• American College of Obstetricians and Gynecologists (ACOG). Intrauterine device. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2005 Jan. 10 p. (ACOG practice bulletin; no. 59). [74 references]

This is the current release of the guideline.

• Unintended pregnancy
• Menorrhagia

Management
Technology Assessment

Obstetrics and Gynecology

Physicians

• To aid practitioners in making decisions about appropriate obstetric and gynecologic care
• To present evidence regarding the safety and efficacy of copper T380A and the levonorgestrel intrauterine system

Women and adolescent girls of child-bearing capability who desire contraception, especially:

• Multiparous and nulliparous women at low risk for sexually transmitted diseases
• Women who desire long-term reversible contraception
• Women with diabetes, thromboembolism, menorrhagia/dysmenorrhea, breast cancer, liver disease, or who are breastfeeding for which an intrauterine device may be an optimal method of contraception

Use of Intrauterine Devices (IUDs)

1. Copper T380A
2. Levonorgestrel intrauterine system
3. Difficulties associated with IUD insertion and removal
4. Routine use of prophylactic antibiotics at time of insertion (not recommended)
5. Treatment options for asymptomatic patients with actinomyces identified on a Pap test
6. Use of copper T380A for emergency contraception
7. Use of levonorgestrel intrauterine system for menorrhagia
8. Removal of IUDs from pregnant women and after menopause
9. Counseling concerning risk factors for sexually transmitted diseases and pelvic inflammatory disease

• Pregnancy rates
• Incidence of complications, eg, pelvic inflammatory disease
• Contraception continuation rate

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The MEDLINE database, the Cochrane Library, and the American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and September 2004. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

In an economic analysis, the levonorgestrel intrauterine system was shown to be the most cost-effective reversible method of contraception after 5 years of continuous use.  As with the copper T380A, return to fertility is rapid after removal of the device.

Internal Peer Review

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

Conclusions

Pelvic inflammatory disease (PID) complicating intrauterine device (IUD) insertion is uncommon, and the risk of PID decreases to the background risk after the first 20 days after insertion.

Nulligravid and multiparous women at low risk of sexually transmitted diseases (STDs) who desire long-term reversible contraception are good candidates for IUDs.

Summary of Recommendations

The following recommendations are based on good and consistent scientific evidence (Level A):

• Routine use of prophylactic antibiotics at the time of IUD insertion confers little benefit.
• The copper T380A is very effective for postcoital emergency contraception and is most effective if inserted within 5 days after unprotected intercourse.

The following recommendations are based on limited or inconsistent scientific evidence (Level B):

• IUDs may be offered to women with a history of ectopic pregnancy.
• The levonorgestrel intrauterine system may be an acceptable alternative to hysterectomy in women with menorrhagia.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• The Food and Drug Administration (FDA) recommends that IUDs be removed from pregnant women when possible without an invasive procedure.
• An IUD placed for contraception should be removed in a woman who has become menopausal.
• Contraception counseling should include information about risk factors for sexually STDs and PID.

Definitions:

Grades of Evidence

I: Evidence obtained from at least one properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendations

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Appropriate use of the intrauterine device

• Some women may experience hormone-related effects, such as headache, nausea, breast tenderness, and depression, with the levonorgestrel intrauterine system.
• Difficulties that may occur at intrauterine device (IUD) insertion include vasovagal reaction, the need for cervical dilation, severe pain, inability to insert the IUD, and uterine perforation. Overall, these conditions rarely occur.
• Complications that may occur in IUD users who become pregnant include an increased risk of spontaneous abortion and an increased risk of septic abortion.

Contraindications to Intrauterine Device (IUD) Use

• Pregnancy
• Pelvic inflammatory disease (current or within the past 3 months)
• Sexually transmitted diseases (current)
• Puerperal or postabortion sepsis (current or within the past 3 months)
• Purulent cervicitis
• Undiagnosed abnormal vaginal bleeding
• Malignancy of the genital tract
• Known uterine anomalies or fibroids distorting the cavity in a way incompatible with IUD insertion
• Allergy to any component of the IUD or Wilson's disease (for copper-containing IUDs)

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Getting Better
Staying Healthy

Effectiveness
Patient-centeredness
Safety
Timeliness

• American College of Obstetricians and Gynecologists (ACOG). Intrauterine device. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2005 Jan. 10 p. (ACOG practice bulletin; no. 59). [74 references]

Not applicable: The guideline was not adapted from another source.

2005 Jan

American College of Obstetricians and Gynecologists - Medical Specialty Society

American College of Obstetricians and Gynecologists (ACOG)

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Gynecology

Not stated

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on October 10, 2007. The information was verified by the guideline developer on December 3, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.