The IUD is a safe, effective method of contraception for appropriate candidates. Women who are at low risk for STIs and who are without menstrual dysfunction or anatomic distortion of the uterine cavity are ideally suited to IUD use. Because the IUD provides no protection against STIs, and may increase the severity of existing infections, a thorough screening of women for STI risk factors is mandatory before IUD insertion.

Absolute contraindications to IUD insertion include a history of current, recent, or recurrent pelvic inflammatory disease, acute cervicitis, acute vaginitis, intrauterine pregnancy, allergy to copper (with copper IUDs), and immunosuppression. The relative contraindications to IUD use include multiple sexual partners, nulligravid condition, menometrorrhagia, hypermenorrhea, severe dysmenorrhea, uterine abnormalities distorting the cavity, anticoagulation therapy or a bleeding disorder, and valvular heart disease. Diabetes mellitus is not a contraindication to IUD use. Women with type 1 or type 2 diabetes mellitus (with no other contraindications to IUD use) may safely use this method of contraception.65,66

The IUD should be inserted during the last days of menstrual flow to ensure that the woman is not pregnant, and because the cervix is partially open at that time, allowing for easier insertion. An IUD may also be placed immediately after a first-trimester abortion without increased rates of expulsion or infection.67,68 In the postpartum period, or after a second-trimester abortion, IUD insertion should be delayed 4 to 8 weeks because of the higher risk of IUD expulsion if performed sooner. Aside from an increased risk of expulsion, IUD insertion immediately postdelivery is not associated with an increased risk of complications.69

Adverse effects of IUD use include expulsion, uterine or cervical perforation, syncope during insertion, severe uterine cramping, menometrorrhagia, chronic cervicitis or leukorrhea, and actinomycotic genital infection. During the first year of use, ˜20% of patients request removal of the IUD because of heavy bleeding and cramping, and 5% to 10% spontaneously expel the IUD.

Among appropriately screened IUD users, pelvic infection is rare.70,71 The risk of infection is highest immediately after insertion, at which time vaginal or cervical pathogenic organisms can be introduced into the uterus. If symptoms of upper genital tract infection develop, the IUD should be removed and sent for culture; cervical cultures should be taken, and antibiotic treatment should be instituted.