Insertion and Removal of Intrauterine Devices

BRETT ANDREW JOHNSON, M.D., Methodist Charlton Medical Center, Dallas, Texas

Am Fam Physician. 2005 Jan 1;71(1):95-102.

The intrauterine device (IUD) is an effective contraceptive for many women. The copper-releasing IUD can be used for 10 years before replacement and is a good choice for women who cannot, or choose not to, use hormone-releasing contraceptives. However, some women experience an increase in menstrual blood loss and dysmenorrhea. The progestin-releasing IUD can be used for five years. It may reduce menorrhagia and dysmenorrhea, although some women have increased spotting and bleeding during the first months after insertion. The ideal candidates for IUD use are parous women in stable, monogamous relationships. Pregnancy, unexplained vaginal bleeding, and a lifestyle placing the woman at risk for sexually transmitted diseases are contraindications to IUD use. Insertion of the IUD can take place at any time during the menstrual cycle provided the woman is not pregnant. Before insertion, a bimanual examination and a sounding of the uterus are necessary to determine the uterus position and the depth of the uterine cavity. The IUD is inserted into the uterus according to individual protocols, with the threads cut at a length to allow the patient to check the device’s position. Expulsion may occur with both types of IUDs.

For many years, the intrauterine device (IUD) has been a contraceptiv choice for women. In 1995, the IUD was used by 11.9 percent of women of reproductive age worldwide, but by only 1.5 percent of women in North America.1 A potential reason for this difference in use is the negative perception of IUDs created as a result of complications associated with the Dalkon Shield.

The Dalkon Shield was an IUD introduced in 1970 and recalled in 1975. It was associated with a significant incidence of pelvic inflammatory disease (PID) because its multifilament threads were believed to be prone to transmitting bacteria into the uterus and fallopian tubes.

Today, two IUDs are approved for use in the United States: a copper-releasing device (ParaGard) and a hormone-releasing device (Mirena). Both IUDs have monofilament threads that minimize the risk for bacteria transmission.

The copper-releasing IUD (Figure 1) is a T-shaped polyethylene device with 380 mm2 of exposed surface area of copper on its arms and stem. The released copper ions interfere with sperm mobility and incite a foreign-body reaction that results in a spermicidal environment.2 Barium sulfate has been added to the polyethylene substrate to make the device radiopaque. A 3-mm plastic ball is located at the base of the IUD, through which the monofilament thread passes. Once inserted, the IUD can remain in place for up to 10 years.

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Figure 1

Copper-releasing intrauterine device (ParaGard) and inserter. Reprinted with permission from FEI Women’s Health.

Figure 1

Copper-releasing intrauterine device (ParaGard) and inserter. Reprinted with permission from FEI Women’s Health.

The hormone-releasing IUD (Figure 2) is a radiopaque T-shaped device with 52 mg of levonorgestrel on its arms and stem. The progestin is released at a rate of 20 mcg a day. Levonorgestrel is thought to thicken cervical mucus, creating a barrier to sperm penetration through the cervix, and it may stop ovulation and thin the uterus lining. Once inserted, the IUD can remain in place for up to five years.

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Figure 2

Hormone-releasing intrauterine device (Mirena) and inserter. Reprinted with permission from Berlex, Inc.

Figure 2

Hormone-releasing intrauterine device (Mirena) and inserter. Reprinted with permission from Berlex, Inc.

Data are conflicting on which mechanism primarily is responsible for efficacy of IUDs. The results of a recent review indicated that pre- and post-fertilization mechanisms of action play a role in both IUDs.3 [Evidence level B, systematic review of studies] The copper-releasing IUD and the hormone-releasing IUD have been shown in clinical trials to be 99. 2 percent and 98 percent effective, respectively, in preventing pregnancy in one year of typical use.4,5

The contraceptive effects of the IUD are reversible after removal. The results of a recent study suggest that long-term IUD use (i.e., more than 78 months [6.5 years]) may be associated with an increased risk for fertility impairment.6 [Evidence level C, prospective cohort study]

Recommended Patient Profile and Contraindications

IUDs are for parous women who are in a stable, mutually monogamous relationship, with no history of PID. Although not contraindicated in this group, nulliparous women tend to have higher expulsion and failure rates, and also offer more challenging insertion because they have a smaller uterine cavity.7

Women exposed to sexually transmitted diseases (STDs) have a greater chance of developing PID. A history of PID suggests a risk for reinfection, although a remote history does not totally preclude choosing an IUD. A World Health Organization scientific working group concluded that women who have been pregnant after an occurrence of PID and are not currently at risk for infection can be candidates for IUDs. 1

The hormone-releasing IUD may benefit women with anemia, menorrhagia, or dysmenorrhea.8 While there is a greater risk for spotting or irregular bleeding during the first three months after insertion of this device, the risk decreases significantly at 12 months post-insertion.9

Both IUDs are classified as pregnancy category X. Contraindications are summarized in Table 1.4,5,7,10,11

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TABLE 1

Contraindications to IUD Insertion

TABLE 1

Contraindications to IUD Insertion

Precautions

IUDs may be inserted anytime during the menstrual cycle. Documentation of a negative pregnancy test is prudent. Insertion may be performed during menstruation to provide additional reassurance that the woman is not pregnant.

If insertion is planned during the luteal phase, another nonhormonal contraceptive should be used until after the next menses. A pregnancy test can be done, but the patient should be made aware that a pregnancy test at this time cannot always rule out early pregnancy.

An IUD should not be inserted in a woman with an STD. The American College of Obstetricians and Gynecologists recommends a pelvic examination before insertion to screen for Chlamydia and gonorrhea.12 [Evidence level C, consensus/expert guidelines]

Routine prophylactic antibiotic administration is not necessary.13 [Evidence level A, high-quality meta-analysis] Studies have demonstrated that the use of prophylactic antibiotics at the time of IUD insertion provides little, if any, benefit. Doxycycline (Vibramycin) or erythromycin may be used for prophylaxis. 10,12

According to the American Heart Association, antibiotic prophylaxis in patients at risk for endocarditis is not necessary before IUD insertion or removal.14 [Evidence level C, expert/consensus guidelines]

Patient Preparation

The physician should discuss with the patient the risks and benefits of the IUD and, if necessary, other forms of contraception. The patient should review the manufacturer’s patient information materials and have the opportunity to discuss with her physician any concerns. Informed consent may be obtained after these steps are completed.

Administration of a nonsteroidal anti-inflammatory drug (e.g., 600 to 800 mg of ibuprofen [Motrin]) one hour before insertion may alleviate discomfort. The physician should instruct the patient about how to locate the IUD threads. It is necessary for the woman to locate the threads to verify the position of the IUD after each menstruation. The patient should be told to call her physician’s office if she is ever unable to locate the IUD threads.

Insertion

COPPER-RELEASING IUD

The proper equipment (Table 2) should be assembled before the procedure. Then, a bimanual examination with nonsterile gloves should be performed to determine the position of the uterus.

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TABLE 2

Equipment for IUD Insertion

TABLE 2

Equipment for IUD Insertion

The arms of the IUD are to be folded into the insertion tube far enough to retain them. This can be done before the start of the procedure, working through the sterile package (Figure 3).

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Figure 3

The arms of the copper-releasing intrauterine device are folded into the insertion tube. Reprinted with permission from FEI Women’s Health.

Figure 3

The arms of the copper-releasing intrauterine device are folded into the insertion tube. Reprinted with permission from FEI Women’s Health.

Sterile technique, including sterile gloves, is necessary during the procedure to minimize the risk of contamination or infection. The cervix and adjacent vaginal fornices should be cleansed liberally with an antiseptic solution. Chlorhexidine gluconate (Hibiclens) may be used if the patient is allergic to iodine.

The physician should stabilize the cervix during the insertion of the IUD with a tenaculum. Local anesthesia, such as 5 percent lidocaine gel (Xylocaine) placed in the cervical canal, or a paracervical block may be used to minimize discomfort.

A sterile uterine sound should be used to determine the depth of the uterine cavity. Contact with the vagina or speculum blades should be avoided. The uterine sound has a bulbous tip to help prevent perforation. An alternative to the uterine sound is an endometrial aspirator such as those used for endometrial biopsy sampling. An adequate uterine depth is between 6 and 9 cm and should be documented in the patient’s record. An IUD should not be inserted if the depth of the uterus is less than 6 cm.

The physician should use sterile gloves to remove the IUD from the sterile package. The blue flange should be aligned with the IUD arms and set at the distance the uterus was sounded. The white inserter rod should then be placed into the insertion tube at the end opposite the arms of the IUD and approximated against the ball at the base of the IUD.

The physician should then insert the IUD into the uterus until the flange is against the cervical os. The clear inserter tube should be pulled back on the insertion rod approximately 2 cm so that the arms can spread to the “T” position (Figure 4). The tube should be advanced slowly to ensure a correct positioning of the IUD (Figure 5). The physician should remove the insertion rod by holding the insertion tube in place (Figure 6) and then remove the insertion tube and the tenaculum. Finally, the threads emerging from the cervical os should be cut to a length of 3 cm. The length of the threads in the vagina should be noted in the patient’s record for further reference.

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Figure 4

The arms of the copper-releasing intrauterine device are released. Reprinted with permission from FEI Women’s Health.

Figure 4

The arms of the copper-releasing intrauterine device are released. Reprinted with permission from FEI Women’s Health.

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Figure 5

The insertion tube is advanced for placement of the copper-releasing intrauterine device. Reprinted with permission from FEI Women’s Health.

Figure 5

The insertion tube is advanced for placement of the copper-releasing intrauterine device. Reprinted with permission from FEI Women’s Health.

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Figure 6

The insertion rod of the copper-releasing intrauterine device is withdrawn. Reprinted with permission from FEI Women’s Health.

Figure 6

The insertion rod of the copper-releasing intrauterine device is withdrawn. Reprinted with permission from FEI Women’s Health.

HORMONE-RELEASING IUD

As with the copper-releasing IUD, the proper equipment (Table 2) for insertion of the hormone-releasing IUD should be assembled before the procedure. Then, a bimanual examination with nonsterile gloves should be done to determine the position of the uterus. Sterile technique with sterile gloves is necessary during the procedure itself to minimize the risk of contamination or infection. The cervix and adjacent vaginal mucosa should be cleansed liberally with an antiseptic solution. Chlorhexidine gluconate may be used if the patient is allergic to iodine.

The physician should stabilize the cervix during the insertion of the IUD with a tenaculum. Local anesthesia, such as 5 percent lidocaine gel placed in the cervical canal, or a paracervical block may be used to minimize discomfort.

A sterile uterine sound or an endometrial aspirator should be used to determine the depth of the uterine cavity. Contact with the vagina or speculum blades should be avoided. An adequate uterine depth is between 6 and 9 cm and should be documented in the patient’s record. An IUD should not be inserted if the depth of the uterus is less than 6 cm.

The physician should open the sterile IUD package, put on sterile gloves, pick up the inserter containing the IUD, and carefully release the threads from behind the slider, allowing them to hang freely. The slider should be positioned at the top of the handle nearest the IUD. While looking at the insertion tube, the physician should check that the arms of the device are horizontal. If not, they must be aligned using sterile technique (Figure 7). The physician should pull on both threads to draw the IUD into the insertion tube so that the knobs at the end of the arms cover the open end of the inserter (Figure 8). The threads should be fixed tightly in the cleft at the end of the handle (Figure 9), and the flange should be set to the depth measured by the sound (Figure 10).

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Figure 7

The arms of the hormone-releasing intrauterine device are aligned to a horizontal position when removing the device from the package. Reprinted with permission from Berlex, Inc.

Figure 7

The arms of the hormone-releasing intrauterine device are aligned to a horizontal position when removing the device from the package. Reprinted with permission from Berlex, Inc.

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Figure 8

The hormone-releasing intrauterine device is drawn into the insertion tube. Reprinted with permission from Berlex, Inc.

Figure 8

The hormone-releasing intrauterine device is drawn into the insertion tube. Reprinted with permission from Berlex, Inc.

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Figure 9

Threads are fixed tightly in the cleft. Reprinted with permission from Berlex, Inc.

Figure 9

Threads are fixed tightly in the cleft. Reprinted with permission from Berlex, Inc.

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Figure 10

The flange is adjusted to sound depth. Reprinted with permission from Berlex, Inc.

Figure 10

The flange is adjusted to sound depth. Reprinted with permission from Berlex, Inc.

The physician should insert the IUD by holding the slider firmly at the top of the handle and gently placing the inserter into the cervical canal. The insertion tube should be advanced into the uterus until the flange is situated at a distance of about 1.5 to 2 cm from the external cervical os, allowing ample space for the IUD arms to open. While holding the inserter steady, the physician should release the arms of the IUD by pulling the slider back until the top of the slider reaches the raised horizontal line on the handle (Figure 11). The inserter should be pushed gently into the uterine cavity until the flange touches the cervix.

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Figure 11

The slider is pulled back to reach the mark. Reprinted with permission from Berlex, Inc.

Figure 11

The slider is pulled back to reach the mark. Reprinted with permission from Berlex, Inc.

The IUD should now be positioned at the top of the fundus. The physician then releases the IUD by pulling the slider all the way down while holding the inserter firmly in position. The threads will be released automatically (Figure 12). The inserter should be removed from the uterus. Finally, the threads emerging from the cervical os should be cut to a length of 2 to 3 cm. The length of the threads in the vagina should be noted in the patient’s record for further reference.

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Figure 12

The inserter is withdrawn while the intrauterine device is released. Reprinted with permission from Berlex, Inc.

Figure 12

The inserter is withdrawn while the intrauterine device is released. Reprinted with permission from Berlex, Inc.

The manufacturers of both IUDs have created practice kits that can help physicians learn to insert an IUD.

Adverse Effects

Following insertion of either device, a follow-up appointment should be planned after the next menses to address any concerns or adverse effects, ensure the absence of infection, and check the presence of the strings.

The most common adverse effects of IUDs are cramping, abnormal uterine bleeding, and expulsion (Table 3).4,5,7,11,12 Adverse effects related specifically to the hormone-releasing IUD include amenorrhea, acne, depression, weight gain, decreased libido, and headache. First-year failure rates are reported to be between 1 and 2 percent.1

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TABLE 3

Adverse Effects or Complications from IUDs

TABLE 3

Adverse Effects or Complications from IUDs

If the IUD threads are ever not present, a pregnancy test should be performed. When the results are negative, a cytobrush can be inserted gently into the cervical canal to locate the threads. If this method is unsuccessful, radiography or ultrasonography may be used to locate the IUD. Uterine perforation, which is more likely to occur during insertion of the device, ranges from 0.1 to 0.3 percent.11

When the results of the pregnancy test are positive, an ectopic implantation must be ruled out. If the strings are visible and the pregnancy is early, the IUD can be removed but with a risk of pregnancy loss. If the strings are not visible, ultrasonography should be performed to identify the IUD for removal.

Removal

An IUD should be removed at the expiration date, when the patient develops a contraindication, when adverse effects do not resolve, or on patient request. Treatment for cervical dysplasia may be different with the IUD present. Colposcopy may be performed, but the IUD should be removed if an excisional procedure is performed.

The IUD is removed by securely grasping the threads at the external os with ring forceps. Traction should be applied away from the cervix. If resistance is met, the removal should be abandoned until it is determined why the IUD is not moving. A deeply embedded IUD may have to be removed hysteroscopically.

Intrauterine Device (IUD) for Birth Control

Treatment Overview

An IUD is a small, T-shaped plastic device that is wrapped in copper or contains hormones. The IUD is inserted into your uterus by your doctor. A plastic string tied to the end of the IUD hangs down through the cervix into the vagina. You can check that the IUD is in place by feeling for this string. The string is also used by your doctor to remove the IUD.

Types of IUDs

• Hormonal IUD. The hormonal IUD releases levonorgestrel, which is a form of the hormone progestin. The hormonal IUD appears to be slightly more effective at preventing pregnancy than the copper IUD. Hormonal IUDs prevent pregnancy for 3 to 5 years, depending on which IUD is used. The hormones in this IUD also reduce menstrual bleeding and cramping.
• Copper IUD. The most commonly used IUD is the copper IUD. Copper wire is wound around the stem of the T-shaped IUD. The copper IUD can stay in place for up to 10 years and is a highly effective form of contraception.

How it works

Both IUD types may prevent fertilization or implantation.

Insertion

You can have an IUD inserted at any time, as long as you are not pregnant and you don’t have a pelvic infection. An IUD is inserted into your uterus by your doctor. The insertion procedure takes only a few minutes and can be done in a doctor’s office. Sometimes a local anesthetic is injected into the area around the cervix, but this is not always needed.

IUD insertion is easiest in women who have had a vaginal childbirth in the past.

Your doctor may have you feel for the IUD string right after insertion, to be sure you know what it feels like.

What To Expect After Treatment

You may want to have someone drive you home after the insertion procedure. You may experience some mild cramping and light bleeding (spotting) for 1 or 2 days.

Do not have sex, use tampons, or put anything in your vagina for the first 24 hours after you have an IUD inserted.^{footnote 1}

Follow-up

Your doctor may want to see you 4 to 6 weeks after the IUD insertion, to make sure it is in place.

A string tied to the end of the IUD hangs down through the opening of the uterus (called the cervix) into the vagina. You can check that the IUD is in place by feeling for the string. The IUD usually stays in the uterus until your doctor removes it.

If you cannot feel the string, it doesn’t necessarily mean that the IUD has been expelled. Sometimes the string is just difficult to feel or has been pulled up into the cervical canal (which will not harm you). An exam and sometimes an ultrasound will show whether the IUD is still in place. Use another form of birth control until your doctor makes sure that the IUD is still in place.

Why It Is Done

You may be a good candidate for an IUD if you:

• Do not have a pelvic infection at the time of IUD insertion.
• Have only one sex partner who does not have other sex partners and who is infection-free. This means you are not at high risk for sexually transmitted infections (STIs) or pelvic inflammatory disease (PID), or you and your partner are willing to also use condoms.
• Want an effective, long-acting method of birth control that requires little effort and is easily reversible.
• Cannot or do not want to use birth control pills or other hormonal birth control methods.
• Are breastfeeding.

The copper IUD is recommended for emergency contraception if you have had unprotected sex in the past few days and need to avoid pregnancy and you plan to continue using the IUD for birth control. As a short-term type of emergency contraception, the copper IUD is more expensive than emergency contraception with hormone pills.

How Well It Works

The IUD is a highly effective method of birth control.

• When using the hormonal or copper IUD, fewer than 1 woman out of 100 becomes pregnant in the first year.^{footnote 2}
• Most pregnancies that occur with IUD use happen because the IUD is pushed out of (expelled from) the uterus unnoticed. IUDs are most likely to come out in the first few months of IUD use or after being inserted just after childbirth.

Advantages of IUDs include cost-effectiveness over time, ease of use, lower risk of ectopic pregnancy, and no interruption of foreplay or intercourse.^{footnote 3}

Other advantages of the hormonal IUD

Also, the hormonal IUD:

• Reduces heavy menstrual bleeding by an average of 90% after the first few months of use.^{footnote 3}
• Reduces menstrual bleeding and cramps and, in many women, eventually causes menstrual periods to stop altogether. In this case, not menstruating is not harmful.
• May prevent endometrial hyperplasia or endometrial cancer.
• May effectively relieve endometriosis and is less likely to cause side effects than high-dose progestin.^{footnote 4}
• Reduces the risk of ectopic pregnancy.
• Does not cause weight gain.

Risks

Risks of using an intrauterine device (IUD) include:

• Menstrual problems. The copper IUD may increase menstrual bleeding or cramps. Women may also experience spotting between periods. The hormonal IUD may reduce menstrual cramps and bleeding.^{footnote 5}
• Perforation. In 1 out of 1,000 women, the IUD will get stuck in or puncture (perforate) the uterus.^{footnote 5} Although perforation is rare, it almost always occurs during insertion. The IUD should be removed if the uterus has been perforated.
• Expulsion. About 2 to 10 out of 100 IUDs are pushed out (expelled) from the uterus into the vagina during the first year. This usually happens in the first few months of use. Expulsion is more likely when the IUD is inserted right after childbirth.^{footnote 5} When an IUD has been expelled, you are no longer protected against pregnancy.

Disadvantages of IUDs include the high cost of insertion, no protection against STIs, and the need to be removed by a doctor.

Disadvantages of the hormonal IUD

The hormonal IUD may cause noncancerous (benign) growths called ovarian cysts, which usually go away on their own.

The hormonal IUD can cause hormonal side effects similar to those caused by oral contraceptives, such as breast tenderness, mood swings, headaches, and acne. This is rare. When side effects do happen, they usually go away after the first few months.

Pregnancy with an IUD

If you become pregnant with an IUD in place, your doctor will recommend that the IUD be removed. This is because the IUD can cause miscarriage or preterm birth (the IUD will not cause birth defects).

When to call your doctor

When using an IUD, be aware of warning signs of a more serious problem related to the IUD.

Call your doctor now or seek immediate medical care if:

• You have severe pain in your belly or pelvis.
• You have severe vaginal bleeding.
• You are soaking through your usual pads or tampons each hour for 2 or more hours.
• You have vaginal discharge that smells bad. You have a fever and chills.
• You think you might be pregnant.

Watch closely for changes in your health, and be sure to contact your doctor if:

• You cannot find the string of your IUD, or the string is shorter or longer than normal.
• You have any problems with your birth control method.
• You think you may have been exposed to or have a sexually transmitted infection.

What To Think About

Pelvic inflammatory disease (PID) concerns have been linked to the IUD for years. But it is now known that the IUD itself does not cause PID. Instead, if you have a genital infection when an IUD is inserted, the infection can be carried into your uterus and fallopian tubes. If you are at risk for a sexually transmitted infection (STI), your doctor will test you and treat you if necessary, before you get an IUD.

Intrauterine devices reduce the risk of all pregnancies, including ectopic (tubal) pregnancy. But if a pregnancy does occur while an IUD is in place, it is a little more likely that the pregnancy will be ectopic. Ectopic pregnancies require medicine or surgery to remove the pregnancy. Sometimes the fallopian tube on that side must be removed as well.

IUD use and medical conditions

An IUD can be a safe birth control choice for women who:^{footnote 6}

• Have a history of ectopic pregnancy. Both the copper IUD and hormonal IUD are appropriate.
• Have a history of irregular menstrual bleeding and pain. The hormonal IUD may be appropriate for these women and for women who have a bleeding disorder or those who take blood thinners (anticoagulants).
• Have diabetes.
• Are breastfeeding.
• Have a history of endometriosis. The hormonal IUD is a good choice for women who have endometriosis.

References

Citations

1. Dean G, Schwarz EB (2011). Intrauterine contraceptives (IUCs). In RA Hatcher et al., eds., Contraceptive Technology, revised 20th ed., pp. 147–191. New York: Ardent Media.
2. Trussell J, Guthrie KA (2011). Choosing a contraceptive: Efficacy, safety, and personal considerations. In RA Hatcher et al., eds., Contraceptive Technology, 20th ed., pp. 45–74. Atlanta: Ardent Media.
3. Grimes DA (2007). Intrauterine devices (IUDs). In RA Hatcher et al., eds., Contraceptive Technology, 19th ed., pp. 117–143. New York: Ardent Media.
4. Fritz MA, Speroff L (2011). Endometriosis. In Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 1221–1248. Philadelphia: Lippincott Williams and Wilkins.
5. Committee on Practice Bulletins-Gynecology (2017). Long-acting reversible contraception: Implants and intrauterine devices. ACOG Practice Bulletin No. 186. Obstetrics and Gynecology, 130(5): e251–e269. DOI: 10.1097/AOG.0000000000002400. Accessed January 26, 2018.
6. Speroff L, Darney PD (2011). Intrauterine contraception. In A Clinical Guide for Contraception, 5th ed., pp. 239–279. Philadelphia: Lippincott Williams and Wilkins.

Credits

Current as of:
October 8, 2020

Author: Healthwise Staff
Medical Review:
Sarah Marshall MD – Family Medicine
Kathleen Romito MD – Family Medicine
Adam Husney MD – Family Medicine
Elizabeth T. Russo MD – Internal Medicine
Rebecca Sue Uranga

Current as of: October 8, 2020

Author:
Healthwise Staff

Medical Review:Sarah Marshall MD – Family Medicine & Kathleen Romito MD – Family Medicine & Adam Husney MD – Family Medicine & Elizabeth T. Russo MD – Internal Medicine & Rebecca Sue Uranga

Dean G, Schwarz EB (2011). Intrauterine contraceptives (IUCs). In RA Hatcher et al., eds., Contraceptive Technology, revised 20th ed., pp. 147-191. New York: Ardent Media.

Trussell J, Guthrie KA (2011). Choosing a contraceptive: Efficacy, safety, and personal considerations. In RA Hatcher et al., eds., Contraceptive Technology, 20th ed., pp. 45-74. Atlanta: Ardent Media.

Grimes DA (2007). Intrauterine devices (IUDs). In RA Hatcher et al. , eds., Contraceptive Technology, 19th ed., pp. 117-143. New York: Ardent Media.

Fritz MA, Speroff L (2011). Endometriosis. In Clinical Gynecologic Endocrinology and Infertility, 8th ed., pp. 1221-1248. Philadelphia: Lippincott Williams and Wilkins.

Committee on Practice Bulletins-Gynecology (2017). Long-acting reversible contraception: Implants and intrauterine devices. ACOG Practice Bulletin No. 186. Obstetrics and Gynecology, 130(5): e251-e269. DOI: 10.1097/AOG.0000000000002400. Accessed January 26, 2018.

Speroff L, Darney PD (2011). Intrauterine contraception. In A Clinical Guide for Contraception, 5th ed., pp. 239-279. Philadelphia: Lippincott Williams and Wilkins.

Intrauterine device (IUD) – NHS

An IUD is a small T-shaped plastic and copper device that’s put into your womb (uterus) by a doctor or nurse.

It releases copper to stop you getting pregnant, and protects against pregnancy for between 5 and 10 years. It’s sometimes called a “coil” or “copper coil”.

At a glance: facts about the IUD

• When inserted correctly, IUDs are more than 99% effective.
• An IUD works as soon as it’s put in and lasts for 5 to 10 years, depending on the type.
• It can be put in at any time during your menstrual cycle, as long as you’re not pregnant.
• It can be taken out at any time by a specially trained doctor or nurse. It’s then possible to get pregnant straight away.
• Your periods can be heavier, longer or more painful in the first 3 to 6 months after an IUD is put in. You might get spotting or bleeding between periods.
• There’s a small risk of getting an infection after it’s been fitted.
• There’s a small risk that your body may push out the IUD or it may move. Your doctor or nurse will teach you how to check it’s in place.
• It can be uncomfortable when the IUD is put in, but you can take painkillers after, if you need to.
• It may not be suitable if you have had previous pelvic infections.
• It does not protect against sexually transmitted infections (STIs), so you may need to use condoms as well.

How it works

The IUD is similar to the intrauterine system (IUS), but instead of releasing the hormone progestogen like the IUS, the IUD releases copper into the womb.

The copper alters the cervical mucus, which makes it more difficult for sperm to reach an egg and survive. It can also stop a fertilised egg from being able to implant itself.

If you’re 40 or over when you have an IUD fitted, it can be left in until you reach the menopause or you no longer need contraception.

Having an IUD fitted

An IUD can be fitted at any time during your menstrual cycle, as long as you’re not pregnant. You’ll be protected against pregnancy straight away.

Before your IUD is fitted, a GP or nurse will check inside your vagina to check the position and size of your womb. You may be tested for any existing infections, such as STIs, and be given antibiotics.

The appointment takes about 20 to 30 minutes, and fitting the IUD should take no longer than 5 minutes:

Having an IUD fitted can be uncomfortable, and some people might find it painful, but you can have a local anaesthetic to help. Discuss this with a GP or nurse beforehand.

Let the person fitting your IUD know if you feel any pain or discomfort while you are having it fitted. You can ask to stop at any time.

You can also take painkillers after having an IUD fitted if you need to.

You may get period-type cramps afterwards, but painkillers can ease the cramps. You may also bleed for a few days after having an IUD fitted.

Once your IUD has been fitted, you may be advised to get it checked by a GP after 3 to 6 weeks to make sure everything is fine. Tell the GP if you have any problems after this initial check or if you want the IUD removed.

See a GP if you or your partner are at risk of getting an STI, as this can lead to an infection in the pelvis.

You may have an infection if you:

• have pain or tenderness in your lower abdomen
• have a high temperature
• have abnormal or smelly discharge

How to tell if it’s still in place

An IUD has 2 thin threads that hang down a little way from your womb into the top of your vagina.

The GP or nurse that fits your IUD will teach you how to feel for these threads and check that it’s still in place.

Check your IUD is in place a few times in the first month and then after each period, or at regular intervals.

It’s very unlikely that your IUD will come out, but if you cannot feel the threads or think it’s moved, you may not be protected against pregnancy.

See a GP or nurse straight away and use additional contraception, such as condoms, until your IUD has been checked.

If you have had sex recently, you may need to use emergency contraception.

Your partner should not be able to feel your IUD during sex. If they can, see a GP or nurse for a check-up.

Removing an IUD

Your IUD can be removed at any time by a trained doctor or nurse.

If you’re not having another IUD put in and do not want to get pregnant, use additional contraception, such as condoms, for 7 days before you have it removed.

It’s possible to get pregnant as soon as the IUD has been taken out.

Who can use an IUD

Most people with a womb can use an IUD.

A GP or nurse will ask about your medical history to check if an IUD is suitable for you.

The IUD may not be suitable if you:

• think you might be pregnant
• have an untreated STI or a pelvic infection
• have problems with your womb or cervix
• have unexplained bleeding between periods or after sex

People who have had an ectopic pregnancy or who have an artificial heart valve must consult their GP or clinician before having an IUD fitted.

Using an IUD after giving birth

An IUD can usually be fitted 4 weeks after giving birth (vaginal or caesarean). You’ll need to use alternative contraception from 3 weeks (21 days) after the birth until the IUD is put in.

In some cases, an IUD can be fitted within 48 hours of giving birth. It’s safe to use an IUD when you’re breastfeeding, and it will not affect your milk supply.

Using an IUD after a miscarriage or abortion

An IUD can be fitted by an experienced GP or nurse straight after an abortion or miscarriage. You’ll be protected against pregnancy immediately.

Advantages and disadvantages of the IUD

Although an IUD is an effective method of contraception, there are some things to consider before having one fitted.

Advantages:

• It protects against pregnancy for 5 or 10 years, depending on the type.
• Once an IUD is fitted, it works straight away.
• Most people with a womb can use it.
• There are no hormonal side effects, such as acne, headaches or breast tenderness.
• It does not interrupt sex.
• It’s safe to use an IUD if you’re breastfeeding.
• It’s possible to get pregnant as soon as the IUD is removed.
• It’s not affected by other medicines.
• There’s no evidence that an IUD will affect your weight or increase the risk of cervical cancer, womb (uterus) cancer or ovarian cancer.

Disadvantages:

• Your periods may become heavier, longer or more painful, though this may improve after a few months.
• It does not protect against STIs, so you may need to use condoms as well.
• If you get an infection when you have an IUD fitted, it could lead to a pelvic infection if not treated.
• Most people who stop using an IUD do so because of vaginal bleeding and pain, although these side effects are uncommon.

Risks of the IUD

Pelvic infections

There’s a very small chance of getting a pelvic infection in the first 20 days after the IUD has been inserted.

You may be advised to have a check for any existing infections before an IUD is fitted.

See a GP if you’ve had an IUD fitted and you:

• have pain or tenderness in your lower abdomen
• have a high temperature
• have abnormal or smelly discharge

Thrush

There’s some limited evidence that if you have an IUD fitted, you may have a slightly higher chance of getting thrush that keeps coming back.

Speak to a GP if you have an IUD and keep getting thrush. You might want to think about trying a different type of contraception.

Rejection

There’s a small chance that the IUD can be rejected (expelled) by the womb or it can move (displacement).

If this happens, it’s usually soon after it’s been fitted. You’ll be taught how to check that your IUD is in place.

Damage to the womb

In rare cases, an IUD can make a hole in the womb when it’s put in. This may be painful, although sometimes there may be no symptoms.

If the GP or nurse fitting your IUD is experienced, the risk is extremely low. But see a GP straight away if you’re feeling pain or cannot feel the threads of your IUD, as you may need surgery to remove it.

Ectopic pregnancy

If the IUD fails and you become pregnant, there’s also an increased risk of ectopic pregnancy.

Where to get an IUD

You can get the IUD for free, even if you’re under 16, from:

• contraception clinics
• sexual health or genitourinary medicine (GUM) clinics
• GP surgeries
• some young people’s services

Find a sexual health clinic

Getting contraception during coronavirus

If you need contraception, call your GP surgery or a sexual health clinic as soon as possible. Only go in person if asked to.

It might not be possible to have an IUD fitted or replaced at the moment.

IUDs are normally used for 5 or 10 years, but can be left in for longer.

If your IUD is due to be replaced and you do not want to get pregnant, use condoms or the progestogen-only pill for now.

If you’re under 16 years old

Contraception services are free and confidential, including for people under the age of 16.

If you’re under 16 and want contraception, the doctor, nurse or pharmacist will not tell your parents or carer as long as they believe you fully understand the information you’re given and the decisions you’re making.

Doctors and nurses work under strict guidelines when dealing with people under 16. They’ll encourage you to consider telling your parents, but they will not make you.

The only time a professional might want to tell someone else is if they believe you’re at risk of harm, such as abuse.

In these circumstances, the risk would need to be serious, and they’d usually discuss it with you first.

Community content from HealthUnlocked

Page last reviewed: 30 March 2021

Next review due: 30 March 2024

Intrauterine Device – StatPearls – NCBI Bookshelf

Continuing Education Activity

Intrauterine devices (IUDs) are one of the most effective forms of contraception available today with rates of failure similar to various forms of sterilization. There are many benefits of IUDs including efficacy, ease of use, reversible nature, and patient satisfaction, especially with time commitment for long-term use and cost. This activity reviews the indications, contraindications, risks, and benefits of intrauterine device placement and removal. This activity will also detail the role of the interprofessional team in providing patients, who undergo intrauterine device placement and removal, the best possible care.

Objectives:

• Identify the anatomical structures, indications, and contraindications of IUD placement and removal.

• Describe the equipment, personnel, preparation, and technique in regards to IUD placement and removal.

• Outline the appropriate evaluation of the potential complications and clinical significance of IUD placement and removal.

• Explain interprofessional team strategies for improving care coordination and communication regarding IUD placement and removal and to improve outcomes.

Access free multiple choice questions on this topic.

Introduction

Intrauterine devices (IUDs) are one of the most effective forms of contraception available today with rates of failure similar to various forms of sterilization.[1] The two types of IUDs that are presently used in the United States, including the copper-containing IUD and levonorgestrel-containing IUD, have similar rates of preventing pregnancy with failure rates of 0.08% and 0.02%, respectively. This makes these devices more than 99% effective in preventing pregnancy.[2] In the United States, there has been an increased use of long-acting reversible contraception (LARC) since 1995. This use has continued to increase from year to year, with 14% of women who use contraception, choosing to use a form of LARC.[1] There has also been a decrease in the number of unplanned pregnancies with the increased use of LARC.[1] Additionally, there are many benefits of IUDs, including efficacy, ease of use, reversible nature, and patient satisfaction, especially with time commitment for long-term use and cost.[3] 

Anatomy and Physiology

All IUDs currently available in the United States are T-shaped with the top of the T resting across the top of the endometrial cavity. IUDs are between 28 mm to 32 mm wide and 30 mm to 36 mm long. Uterine width traditionally has been assumed to be adequate in all patients; however, recent ultrasound studies have indicated that cavity width in nulliparous women may be narrower than device width.[4] Therefore, it is important to consider the available IUD options available. The smallest IUDs measure 28 mm wide, and 30 mm long and are best suited for nulliparous and young women. When performing IUD insertion and removal, the primary anatomical landmarks that need to be identified are the cervix and uterus. The uterus will be identified by the bimanual exam to assess for size, shape, position, and to identify any anatomical abnormalities.[5] The cervix will be identified during the speculum examination.[5] 

Indications

Based on the fact that there are two different types of IUDs, including levonorgestrel and copper-containing, it should be understood that there are different indications for each of these. All IUDs are indicated for the use of contraception. 

For the levonorgestrel-containing IUD, there are three different strengths of levonorgestrel available, 13.5 mg, 19.5 mg, and 52 mg. They are all equally effective at providing reliable contraception.[6] However, the higher dose IUD, 52 mg device, is also approved for the treatment of menorrhagia and endometrium protection during hormone replacement therapy.[7][8] The 13.5 mg IUD is approved for use for up to 3 years, while the 19.5 mg and 52 mg IUDs are approved for up to 5 years.[6]

The copper IUD is approved for contraceptive use for up to 10 years. However, there is a documented off-label indication to use this as emergency contraception within 5 days of unprotected intercourse. The failure rate after placement for emergency contraception is approximately 0.1%.[9] 

IUDs may be placed immediately post-partum within 10 minutes of delivery of the placenta, delayed post-partum within 4-6 weeks of delivery, and post-abortion, so long as it was not a septic abortion.[10][11]

Additionally, there are also indications for removal of the IUD. The primary indication for removal is the patient’s preference for any reason including, but not limited to, desire for pregnancy, irregular bleeding pattern, heavy vaginal bleeding, and discomfort or pain, which may represent the displacement of the device.[12] Bleeding changes, especially heavier bleeding, were more likely to occur in the copper-containing IUDs rather than the levonorgestrel-IUD prompting patient’s desire for removal.[13] Another indication for removal is an intrauterine pregnancy. However, the device should only be removed if the strings are visible or easily found within the cervical os with no devices entering the uterine cavity.[14] Leaving the IUD in place increases the risk of spontaneous abortion by 40% to 50%. However, there is no risk of teratogenesis with leaving the IUD in place. I such cases, removing the IUD decreases the risk of spontaneous abortion to 20%.[14] For the levonorgestrel-containing IUD, additional indications for removal include the diagnosis of a cervical or uterine malignancy or jaundice.[15] The last indication for removal is if the device has been in for longer than the approved efficacy period. For the 19.5 mg and 52 mg device, the approved duration is 5 years. For the 13.5 mg device, the approved duration is 3 years. For some, the approved duration is 10 years. These approved durations are constantly changing, and it is best practice to refer to the individual product’s package insert for the most up-to-date prescribing information.

Contraindications

Given that there are two classes of IUDs available, there are specific contraindications for each type of IUD. However, there are also universal contraindications that are specific to both types.

Universal contraindications for the use of IUD:[16]

• Pregnancy, or suspected pregnancy 

• Sexually transmitted infection at the time of insertion, including cervicitis, vaginitis, or any other lower genital tract infection 

• A congenital uterine abnormality that distorts the shape of the uterine cavity making insertion difficult

• Acute pelvic inflammatory disease

• History of pelvic inflammatory disease, unless a subsequent successful intrauterine pregnancy has occurred

• History of septic abortion or history of postpartum endometritis within the last 3 months

• Confirmed or suspicion of uterine or cervical malignancy/neoplasia 

• Abnormal uterine bleeding of unknown origin

• Any condition that increases the risk of pelvic infection

• History of previously inserted IUD that has not been removed

• Hypersensitivity to any component of the device 

For the levonorgestrel IUD, additional contraindications include:[16]

• Confirmed or suspicion of breast malignancy or other progestin-sensitive cancer 

• Liver tumors, benign or malignant 

• Acute liver disease 

For the copper IUD, additional contraindications include:[16]

• Wilson disease 

• Sensitivity to copper 

Equipment

Regardless of the type of IUD being used or removed, the equipment remains essentially the same, except for the specific IUD being inserted. The equipment needed to perform IUD placement includes:

• Gloves – two pairs, including a pair of sterile gloves

• Speculum

• An anti-septic solution with applicators

• Sterile uterine sound

• Sterile tenaculum

• An IUD in sterile packaging

• Anesthesia with appropriate materials if planning to perform a paracervical block

• Sterile sharp

• Long-handled scissors

The equipment needed to perform IUD removal includes gloves, speculum, sterile forceps, and a cytobrush.[5]

Personnel

For a successful IUD placement and/or removal, the healthcare professional performing the procedure must be trained for using the specific inserters and comfortable with the various procedures. The manufacturing companies of the various IUDs provide training for providers and have extensive resources available through their respective websites. It would also be beneficial to have at least one other individual present to help with handing the materials needed. There is a risk of displacement and possible uterine perforation if a less experienced provider places the device.[15] 

Preparation

The first step in setting a patient up for success with an IUD is to provide counseling about the various forms of contraception available. Patients should be counseled that all forms of long-acting reversible contraception (LARC), including IUDs and subdermal implants, are the most efficacious in preventing pregnancy, and are similar to the efficacy of tubal ligation and vasectomy.[17] Additionally, there is strong guidance that LARC should be first-line in preventing teenage pregnancy and that IUDs are safe to use in this age group.[18] The Contraceptive CHOICE project has studied the use of LARC and promoted its use by increasing patient’s knowledge and acceptability of this form of contraception and removing financial barriers by providing the devices at no cost.[19] By removing these barriers, researchers found that almost two-thirds of the women screened in this study chose LARC options, including both IUDs and subdermal implants.[19] Therefore, it is recommended that all patients, who do not have any contraindications to using IUDs, should be counseled on the benefits of these devices. Ultimately, it is up to the patient on what form of contraception is most beneficial for them. After a patient decides what device they would like, the office should order the device and ensure insurance coverage and/or prior authorization for the device and placement.

After a patient decides that the IUD is the most appropriate contraception option, there are several different ways to get the patient ready for insertion. Prior to beginning the procedure, it is crucial to confirm a negative pregnancy test. First, there is the quick start method, which allows for same-day counseling and insertion, and improves the rate of patient follow-through and decreases the rate of unintended pregnancies.[20] However, this is not always an option when the provider is unable to confirm a negative pregnancy test because of recent unprotected sex without a current form of birth control. For a pregnancy test to be accurate, one of the following criteria must be met:[21] 

• Less than seven days after the start of regular menses

• No sexual intercourse since the start of last menses 

• Consistently using another form of contraception reliably

• Less than 7 days after spontaneous or induced abortion

• 4 weeks postpartum

• Fully or nearly fully breastfeeding and amenorrheic, and less than six months postpartum 

If these criteria are not met, it is an acceptable practice to bridge the patient with a non-implantable form of contraception, including oral contraceptives, vaginal rings, transdermal patches, condoms, or medroxyprogesterone acetate injections.[19] If the patient still desires LARC insertion after starting one of these bridge methods, a repeat pregnancy test may be conducted in 3-4 weeks, and if negative, the patient may undergo LARC placement.[19] If placing a copper IUD, the prior form of birth control used does not need to be continued, as it will be effective immediately. However, if the levonorgestrel IUD is not placed within 7 days of the start of menses, an additional form of birth control should be used for 7 days.[21]

Additionally, if needed, based on the patient’s sexual history, a screen for sexually transmitted infections should also be done. Women, who have not been screened for sexually transmitted infection, should be screened at the time of insertion if indicated by guidelines; however, this should not delay the insertion of the device.[13] If a patient is found to be positive for an infection after insertion of the IUD, the patient should be treated with antibiotics, and the IUD should remain in place.[13] There is a small risk, approximately 0.1%, of progression to pelvic inflammatory disease if patients have an infection at the time of insertion. However, the device should not be removed.[22] If a patient is noted to have purulent cervical discharge or physical exam consistent with an active infection, the IUD insertion should be postponed, and the patient should be treated.[16] 

Once counseling and negative pregnancy test is confirmed, the next step is to obtain informed consent. Risks, benefits, and side effects of the procedure must be explained to the patient. Risks to the patient include pain at the time of insertion, uterine perforation, which may necessitate surgery or cause unintended pregnancy, infection, bleeding at the site of insertion, possible expulsion, which may go unnoticed leading to unintended pregnancy, and alterations in a patient’s monthly bleeding pattern. Additionally, if pregnancy does occur with IUD in place, there is a higher risk of ectopic pregnancy or septic abortion.[23] When comparing the copper IUD and levonorgestrel IUD, there are key differences in the bleeding pattern changes. The copper IUD will typically cause menses to become heavier and occasionally longer.[14] Conversely, the levonorgestrel IUD leads to lighter menses and often complete cessation of menstrual bleeding because of the inhibitory action of progesterone on the endometrium.[24] This effect can also be seen with the lower dose levonorgestrel IUDs. However, there is a small percentage of patients that develop irregular bleeding and/or spotting with lower progesterone levels.[6][25] 

There is also some discussion and disagreement regarding the using medications prior to the procedure and during the procedure for pain control. Starting with oral pain medications, researchers have looked at various non-steroidal anti-inflammatories, including ibuprofen and naproxen, as well as tramadol, and found some benefit to prescribing naproxen or tramadol prior to insertion.[26] Additionally, the use of misoprostol to help with cervical dilation and insertion has been studied in nulliparous patients, but no benefit was noted with its use. It was considered detrimental because of delaying the IUD insertion.[26] However, if a patient has a history of previous difficult insertion, it may be beneficial to use misoprostol.[26] Nitroprusside was also studied as a possible option to help with pain control, however, no benefit was seen with this intervention.[27] Topical anesthetics in both cream and gel forms show some benefit for pain control with tenaculum placement, however, no benefit with uterine sounding or IUD placement.[28] The use of paracervical blocks has also been studied both for IUD insertion and for other cervical procedures. There is conflicting evidence over the use of these blocks for routine IUD insertion.[27] There is evidence that buffered 1% lidocaine blocks work better than nonbuffered lidocaine for pain during uterine sounding and IUD placement. These blocks are placed at the 4 and 8 o’clock positions in nulliparous patients.[29]

Technique

After deciding that an IUD placement is the best choice for the patient, the following procedure is followed: 

1. Confirm a negative pregnancy test.

2. Obtain informed consent. 

3. Have the patient move into a dorsal lithotomy position.

4. With gloved hands, perform a bimanual exam to determine whether the uterus is anteverted or retroverted.

5. Insert speculum and identify the cervix. 

6. Cleanse cervix and vaginal fornices with a cleansing solution, typically povidone-iodine. If the patient has iodine or shellfish allergy, use chlorhexidine gluconate. 

7. At this time, if desired, consider paracervical block placement or application of the anesthetic gel, as discussed above. 

8. Switch to sterile gloves at this time, and using sterile single-tooth tenaculum grasp the anterior lip of the cervix and apply gentle traction to straighten the cervical canal and uterine cavity. If the uterus is retroverted, it may be beneficial to grasp the posterior lip of the cervix. 

9. Using sterile uterine sound, determine the depth of the uterine cavity, typically between 6cm to 9 cm. If less than 6 cm, IUD should not be placed. If there is difficulty in placing the uterine sound, try cervical dilators. If cervical dilators are needed, it is recommended to use a paracervical block. 

10. Once uterine depth is determined, follow package instructions for the specific IUD being inserted. 

11. Once IUD is inserted, and strings are visible, cut strings to a length of 3 cm to 4 cm with sharp scissors; note this length in the chart. 

12. Remove tenaculum and make sure there is no bleeding from the site of the tenaculum, and remove the speculum. 

13. Have the patient follow up in 4-6 weeks for a string check to ensure proper placement.[5]

After the IUD has been in for the approved amount of time, it is time to remove the IUD. If the patient desires further contraception, it is permissible to remove and insert an IUD on the same day. For IUD removal, the steps are as follows: 

1. Obtain informed consent.

2. Have the patient move into a dorsal lithotomy position.

3. With gloved hands, insert the speculum, identify cervix, and IUD strings. If IUD strings are not immediately identified, twirl cytobrush in os to help identify strings. 

4. Grasp IUD strings with ring forceps. 

5. Place gentle traction on the IUD strings and remove the device from the uterine cavity.

6. Ensure that the IUD is intact, and no portions are missing.[5]

Complications

When counseling patients about the risks associated with the insertion of IUDs, it is important to realize that there are specific factors that contribute to a poor or unexpected outcome. One study looked at predicting complications based on various characteristics of patients and providers.[15] Less experienced health care professionals placing the IUD and women who had never had a vaginal delivery were more likely to have a difficult insertion or inability to insert IUD.[15] Issues with cervical dilatation and bradycardia/vasovagal symptoms were more common in nulliparous women, likely because of cervical manipulation.[15] Additionally, older women also had increased issues with appropriate cervical dilatation.[15] In all of these cases, the ability and experience of the inserting provider to handle the complication at hand was protective.[15] Therefore, as part of the consent process, it would make good sense to counsel patients about their specific risks given their individual history.

There are very few complications associated with the procedure of IUD insertion. The most common complication is displacement or accidental removal of the IUD after insertion, usually occurring within the first three months of insertion.[30] There is also an increased risk of expulsion if placed after vaginal delivery or after an abortion.[10][11] However, there is a benefit to placing IUDs in patients immediately postpartum, in that patients did not always follow up for a postpartum visit and IUD placement, putting them at risk of unwanted pregnancy.[10] 

The most concerning complication for a patient is unintended pregnancy. While becoming pregnant with an IUD is exceedingly rare, this can happen in a small percentage of patients. The percentage of patients to become pregnant with the copper IUD is approximately 6%, and for the 20 mg levonorgestrel IUD, the rate is approximately 0.2%.[17]

Additionally, in a small percentage of patients, there is also a risk of possible uterine perforation when inserting the IUD. There is conflicting data on the rate of this as sometimes the initial perforation is not identified at the time of insertion.[31] It is reported that the levonorgestrel IUD has a slightly higher risk of perforation compared to the copper IUD. However, it should be noted that in this study, they used the larger levonorgestrel device.[31]

With both insertion and removal of IUDs, there is a risk of vasovagal symptoms with associated bradycardia that may occur when engaging with the cervix. These patients should be managed symptomatically. These symptoms are more likely to occur in nulliparous women or women who perceive greater pain at the time of insertion or removal.[32]

Clinical Significance

As noted above, there are two types of IUDs available in the United States, which include copper-containing and levonorgestrel-containing devices. These two types of devices have different methods of action to prevent pregnancy. The copper IUD works by preventing sperm motility and viability within the uterine cavity by causing a localized cytotoxic inflammatory response.[33] Because of this mechanism, copper IUDs are also an extremely effective form of emergency contraception, if placed within 5 days of unprotected intercourse.[33] The levonorgestrel-containing IUDs work by the progesterone acting on the endometrium to suppress growth. The endometrium becomes insensitive to estradiol produced by the ovary.[7] Additionally, the levonorgestrel thickens the consistency of the cervical mucus, which prevents pregnancy by inhibiting the motility of the sperm.[7] Because of the efficacy, reliability, and reversible nature of these devices, these are often an excellent choice for women to prevent pregnancy. The higher dose levonorgestrel-containing IUDs are also useful in the treatment of menorrhagia and endometrium protection during hormone replacement therapy. An additional benefit of IUDs lies in the fact that they may be placed immediately post-partum, within 10 minutes of delivery of the placenta. This improves patient compliance and effectively increases the rate of effective contraception. 

Enhancing Healthcare Team Outcomes

There has been great improvement in increasing access to various forms of LARC in recent years. However, some barriers remain, especially for nulliparous women and adolescents. There are groups of healthcare providers that have not been fully educated on the use of LARC in nulliparous patients, including adolescents. There is evidence to suggest that these methods should be encouraged in these populations because of their reversibility, effectiveness, and patient satisfaction. Additionally, the barriers that remain for adolescents and nulliparous women include unfamiliarity and/or discomfort with the device, initial cost of device and insertion, lack of parental acceptance, and unfamiliarity of the healthcare provider providing the consultation. However, research has shown that when patients are educated at length on the various forms of contraception available with no worry of cost, 67% of women chose a form of LARC with 56% choosing an IUD.[19][Level 3] Therefore, as healthcare providers, it is imperative to stay up-to-date on guidelines for improving access to critical healthcare for patients. For example, there had been studies that showed nulliparous women should not be started on IUDs because of an inherent risk of pelvic inflammatory disorder, leading to future infertility. However, these reports have since been refuted and show that these devices are safe for nulliparous women to use.[34] Various medical societies, including the American College of Obstetrics and Gynecology, Centers for Disease Control, American Academy of Pediatrics, and the Society for Family Planning, support the use of LARC, including IUDs in adolescents.[18] Additionally, there is good data to support the use of IUDs in these patients with no difficulty inserting the device on the first try in comparison to parous women with greater than 96% success.[35][Level 3] Additionally, if there is concern about placing an IUD in a nulliparous woman, the two smaller diameter levonorgestrel IUDs may be beneficial.[18]

Figure

Intrauterine device malposition. Image courtesy S Bhimji MD

Figure

Single sonographic evaluation of the uterus demonstrates a malpositioned intrauterine device. Contributed by Dr.Dawood Tafti, MD.

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Wildemeersch D, Hasskamp T, Nolte K, Jandi S, Pett A, Linden S, van Santen M, Julen O. A multicenter study assessing uterine cavity width in over 400 nulliparous women seeking IUD insertion using 2D and 3D sonography. Eur J Obstet Gynecol Reprod Biol. 2016 Nov;206:232-238. [PubMed: 27768966]

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Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD. Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial. Obstet Gynecol. 2010 Nov;116(5):1079-87. [PMC free article: PMC3104850] [PubMed: 20966692]

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Strasser J, Borkowski L, Couillard M, Allina A, Wood SF. Access to Removal of Long-acting Reversible Contraceptive Methods Is an Essential Component of High-Quality Contraceptive Care. Womens Health Issues. 2017 May – Jun;27(3):253-255. [PubMed: 28476290]

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Kaneshiro B, Aeby T. Long-term safety, efficacy, and patient acceptability of the intrauterine Copper T-380A contraceptive device. Int J Womens Health. 2010 Aug 09;2:211-20. [PMC free article: PMC2971735] [PubMed: 21072313]

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Curtis KM, Tepper NK, Jatlaoui TC, Berry-Bibee E, Horton LG, Zapata LB, Simmons KB, Pagano HP, Jamieson DJ, Whiteman MK. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep. 2016 Jul 29;65(3):1-103. [PubMed: 27467196]

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ACOG Committee Opinion No. 735: Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices. Obstet Gynecol. 2018 May;131(5):e130-e139. [PubMed: 29683910]

19.

Secura GM, Allsworth JE, Madden T, Mullersman JL, Peipert JF. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. Am J Obstet Gynecol. 2010 Aug;203(2):115.e1-7. [PMC free article: PMC2910826] [PubMed: 20541171]

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Reeves MF, Zhao Q, Secura GM, Peipert JF. Risk of unintended pregnancy based on intended compared to actual contraceptive use. Am J Obstet Gynecol. 2016 Jul;215(1):71.e1-6. [PubMed: 26805610]

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Min J, Buckel C, Secura GM, Peipert JF, Madden T. Performance of a checklist to exclude pregnancy at the time of contraceptive initiation among women with a negative urine pregnancy test. Contraception. 2015 Jan;91(1):80-4. [PMC free article: PMC4267981] [PubMed: 25218500]

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Mohllajee AP, Curtis KM, Peterson HB. Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review. Contraception. 2006 Feb;73(2):145-53. [PubMed: 16413845]

23.

Intrauterine devices: an effective alternative to oral hormonal contraception. Prescrire Int. 2009 Jun;18(101):125-30. [PubMed: 19637436]

24.

Gemzell-Danielsson K, Schellschmidt I, Apter D. A randomized, phase II study describing the efficacy, bleeding profile, and safety of two low-dose levonorgestrel-releasing intrauterine contraceptive systems and Mirena. Fertil Steril. 2012 Mar;97(3):616-22.e1-3. [PubMed: 22222193]

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Bahamondes L, Bahamondes MV. Assessment of the use of two new low-dose levonorgestrel-releasing intrauterine systems as contraceptives. Womens Health (Lond). 2012 May;8(3):235-8. [PubMed: 22554171]

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Lopez LM, Bernholc A, Zeng Y, Allen RH, Bartz D, O’Brien PA, Hubacher D. Interventions for pain with intrauterine device insertion. Cochrane Database Syst Rev. 2015 Jul 29;(7):CD007373. [PubMed: 26222246]

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American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice; Long-Acting Reversible Contraceptive Expert Work Group. Committee Opinion No 672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods. Obstet Gynecol. 2016 Sep;128(3):e69-77. [PubMed: 27548557]

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Perez-Lopez FR, Martinez-Dominguez SJ, Perez-Roncero GR, Hernandez AV. Uterine or paracervical lidocaine application for pain control during intrauterine contraceptive device insertion: a meta-analysis of randomised controlled trials. Eur J Contracept Reprod Health Care. 2018 Jun;23(3):207-217. [PubMed: 29792756]

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Levine EM, Fernandez CM. Paracervical Block for Intrauterine Device Placement Among Nulliparous Women: A Randomized Controlled Trial. Obstet Gynecol. 2019 Jan;133(1):189. [PubMed: 30575660]

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Aisien AO. Intrauterine contraceptive device (IUCD): acceptability and effectiveness in a tertiary institution. Afr J Med Med Sci. 2007 Sep;36(3):193-200. [PubMed: 18390056]

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Barnett C, Moehner S, Do Minh T, Heinemann K. Perforation risk and intra-uterine devices: results of the EURAS-IUD 5-year extension study. Eur J Contracept Reprod Health Care. 2017 Dec;22(6):424-428. [PubMed: 29322856]

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Chi IC, Wilkens LR, Siemens AJ, Lippes J. Syncope and other vasovagal reactions at interval insertion of Lippes Loop D–who is most vulnerable? Contraception. 1986 Feb;33(2):179-87. [PubMed: 3516567]

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Bahamondes L, Fernandes A, Monteiro I, Bahamondes MV. Long-acting reversible contraceptive (LARCs) methods. Best Pract Res Clin Obstet Gynaecol. 2020 Jul;66:28-40. [PubMed: 32014434]

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Teal SB, Romer SE, Goldthwaite LM, Peters MG, Kaplan DW, Sheeder J. Insertion characteristics of intrauterine devices in adolescents and young women: success, ancillary measures, and complications. Am J Obstet Gynecol. 2015 Oct;213(4):515.e1-5. [PubMed: 26116873]

Why isn’t this birth control used more?

In fact, for years doctors thought that the pain of inserting an IUD would only be bearable for women who had already given birth, because their birth canals would be slightly stretched. This had an unfortunate effect: for years, many women didn’t hear about this method from their doctors. We now know that it doesn’t make a lot of difference – women who have already given birth tend to rate their pain as a “level four”, as opposed to a “level six”.

Many doctors are now arguing that all women should be given the option of having a local anaesthetic before insertion, in the hope that this will increase the number of women getting IUDs. Regardless, the popularity of these ingenious, sperm-slaying devices has been increasing steadily since the 2000s. “There’s a big push to recommend IUDs as a first-line option,” says Dweck. Though they’re expensive to buy and insert, over, say, a 10-year lifespan, they can be more cost effective than birth control pills – and health providers have caught on.

Who knows – maybe articles about how they exist will soon be redundant.

—

This story is part of the Health Gap, a special series about how men and women experience the medical system – and their own health – in starkly different ways.

Do you have an experience to share? Or are you just interested in sharing information about women’s health and wellbeing? Join our Facebook group Future Woman and be a part of the conversation about the day-to-day issues that affect women’s lives. 

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Long-Acting Reversible Contraception (LARC): Intrauterine Device (IUD) and Implant

Anesthetic: A drug used to relieve pain.

Birth Control Implant: A small, single rod that is inserted under the skin in the upper arm. The implant releases a hormone to prevent pregnancy.

Cervix: The lower, narrow end of uterus at the top of the vagina.

Ectopic Pregnancy: A pregnancy in a place other than the uterus, usually in one of the fallopian tubes.

Egg: The female reproductive cell made in and released from the ovaries. Also called the ovum.

Emergency Contraception (EC): Methods that are used to prevent pregnancy after a woman has had sex without birth control, after the method has failed, or after a rape.

Fertilization: A multistep process that joins the egg and sperm.

Human Immunodeficiency Virus (HIV): A virus that attacks certain cells of the body’s immune system. If left untreated, HIV can cause acquired immunodeficiency syndrome (AIDS).

Intrauterine Device (IUD): A small device that is inserted and left inside the uterus to prevent pregnancy.

Menstrual Cycle: The monthly process of changes that occur to prepare a woman’s body for possible pregnancy. A menstrual cycle is defined as the first day of menstrual bleeding of one cycle to the first day of menstrual bleeding of the next cycle.

Miscarriage: Loss of a pregnancy that is in the uterus.

Obstetrician–Gynecologist (Ob-Gyn): A doctor with special training and education in women’s health.

Ovulation: The time when an ovary releases an egg.

Pelvic Exam: A physical examination of a woman’s pelvic organs.

Pelvic Inflammatory Disease (PID): An infection of the upper female genital tract.

Progestin: A synthetic form of progesterone that is similar to the hormone produced naturally by the body.

Sexually Transmitted Infections (STIs): Infections that are spread by sexual contact. Infections include chlamydia, gonorrhea, human papillomavirus (HPV), herpes, syphilis, and human immunodeficiency virus (HIV, the cause of acquired immunodeficiency syndrome [AIDS]).

Sperm: A cell produced in the male testicles that can fertilize a female egg.

Uterus: A muscular organ in the female pelvis. During pregnancy, this organ holds and nourishes the fetus. Also called the womb.

Vagina: A tube-like structure surrounded by muscles. The vagina leads from the uterus to the outside of the body.

IUDs: Everything You Need To Know

One of the major issues that a woman in today’s generation faces is birth control. Many females feel skeptic of dealing with this issue without the help of pills, oblivious of the fact that taking pills might actually disrupt their health. One of the simplest and safest methods for birth control is IUD, or intrauterine device, which may also be known as an intrauterine contraceptive device (IUCD or ICD) or coil. 

An IUD is small, which mostly takes the look of the shape of “T.” The device is inserted into the uterus to prevent pregnancy by stopping sperm from actually reaching the eggs and fertilizing them. 

Effective equally among adolescents as adult women, who have not had children yet, IUD is a long-acting reversible birth control (LARC). LARC methods are proven to result in greater satisfaction among women. Thereby, these methods are preferred by family planning providers than the other general female users. The best part of using IUDs is that it is safe. And once it is removed, fertility rate returns to normal speedily among users, even if it was used for an extended period.

Differing according to location, IUDs can be found carrying a variety of names. In the United States, though, two types of IUDs are commonly available:

Usually consisting of brands such as Skyla, Mirena, Liletta, and Kyleena, these types of IUDs are Progestogen-releasing ones. They work by releasing small amounts of levonorgestrel, which is the same hormone that is used in a couple of contraceptive pills. 

The mechanism of the device is such that it makes the uterus not fit to live in for the sperm. This type of IUD has a lesser failure rate than the non-hormonal ones, as proved by reports. 

The Non-hormonal IUDs are the ones that contain Copper in their device. It goes by the brand Paragard. Framed in the shape of “T,” the device has copper collars or sleeves in it or/and is encompassed with pure electrolytic copper wire. The wire helps in distorting the sperm so that its motility is destroyed, which prevents them from fertilizing the eggs. 

The arms assists in keeping IUD intact inside the upper part of the uterus. These types of IUDs are beneficial and also highly active during emergencies since they provide emergency contraception after up to around five days of having unprotected sex. Learn more about emergency contraception through these FAQs.

Available in a variety of sizes and shapes, these IUDs last much longer than the hormonal ones. Since the device contains no hormones, it can be used appropriately after pregnancy, when breastfeeding has to be done. 

Fertility rate jumps back to normal after one removes this device. However, it cannot be used to disrupt already implanted embryos since the working involves preventing fertilization in the first stage itself. In spite of all these advantages, a few side effects may be faced by users such as heavy menstrual periods and painful cramps. Find out some more similarities and differences between different types of IUD before finalizing the right choice for yourself. 

It is recommended to almost all healthy women to use IUDs. However, one should avoid using IUDs if there is a high probability of catching an STD through a variety of partners. IUDs do not help in protecting a person from catching STD. Sizes and shapes of IUDs may also pose a problem for various numbers of women. However, women having the following concerns are not advised to use IUDs:

• Pregnancy.
• STD or recent pelvic infection.
• Cervical or Uterus cancer
• Vaginal bleeding. 

Nonetheless, certain precautions also need to be kept in mind before choosing the type of IUD you wish to use. For example, you cannot opt to use the Copper IUD if you are allergic to Copper. Also, for that matter, you have Wilson’s disease because you cannot afford to have any more amount of Copper in your body. If you are suffering from liver disease or have the risk of having breast cancer or already have it, then it is advised not to use the hormonal IUD. Discuss your requirements with IUD specialist and see what suits your body.

Taking the shape of “T”, an intrauterine device (IUD) is a small plastic device which is positioned in the top part of the uterus to prevent fertilization of the egg by sperm. 

The T-shaped device has a plastic ring attached to it at the end of the device. The ring helps later when the device is to be removed and also, it ensures that it is correctly placed. Since the string helps in the easy removal of the IUD, it makes the device an uncomplicated reversible form of contraception. One should always take the aid of a medical practitioner to remove an IUD. 

The working mechanism of the hormonal and non-hormonal device differs; nonetheless, the precise working mechanism of the contraceptive functioning of IUDs is yet not known. 

It is recommended that you take a pre-insertion appointment from the doctor or clinicians to discuss the procedure and how to prepare yourself. Depending on the medical history, the doctor may conduct STI tests to rule out the possible risk of pregnancy or STIs. Clinicians, in general, prefer the IUD insertion while the clients are on period, for the safest reason that your cervix is the softest during your menstrual cycle. 

Once your doctor has all your medical information and determines the safety of the IUD device for you, your doctor will insert the device into your uterus on a decided date. You may be suggested to take certain medications to prevent cramps before the procedure begins, for example, ibuprofen. The reason being, the IUD insertion can be uncomfortable and painful, even though the procedure is nearly 5-20 minutes long. The insertion procedure is as simple as a mere small uncomplicated surgery. 

• Firstly, a small Pap smear test is taken. Then, shifting to the insertion procedure, your feet will be put up in stirrups for better access. 
• A speculum will be placed in the vagina to hold it open for the doctor to insert the IUD in your vagina in a small tube. The tube will be moved up through the cervix and finally, placed into your uterus. 
• After the device is placed correctly, the doctor will try and push the IUD further into the uterus. Then they pull the tube out of the vagina. The attached strings from the device will hang into the vagina up to 1 to 2 inches.

The procedure might call in for cramps during, and even after the procedure takes place, and it may also be uncomfortable for you. You might have a small amount of bleeding too. However, they usually go away within a few days after the procedure. You might also feel a bit lightheaded after the insertion. 

You can have your IUD placed any time; however, it is suggested to have it placed while you are in your period. Because your cervix remains the softest and most open. Also, it is during this time that it is least likely for you to get pregnant. 

After the IUD is properly inserted inside your uterus, you can go about your normal life without any hesitation. All types of physical activities can be hopped into right after you get comfortable such as swimming, cycling, etc. The position of the device does not change, nor does any physical harm occur due to any physical activity. Tampons and menstrual cups can also be used after the IUD is placed.

Note: If you are someone who cannot handle pain very well, it is fair not to get an IUD. One can opt for other birth control methods. However, hearing about pain can make things look scarier than it actually is. Therefore, it is important that you also look for the experience of the people who did not undergo much pain (or discomfort was not much of a deal).

The lasting of an IUD depends on the kind of device you are using. For example, the device from the brand Skyla lasts for up to 3 years. IUDs from Kyleena, Mirena and Liletta last up to 5 years, and ParaGard lasts the longest up to 10 years.

For over many years, IUDs are known for being the best birth control options, which is readily available for females. This also means the chance of getting pregnant is 1 in 100 people. With IUD, there is no room for mistakes like using it incorrectly or birth control pills. 

You are protected 24/7, and for 4-10 years depending on the type of IUD you choose to get. All you need is to keep track of the insertion and removal period of your IUD. 

•  When used as birth control

Since it is a reversible contraception as well as one of the best methods of birth control, most women prefer to use IUDs. There is a chance of the IUD being effective for more than 99%. With a failure rate of less than 0.8%, IUDs tend to be more effective than other birth control methods. The reason is that there is no possibility of making a mistake in using it. 

For example, you might forget to take your contraceptive pill or use a condom in the wrong manner, etc. Once you place the IUD into the uterus, you will remain tension and hassle-free up to 3 to 10 years, depending on the type of device you are using. 

You will be protected from getting pregnant all 24 hours of the day. It is so effective that you can even forget about the device unless you keep track of the date of insertion and removal. 

• When used as contraception

The hormonal type of device cannot be used as emergency contraception. However, the copper IUD can work as an emergency contraception in the most effective manner. Within five days of having unprotected sex, you can get the device placed into your uterus if you want to prevent getting pregnant up to 12 years. This has a 99.99% effective rate of preventing you from getting pregnant.

• Effectiveness – The rate of effectiveness (99%) of IUDs is much higher than the other non-permanent forms of birth control. The failure rate ranges from 0.2% to 0.8%. Thus, IUDs work as both, sterilization as well as birth control implant. 
• Convenient – IUDs are such that they need no care, unlike other methods. There is no need to keep track of the pills you take or worry about putting the condom right. You can simply put the device and forget about it.
• Reversible – These are reversible contraceptive devices so that as soon as you decide to get pregnant, you can get it removed. The device does not affect your fertility by any chance. As soon as you get your IUD removed you can get pregnant.
• Healthier menstrual cycles – The hormonal devices help in putting your period cramps and flow in check. The women who suffer from heavy periods can get some relief after using IUDs. It also helps with pregnancy-related issues.
• Emergency contraception – The ParaGard device is one of the most effective methods of preventing pregnancy if it used within five days of having unprotected sex. This option can be opted for if you want to get birth control for 12 years after that.
• Long-term – The durability of the IUDs ranges from 3 to 12 years, depending on the type of device used.
• Affordability – Since the insertion of the IUD is a one-time job, women do not need frequent visits to the doctor or medications. Therefore, this method is quite affordable, especially if you have health insurance to cover it.
• Flexibility – The insertion requires no specific time of the month. It can be used at any time as long as there is no possibility of you getting pregnant. 

• You will have satisfaction with the effective rate. They are relatively available at an affordable rate.
• Hassle-free since you do not have to remember taking pills or such issues.
• Starts being effective right from the moment of insertion and stops as soon as it is removed.
• Since a copper IUD does not contain any hormones, it does not affect the health of the woman using it. She can normally breastfeed her child after the removal.
• The person using it cannot feel the device, nor can her partner feel it during the sex.
• These devices are reversible so much so that one can get pregnant as soon as the device is removed.
• These devices also last for a long time, ranging from 3 to 12 years. It also depends on the type of device you are using.

• Certain complications might arise during the insertion of the device into your uterus, such as the device might puncture the wall of the uterus, although this happens very rarely.
• Almost 5% of the women have reported falling out of the device during the first year of the insertion. This happens mainly when a woman is on her period or has already had childbirth.
• Cramps, backache, and bleeding are some of the side effects that might occur for some time after the insertion.
• IUDs do not protect women from catching STDs. In fact, a woman may be more prone to catching an STD if she is not in a monogamous relationship during the first four months of the insertion.
• IUDs can also lead to Pelvic inflammatory disease, although the hormonal devices tend to protect against such diseases.

• Can the IUD fall out on its own?

There is the slightest chance of the IUD coming out of the uterus during the first year of the insertion. It can happen especially during your periods or if you have had childbirth previously.

• Will my partner or I feel it during sex?

No, neither your partner nor you will feel the device during the intercourse or even in your normal day-to-day life.

• Does the IUD make the woman infertile?

No, using an IUD does not make a woman infertile by any chance. It simply works by disrupting the sperms from getting fertilized.

• Is it safe to use tampons during my period if I have an IUD fitted?

Yes, it is absolutely safe to use tampons. The women should make sure that they change the tampons carefully so that they do not end up putting the threads of IUDs while removing it. 

• Will I bleed after having an IUD fitted?

There might be the possibility of bleeding after the IUD is fitted for a few weeks. However, once the IUD settles properly, the bleeding will stop.

• Do all the IUDs protect against the Sexually Transmitted Disease?

IUDs do not protect against Sexually Transmitted Diseases. Using a condom is still considered to be the safest option. That is because it helps lower your chance of getting as well as spreading STDs. Hence, using condoms alone with IUD is the best way to control unwanted pregnancy as well as STD.

Women all across the United States, as well as the United Kingdom use IUDs as one of the safest and reliable sources of birth control. Women find the device safe and hassle-free.  Since the efficiency rate is so high, the risk of getting pregnant also gets dissolved. 

IUDs have become one of the beloved forms of birth control. The chances are that you are already aware of the benefits. Such as 99% effectiveness, convenience, ease of use, safe and long-acting of this device. 

Health experts and IUD users swear by the device and the long term benefits. However, at the same time, it is also understandable if women are confused and afraid of insertion, pain and other after-effects. But, ultimately, you will need to make a choice that works perfectly for you. 

An IUD is just the right choice for you someone who cannot remember to take birth control pills on a daily basis. Also, if they wants a steady birth control method. It is ok to be a little nervous about a foreign object inside your uterus, but if you get highly anxious about this idea, then IUD may not be for you. Think and discuss your choices with your gynaecologist. 

https://www.emedicinehealth.com/birth_control_intrauterine_devices_iuds/article_em.htm

https://www.plannedparenthood.org/learn/birth-control/iud/how-effective-are-iuds

https://www.medicalnewstoday.com/articles/323230.php

https://www.webmd.com/sex/birth-control/iud-intrauterine-device#1

ID-card and how it can be used

ID-card is a compulsory document, proving the identity of Estonian citizens and citizens of the European Union permanently residing in Estonia. The ID-card is issued by the Police and Border Guard Board for a period of 5 years.

For what purposes can the ID-card be used?

ID-card is the most versatile digital document that allows you to perform many tasks.For example, the ID-card is …

An identity document of an individual.

The

ID-card is the only digital document that is also valid as document for travel within the European Union and European Economic Area , and there is no need to have a passport with you.

Digital ID.

With an ID card, you can access electronic services such as online banking.

Digital means for affixing the signature.

Thanks to electronic identification or authentication, in addition to access to services, the ID-card is used by to digitally sign : you can sign contracts, confirm transactions, order services, etc. Digital signature made with an ID-card is legally is equivalent to a regular signature. You can also encrypt electronic documents.

Customer card.

Many companies use an ID-card as a client card: this is very convenient, since the client does not need to fill his wallet with many different plastic cards, and most people always carry an ID-card with them just in case.

E-voting.

In order to take part in Estonian politics, you do not need to come to the polling station: you can vote in elections anywhere: for example, in a lingonberry forest or from some distant corner of the planet.

Provide email address @ eesti.ee

Each ID-card holder has an e-mail address @ eesti.ee provided by the Republic of Estonia, to which the state will send official documents in case the user cannot be contacted through other channels. You can set up the forwarding of letters from your Eesti.ee e-mail address to your main mailbox via the Eesti.ee portal or using DigiDoc4!

Good recommendation:

If you plan to use your ID-card on a daily basis, we recommend that you additionally order a digital ID for yourself.This way, you can put your ID card in a safe place without worrying about accidentally losing it or damaging the chip due to constant use. Digi-ID allows you to use the same electronic services as with your ID-card, but is not suitable as an identity document.

Keywords

ID card

travel document

possibilities of using

customer card

ID-card

90,000 Identity Token and Access Token: What’s the Difference?

“Let’s use a token to secure the API call.Should I use an ID token or an Access token? ID token seems preferable to me. After all, if I know who the user is, I can make more informed authorization decisions, right? ”

Have you ever made such an argument? Choices based on intuition can be good, but what seems intuitive is not always right. In the case of ID and Access tokens, which have clear and well-defined purposes, they should be used based on these considerations.Using the wrong token can lead to your decision being insecure.

“What will eventually change? These are just tokens. I can use them as I see fit. What’s so bad that can happen? ”

Let’s take a closer look at these two types of tokens to better understand their role in authentication and authorization processes.

What is an Identity Token?

ID token is an artifact that confirms that the user is authenticated.It was introduced by OpenID Connect (OIDC), an open authentication standard used by many identity systems such as Google, Facebook and of course Auth0. Check out this document for more information on OpenID Connect. Let’s take a quick look at the problem that OIDC aims to solve.

Consider the following diagram:

Here, a user with their browser authenticates through an OpenID provider and gains access to the web application.The result of the OpenID Connect based authentication process is an ID token that is passed to the application as proof that the user is authenticated.

User Authentication Proof is just a basic understanding of token ID. Let’s take a closer look at this.

Identity Token JSON Web Token (JWT) is a standard format that allows your application to easily inspect its content and make sure it comes from the expected issuer and that no one else has changed it.If you want to know more about JWT, check out The JWT Handbook.

Simply put, an example token ID looks like this:

eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpc3MiOiJodHRwOi8vbXktZG9tYWluLmF1dGgwLmNvbSIsInN1YiI6
ImF1dGgwfDEyMzQ1NiIsImF1ZCI6IjEyMzRhYmNkZWYiLCJleHAiOjEzMTEyODE5NzAsImlhdCI6MTMxMTI4MDk3MCwibm
FtZSI6IkphbmUgRG 9lIiwiZ2l2ZW5fbmFtZSI6IkphbmUiLCJmYW1pbHlfbmFtZSI6IkRvZSJ9

Of course, this is not readable by eye, so you need to decipher it to see what content the JWT contains.By the way, the ID token is not encrypted, but encoded only in Base 64. You can use one of the many available libraries to decode it, or check it yourself using the jwt.io website.

Without going into details, the relevant information contained in the above token ID is as follows:

{

“iss”: “http://my-domain.auth0.com”,

“sub”: “auth0 | 123456”,

“aud”: “1234abcdef”,

“exp”: 1311281970,

“iat”: 1311280970,

“name”: “Jane Doe”,

“given_name”: “Jane”,

“family_name”: “Doe”

}

These JSON properties are called “claims” , and they represent claims about user and the token itself.User claims make it possible to identify their identity.

In fact, the OpenID Connect specifications do not require the ID token to contain claim for user . In its minimal structure, it contains data only for authentication.

One of the important requirements is the “aud” application. It defines recipient , that is, the web application should be the ultimate recipient of the token. In the case of using a token ID, the value “aud” will be the Client ID of the application that should use the token.

Remember this little clarification about the target information system limitation, as it will help you better understand how to use it correctly in the future.

The identification token may contain additional information about the user: his email address, photo, birthday, etc.

Finally, and perhaps most importantly, the ID token is signed by the issuer with its private key. For you, this is a guarantee of the origin of the token and that it has not been tampered with.This can be verified using the issuer’s public key.

Great! Now you know what an identity token is. But what can you do with it?

First, it demonstrates that the user has been authenticated by an organization you trust (the OpenID provider) and therefore you can trust his personal information .

In addition, your application can personalize user interactions using the user data included in the ID token.For example, you can show the name in the user interface, or display a “Best wishes” message on your birthday. The best part is that you don’t need to make additional requests, so you can slightly improve the performance of your application.

What is an access token?

Now that you know what an identity token is, let’s try to understand what an Access token is.

Let’s start by describing the scenario that the access token fits into:

In the diagram above , client application wants to access resource , such as an API or anything else that is protected from unauthorized access.The other two items in this diagram are the user who owns the resource and the authorization server . In this scenario, the Access token is an artifact that allows the client application to access the resource of user . It is issued by the authorization server after successfully authenticating the user and obtaining his consent.

In the context of OAuth 2 Access, token allows a client application to access a specific resource to perform specific actions on behalf of user .What is known as Delegated Authorization Scenario : The user delegates to the client application access to a resource on his behalf. This means, for example, that you can, on your behalf, allow the LinkedIn app to access the Twitter cross-posting API on both social platforms. Please note that you only allow LinkedIn to post to Twitter. You do not authorize him to delete them, change your profile information, or do anything else. This limitation is very important in a delegated authorization scenario and is achieved using scopes, or scopes. Scopes are a mechanism that allows a user to authorize a third party application to perform only certain operations.

Of course, an API that receives an Access token must obtain confirmation that it is indeed a valid token issued by an authorization server that it trusts, and make authorization decisions based on the information associated with it. In other words, the API must somehow use this token to authorize the client application to perform the desired operation on the resource.

How the Access token should be used to make authorization decisions depends on many factors: the overall system architecture, the format of the token, etc. For example, an access token can be a key that allows an API to retrieve necessary information from a database shared with a server authorization, or can directly contain the required information in an encoded format. This means that the understanding of how to obtain the necessary information to make authorization decisions is an agreement between the authorization server and the resource server, that is, the API.

The OAuth 2 specification says nothing about the format of the Access token. It can be lines in any format. A common format used for access tokens is JWT, and this standard is currently under development. However, this does not mean that Access tokens must be in this format.

Good! Now you know what an ID token and an Access token are. So, you are ready to use them without fear of making mistakes. But wait. I think you are not sure.Perhaps you need other information. Ok. So let’s see what these tokens are not for.

What is the ID-token NOT suitable for?

One of the most common mistakes developers make when using an identity token is using it to make an API call.

As stated above, the ID token proves that the user is authenticated. In your own scenario, that is, in a scenario where the client and API are controlled by you, you might decide that your identity token is appropriate for making authorization decisions and perhaps all you need to know is the identity of the user.

However, even in this scenario, the security of your client / API application could be compromised. In fact, there is no mechanism that binds the ID token to the client API channel . If an attacker succeeds in stealing your “identity”, he can use it to call your API as a legitimate client.

On the other hand, for the Acces token, there is a set of methods known as sender constraint ( sender constraint ) that allows you to bind an access token to a specific sender.This is a guarantee that even if an attacker steals the Access token, they cannot use it to access your API, since the token is tied to the client that originally requested it.

In a delegated authorization scenario, when a third party client wants to call your API, you cannot use the ID token to call API . In addition to the lack of client binding mechanisms, there are several other reasons why this should not be done.

If your API accepts a token ID as an authorization token, you initially ignore the intended recipient specified in aud (audience claim).This statement says that it is intended for your client application, not a resource server (i.e., an API).

One might think that this is just a formality, but this approach may entail security risks.

First of all, among other checks, your API should not accept a token that is not intended for it. If this happens, his safety will be at risk. In fact, if your API doesn’t care if a token is for it, an ID token stolen from any client application can be used to access it, can be used to access your API.Of course, to prevent unauthorized access, the aud check is just one of the checks your API must perform.

Also, your ID won’t be given scopes (yes, that’s another pain). As stated earlier, scopes allow the user to restrict the operations that your client application can perform on their behalf. These scopes are associated with the Access token so that your API knows what the client application can and cannot do.If your client application uses an ID token to call an API, you ignore this function and potentially allow the application to perform actions not authorized by the user.

What is the Access token NOT suitable for?

The Access token was designed to demonstrate that you are authorized to access a resource, for example, to call an API.

Your client application should only use it for this purpose. In other words, the Access token should not be validated by the client application.It is for a resource server, and the client application must treat Access tokens as opaque strings, that is, strings without a specific value. Even if you know the format of the Access token, you should not try to interpret its contents in the client application. As stated, the Access token format is an agreement between the authorization server and the resource server, and the client application should not interfere. Consider what might happen if one day the format of the Access token changes.If your client code checked this Access token, then it will be broken immediately.

At-a-glance

Confusion between ID and Access tokens is very common and it may be difficult to understand the differences between the two. Maybe this is mainly due to the lack of a clear understanding of the various purposes of each artifact as defined in the OAuth and OpenID Connect specifications. In addition, understanding the scenarios in which these artifacts were originally intended to operate plays an important role in preventing confusion when using them.However, I hope this topic has cleared up a bit now.

The illustration summarizes what can and cannot be done with ID and Access tokens:

Translated from the article, the full text is available here.

overview of the standard, explaining in detail how to choose a smart card?

Mifare is a trademark of the most common contactless smart card technology in Russia owned by the Netherlands company NXP Semiconductors, NXP Semiconductors is owned by Philips Austria GmbH.The official website of the brand is www.mifare.net

In general, the technologies used in modern smart cards are not limited to Mifare cards, so if you want to expand the space for choosing our smart cards, welkome is written for this in our detailed guide to choosing smart cards.

Contents of article

Chip manufacturers

Original Mifare chips

Except
NXP Semiconductors Mifare smart card chips, licensed by a German company
Infineon.Only smart cards with chips from NXP Semiconductors and Infineon may carry the Mifare trademark in their name. Only cards with these chips can be called “original”.

Non-original chips

There are several large chip manufacturers, cards with which some Russian resellers call “compatible Mifare” or “non-original Mifare”

Here are some of the biggest
Fudan micro,
Shanghai Belling,
Shanghai Huahong.These manufacturers produce the chips based on the international standard.
ISO 14443 Type A, because are not allowed to use the Mifare trademark. Naturally, non-original chips are cheaper than original ones, but in the pursuit of price, as a rule, quality suffers.

The fact is that the ISO 14443 standard does not describe any specific materials that should be used, nor the equipment on which the chips should be manufactured, and this is what manufacturers of non-original Mifare usually save on.

Uniqueness of serial number

The serial number of the Mifare Classic 1K smart card is 4 bytes, which means there is a finite number of cards with a unique serial number, NXP Semiconductors strictly controls the release of chips only with a unique number, i.e. all cards with an original chip have a unique non-repeating number.

The uniqueness of the serial number is, by the way, one of the reasons why NXP stopped production of chips for Mifare Classic smart cards, they were replaced by already produced and fully compatible Mifare Plus

Naturally, the manufacturers of non-original Mifare do not track the uniqueness of the numbers of the produced chips and until now have been successfully releasing Mifare Classic.Which can lead to both trivial confusion and errors in the software and jeopardize security.

A banal conclusion: original chips are always better than non-original ones.

Manufacturers of contactless cards Mifare

If you can count chip manufacturers on one hand, then the number of card manufacturers cannot be counted, neither in Russia, let alone in China.

I will give only a couple of the largest in China:
Tatwah Smartech, a Russian company
Angstrem and
Mikron (produces identifiers for the Moscow metro).

As you understand, any of the manufacturers can use both original chips and non-original ones, as the manufacturer usually produces cards with an original chip and a non-original one.

The production quality of the card itself can both neutralize all the advantages of the original chips and raise the quality of cards with a non-original chip to an acceptable level.

Unfortunately, the quality of the card production can be determined only by looking inside, which is extremely difficult to do, since.Because the cards are made of dense plastic and it is almost impossible to get to the chip and the antenna without special equipment.

You can give only one recommendation, buy cards from trusted suppliers, and if you don’t have any, then take them for a sample in small batches and be sure to conclude an agreement.

Types of cards with the original chip Mifare

MIFARE Ultralight>
The simplest cards of the Mifare brand are produced both without cryptographic protection and with cryptographic protection
3DES – MIFARE Ultralight C

MIFARE Classic>
One of the most common smart card families in the world, Mifare Classic is a rather old technology.It uses an encryption algorithm
Crypto 1, which does not meet modern standards and can be said to be hacked. Currently, the production of this family by NXP has been discontinued both due to the fact that serial numbers are running out and because of security problems, which they declare on their official website and recommend switching to MIFARE Plus and MIFARE DESFire. Currently in production MIFARE Classic is available in EV1 1K and 4K modifications

MIFARE Plus>
This family is a development of the classic family, MIFARE Plus are fully compatible and devoid of the disadvantages inherent in MIFARE Classic.Mifare Plus supports modern algorithms, including the
AES that shouldn’t be cracked. In this case, we are only talking about the support of these capabilities by the identifier itself.

MIFARE DESFire>
The most reliable smart cards from the MIFER brand, but also the most expensive ones, they are used in the most secure access control systems for the European Commission (the executive authority of the European Union) and National Aeronautics and Space Administration.

MIFARE on SmartMX>
have a mode of emulation of cards of previous formats, at the moment they have not received proper commercial distribution in Russia, they can be purchased only to order.

Types of cards with a non-original chip Mifare

Actually in Russia you can buy two modifications of a non-original Mifer this is an analogue of MIFARE Ultralight> , an analogue of MIFARE Classic 1K> , analog
MIFARE Classic 4K> .

How to distinguish an original Mifare card with an NXP chip from a non-original

Much easier than it seems at first glance, all you consume is a smartphone with an NFC module, then you need to install the NFC TagInfo application on your smartphone for
Android or for
iOS.

On the screen in the “IC MANUFACTURER” section, the manufacturer of the chip is indicated, in the first case it is “UNKNOWN MANUFACTURER” i.e. unknown manufacturer, not NXP, in the second case it is “NXP Semiconductors” i.e.That is, there is nowhere more original.

The same application can be used to distinguish a thin EM-Marine card from a Mifare card; in the case of EM-Marine, the IC MANUFACTURER section will not be filled at all. it just won’t read. Exactly as a card of any format other than Mifare cannot be read.

Using Mifare in ACS

Mifare, the second most popular type of ACS identifiers in Russia after EM Marine, costs a little more than, but unlike EM Marine, it has copy protection.

The technology is based on the popular ISO 14443 contactless card standard, which in particular allows Mifare cards to be combined with anything else. For example, the Mifare ID is embedded in a bank card, or in some rare cases, an NFC phone can be used as a Mifare ID.

It should be noted that Mifare is a fairly large line of products that are focused not only on the use in access control systems. For the purposes of access control in Russia, as a rule, two versions are used – these are Mifare Classic and Mifare Plus.These options are most used in access control systems in Russia.

The Mifare identifier contains an identification number – the so-called UID number and rewritable memory, it is not read-protected and not secret and is sometimes even written on the outside on the card

But memory access is protected. Reading and writing is possible only if the access keys are known, and the data transferred between the card and the reader is protected.

A reader like Mifare can read UID or read data from memory.Most cheap readers can only read the UID, which is bad since the UID is not secure and you can still duplicate the card.

If the reader supports reading from memory, then by default it is usually configured to read the UID anyway, and this requires certain additional steps to put it into read mode from memory.

Let’s make a remark here that if the system is built on the basis of UID, then use between the reader and the interface controller should be avoided
Wiegand-26 (the most popular), because this interface will truncate the UID of the card to 3 bytes and create the risk that different cards will be read the same.

Video review of the Wiegand interface

In order for the reader to read from memory, configuration and preparation of cards is required. Both the reader and the cards must contain a secret for this particular implementation. This can complicate the preparation of the card and reader a little. To perform this procedure, you need to run a specific program and run the cards one by one before issuing them to employees. This software is already built into the basic software packages for ACS controllers.

It is important to remember that not all controller manufacturers support MIfare. In addition to the controller, the reader must not only support work with Mifare, but also be configured to use them. Thus, you can use the most secure Plus cards, but still work with a weak cipher or generally by UID. At the time of this writing, the best manufacturers of controllers working with Mifare, from the ones we tested are Sphinx, Parsec, RusGuard

Equipment that supports the use of Mifare

Mifare standard video review

Conclusions:

Mifare IDs have high copy protection, have a higher price than the cheapest EM Marine IDs, but still their price is not high.They have a smaller choice of readers than the most common EM Marine format, but there is still a choice.

You need to use Mifare format identifiers correctly. If you just purchase a card and a reader and bring the card to the reader, then visually it will work – it will emit a sound and send data to the controller. But most likely the UID number will be read and no protection against copying cards is guaranteed. It is important to set up both the card and the reader correctly.

Cards with a non-original chip can be used in small ACS systems, because the possibility of forging from is extremely small, as well as the likelihood of encountering non-unique numbers, and even if this happens, the cost of such an error in small ACS systems is usually small.

In ACS systems with high safety and reliability requirements, use only original Mifare Plus chips, which are currently impossible to counterfeit.

Well, and the most important thing is your opinion

Nothing motivates me to write new articles as much as your rating, if the rating is good I will cut the articles further, if negative I think how to improve this article.But, without your assessment, I do not have the most valuable thing for me – feedback from you. Do not take it for work, choose from 1 to 5 stars, I tried.

Definition and synonyms of IUD in the English dictionary

IUD – Definition and synonyms of IUD in the English dictionary

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PRONUNCIATION OF IUD

WHAT DOES IUD

MEAN

Click to see the original definition of of “IUD” in the English dictionary.

Click to see automatic translation of definitions in Russian.

Intrauterine device

Intrauterine device

An intrauterine device is a small contraceptive device, often “T’-shaped,” often containing either copper or levonorgestrel, which is inserted into the uterus. They are a form of long-term reversible birth control and are the most effective forms of reversible birth control.The failure rate with the copper IUD is about 0.8%, while the levonorgestrel IUD has a 0.2% failure rate in the first year of use. Among the types of birth control, they, together with birth control implants, lead to the highest satisfaction among users. As of 2007, IUDs are the most widely used form of reversible contraception with over 180 million users worldwide. Evidence supports the effectiveness and safety of adolescents and non-children.The IUD does not interfere with breastfeeding and can be inserted immediately after delivery. They can also be used immediately after an abortion. Once removed, even after prolonged use, fertility returns to normal immediately. While copper IUDs can increase menstrual bleeding and lead to more painful cramps, hormonal IUDs can reduce menstrual bleeding or stop menstruation altogether. Spasms can be treated with NSAIDs. An intrauterine device is a small contraceptive device, often ‘T’-shaped, often containing either copper or levonorgestrel, which is inserted into the uterus.They are one form of long-acting reversible contraception which are the most effective types of reversible birth control. Failure rates with the copper IUD is about 0.8% while the levonorgestrel IUD has a failure rate of 0.2% in the first year of use. Among types of birth control, they along with birth control implants result in the greatest satisfaction among users. As of 2007, IUDs are the most widely used form of reversible contraception, with more than 180 million users worldwide. Evidence supports effectiveness and safety in adolescents and those who have and have not previously had children.IUDs do not affect breastfeeding and can be inserted immediately after delivery. They may also be used immediately after an abortion. Once removed, even after long term use, fertility returns to normal immediately. While copper IUDs may increase menstrual bleeding and result in more painful cramps hormonal IUDs may reduce menstrual bleeding or stop menstruation altogether. Cramping can be treated with NSAIDs.

Definition of IUD in the English dictionary

The definition of an IUD in the dictionary is an intrauterine device or intrauterine contraceptive device.

The definition of IUD in the dictionary is intrauterine device or intrauterine contraceptive device.

Click to see the original definition of of “IUD” in the English dictionary.

Click to see automatic translation of definitions in Russian.

WORDS THAT END LIKE IUD

HUD

JUD

SUD

Synonyms and antonyms of IUD in the English dictionary

Translation of “IUD” into 25 languages ​​

TRANSLATION OF IUD

Find out the translation of IUD to 25 languages ​​ with our English multilingual translator. The translations of the word IUD from English into other languages ​​presented in this section were performed using automatic translation, in which the main element of the translation is the word “IUD” in English.

Translator from English to Chinese

宫内节育器

1,325 million speakers

Translator from English to Spanish

DIU

570 million speakers

English

IUD

510 million speakers

Translator from English to

Hindi language

आईयूडी

380 million speakers

Translator from English to Arabic

اللولب

280 million speakers

Translator from English to

Russian language

Navy

278 million speakers

Translator from English to

Portuguese

DIU

270 million speakers

Translator from English to Bengali

IUD

260 million speakers

Translator from English to French

DIU

220 million speakers

Translator from English to

Malay

IUD

190 million speakers

Translator from English to German 9003 90 004

IUP

180 million speakers

Translator from English to Japanese

IUD

130 million speakers

Translator from English to Korean

IUD

85 million speakers

Translator from English to Javanese 9003 90 004

IUD

85 million speakers

Translator from English to

Vietnamese language

vòng tránh thai

80 million speakers

Translator from English to

Tamil

IUD

75 million speakers

Translator from English to

Marathi language

आययूडी

75 million speakers

Translator from English to Turkish

RİA

70 million speakers

Translator from English to Italian

IUD

65 million speakers

Translator from English to

Polish

Wkładka wewnątrzmaciczna

50 million speakers

Translator from English into

Ukrainian language

Navy

40 million speakers

Translator from English to Romanian

DIU

30 million speakers

Translator from English to

Greek

IUD

15 million speakers

Translator from English to

Afrikaans language

IUD

14 million speakers

Translator from English to Swedish

lUD

10 million speakers

Translator from English to

Norwegian language

spiral

5 million speakers

Trends of use of IUD

TRENDS IN USE OF THE TERM “IUD”

FREQUENCY

The word is used quite often

The map shown above shows the frequency of use of the term “IUD” in different countries.Major Search Trends and Examples of Use of IUD

A list of the major searches that users have entered to access our online English dictionary and the most commonly used expressions with the word “IUD”.

FREQUENCY OF USING THE TERM “IUD” OVER TIME

The graph shows the annual change in the frequency of use of the word “IUD” over the past 500 years.The plotting is based on an analysis of how often the term “IUD” appears in digitized print sources in English from 1500 to the present.

Examples of use in the English literature, quotes and news about the word IUD

BOOKS IN ENGLISH RELATED TO THE WORD

“IUD”

Discover the use of IUD in the following bibliographical selection.Books related to the word IUD and short excerpts from these books to provide an understanding of the context of the word’s use in English literature.

1

The Global Biopolitics of the IUD : How Science Constructs …

In this book, Chikako Takeshita investigates the development, marketing, and use of the IUD since the 1960s.

2

Ultrasound in Obstetrics and Gynecology

The intrauterine device ( IUD ) is currently the second most widely practiced
method of birth control.On a worldwide scale, it is estimated that 156 million
women wear an IUD . Just over two-thirds, or 104 million, are in China, where
lUDs are …

Screening for Sexually Transmitted Infections Some practice sites continue to
require an office visit prior to IUD insertion to screen for sexually transmitted
infections (STIs) and allow time for results to be available before the device is
placed.

Tekoa L.King, Mary C. Brucker, Jan M. Kriebs, 2013

4

The New Harvard Guide to Women’s Health

The string is used to remove the IUD , as well as to make sure that it stays
properly positioned. Some women feel uncomfortable cramping during insertion.
After insertion many experience cramping and spotting for a few days. The ideal
time to …

Karen J.Carlson, Stephanie A. Eisenstat, Terra Diane Ziporyn, 2004

5

Clinical Gynecologic Endocrinology and Infertility

Patient selection for successful IUD use requires attention to menstrual history
and the risk for STIs. Age and parity are not the critical factors in selection; the risk
factors for STIs are the most important consideration. Women who have multiple …

Marc A.Fritz, Leon Speroff, 2011

6

Clinical Reproductive Medicine and Surgery

Contraception decidualization and fewer polyps and fibroids in women with an
IUD compared to controls.42 Unfortunately, the women using the Mirena IUD had
excessive bleeding that often took 6 months or more to resolve. This study was …

Tommaso Falcone, William W.Hurd, 2007

7

Clinical Sonography: A Practical Guide

LOST INTRAUTERINE DEVICE When a patient cannot feel the IUD string in the
vagina, it is termed a “lost IUD .” Most often the IUD is still in good position, but the
string is balled up and visible in the region of the internal os (Fig. 34-3).

Roger C. Sanders, Thomas Charles Winter, 2007

8

Sexuality Now: Embracing Diversity

(c) IUD in place Copyright 2011 Cengage Learning…. GyneFix, an IUD
containing a flexible row of copper beads. FIGURE 13.11 Insertion of an
intrauterine device: (a) IUD is inserted through tube into 2 Explain how changes
in cervical mucus …

migration occurs and the IUD may gradually progress through the wa 1 1 a nd
enter the peritoneal / pelvic cavity at some later time. The diagnosis may be made
when pregnancy occurs (since the IUD is no longer in the endometrial cavity).

S.L. Corson, R.J. Derman, 1995

The IUD is the modern outgrowth of the pebbles that camel herders would put
inside their animals to prevent pregnancy (see the sidebar on the history of
contraception earlier in this chapter). Perhaps pebbles would also work on
women, but I …

NEWS THAT COUNTER THE TERM “IUD”

This shows how the national and international press uses the term IUD in the context of the news articles below.

Options Clinic rebrands to Essential Health ro reflect vital role

… cancer screenings, FDA-approved birth control methods, emergency contraception, IUD insertion and removal, implant insertion and removal … “La Crosse Tribune, Jul 15”

The biggest threats to birth control in North America – Shine from…

Research shows that if cost and availability were not an issue, many women would choose a hormonal implant or IUD as their preferred… “Yahoo Canada Shine On, Jul 15”

5 Benefits Of The Copper IUD , Because It Might Just Be Time To …

The IUD is a small, flexible T-shaped device inserted into your uterus by your doctor. There are currently two kinds available to women in the United States: the … “Bustle, Jul 15”

Mirena May Have Far-Reaching Complications

Orlando, FL: Amber has suffered a lot of pain and more due to the Mirena IUD .She had it removed but there may be far-reaching Mirena … “LawyersandSettlements.com, Jul 15”

Small Business Owners Are More Progressive than the US Supreme …

For women using an intrauterine device, or IUD —a longer-acting, more expensive form of reversible birth control — that percentage rose to 44 … “Center For American Progress, Jul 15”

The 6 biggest health mistakes women make in their 20s

“There’s increasing evidence that the long acting reversible contraception – the IUD and the implant – are really effective and something… “Today.com, Jul 15”

22-year-old’s Facebook post on dangers of Mirena IUD goes viral

The Mirena IUD is a fairly new birth control device, approved by the FDA in 2000. Time and again, Mirena has come under fire for its many … “Live Action News, Jul 15”

Seattle Public School Offers IUD Implants To Young Female …

A Seattle public school is offering female students, even those as young as 11, the chance to have an IUD implant that was paid for through… “iSchoolGuide, Jul 15”

Recipharm buys IUD -pain drug firm Pharmanest as part of consortium

She went on to say it is “in late-stage development for lead indication in IUD insertion and the Phase II study demonstrated statistically …” OutSourcing-Pharma.com, Jul 15 “

Out-of-pocket expenses for oral contraceptive pills, IUD decrease…

Average out-of-pocket spending for oral contraceptive pills and the intrauterine device ( IUD ), the two most common forms of contraception for… “News-Medical.net, Jul 15”

REFERENCES

“EDUCALINGO. Iud [online]. Available . Dec 2021 “.

How to sign documents using Smart-ID?

Since November 2018, Smart-ID is considered a QSCD (Quality Signature Creation Device). This means that electronic signatures provided via Smart-ID have the same legal effect as handwritten signatures (QES level ) and are accepted throughout the European Union.Read more about e-signature levels here.

Signing documents with Smart-ID is easy.

First, check that your Smart-ID account has the required level for this by opening the menu item “User data” (User info) in the Smart-ID application. If it contains Smart-ID Smart-ID Qualified Electronic Signature , then everything is in order. If it says something else, you need to upgrade your account to : update the application, delete the existing account and register a new one.

There are several ways to sign documents:

• Using the online signature service : you can use Smart-ID to sign documents using the signing portals Dokobit or Lahdes .
• Install app: If you are using an iPhone, you can download the Dokobit app .
• DigiDoc4 Software : You can sign or validate documents directly on your computer using the latest Estonian software DigiDoc4 Client .Unfortunately, the use of Latvian and Lithuanian personal codes in it is limited, therefore DigiDoc4 can only be used in commercial mode.
• Try the add-in for your computer: you can sign documents directly in Microsoft Word using the Dokobit add-in .

Please note that electronically signed documents come in different formats, not all of which are supported everywhere. If you have a choice, we recommend giving preference to asice file format – this is the standard for all European Union countries (your signed documents will look like this: filename.asice).

90,000 What kind of identity cards are used in different countries – Rossiyskaya Gazeta

There is nothing revolutionary about a French identity card. A plastic card measuring 105 mm by 74 mm (“eight” of a standard A4 paper sheet), which, in addition to a photograph, contains basic information about the owner (date and place of birth), a sample signature, as well as by whom and when the document was issued.True, several degrees of protection have been introduced into it, which, nevertheless, has not recently been able to stop the swindlers who fabricate forgeries. According to some reports, about two hundred counterfeit plastic “eights” are put into circulation every year, and not all of them end up in the hands of the police.

Certificates are issued at city halls or police prefectures, for which you need to present a birth certificate, a certificate of residence in the form of a gas or electricity bill (the name and address of residence are indicated there), and

also fill out the corresponding form.The document is issued for a period of 10 years and free of charge. In case of loss, you will have to pay 25 euros to issue a duplicate. Although the overwhelming majority of French people have this certificate, it is, surprisingly, not something obligatory. Some do without a “eight”, and, if necessary, show a “pink crust” of a driver’s license.

As for the electronic identity card (EUL), the French are clearly in no hurry with it. A completely real project appeared in the middle of the 2000s, and by their completion, it was believed, was about to be launched.EUL supporters wanted to make it not only an order of magnitude more secure than the current ID, but also multifunctional. The electronic microchip was supposed to be filled with a wide variety of information, including biometric data, fingerprints, the owner’s personal crypto key for digital signature of documents, information about the parameters of social security, and so on.

However, human rights organizations and lawyers opposed. They saw in EUL an attempt to create a total dossier on all Frenchmen.The case was referred to the Constitutional Council, and there, after much deliberation, they came to the conclusion that the creation of such a data bank “would infringe upon the citizens’ right to privacy.” Council members also expressed concern that information stored in a centralized manner, under certain conditions, could be used “not only to establish the identity of the owner.”

The EUL project was handed over for revision, as a result of which many functions that could supposedly make it indispensable in many life situations, for example, serve as an electronic wallet, were left out.

What’s in the bottom line? An identity card that differs from the old one only in that biometric information and fingerprints are added to it. Dot.

By the way

When, in the spring of this year, MP Philippe Meunier asked the Minister of the Interior, Manuel Valls, when the EUL would get a start in life, the answer was short: “Now it is undesirable.” Perhaps the main reason is that the launch of the EUL program would require a minimum of € 85 million, which would be an unacceptable luxury under the current austerity regime.

ID cards instead of passports: what will change?

3 August 2016

Photo author, UNIAN

Sign up to photo,

Sample of a new passport

President of Ukraine Petro Poroshenko signed a law on the introduction of new internal passports in the form of a plastic ID-card, which will be issued from October 2016 …

The construction of the plastic card provides for a contactless electronic carrier.

As a reminder, new internal passports have been introduced in Ukraine since January 1, 2016.

From October 1, when new legislative norms come into force, ID-certificates will be received by all citizens of Ukraine, starting from the age of 14.

All other citizens will be able to exchange old passports for new ones of their own free will.

Documents issued before this law came into force will remain valid until the end of the stipulated period of validity.

Without stamps, but with digital signature

Data in the passport will be entered in English and Ukrainian.There will be no inscriptions in Russian.

The document will contain the name, gender, citizenship, date of birth, place of birth, photograph, digital signature and record number in the unified register.

The document may also contain fingerprints. However, this option is made with the consent of the owner.

Author of the photo, UNIAN

Pidpis to photo,

Passports of a new sample in Ukraine will be issued from the age of 14

In addition, the passport will not include marks on the conclusion or dissolution of marriage.

The passport will be issued to persons under the age of 18 for four years, and to persons who have reached the age of 18 – for 10 years.

At the first stage, ID-cards will be issued free of charge to persons over 14 years of age.

ID-card will be valid for 10 years from the date of issue, then you will need to get a new one – also for 10 years, but already for a fee.

Administrative service for issuing a passport will amount to 10% of the minimum wage, which is now set at 1,450 hryvnia.

A step towards the EU and a single database

The adoption of the law on new passports is one of the requirements for the liberalization of the visa regime with the EU.

The system of new passports with electronic chips will make it possible to create a Unified State Demographic Register for quick identification of a person.

Author of the photo, UNIAN

Pidpis to the photo,

Fingerprints will be taken only with the consent of the owner

This register will collect all the necessary administrative information about the citizens of Ukraine.

In the future, plastic passports can be used to identify digital signatures, receive online administrative services, and possibly electronic voting.

New passports, according to the Ministry of Internal Affairs, will be better protected from counterfeiting and unauthorized use in the event of theft.

Also, the Ministry of Internal Affairs announces that new internal passports can be obtained, in particular, in the centers for the provision of administrative services.

The state migration service notes that they want to replace a significant part of old passports with new ones within four years.

For this purpose, they will offer to obtain a new passport for those who draw up a passport, change their surname or have lost their documents.

When the majority of the country’s population receives ID-passports, they, according to officials, will begin to be actively used in the banking sector, they will also become the key to other types of services.