1. Copper-Bearing Intrauterine Devices (IUDs)
Adapted by Dr Rodica Comendant, based on Training Resource Package for Family Planning:
Illustration credit: Salim Khalaf/FHI
Copper T 380A

2. Characteristics of IUDs

3. IUDs: Key Points for Providers and Clients
Copper IUD
5/25/2012
Small plastic device inserted through the vagina and cervix into the uterus.
Works mainly by stopping sperm and egg from meeting.
Requires no user action.
Requires a clinically trained provider to properly insert and remove.
Most women can use IUDs, including women who have never been pregnant.
Very effective
Very effective, with little to remember.
A woman can soon become pregnant when IUD is taken out.
Long acting
Long acting – up to 12 years – depending on type of device.
Can be removed whenever woman wants.
For older women: should be removed 1 year after last menstrual period (menopause).
Adapted from WHO’s Decision-making tool for family planning clients and providers.

4. IUDs: Key Points for Providers and Clients
Copper IUD
5/25/2012
Very safe
Copper-bearing IUDs act locally on the reproductive tract and have no systemic effects. For this reason, copper IUDs can be used safely by breastfeeding women and by women who cannot use hormonal contraceptives.
IUDs do not:
Leave the womb and move around the body.
Get in the way during intercourse, although sometimes the man may feel the strings.
Rust inside the body, even after many years.
Some women have side-effects
Side-effects usually get better after first 3 months.
Side-effects include increase in menstrual bleeding or cramps.
No protection against STIS or HIV/AIDS
For STI/HIV and AIDS protection, also use condoms.
Adapted from WHO’s Decision-making tool for family planning clients and providers.

5. Copper IUDs
Copper IUDs have a small plastic frame with copper sleeves or wire around it
TCu-380A, “Copper T” is most widely used copper IUD
Multiload 375 is another copper IUD commonly available in some countries
Copper T-380A
Multiload 375

6. Effectiveness of IUDs
In this progression of effectiveness, where would you place copper intrauterine devices (IUDs)?
Implants
Male Sterilization
Female Sterilization
Progestin-only Injectables
Combined Oral Contraceptives
Male Condoms
Standard Days Method
Female Condoms
Spermicides
More effective
Copper IUDs
Less effective

7. Relative Effectiveness of Family Planning Methods
# of unintended pregnancies among
1,000 women in 1st year of typical use
No method
850
Withdrawal
220
Female condom
210
Male condom
180
Pill 90
Injectable 60
IUD (CU-T 380A / LNG-IUS)
8 / 2
Female sterilization 5
Vasectomy
1.5
Implant
0.5
Source: Trussell J., Contraceptive Failure in the United States, Contraception 83 (2011) , Elsevier Inc.

8. Effectiveness Copper IUDs: Spermicides Female condom
Standard Days Method
Male condom
Oral contraceptives
Suggested script:
IUDs are among the most effective reversible methods of contraception, with failure rates of less than 1 percent. This chart compares the pregnancy rates for the Copper T IUD with the rates for other contraceptive methods.
The red rectangles show pregnancy rates for correct and consistent use, reflecting how often a contraceptive fails when it is used both correctly and consistently. The blue rectangles show pregnancy rates for methods as they are commonly used, reflecting how often a contraceptive fails in real-life situations, when it may not always be used correctly and consistently.
With IUDs there is virtually no difference between the pregnancy rates for correct and consistent use and pregnancy rates as commonly used. As the chart shows, other reversible contraceptive methods, such as barrier methods or oral contraceptives, may have low pregnancy rates with correct and consistent use but much higher rates for typical use.
With the IUD, the woman does not need to do anything on a regular basis. (If she wants, she can check for IUD strings once a month to make sure that it is still in place, but this is not mandatory). Because the effectiveness of IUDs does not depend on daily user compliance, pregnancy rates for the IUD are extremely low even as commonly used.
Women who use the IUD have about the same pregnancy rate as women who have chosen sterilization, which is a non-reversible method.
eferences:
1. Trussell J. Contraceptive failure in the United States. Contraception 2011;83:
2. Kulier R, Helmerhorst FM, O'Brien P, et al. Copper containing, framed intra-uterine devices for contraception. Cochrane Database Syst Rev 2006;3:CD
DMPA
IUD (TCu-380A)
Pregnancy rate when used correctly and consistently
Female sterilization
Male sterilization
Pregnancy rate as commonly used
Implants 5 10 15 20 25 30
Percentage of women pregnant in first year of use
Source: Trussell, 2011.

9. IUDs: Mechanism of Action
Prevents fertilization by:
Impairing the viability of the sperm
Interfering with movement of the sperm
Source: Ortiz, 1996

10. Copper IUDs: Characteristics
Safe and highly effective
Require no user action
Long-acting (up to 12 years)
Rapid return to fertility
No systemic effects
Have health benefits
Trained provider needed to insert and remove
Require pelvic exam
Possible pain or discomfort during insertion
Have potential side effects
Complications are rare, but may occur
Do not protect against STIs/HIV
Source: CCP and WHO, 2011.

11. Copper IUDs: Health Benefits
IUDs are known to:
Prevent risks of pregnancy
Help protect against endometrial cancer
Reduce risk of ectopic pregnancy
Rate in IUD users is 12 in 10,000 (2 in 10,000 for Copper T380A)
Rate in women using no contraception is 65 in 10,000

12. Possible Side-Effects
Copper IUD
If a woman chooses this method, she may have some side-effects. They are not usually signs of illness.
After insertion:
Other common side-effects:
Some cramps for several days
Longer and heavier periods
Bleeding or spotting between periods
Some spotting for a few weeks
Adapted from WHO’s Decision-making tool for family planning clients and providers.
More cramps or pain during periods
May get less after a few months

13. Copper IUDs: Counseling about Side Effects
Before insertion, describe common side effects:
Heavier and/or prolonged menstrual bleeding
Menstrual cramping
Spotting between periods
Explain that side effects:
Are not signs of illness
Usually become less within the first 3–6 months
Encourage to come back with questions or concerns
If client cannot tolerate side effects, treatment or discontinuation may be necessary

14. Who Can and Cannot Use IUDs?
Illustration credit: Salim Khalaf/FHI
Copper T 380A

15. Copper IUD Is Safe for Most Women
Most women can use the Copper T IUD safely, including women who:
Have or have not had children
Are not married
Are of any age
Have just had an abortion or miscarriage (no infection)
Are breastfeeding
Have had PID
Have vaginal infections
Are infected with HIV or have AIDS and on ARVs
Source: CCP and WHO, 2011.

16. Who Can and Cannot Use the IUD
Copper IUD
Most women can safely use the IUD
But usually cannot use IUD if :
May be pregnant
Gave birth recently (more than 2 days ago)
Unusual vaginal bleeding recently
At high risk for STIs
Infection or problem in female organs
Adapted from WHO

17. When clinical judgment is available
WHO’s Medical Eligibility Criteria
Categories for IUDs, Hormonal and Barrier Methods
Category
When clinical judgment is available 1
Use the method 2 3
Do not use the method 4
Source: WHO, 2010.

18. Conditions (selected examples)
Category 1 and 2 Examples (not inclusive): Who Can Use Copper IUDs
WHO Category
Conditions (selected examples)
Category 1
≥20 years, cervical ectopy, uterine fibroids without distortion of the uterine cavity, irregular bleeding without heavy bleeding
Category 2
Menarche to <20 years, nulliparous, heavy or prolonged bleeding, severe dysmenorrhea, anemia
Source: WHO, 2010.

19. IUD Use by Women with HIV and AIDS
WHO Eligibility Criteria
Condition
Category
Initiate
Continue
HIV-infected 2
AIDS (without ARVs) 3
ARV therapy
(clinically well)
IUDs safe for majority of women with HIV
Initiation not recommended if woman has AIDS and is not on ARVs
Encourage dual method use
Source: WHO, 2010.

20. Conditions (selected examples)
Category 3 and 4 Examples (not inclusive): Who Should Not Use Copper IUDs
WHO Category
Conditions (selected examples)
Category 3
48 hours to <4 weeks postpartum, ovarian cancer/if initiating use, high individual risk of STI/ if initiating use
Category 4
Pregnancy, unexplained vaginal bleeding (prior to evaluation), current PID or cervical infection, endometrial or cervical cancer/if initiating use
Source: WHO, 2010.

21. IUD Use by Postpartum Women
Women less than 48 hours postpartum can have copper IUD inserted
Women 48 hours to 4 weeks postpartum generally should not initiate IUDs
No restrictions starting at 4 weeks postpartum
Women with puerperal sepsis should not have IUD inserted
WHO Eligibility Criteria
Characteristic/ Condition
Category
<48 hours 1
48 hours to <4 weeks 3
≥4 weeks
Puerperal sepsis 4
Source: WHO, 2010.

22. Understanding the Copper IUD Checklist
Read questions 7–21 on the checklist and match them with the conditions and categories on the MEC quick reference chart.
This set of questions identifies women who are not pregnant.
This set of questions identifies women who should not use IUDs.
The provider uses these questions during the pelvic exam to identify any category 3 and 4 conditions.

23. Providing IUDs
Illustration credit: Salim Khalaf/FHI
Copper T 380A

24. You May be Able to Get Your IUD Now
Copper IUD
IUD can be inserted in first 2 days after you give birth.
Insertion after childbirth:
Can insert within 48 hours after birth. Special training needed.
Between 48 hours and 4 weeks after birth, delay insertion. Offer condoms or another method if she is not fully breastfeeding.
Can insert after 4 weeks after birth. Must be reasonably certain she is not pregnant.
You can start any day of the menstrual cycle if we can be sure you aren’t pregnant.
If menstrual bleeding started in last 12 days, can insert IUD now.
If menstrual bleeding started more than 12 days ago, can insert IUD now if reasonably certain she is not pregnant. No need to wait for next menstrual period.
Adapted from WHO

25. You May be Able to Get Your IUD Now
Copper IUD
Copper IUD
IUD can be inserted if fully or nearly fully breastfeeding less than 6 months after giving birth.
An IUD can be inserted anytime from 4 weeks to 6 months after giving birth and menstruation has not returned.
IUD can be inserted after an abortion or miscarriage.
Can be inserted immediately or within 12 days after a first- or second-trimester abortion or miscarriage and if no infection is present. No need for a backup method.
IUD insertion after second-trimester abortion or miscarriage requires specific training. If not specifically trained, delay insertion until at least 4 weeks after miscarriage or abortion.
If infection, insert after infection has been treated and cured.
IUD can be inserted if switching from another method.
Can be inserted immediately, if she has been using the method consistently and correctly or if it is otherwise reasonably certain she is not pregnant.
Adapted from WHO

26. Correcting Rumors and Misconceptions
IUDs:
Rarely lead to PID
Do not increase risk of STIs, including HIV
Do not work by causing abortion
Do not make women infertile
Do not move to the heart or brain
Do not cause birth defects
Do not cause pain for woman or man during sex
Significantly reduce risk of ectopic pregnancy
Source: CCP and WHO, 2011.

27. What Will Happen When You Get Your IUD
Steps:
Pelvic examination
Cleaning the vagina and cervix
Placing IUD in the womb through the cervix   
May hurt at insertion
Please tell us if it hurts
Rest as long as you like afterwards
May have cramps for several days after insertion
Adapted from WHO
Afterwards: you can check your IUD from time to time if you want.

28. Explaining the IUD Insertion Procedure
You may feel discomfort, like heavy menstrual cramps.
The provider:
Performs a pelvic examination
Cleans the cervix and vagina with an antiseptic
Inserts a small rod into the uterus to measure the depth of the uterus
Inserts the IUD through the vagina and into the uterus using a small applicator
After the insertion, you will rest.

29. Post-Insertion Instructions
Tell client to expect cramping and spotting for a few days
If client wants to check strings, teach her how:
Use clean hands
Check after menses
If convenient for client, schedule follow-up visit for 3–6 weeks
Counsel to return immediately if there are any signs of complications.
Source: CCP and WHO, 2011; WHO, 2004, updated 2008.

30. Complications of IUDs
Potential complications of IUDs include perforations, pelvic inflammatory disease (PID), and expulsions.
Biases in early research overstated risks of PID.
Most research since the 1980s has concluded that serious complications are rare with modern IUDs.

31. Expulsion Rates are Higher for Postpartum Insertion
Timing of Insertion
Expulsion Rates
Interval
(more than 6 weeks after delivery)
Low
(3% for skilled provider)
Immediate postpartum
(within 10 minutes)
Slightly higher
Early postpartum
(between 10 minutes and 48 hours)
Moderately higher
Late Postpartum
(48 hours to 4 weeks)
High – generally not recommended
Suggested script:
An IUD is least likely to be expelled from a woman’s body if it is inserted any time other than during the four weeks following childbirth. Though an expulsion is not a serious complication, an undetected expulsion puts the woman at risk of pregnancy.
Studies have shown that the expulsion rate is generally higher during the postpartum period due to the changes the uterus undergoes as it returns to its normal size. The expulsion rate is only slightly higher for insertions done in the immediate postpartum period (within the first 10 minutes after the placenta is expelled). It is moderately higher if inserted after 10 minutes but before the woman is discharged from the hospital, usually 48 hours after delivery.
Data on expulsion rates for late postpartum insertions—done between 48 hours and 4 weeks after delivery—are limited, but the rates appear to be quite high and insertion is not recommended unless no other method is available or acceptable to woman.
Although the expulsion rate for postpartum insertions is higher, postpartum IUD insertion may be advantageous when compared to the generally low rate of women who return later for IUD insertion. Clients choosing to have the IUD inserted immediately postpartum should be counseled that the risk of expulsion is greater if the IUD is inserted during this period. Before performing postpartum insertions, providers need to receive specific training and supervised practice. The inserter’s skill can greatly affect the risk of expulsion.1
Reference:
1. Chi IC, Wilkens L, Rogers S. Expulsions in immediate postpartum insertion of Lippes Loop D and copper T IUDs and their counterpart delta devices: An epidemiological analysis. Contraception, 1985; 32(2):
Source: Chi, et al, 1985.

32. Explain Removal Procedure to Client
IUD removal is quick and usually quite painless.
The provider:
Inserts a speculum to see the cervix and IUD strings.
Cleans the cervix and vagina with an antiseptic.
Asks the woman to take slow, deep breaths, and tell the provider if she feels pain during the procedure.
Using forceps, pulls the IUD strings slowly and gently until the IUD is completely out of uterus.
Source: CCP and WHO, 2011.

33. Copper IUDs: Summary Copper IUDs are:
Safe, highly effective, convenient, reversible, long lasting, cost-effective, easy to use, and appropriate for the majority of women.
Providers can ensure safety by:
Informative counseling
Careful screening
Appropriate infection prevention practices
Proper follow-up