeeding women 2
• Safe in women with diabetes or HIV infection 2
• Safe after ectopic pregnancy 2
• Compatible with NSAID therapy 2

Follow-Up Recommendations

• Approximately 50% of women continue using the copper IUD after 5 years, indicating high acceptability 5
• Cumulative discontinuation rates are lower than other contraceptive methods 5
• No specific routine follow-up schedule is mandated by the guidelines provided, though clinical judgment should guide monitoring for complications

Common Pitfalls to Avoid

• Do not delay insertion waiting for menses when switching methods or in amenorrheic women 1
• Do not provide backup contraception after copper IUD insertion—it is immediately effective 1
• Do not use routine antibiotic prophylaxis 2
• Do not insert if pregnancy cannot be reasonably excluded—provide alternative contraception until certainty is achieved 1
• Do not insert during active pelvic infection 2
• Do not forget to counsel about lack of STI protection 1