Copper IUD for Emergency Contraception

The copper IUD is the most effective emergency contraceptive. A copper T 380A device is inserted within 5 days of unprotected intercourse, or within 5 days of expected ovulation. Fewer than 1 in 100 women become pregnant afterwards. It then continues as long-term contraception for up to 12 years, or it is removed at the next menses if no further protection is wanted.

Device. T-shaped polyethylene frame with a copper wire wound on the stem and copper sleeves on the arms, giving 380 square millimetres of copper surface.

Mechanism. Copper ions are toxic to sperm and ovum, so fertilisation is prevented. The device does not rely on timing within the cycle.

Effectiveness. As a regular method, the first-year pregnancy rate is about 0.8 in 100 women with typical use and 0.6 in 100 with perfect use. As emergency contraception, the failure rate is lower than that of any oral option.

Onset, duration and return to fertility. Protection is immediate. The device lasts up to 12 years. Fertility returns at once on removal.

Best candidates. Patients within 5 days of intercourse who want the most effective option, and those who want long-term contraception. Obesity and enzyme-inducing medicines do not reduce its effect, and breastfeeding is not affected.

Pregnancy and infection. The device is not placed in:

• Known pregnancy (category 4).
• Current pelvic inflammatory disease (category 4).
• Purulent cervicitis or current chlamydia or gonorrhoea (category 4).
• Unexplained abnormal vaginal bleeding (category 4).
• Distorting uterine anomaly (category 4).
• Pelvic tuberculosis (category 4).
• Cervical or endometrial cancer awaiting treatment (category 4).
• Malignant gestational trophoblastic disease (category 4).

Higher-risk groups. After sexual assault the device is category 3 because of high infection exposure; oral options are used unless the patient prefers the IUD and presumptive treatment is given. Insertion between 48 hours and 4 weeks after birth is category 3. Advanced HIV disease in a patient who is not clinically well is category 3. Nulliparity and age under 20 years are category 2.

Contraindications to copper. Wilson disease and copper allergy.

History and examination. Time since intercourse, cycle length and regularity, earlier IUD use, pain or discharge, sexual assault. Speculum and bimanual examination confirm uterine position and exclude cervicitis and tenderness.

Investigations. None are routine. A pregnancy test is done when pregnancy is possible from earlier intercourse. Routine screening for infection, HIV testing and cervical screening are not required before insertion and must not delay it. Screen and treat when risk is high.

Counselling points for the clinician. Obtain consent and protect confidentiality. Explain cramping, heavier menses for the first 3 to 6 months and the warning signs of infection and expulsion. Offer condoms for dual protection.

Special groups.

• Postpartum: within 48 hours of birth or from 4 weeks.

• Breastfeeding: the device does not affect milk.

• Postabortion: immediate insertion is acceptable after uncomplicated first-trimester abortion.

• HIV: stable patients on treatment may use it.

Timing.

• Within 5 days of unprotected intercourse.

• When intercourse was more than 5 days ago, within 5 days of the earliest expected ovulation. In a regular 28-day cycle this is up to about cycle day 19.

• Several episodes: insertion is acceptable if the most recent episode was within 5 days, or if insertion is within 5 days of the earliest expected ovulation.

Regimen line. Copper T 380A, intrauterine, inserted once. Protection lasts up to 12 years. No backup is needed. No missed-use rule applies. No drug interactions.

Pregnancy exclusion. Be reasonably certain the patient is not already pregnant, by history and a test where doubt exists. Quick start on any cycle day is acceptable within the 5-day window.

Analgesia. Ibuprofen 400 mg by mouth 30 to 60 minutes before insertion, once. Maximum 1200 mg in 24 hours. Avoid in peptic ulcer, aspirin-sensitive asthma and significant kidney impairment. Suitable in breastfeeding.

Insertion steps.

• Wash hands, use a speculum and clean the cervix with antiseptic.

• Steady the cervix with a tenaculum and pass a uterine sound.

• Load the device without touching non-sterile surfaces, insert to the fundus and release.

• Cut the strings 3 to 4 cm from the cervix.

After insertion. Advise return for pain, fever, foul discharge, a missed period or if the strings cannot be felt. A check at 3 to 6 weeks is advised. For emergency use only, the device may be removed at the next menses once pregnancy is excluded and there has been no further unprotected intercourse; it may also stay.

Switching. Removal restores fertility immediately, so start the next method before removal if protection is needed. Combined or progestin-only methods need the usual backup.

Expected effects. Cramping, and heavier or longer menses in the first 3 to 6 months.

Management of pain and bleeding. Ibuprofen 400 mg by mouth every 8 hours with food for up to 5 days. Maximum 1200 mg in 24 hours. Avoid in peptic ulcer, significant kidney impairment and after 20 weeks of pregnancy. Acceptable in breastfeeding. Persistent anaemia or bleeding that does not settle needs removal and review.

Infection. Pelvic infection after insertion is uncommon and usually follows infection already present at insertion.

• Treatment: ceftriaxone 500 mg intramuscularly as one dose, with doxycycline 100 mg by mouth twice daily for 14 days and metronidazole 400 mg by mouth twice daily for 14 days.

• Doxycycline is avoided in pregnancy. No kidney adjustment is needed at these doses. Reduce metronidazole in severe liver disease. Courses of this length are acceptable in breastfeeding.

• The device may stay if there is improvement within 48 to 72 hours. Remove it if there is no improvement.

Expulsion. Most common in the first 3 months. Partial expulsion needs removal. Test for pregnancy before replacing it.

Perforation. Suspect in severe pain, missing strings or difficult insertion. Confirm by ultrasound and refer for retrieval.

Pregnancy with the device in place. Remove the device if the strings are visible, because this lowers the risk of miscarriage. If the strings are not visible, do an ultrasound. Exclude ectopic pregnancy.

Red flags. Severe lower abdominal pain, fainting, fever with pelvic pain, heavy bleeding and a positive pregnancy test.

Referral and escalation. Refer for suspected perforation, ectopic pregnancy, non-responding infection or an IUD that cannot be removed.