Answers to Resident IUD Questionnaire
14) If 100 women used the IUD correctly for 1 year, what percentage of women would you
expect to get pregnant (i.e., what is the failure rate of the IUD)?
Answer: < 1%. 0.8% and 0.2% of women will experience an unintended pregnancy
within the first year of typical use of the Paragard (Copper T380A) and Mirena IUDs,
respectively.1
15) and 16) According to the FDA, the Paragard (Copper T380A) IUD and Mirena IUD
should be left in place for a maximum of how many years?
Answer: 10 years for the Paragard (Copper T380A), 5 years for the Mirena. The
Paragard (Copper T380A) IUD is approved for use in the United States for 10 years, although it
has been demonstrated to maintain its efficacy over at least 12 years of use. The Mirena IUD is
approved for use in the United States for 5 years, although it is effective for at least 7 years and
probably 10 years.2
17) How quickly does fertility typically return after IUD removal?
Answer: Immediately. Following removal of IUDs, the normal intrauterine
environment is rapidly restored. In large studies, there is no delay, regardless of duration of use,
in achieving pregnancy at normal rates. There has been no significant difference in cumulative
pregnancy rates between parous and nulliparous or nulligravid women.2, 3
18) What is the overall discontinuation rate for the Paragard (Copper T380A) and Mirena
IUDs after 1 year of use?
Answer: 0-25%. 78% of women using the Paragard (Copper T380A) IUD and 80% of
women using the Mirena IUD are still continuing its use at 1 year.1
19) What is the average expulsion rate for an IUD in the first year after insertion?
Answer: 0-15%. Up to 15% of women will expel their IUD within the first year after
insertion. Those who have it placed immediately post-partum within 48 hours or post-abortion do
have higher expulsion rates of up to 12%4 and 8%,5 respectively, whereas those who have delayed
insertion have an expulsion rate of only 3-4%.6 Younger age, a higher than normal amount of
menstrual flow, and dysmenorrhea are also associated with higher expulsion rates.7 Evidence
suggests that despite the higher expulsion rate post-abortion, it may still decrease repeat abortions
since many women do not come back for their post-abortion visit and delayed IUD insertion.8
20) Which IUD(s) is/are FDA-approved to be used as emergency contraception to prevent
unintended pregnancy if placed within 5 days of unprotected intercourse?
Answer: the Paragard (Copper T380A). The Paragard (Copper T380A) IUD can be
inserted up to 5 days after unprotected intercourse to prevent pregnancy and is extremely
effective, reducing the risk of pregnancy after unprotected intercourse by 99%.9
21) Which statement(s) below describe(s) the mechanism of action of the IUD?
Answer: prevents fertilization and implantation of an embryo. Both the Paragard
(Copper T380A) and Mirena IUDs create an intrauterine environment that is spermicidal by
producing a sterile inflammatory response within the uterus, which is their primary mechanism of
action. The Paragard (Copper T380A) IUD does this by releasing free copper and copper salts
into the cervical mucus and endometrium, which inhibits sperm motility through both mediums
and releases cytokines in the endometrium that is spermicidal. Very few, if any, sperm reach the
ovum in the fallopian tube. Sensitive assays for human chorionic gonadotrophin do not find
evidence of fertilization. The Mirena IUD creates a similar effect by releasing a steady amount of
20ug levonorgestrel (progesterone) into the uterine cavity, causing inflammation of the
endometrium similar to that of inert IUDs, while also suppressing the endometrial glands and
secretions. This process results in endometrial atrophy and inhibits both sperm migration and
survival and prevents implantation of any embryos. The progesterone also thickens the cervical
mucus, creating a barrier to sperm penetration, and decreases activity of the tubal epithelium,
inhibiting transport of both the ovum and sperm in the fallopian tube. The medical definition of
conception is considered to be the time of implantation of the blastocyst into the endometrium.
Since IUDs do not destroy any implanted embryos, they are not considered abortifacients.2, 10
22) Do IUDs increase a patient’s overall risk of ectopic pregnancy as compared to a patient
using a different method of contraception or no contraception?
Answer: No. Previous use of an IUD does not increase the risk of a subsequent ectopic
pregnancy, and the current use of an IUD actually offers some protection against ectopic
pregnancy by the above-mentioned mechanisms of action (i.e., inhibition of sperm motility and
function, thereby preventing fertilization). The Mirena IUD has the added benefit of partially
suppressing gonadotropins, so that the number of ovulatory cycles is decreased, with less overall
opportunity for an ectopic pregnancy to occur. However, if a pregnancy does occur with an IUD
in place, the likelihood of an ectopic pregnancy is high. A WHO multicenter study concluded
that IUD users were 50% less likely to have an ectopic pregnancy when compared with women
using no contraception. The risk of ectopic pregnancy does not increase with increasing duration
of use with the Paragard (Copper T380A) or Mirena IUD.2
23) Does inserting an IUD increase a patient’s risk of pelvic infection during the first 20
days after insertion?
Answer: Yes. A review of the WHO database derived from all of the WHO IUD clinical
trials concluded that the risk of pelvic inflammatory disease (PID) was six times higher during the
20 days after the insertion compared with later times during follow-up. Of note, PID was
extremely rare beyond the first 20 days after insertion. In nearly 23,000 insertions, only 81 cases
of PID were diagnosed. A large case-control study from the USA found the increase in risk is
limited to the first 4 months after insertion; by 5 months and thereafter, the risk was not
significantly increased. Other studies have shown that there is no increased risk of Chlamydia
acquisition by IUD users and that the monofilament tailstring that is used in modern IUDs does
not increase the risk of infection. The Dalkon Shield had a multifilament string that did increase
infection by carrying bacteria cephalad, but has not been manufactured since the 1980s.2, 11, 12
24) Do you routinely give antibiotic prophylaxis prior to IUD insertion?
Answer: Per ACOG Practice Bulletin #59 (Intrauterine Device, 1/05), Level A evidence
shows that routine use of antibiotic prophylaxis at the time of IUD insertion confers very little
benefit. It has not been found to decrease the risk of subsequent PID and therefore is not
routinely recommended, even for patients who are at risk for subacute bacterial endocarditis (per
the American Heart Association). This opinion is based upon four randomized trials and a metaanalysis.13, 14
25) Do you wait until you have negative gonorrhea and chlamydia culture results on ALL
patients before inserting an IUD?
Answer: According to ACOG Practice Bulletin #59, current data do not support routine
screening in women at low risk for STDs.15 Women who are at high risk of STDs may benefit
from the screening as a systemic review revealed that women with chlamydial infection or
gonorrhea at the time of IUD insertion were at increased risk of PID relative to women without
infection, although the absolute risk of PID was still low for both groups (0-5% for those with
STIs and 0-2% for those without).15 If a patient’s cultures do come back as positive after an IUD
is inserted, it is possible to initially treat with the IUD in place and to remove the IUD only if
subsequent PID develops and is non-responsive to treatment.16, 17
26) Do you wait until a patient’s next menses to insert an IUD if you are reasonably certain
that she is not pregnant?
Answer: The advantages of inserting an IUD during a patient’s menses are that it may be
easier due to a more open cervical os, it may mask bleeding from the insertion process, and it
creates certainty that the patient is not currently pregnant. However, these advantages must be
weighed against the risk of unintended pregnancy if insertion is delayed to await menses.2
Furthermore, the expulsion rate and termination rates for pain, bleeding, and pregnancy are lower
if insertions are performed after day 11 of the menstrual cycle, and the infection rate may be
lower with insertions after day 17.18 If the patient has been sexually active within 2 weeks and
has not been on adequate birth control, one should wait until at least 2 weeks after the last episode
of intercourse to obtain a pregnancy test.19 Or, if it is within 5 days of unprotected intercourse,
the Paragard (T380A) may be used as emergency contraception.
27) Which off-label non-contraceptive benefits has the Mirena IUD been found to have
(please check all that apply)?
Answers: improvement of bleeding from menorrhagia, improvement of pain from
endometriosis, improvement of pain and bleeding from adenomyosis, protection from
endometrial hyperplasia and cancer. According to ACOG Committee Opinion #337
(Noncontraceptive uses of levonorgestrel intrauterine system), there is sufficient evidence to
support the use of the levonorgestrel intrauterine system as a treatment option for idiopathic
menorrhagia and that it protects against endometrial hyperplasia in women using menopausal
estrogen therapy. Small pilot studies suggest that it also improves endometriosis-associated
pelvic pain for up to 3 years, and therefore the Committee Opinion states that it is reasonable to
consider its use by women with endometriosis who desire effective, long-term contraception.20
Three small studies have shown that it also can assist with treatment of adenomyosis by
decreasing uterine volume, bleeding, and pain.21 When used in the setting of myomas, it has been
shown to reduce menstrual blood loss and pain, but it does not reduce overall uterine size or size
of uterine fibroids, and expulsion rates may be higher.22 The Mirena IUD has not been found to
offer protection from breast cancer or to improve pain from ovarian cysts.
28) How would you recommend an IUD to a patient in the following situations? Assume no
contraindications for use of an IUD and that all other factors are favorable for use.
Answer: According to ACOG Practice Bulletin #59, candidates for intrauterine device
use include both nulliparous and multiparous women at low risk for sexually transmitted diseases.
It may be an optimal method for women with certain medical conditions, including diabetes,
thromboembolism (for which Mirena may be ideal if patients are on anticoagulants since it
decreases menstrual bleeding), menorrhagia/dysmenorrhea, and breastfeeding. Contraindications
include pelvic inflammatory disease within the past 3 months or a current diagnosis of a sexually
transmitted disease that has been untreated.13
ACOG Committee Opinion #392 addresses the issue of “Intrauterine device and
adolescents.” It states that “top-tier methods of contraception, including IUDs and implants,
should be considered as first-line choices for both nulliparous and parous adolescents. After
thorough counseling regarding contraceptive options, health care providers should strongly
encourage young women who are appropriate candidates to use this method.” Because
adolescents have the highest rates of chlamydia and co-infection with gonorrhea, all adolescents
should be screened for both before IUD insertion, and screening at the time of insertion expedites
contraceptive use.23
The 3rd Edition of the WHO Medical Eligibility Criteria (MEC) for Contraceptive Use,
published in 2004, is another helpful guide to selecting appropriate candidates for IUD use. It
classifies various clinical scenarios of contraceptive use into four different categories. If a
condition is classified as Category 1, the contraceptive can used in any circumstances. Category
2 indicates that the method can generally be used, Category 3 indicates that use of the method is
not usually recommended unless other more appropriate methods are not available or not
acceptable, and Category 4 indicates that the method is not to be used. By this classification
system, placing an IUD in a patient who is <48 hours postpartum is considered to be Category 2
for the Copper IUD and Category 3 for the LNG-IUD. However, placement of an IUD
immediately after a first-trimester abortion, whether spontaneous or induced, is considered
Category 1. For second-trimester abortions, it becomes a Category 2 because of greater risk of
expulsion.24
For patients who are infected with HIV, the WHO MEC lists IUD use and insertion as
Category 2 for both the copper and levonorgestrel IUDs. The exception is if the patient has AIDS
and is not clinically well on anti-retroviral therapy. If this is the case, the IUD becomes a
Category 3 for insertion, but it is still a Category 2 for continued use if they already have an IUD
in place. If a patient has AIDS but is clinically well on anti-retroviral therapy, it is still Category
2 to insert and continue the IUD. IUD use among HIV-infected women has not been associated
with increased risk of transmission to sexual partners, and having an IUD does not increase the
risk of HIV acquisition for women without HIV. However, the WHO does suggest that IUD
users with AIDS be closely monitored for pelvic infection.24
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