Series B, Number 7
Intrauterine Devices

CONTENTS

Home (Key Points)

The IUD: An Important Method with Potential
Table 1. Overview of IUDs
Figure 1. Most IUD Users Are in China
Web Table 1. Current Use of Contraceptive Methods Reported by Married Women 15-49, 1976-2005
Table 2. Estimated Worldwide Use of IUDs Among Married Women Ages 15–49, 2005

Providing High-Quality IUD Services

Spotlight: Kenya Commits To Renewing Interest in the IUD

Feature: Good Counseling Increases Client Satisfaction

Very Low Overall Risk of Infection with IUDs
Figure 2. Risk of Pelvic Inflammatory Disease (PID) Greatest in First Few Weeks After IUD Insertion

Box: Evidence Shows Many Women with HIV Can Use IUDs

Minimizing the Risk of Infection

Clinical Characteristics of IUDs
Web Box 1. Managing Problems with IUD Use

Bibliography

Credits

Go to the IUD Toolkit at http://www.iudtoolkit.org for full-text resources, including tools and best practices, on IUDs.

• Checklist: Program Plan for Providing High-Quality IUD Services
• Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, from Family Health International
• Counseling Aid for Communicating IUD Effectiveness

• IUD Use, STIs, and HIV-Related Conditions: 2004 WHO Medical Eligibility Criteria
• Do IUDs Increase the Risk of PID in Women with STIs?

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Feature: Good Counseling Increases Client Satisfaction

Informative counseling that is focused on clients’ needs helps clients make good choices and can increase successful use of contraceptive methods (193). Women who receive good counseling are more satisfied with their methods (9, 190) and use them longer than women who receive poorer counseling (2, 37, 73, 119, 227). Among users of copper-bearing IUDs, levonorgestrel- releasing IUDs, injectables, and implants, good counseling about potential bleeding changes makes it more likely that women will tolerate the changes and be satisfied with these methods (2, 9, 12, 80, 119, 211).

Good counseling entails a partnership between client and provider, in which they each share information openly and ask and answer questions freely (254). Family planning programs once thought that providers should give clients a lot of information about all methods equally to help clients make informed choices. This approach, however, can overload the client with information about irrelevant methods and can leave little time for discussing how to use the chosen method (120, 254).

Today, programs increasingly encourage client-centered counseling, in which the clients’ concerns, desires, and comfort are most important, and clients’ wishes guide the counseling process (254). Providers tailor information based on the client’s needs and preferences. For example, the provider should focus on the client’s desired method first, if she has one, helping the client take into account her situation and lifestyle. Also, involving clients’ partners in counseling, whenever possible and acceptable to the client, can help clients use contraception effectively (290, 291, 297).

Once a client expresses a preference for a specific method, the provider and client should discuss that method in more detail to confirm her decision and to help her learn how to use the method correctly. Important information for providers to discuss includes the characteristics of the method, medical eligibility criteria, potential side effects, how to use the method, when to start it, and what to remember about it (266). This counseling is not simply the provider presenting facts, however. Rather, it involves discussion of what these facts would mean to the client. For example, the provider can explore with the client whether bleeding changes due to the IUD would be too bothersome for her or interfere with her daily life. Would she want to change methods if she experienced these side effects?

Essential information to discuss with a client who chooses the IUD includes:

• How the IUD is inserted and removed (shown using a pelvic model if possible).
• Potential side effects (especially bleeding changes) and other possible problems, such as expulsion, perforation, and PID.
• How the client can check that her IUD is in place by feeling for the IUD strings.
• When and where the insertion will take place and who will perform the procedure.

Just before the insertion, the IUD provider should discuss in detail the steps of the insertion procedure:

• The provider should explain to the client that she may experience some discomfort or cramping during insertion and that she may have cramps for several days following insertion.
• The provider should encourage the client to speak up any time during the procedure if she feels discomfort or pain.
• The provider can advise the client to take ibuprofen 30 minutes before insertion and in the days following insertion to reduce cramping and pain.

After the insertion procedure, the provider should:

• Give the client the name of the IUD, date of insertion, and date when it will need to be removed or replaced, preferably written on an information card.
• Advise the client to come back any time she wants, including if she has problems with the IUD, has any questions, or wants the IUD removed; she thinks the IUD might be out of place; she thinks she might be pregnant; or she has symptoms of PID.
• Plan for a routine follow-up visit in three to six weeks or after the client’s next menstrual period to discuss her experience with the IUD. The provider should explain that the routine follow-up visit is an opportunity to check for any problems. If routine follow-up is not possible, the client can still have an IUD inserted. Counsel the client on where to go for immediate care if it is needed.