IUD Replacement and Extended Use

Intrauterine device replacement is the removal of a device at the end of its duration, or earlier at the patient’s request, with placement of a new device at the same visit so that protection is continuous. Each device has its own duration, and protection beyond that duration is not assured. Replacement uses the same eligibility, asepsis and technique as a first insertion.

Duration of use.

Effectiveness at replacement. A replacement device carries the failure rate of a new device. Fertility returns immediately after removal if no new device is placed.

Removal alone. Removal can be done at any time on request. The device remains effective until it is removed.

Reassess eligibility at each replacement. Medical conditions may have changed since first placement. Review blood pressure, thrombotic history, liver disease, breast disease, migraine, HIV status and medicines.

Category rules for continuation.

• Pelvic inflammatory disease, chlamydia or gonorrhoea in a current user: category 2; treat with the device in place.
• HIV with AIDS: category 2 for continuation, category 3 for initiation.
• Unexplained vaginal bleeding during use: category 2 pending evaluation; evaluate before replacing.
• Levonorgestrel devices: ischaemic heart disease developing during use, and migraine with aura that worsens during use, are category 3 for continuation. Current breast cancer is category 4.
• Copper devices: continuation in current breast cancer is category 1.

Do not replace, remove only. Pregnancy, current pelvic infection, suspected malignancy, partial expulsion, perforation, and a patient who declines a new device.

Pregnancy exclusion. Not needed if the existing device is in place within its duration and the new device is placed at the same visit. If the device has expired, or the patient has had unprotected sex without a device in place, exclude pregnancy by history and test before replacement.

Choosing the replacement. The same device is usual. Change from copper to a levonorgestrel 52 mg device for unacceptable heavy bleeding or dysmenorrhoea. Change from levonorgestrel to copper for unacceptable hormonal effects, or for emergency contraception and ongoing cover.

Perimenopause.

• A copper device inserted at 40 or over may remain until 12 months after the last menstrual period, then be removed.
• A copper device placed earlier is replaced at its duration; if the patient is 50 or over at that point, replacement is needed only if she has had menses in the previous 12 months.
• Levonorgestrel devices mask menstrual cessation. At 50 or over, remove at expiry, use a nonhormonal method, and decide on stopping contraception after 12 months without menses.

Endometrial protection. A levonorgestrel 52 mg device used with oestrogen therapy is replaced at 5 years.

Regimen line, same-class replacement. Remove the expired device and place a new device of the same type in the same sitting.

• Copper device: no backup needed.
• Levonorgestrel device: no backup if the old device was in place and effective until removal.
• Replace copper T 380A at 12 years, levonorgestrel 52 mg and 19.5 mg at 5 years, and levonorgestrel 13.5 mg at 3 years.

Regimen line, class change.

• Copper to levonorgestrel within 7 days of menses start: exchange directly with no backup.
• Copper to levonorgestrel after day 7: advise condoms or abstinence for 7 days before the exchange and backup for 7 days after it, or keep the copper device until the next menses.
• Levonorgestrel to copper: exchange at any time with immediate cover and no backup.

Technique.

• Confirm the position of the existing device by speculum examination and, if threads are absent, by ultrasound.
• Clean the cervix and use sterile no-touch technique throughout.
• Grasp the threads close to the external os with forceps and apply steady, gentle traction in the line of the canal.
• Insert the new device in the same sitting, sounding the uterus first.
• Give ibuprofen 400 mg orally 30 to 60 minutes before the procedure unless contraindicated.

Overdue devices. A device kept beyond its duration can be removed and replaced in the same way. Protection beyond the duration is not assured, so exclude pregnancy first. For a levonorgestrel device placed later than day 7 of the cycle, give backup for 7 days.

Follow up. Review at 3 to 6 weeks after replacement, checking threads and bleeding. Record the date of insertion, device type and the replacement date, and give the patient the next replacement date.

Missing threads. Examine the cervical canal with a thread retriever. If the device is not retrieved, perform ultrasound, and X-ray if the device is not seen. Give backup in the meantime. A device outside the uterus needs surgical referral.

Embedded or difficult removal. If traction fails, do not use force. Refer for ultrasound, hysteroscopic removal or specialist care. Embedded devices are common after prolonged retention.

Broken device. If an arm breaks during removal, confirm all fragments are removed by examination and ultrasound. Retained fragments need hysteroscopic retrieval.

Pain and vasovagal reaction. Pause, place the patient supine, and give analgesia. Ibuprofen 400 mg orally 30 to 60 minutes before the procedure reduces pain; maximum 2.4 g daily.

Expulsion or malposition of the new device. Confirm by ultrasound and replace.

Bleeding after replacement. Mild spotting is expected. Persistent heavy bleeding after replacement needs ultrasound and exclusion of infection, expulsion and pregnancy.

Infection. Rare after replacement. Treat pelvic inflammatory disease with ceftriaxone 500 mg intramuscularly once, doxycycline 100 mg orally twice daily for 14 days and metronidazole 500 mg orally twice daily for 14 days, with the device in place. Remove it if there is no improvement at 48 to 72 hours.

Pregnancy with an overdue or new device. Exclude ectopic pregnancy by ultrasound. If intrauterine and threads are visible in the first trimester, offer removal.

Referral and escalation. Refer for embedded or fragmented devices, devices outside the uterus, sepsis, ectopic pregnancy, and unexplained bleeding that persists after replacement.