Copper Intrauterine Devices
Case Study 1
Ida is a married 30-year-old mother of one infant child. She and her husband both wish to delay having a second child. Ida is currently breastfeeding. She had an occurrence of pelvic inflammatory disease (PID) in her mid-20’s. Ida knows that her husband has had other relationships. She heard about IUDs from a community health worker and has come to the clinic to learn more about them.
Question Set A
During your initial meeting, Ida wants to learn more about IUDs and asks the following questions:
1. How do IUDs prevent pregnancy?
2. What are some advantages of using a copper IUD?
3. Are there any disadvantages to using a copper IUD?
4. Is it safe to use copper IUDs while breastfeeding?
Question Set B
After you answer her questions about IUDs and provide her with information on other appropriate and available contraceptive methods, Ida chooses the IUD and says she would like to start using an IUD as soon as possible. You also learn that her period returned last week; it has been six months since her baby was born. Her husband was recently diagnosed with gonorrhea, though Ida has not been tested, nor has she had symptoms.
1. What tools would you select to help you screen Ida for medical eligibility?
2. Does Ida’s medical history, or her husband’s diagnosis of gonorrhea, affect her eligibility for an IUD? Why or why not?
3. What additional information should you provide to Ida, given her current situation?
4. How soon could Ida start IUD use?
Question Set C
Since her previous visit Ida has tested negative for gonorrhea and other STIs. Her husband has been treated for gonorrhea. Ida has considered her options, and has decided to move forward with starting to use an IUD. Before the IUD is inserted, Ida attends a pre-insertion counseling session.
1. What tool(s) would you use to help conduct this counseling session?
2. What should you tell Ida about the side effects of IUDs?
3. What type of medical exam does Ida require before starting to use an IUD?
4. What additional instructions would you give Ida about the insertion procedure and/or possible complications?
Question Set D
Ida has had her IUD for three months. She is returning to the clinic and complains that she still has cramping, especially during menses, and heavy bleeding during her periods.
1. Is heavy bleeding normal with IUD use?
2. What would you advise Ida to do about her bleeding?
3. What you would advise her to do about the cramping?
4. What other family planning methods may Ida be eligible for?
Case Study 1—Answer Key
Knowledge and Skills Objectives Addressed by IUDs Case Study 1
1. Describe the characteristics of IUDs in a manner that clients can understand2. Demonstrate the ability to:
a. Screen clients for medical eligibility for the copper IUD
b. Explain insertion and follow-up procedures to clients
c. Explain when to return to the clinic
d. Address common concerns, misconceptions, and myths
e. Conduct follow-up for clients using copper IUDs in a way that enhances continuing satisfaction and acceptance
3. Describe when to initiate use of the copper IUD
4. Explain how to manage side effects of the copper IUD
Answers to Question Set A
1. How do IUDs prevent pregnancy?
IUDs prevent pregnancy primarily by preventing sperm from uniting with an egg. IUDs release small amounts of copper, which both damages sperm and interferes with sperm movement, so sperm can’t reach an egg. If sperm cannot unite with an egg, pregnancy cannot occur.
2. What are some advantages of copper IUDs?
Copper IUDs:
· Are safe and highly effective
· Provide long-acting contraception
· Are affordable, with no further cost after insertion
· Do not require the user to do anything once the IUD is inserted.
· Are easily reversible (If a woman wants to become pregnant, she can have the IUD removed, and fertility returns immediately.)
· Do not contain estrogen, so can be used by women who are breastfeeding or have health conditions that might restrict their use of contraceptives containing estrogen.
3. Are there any disadvantages to using IUDs?
· They have side effects, especially heavy bleeding and more cramping during menses in the first three to six months of use.
· Complications are rare, but may occur.
· They cannot be inserted or removed without a provider’s help.
· IUDs provide no protection against STIs, including HIV.
4. Is it safe to use IUDs while breastfeeding?
Because copper IUDs contain no hormones, they can be safely used by breastfeeding women. Copper IUDs have no effect on quantity or quality of breastmilk.
Answers to Question Set B
1. What tool(s) would you select to help screen Ida for medical eligibility?
The Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, the WHO Medical Eligibility Criteria Wheel for Contraceptive Use, or the Quick Reference Chart for the WHO Medical Eligibility Criteria for Contraceptive Use.
2. Does Ida’s medical history or her husband’s diagnosis of gonorrhea affect her eligibility for IUDs?
Previous PID does not affect eligibility for IUDs (WHO medical eligibility category 1 with subsequent pregnancy). Her husband’s diagnosis of gonorrhea does affect her eligibility, because it puts her at high risk for STIs. (She would answer “Yes” to question 13 on the screening checklist.) She should not have an IUD inserted unless the provider could rule out current chlamydia and gonorrhea infection.
3. What additional information should you provide to Ida, given her current situation?
You should counsel her about other available FP methods. If no other FP methods are acceptable to Ida and testing for gonorrhea and chlamydia is available, refer her for testing. In case there is an infection, you may safely insert an IUD after a full course of treatment for gonorrhea and chlamydia. If testing is not available, but Ida insists on using an IUD, explain that you can insert an IUD, but she will need to watch closely for signs of infection and come back for follow-up if she is having low abdominal pain, fever, or unusual vaginal discharge. She may also want to bring her husband in for treatment. Advise her to use condoms to prevent STI transmission as well as pregnancy while she is waiting for test results and during treatment if it turns out she has an infection.
4. How soon could Ida start IUD use?
After gonorrhea and chlamydia are ruled out, or treated and resolved, Ida could have an IUD inserted within the first 12 days of her menstrual cycle, or at any other time that the provider can be reasonably certain she is not pregnant. Because Ida’s baby is six months old, and Ida’s menses have returned, her eligibility is based on recommendations for women who are menstruating.
Answers to Question Set C
1. What tool(s) would you use to help conduct this counseling session?
The IUD Fact Sheet; and/or other brochures, illustrations or handouts provided by your workplace that describe and summarize side effects and characteristics of IUDs, the insertion procedure, and what to expect after IUD insertion.
2. What should you tell Ida about possible side effects of IUDs?
You should review with Ida the side effects that you discussed in an earlier visit—that she may experience heavier and prolonged menstrual bleeding, as well as increased menstrual cramping and spotting between periods. These side effects usually diminish after the first three to six months of use. They do not necessitate removal of the IUD.
Reassure Ida that these side effects may be unpleasant, but are not harmful and do not indicate a serious medical problem. They can be alleviated by taking ibuprofen, paracetamol, or other pain reliever—except aspirin—as needed.
3. What type of medical exam does Ida require before starting to use an IUD?
A pelvic examination (bimanual and speculum).
4. What additional instructions should you give Ida about the insertion procedure and about complications?
You should briefly describe the insertion procedure, using appropriate visual aids, if available, and inform Ida that she may experience mild discomfort/pain and cramping during the insertion and light bleeding and mild cramping for a few days following insertion.
After the IUD is inserted, you should ask if Ida wants to know how to check that her IUD is in place by feeling for the strings. If she does, advise her to check for the strings after each menses, especially in the first three months. Make sure that she knows to wash her hands thoroughly before inserting her fingers into her vagina. If she is doesn’t want to check with her hand, she can inspect the pads she uses during menses for a possible expulsion of the IUD.
Also discuss with Ida the signs of possible IUD complications and advise Ida to return immediately if she experiences any of the following signs or symptoms:
• Bleeding or severe abdominal cramping during the first three to five days after insertion—this could indicate that the uterus may have been perforated when the IUD was inserted.
• Irregular bleeding or pain in every cycle—this could indicate an IUD dislocation, partial expulsion, or perforation.
• Fever and chills, unusual vaginal discharge, or lower abdominal pain—this could indicate an infection, which is a concern especially during the first month after the IUD is inserted. This is when PID, although rare, is most likely to develop.
• Missing IUD strings or a missed menstrual period—these could indicate IUD expulsion and pregnancy, either uterine or ectopic.
Answers to Question Set D
1. Is heavy bleeding normal with IUD use?
Heavier and prolonged menstrual bleeding, as well as menstrual cramping and spotting between periods, are common but usually temporary.
2. What would you advise Ida to do about her bleeding?
Reassure Ida that heavier and prolonged menstrual bleeding are common but usually temporary. Inform Ida that these side effects do not indicate a serious medical problem and can be alleviated by taking ibuprofen, paracetamol, or other pain reliever—except aspirin—as needed. Also, recommend that she take iron tablets if possible.
3. What you would advise Ida to do about her cramping?
Reassure Ida that increased cramping is another side effect associated with IUD use. Reassure her that cramping is particularly common during menses. Inform Ida that this is generally not harmful and decreases over time. Suggest a pain reliever, aspirin (325-650 mg), ibuprofen (200-400 mg) or other pain reliever. If there is also heavy bleeding, do not prescribe aspirin. If Ida’s cramping continues and occurs outside of monthly bleeding, you should evaluate her for underlying health conditions, treat and refer. If no underlying conditions are found but cramping continues and Ida finds it unacceptable, discuss removing the IUD.
4. Would you advise Ida to have the IUD removed? Why or why not?
There is no medical reason that Ida would need to have the IUD removed. Correct any misperceptions Ida may have. Provide ongoing counseling and reassurance if needed.
If Ida continues to be concerned and finds the side effects unacceptable, she may want to have the IUD removed. If Ida asks to have it taken out, the provider must remove it, no matter what the reason, and counsel Ida about other available FP methods.
5. What other family planning methods may Ida be eligible for?
According to the information you have so far, Ida is eligible for combined oral contraceptives (COC), implants, and injectable contraceptives. However she should know that implants and injectables also may cause heavy, prolonged and irregular bleeding. Keep in mind her risk for STIs and her need to use condoms in addition to another method for dual protection.
Note: The recommendations provided in the Answer Key comply with the guidance in Family Planning: A Global Handbook for Providers (2011 update). If national guidelines are available and provide guidance on these topics, participants should follow the recommendations in the national guidelines.
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