 Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD
Research findings over the past 20 years have established that intrauterine devices (IUDs) are generally safe and effective for use by many women, including those who have not given birth, who want to space births, and those living with or at risk of HIV infection. For some women, IUDs are not recommended due to the presence of certain medical conditions, such as genital cancer and current cervical infection. For these reasons, women who desire to use an IUD must be screened for certain medical conditions to determine if they are appropriate candidates for the IUD.
 Family Health International (FHI), with support from the U.S. Agency for International Development (USAID), has developed a simple checklist (see 'Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, from Family Health International') to help providers determine quickly and with confidence whether a client may use an IUD. The checklist is included in this issue of Population Reports as a collaborative distribution service of the INFO Project. Based on the Medical Eligibility Criteria for Contraceptive Use (WHO, 2004), the checklist consists of a series of questions designed to identify any medical conditions or behaviors that would either prevent safe IUD use or require further screening. The IUD screening checklist has been successfully field-tested in four countries (Bangladesh, the Dominican Republic, Kenya, and Senegal) for comprehensibility and effectiveness in ruling clients in or out for IUD use. The language and style of the checklist can be adapted to meet local cultural and linguistic needs as long as the meaning of the questions is not changed. Because even small changes in wording can cause significant changes in meaning, FHI recommends that any translations be reviewed by someone with expertise and knowledge of the medical basis for the checklist.
This checklist is part of a series of provider checklists for reproductive health services, which was first produced in 2000 and recently revised by FHI. The other checklists include the Checklist for Screening Clients Who Want to Initiate Combined Oral Contraceptives, Checklist for Screening Clients Who Want to Initiate DMPA (or NET-EN), and the Checklist on How to be Reasonably Sure a Client is Not Pregnant. For more information about the provider checklists, please visit www.fhi.org. Please address comments about the contents of this checklist to FHI’s Research to Practice Initiative at rtop@fhi.org.
Explanation of the IUD Checklist
The checklist is designed for use by health care providers to screen clients who intend to use IUDs as a contraceptive method of choice. Hence, clients should first be appropriately counseled to ensure an informed decision is made to use an IUD. The checklist consists of a list of 21 questions, designed to identify medical conditions and high-risk behaviors that would prevent safe IUD use or require further screening, as well as provide further guidance and directions based on clients' responses. A health provider should determine responses to all 21 questions before inserting an IUD. In some settings the responsibility for completing the checklist may be shared - with a counselor completing questions 1-14 and an appropriately trained health provider, including a physician, midwife, clinical officer, nurse, or auxiliary nurse, determining the answers to the remaining questions during the pelvic exam. Clients who are ruled out because they answered "YES" to some of the medical eligibility questions may still be good candidates for an IUD after the suspected condition is excluded through appropriate evaluation.
Determining Current Pregnancy
Questions 1-6 are intended to help a provider determine, with reasonable certainty, whether a client is not pregnant. If a client answers "yes" to any of these questions and there are no signs or symptoms of pregnancy, it is highly likely that she is not pregnant. An IUD should never be inserted in a woman who is pregnant as it may result in a septic miscarriage.
Assessing Medical Eligibility for the IUD
7. Have you given birth within the last 4 weeks?
There is an increased risk of perforating the uterus when IUDs are inserted after 48 hours and up to four weeks postpartum. However, IUDs can be inserted by a trained professional within the first 48 hours after the client has given birth. Clients who answered "yes" to this question only should wait until four weeks after delivery to have an IUD inserted. Since there is no risk of pregnancy during the first four weeks postpartum in breastfeeding and nonbreastfeeding women, there is no need to provide her with contraceptives to use in the meantime, unless it is unlikely that the woman will return to the clinic at the specified time.
8. Do you have bleeding between menstrual periods that is unusual for you, or bleeding after intercourse (sex)?
Unexplained vaginal bleeding may be a sign of an underlying pathological condition, such as genital malignancy (cancer), or a pregnancy-related problem. All these possibilities must be ruled out before an IUD can be inserted. If necessary, refer clients to a higher-level provider or specialist for evaluation and diagnosis. Counsel the client about other contraceptive options available and provide condoms to use in the meantime.
9. Have you been told that you have any type of cancer in your genital organs, trophoblastic disease, or pelvic tuberculosis?
There is a concern about the increased risk of infection, perforation, and bleeding at insertion in clients with genital cancer. Clients with trophoblastic disease may require multiple uterine curettages, and an IUD is unwise in this situation. There is also an increased risk of perforation. Clients with known pelvic tuberculosis may have a higher risk of secondary infection and bleeding if an IUD is inserted. If a woman has any one of these three conditions, she should not have an IUD inserted. Counsel her about other contraceptive options available and provide condoms to use in the meantime.
Note: Questions 10-13 are intended to identify clients at high individual risk of sexually transmitted infections (STIs), because there is a possibility that they may currently have chlamydia and/or gonorrhea infection. Unless these STIs can be reliably ruled out, clients at high risk are not good candidates for IUD insertion. IUD insertion may increase risk of pelvic inflammatory disease (PID) in these clients. They should be counseled about other contraceptive options and provided with condoms for STI protection. However, if other contraceptive methods are not available or acceptable and there are no signs of STI, an IUD still can be inserted. Careful follow-up is required in such cases.
10. Within the last 3 months, have you had more than one sexual partner?
Clients who have multiple sexual partners are at high risk of contracting STIs. Unless chlamydia and/or gonorrhea infection can be reliably ruled out, these clients are not good candidates for IUD insertion. (See note above regarding questions 10-13.)
11. Within the last 3 months, do you think your partner has had another sexual partner ?
Clients whose partners have more than one sexual partner are at high risk of contracting STIs. Unless chlamydia and/or gonorrhea infection can be reliably ruled out, these clients are not good candidates for IUD insertion. In situations where polygamy is common, the provider should ask about sexual partners outside of the union. (See note above regarding questions 10-13.)
12. Within the last 3 months, have you been told you have an STI?
There is a possibility that these clients currently have chlamydia and/or gonorrhea infection. Unless these STIs can be reliably ruled out, these clients are not good candidates for IUD insertion. (See note above regarding questions 10-13.)
13. Within the last 3 months, has your partner been told that he has an STI or do you know if he has any symptoms - for example, penile discharge?
(Note: There are two parts to this question. Answering "yes" to either part or both parts of the question restricts IUD insertion.)
Clients whose partners have STIs may have these infections as well. Unless chlamydia and/or gonorrhea infection can be reliably ruled out, these clients are not good candidates for IUD insertion. (See note above regarding questions 10-13.)
14. Are you HIV-positive and have you developed AIDS?
This is a two part question, and both parts must be asked together. If the woman answers "yes" to both parts, ask whether she is taking ARVs and make sure she is doing clinically well. If she is, she may be a candidate for the IUD. If she is not, an IUD is usually not recommended unless other more appropriate methods are not available or not acceptable. There is concern that HIV-positive clients who have developed AIDS and are not taking ARVs may be at increased risk of STIs and PID because of a suppressed immune system. IUD use may further increase that risk. If the woman is HIV-positive but has not developed AIDS, the IUD may generally be used. Pelvic Examination
15. Is there any type of ulcer on the vulva, vagina, or cervix?
Genital ulcers or lesions may indicate a current STI. While ulcerative STI is not a contraindication for IUD insertion, it indicates that the woman is at high individual risk of STIs, in which case IUDs are not generally recommended. Diagnosis should be established and treatment provided as needed. An IUD can still be inserted if co-infection with gonorrhea and chlamydia are reliably ruled out.
16. Does the client feel pain in her lower abdomen when you move the cervix?
Cervical motion tenderness is a sign of PID. Clients with current PID should not use an IUD. Treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist. Counsel the client about condom use and other contraceptives.
17. Is there adnexa tenderness?
Adnexa tenderness or/and adnexa mass may be a sign of a malignancy or PID. Clients with genital cancer or PID should not use an IUD. Diagnosis and treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist.
18. Is there a purulent cervical discharge?
Purulent cervical discharge is a sign of cervicitis and possibly PID. Clients with current cervicitis or PID should not use an IUD. Treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist. Counsel the client about condom use.
19. Does the cervix bleed easily when touched?
If the cervix bleeds easily at contact, it may indicate that the client has cervicitis or cervical cancer. Clients with current cervicitis or cervical cancer should not have an IUD inserted. Treatment should be provided as appropriate. If necessary, referral should be made to a higher-level provider or specialist. If, through appropriate additional evaluation beyond the checklist, these conditions may be excluded, then the woman can receive the IUD.
20. Is there an anatomical abnormality of the uterine cavity that will not allow appropriate IUD insertion?
If there is an anatomical abnormality that distorts the uterine cavity, proper IUD placement may not be possible. Cervical stenosis also may preclude an IUD insertion.
21. Were you unable to determine the size and/or position of the uterus?
Determining size and position of the uterus is essential before IUD insertion to ensure high fundal placement of the IUD and to minimize the risk of perforation.
|
Order this report
Download PDF
E-mail this page 
See more Population Reports