Chapter 11 Download Chapter

Providing the Levonorgestrel Intrauterine Device

When to Start

IMPORTANT: In many cases a woman can start the LNG-IUD any time if it is reasonably certain she is not pregnant. To be reasonably certain she is not pregnant, use the Pregnancy Checklist.
Woman's situation When to start
Having menstrual cycles or switching from a nonhormonal method

 Any time of the month

  • If she is starting within 7 days after the start of her monthly bleeding, no need for a backup method.
  • If it is more than 7 days after the start of her monthly bleeding, she can have the LNG-IUD inserted any time if it is reasonably certain she is not pregnant. She will need a backup method* for the first 7 days after insertion.
Switching from a hormonal method
  • Immediately, if she has been using the method consistently and correctly or if it is otherwise reasonably certain she is not pregnant. No need to wait for her next monthly bleeding.
  • If she is starting within 7 days after the start of her monthly bleeding, no need for a backup method.
  • If it is more than 7 days after the start of her monthly bleeding, she will need a backup method* for the first 7 days after insertion.
  • If she is switching from an injectable, she can have the LNG-IUD inserted when the repeat injection would have been given. No need  for a backup method.

Soon after childbirth (regardless of breastfeeding status)
  • Any time within 48 hours after giving birth (requires a provider with specific training in postpartum insertion by hand or using a ring forceps).
  • After 48 hours, delay until at least 4 weeks.
Fully or nearly fully breastfeeding

Less than 6 months after giving birth
  • If the LNG-IUD is not inserted within the first 48 hours and her monthly bleeding has not returned, she can have the LNG-IUD inserted any time between 4 weeks and 6 months. No need for a backup method.
  • If her monthly bleeding has returned, she can have the LNG-IUD inserted as advised for women having menstrual cycles.
More than 6 months since giving birth

 
  • If her monthly bleeding has not returned, she can have the LNG-IUD inserted any time if it is reasonably certain she is not pregnant. She will need a backup method* for the first 7 days after insertion.
  • If her monthly bleeding has returned, she can have the LNG-IUD inserted as advised for women having menstrual cycles.
Partially breastfeeding or not breastfeeding

Less than 4 weeks after giving birth

 
  • If the LNG-IUD is not inserted within the first 48 hours, delay insertion until at least 4 weeks after giving birth.
More than 4 weeks after giving birth
  • If her monthly bleeding has not returned, she can have the LNG-IUD inserted any time if it can be determined that she is not pregnant (see Ruling Out Pregnancy). She will need a backup method* for the first 7 days after insertion.
  • If her monthly bleeding has returned, she can have the LNG-IUD inserted as advised for women having menstrual cycles.

 
No monthly bleeding (not related to childbirth or breastfeeding)
  • Any time if it can be determined that she is not pregnant (see Ruling Out Pregnancy). She will need a backup method* for the first 7 days after insertion.
After miscarriage or abortion
  • Immediately, if the LNG-IUD is inserted within 7 days after first- or second-trimester abortion or miscarriage and if no infection is present. No need for a backup method.
  • If it is more than 7 days after first- or second-trimester miscarriage or abortion and no infection is present, she can have the LNG-IUD inserted any time if it is reasonably certain she is not pregnant. She will need a backup method* for the first 7 days after insertion.
  • If infection is present, treat or refer and help the client choose another method. If she still wants the LNG-IUD, it can be inserted after the infection has completely cleared.
  • LNG-IUD insertion after second-trimester abortion or miscarriage requires specific training. If not specifically trained, delay insertion until at least 4 weeks after miscarriage or abortion.
After taking progestin-only, combined, or ulipristal acetate (UPA) emergency contraceptive pills (ECPs)
  • She can have the LNG IUD inserted when it can be determined that she is not pregnant, for example, after the start of her next monthly bleeding (see Ruling Out Pregnancy). Give her a backup method* or oral contraceptive pills to use until she can have the IUD inserted.
  • She should not have the LNG-IUD inserted in the first 6 days after taking UPA-ECPs. These drugs interact. If the LNG-IUD is inserted sooner, and thus both LNG and UPA are present in the body, one or both may be less effective.

*Backup methods include abstinence, male and female condoms, spermicides, and withdrawal. Tell her that spermicides and withdrawal are the least effective contraceptive methods. If possible, give her condoms.
Preventing Infection at LNG-IUD Insertion

Proper insertion technique can help prevent many problems, such as infection, expulsion, and perforation.

  • Follow proper infection-prevention procedures.
  • Use high-level disinfected or sterile instruments. High-level disinfect by boiling, steaming, or soaking instruments in disinfectant chemicals.
  • Use a new, presterilized LNG-IUD that is packaged with its inserter.
  • The “no-touch” insertion technique is safest. This includes not letting the loaded IUD or uterine sound touch any unsterile surfaces (for example, hands, speculum, vagina, table top). The no-touch technique involves:
    • Cleaning the cervix thoroughly with antiseptic before IUD insertion
    • Being careful not to touch the vaginal wall or speculum blades with the uterine sound or loaded IUD inserter
    • Passing both the uterine sound and the loaded IUD inserter only once each through the cervical canal
  •  Giving antibiotics routinely is generally not recommended for women at low risk of STIs.