• The preferred copper intrauterine devices (IUDs) contain 380 mm² of copper, have banded copper on the arms, and are licensed for longer durations of use.

In depth

• The advantages, disadvantages and risks of the IUD.
• Ectopic pregnancy. The risk of ectopic pregnancy when using an IUD is lower than when using no contraception. The overall risk of ectopic pregnancy when using an IUD is very low, about 1 in 1000 in 5 years. However, if a woman becomes pregnant with the IUD in situ, the risk of ectopic pregnancy is about 1 in 20, and she should seek advice to exclude ectopic pregnancy.
• Pregnancy with the copper IUD in situ. The IUD should be removed.
• Expulsion of the copper IUD. The copper IUD can be expelled from the uterus (uncommon), sometimes without the woman knowing.
• Effect on weight, mood, libido, and cancer-risk. There is no evidence that a copper IUD affects weight. Any changes in mood and libido are similar whether using IUDs or the levonorgestrel-releasing intrauterine system (LNG-IUS), and the changes are small. There is no evidence of an increase in cancer of the cervix, endometrium or ovaries with copper IUD use.
• Managing a copper IUD when it is in place:
• Offer instruction on how to check for the copper IUD and its threads. Advise that if it is not possible to feel the threads to use an alternative method of contraception until reviewed, as the device may have been expelled.
• Advise that heavier and/or prolonged bleeding and/or pain associated with copper IUD use can be treated.
• Advise if menstrual abnormalities persist beyond the initial 6 months of use, to seek medical advice to exclude infection and gynaecological pathology.
• Advise to seek medical advice if symptoms of pelvic inflammatory disease occur, especially within the first 3–4 weeks after insertion.

• Enquire about the user's preferences and any concerns.
• In young women and women with special needs, assess their competence to decide, and support them in making their own decisions about contraception.
• Exclude pregnancy.
• Check the UK Medical Eligibility Criteria to ensure that the woman is eligible for insertion of a copper intrauterine device (IUD).
• Assess the risk for sexually transmitted infection and, when appropriate, advise testing, promote safer sex, and/or refer for counselling (also consider each time the IUD is reinserted). If testing for sexually transmitted infections is requested, do this before inserting the device.

In depth

• Provided that it is reasonably certain that the woman is not pregnant, a copper intrauterine device (IUD) can be inserted:
• At any time during the menstrual cycle.
• Postpartum (irrespective of mode of delivery): 4 weeks after delivery.
• Immediately after first- or second-trimester abortion, or at any time thereafter.
• If there is a delay before the IUD can be fitted, combined hormonal contraception (pill, patch, or vaginal ring [not suitable post-partum if the woman is breastfeeding]), the progestogen-only pill, or the progestogen-only injectable can be used as a bridging method.
• When replacing an IUD, consider delaying replacement if the woman has recently had unprotected sexual intercourse.

In depth

• If uterine perforation at insertion is suspected, the procedure should be stopped and vital signs and the level of discomfort monitored until stable.
• Uterine perforation should also be considered if a woman returns within the first few days of insertion complaining of marked pain (which may only be intermittent), and the threads cannot be located.
• Urgent and specific follow-up should be arranged to include ultrasound scan and/or plain abdominal X-ray to locate the device if it has been left in situ.

In depth

• Review 3–6 weeks after insertion of the copper intrauterine device to exclude infection, perforation and expulsion.
• Advise the woman to return if she cannot find the threads of her device.

In depth