Eligibility and Infection Screening Before IUD Placement

Before any intrauterine device is placed, the clinician confirms that the patient is not pregnant, has no condition that makes insertion unsafe, and has no current cervical or pelvic infection. Eligibility categories for intrauterine devices reflect both device effects and, for levonorgestrel devices, progestogen effects. Infection risk after insertion is confined mainly to the first 20 days and comes from existing cervical infection, not from the device.

Category meanings. Category 1: use without restriction. Category 2: advantages generally outweigh risks; use with follow up. Category 3: risks usually outweigh advantages; use only when no acceptable alternative exists and with specialist input. Category 4: do not use.

Device-related mechanism of infection. Insertion can carry cervical organisms into the uterus. The absolute risk of pelvic inflammatory disease is low and falls to baseline after the first 20 days.

Category 4 for both device classes (do not insert).

• Pregnancy.
• Unexplained vaginal bleeding suspicious of serious pathology, before evaluation.
• Current pelvic inflammatory disease or current purulent cervicitis, chlamydia or gonorrhoea.
• Puerperal sepsis or immediately after septic abortion.
• Known pelvic tuberculosis.
• Uterine fibroids or anomalies distorting the cavity, or a uterine cavity sounding under 6 cm.
• Gestational trophoblastic disease with persistently raised beta hCG or malignant disease.
• Cervical or endometrial cancer awaiting treatment.

Category 3 for both.

• 48 hours to 4 weeks postpartum.
• AIDS when initiating, unless clinically well on antiretroviral therapy.
• Very high individual likelihood of gonorrhoea or chlamydia exposure, for example multiple partners or a partner with multiple partners.
• Gestational trophoblastic disease with falling or undetectable beta hCG.

Category 2 for both.

• Menarche to under 18 years, and nulliparity.
• Second-trimester abortion without sepsis.
• Past pelvic inflammatory disease without later pregnancy.
• Increased STI risk; vaginitis, including trichomoniasis and bacterial vaginosis.
• HIV, clinically well on antiretroviral therapy.
• Complicated valvular heart disease.

Levonorgestrel devices only. Current breast cancer category 4. Acute venous thromboembolism, severe decompensated cirrhosis, hepatocellular adenoma or hepatoma, and lupus with positive or unknown antiphospholipid antibodies category 3.

Copper devices only. Lupus with severe thrombocytopenia category 3 for initiation. Heavy or prolonged bleeding, endometriosis, severe dysmenorrhoea and anaemia category 2.

Continuation rules. A patient who develops pelvic inflammatory disease, chlamydia or gonorrhoea with a device in place may continue (category 2) and is treated with the device in place. Unexplained bleeding during use is category 2 for continuation pending evaluation.

Pregnancy exclusion. Be reasonably certain the patient is not pregnant using the clinical criteria: within 7 days of a normal menses (12 days for a copper device); within 7 days after abortion; under 4 weeks postpartum; fully breastfeeding, amenorrhoeic and under 6 months postpartum; abstinent since the last menses; or correctly using a reliable method. A pregnancy test is needed when none applies or examination is equivocal. If unprotected sex occurred in the past 5 days, a copper device can be inserted as emergency contraception.

STI risk assessment. Ask about age under 25, a new partner in the past 3 months, more than one partner, a partner with other partners, symptoms, and a partner with an STI.

Testing.

• Asymptomatic, low risk: no testing needed before insertion.
• Increased risk: take a cervical or vaginal swab for chlamydia and gonorrhoea nucleic acid amplification testing where available, and insert the same day without waiting for results.
• Positive result after insertion: treat with the device in place and notify partners.
• Testing unavailable: assess clinically by history and speculum examination; do not insert if cervicitis or pelvic tenderness is present.
• Offer HIV testing and syphilis serology to all patients at risk.

Treatment before insertion when infection is found.

• Purulent cervicitis or confirmed gonorrhoea or chlamydia: ceftriaxone 500 mg intramuscularly once plus doxycycline 100 mg orally twice daily for 7 days. If doxycycline is unsuitable, including pregnancy, give azithromycin 1 g orally once. Insert after treatment and clinical resolution.
• Pelvic inflammatory disease: ceftriaxone 500 mg intramuscularly once, plus doxycycline 100 mg orally twice daily for 14 days, plus metronidazole 500 mg orally twice daily for 14 days. Delay insertion until clinical cure.
• Symptomatic bacterial vaginosis or trichomoniasis: metronidazole 500 mg orally twice daily for 7 days; insertion may proceed during treatment.

Antibiotic prophylaxis. Not advised routinely at insertion. For complicated valvular heart disease, give endocarditis prophylaxis before insertion, with the agent set by the treating cardiology team.

Cervical screening. Not a prerequisite. Offer if due, and take the sample at the same visit before insertion.

Follow up. Review at 3 to 6 weeks. Tell every patient to return urgently with fever, rising pelvic pain, dyspareunia or abnormal discharge in the first 20 days.

Post-insertion pelvic inflammatory disease. Presents with lower abdominal pain, fever, cervical motion or adnexal tenderness and discharge. Give the triple regimen with the device in place. Reassess at 48 to 72 hours; remove the device if there is no improvement, while continuing antibiotics, and consider emergency contraception if unprotected sex occurred in the previous 5 days.

Tubo-ovarian abscess. Suspect with a tender adnexal mass, high fever or failure of oral treatment. Admit for intravenous antibiotics and ultrasound; refer for drainage if no response.

Actinomyces-like organisms on cytology. In an asymptomatic patient, no treatment or removal is needed. Remove the device and treat if pelvic pain or signs of infection develop.

Missed infection screening errors. Inserting through purulent cervicitis, failing to perform a pelvic examination, and delaying insertion in asymptomatic patients while awaiting results are the common errors.

Referral and escalation. Refer pelvic abscess, peritonitis, sepsis, suspected pelvic tuberculosis, malignancy and complicated valvular heart disease.