Can an IUD be inserted before a client has completed STI testing and received negative results?
According to the Journal of the American Medical Association (JAMA) & the American College of Obstetricians and Gynecologists (ACOG), requiring STI testing and/or awaiting STI test results prior to inserting an IUD creates unnecessary barriers to care and are no longer considered evidence-based standards of care. Scheduling a separate visit for an IUD insertion can result in a client not receiving their method of choice or an unplanned pregnancy. A study in Contraception found that only 54% of women who wanted an IUD returned to their second visit to receive the IUD. ACOG clinical guidance recommends that only clients who have not had routine screening for STIs or who are at an increased risk of STIs should receive STI testing. In those cases, ACOG advises that STI testing can happen at the same time as an IUD insertion, and if the results are positive, STI treatment can occur with the IUD in place.
Can a provider insert an IUD or Implant at the same time as a non-contraceptive appointment, such as a wellness visit?
According to the CDC’s U.S. Selected Practice Recommendations for Contraceptive Use, removing unnecessary barriers, such as multiple visits, can help clients access and successfully use their contraceptive method of choice. While there may be clinic flow barriers to providing an IUD or Implant during non-contraceptive focused appointments, there are no medical reasons for why providers cannot provide an IUD or implant during these appointments.
To learn more about “Quick Start” contraception provision and how to make contraceptive supplies readily available at clinic sites, visit the Family Planning National Training Center’s Same Visit Contraception Toolkit.
Do clients have to have a wellness/pelvic exam prior to or within the last 12 months of receiving a contraceptive method?
According to the CDC and the U.S. Office of Population Affairs’ Providing Quality Family Planning Recommendations (QFP), clients do not need a wellness/pelvic exam to receive a method of contraception, unless an IUD is being inserted, in which case the size and position of the uterus need to be determined to ensure correct IUD placement. A pap smear is unrelated to birth control and the QFP notes that, for both adolescent and adult clients, this test is not routinely needed to provide a contraceptive method to a healthy client. Additionally, the CDC’s U.S. Selected Practice Recommendations for Contraceptive Use states, “screening asymptomatic women with cervical cytology before IUD insertion is not necessary” and does not contribute substantially to safe and effective use of any contraceptive method. It is important for clinical providers to ensure their clinical processes and procedures reflect these practice standards. Leaving outdated and unnecessary clinical requirements for pap smears and pelvic exams in place can lead to clients receiving needless testing which can be a logistical, emotional, and/or economic barrier for some clients, particularly teens and low-income individuals.
Can clients that are nulliparous (have not given birth) receive an IUD?
ACOG advises IUDs “should be offered routinely as safe and effective contraceptive options” for individuals with a uterus who have not given birth. Practices discouraging people from IUDs because they are nulliparous are outdated and misinformed. According to ACOG, even though IUD complications are uncommon, some providers still hold beliefs that nulliparous clients will have pain and difficulty with insertion and develop Pelvic Inflammatory Disease and therefore discourage IUD usage. Additionally, the U.S. Medical Eligibility Criteria notes that the advantages of a nulliparous person using an IUD generally outweighs the risk. Providers should ensure their practices are in alignment with ACOG recommended practice guidelines to ensure no client is denied their chosen contraceptive method simply because they have not given birth.
Are clients who are not married or not in a monogamous relationship good candidates for an IUD?
Most clients, regardless of their marital or monogamy status, are good candidates for the IUD. However, eligible clients are sometimes not counseled on IUDs due to a provider's outdated beliefs and concerns an IUD may cause complications, especially if the client has multiple sexual partners. According to the European Journal of Contraceptive and Reproductive Health Care, many providers may still hold outdated beliefs that IUDs cause an ongoing risk of pelvic inflammatory disease (PID) and infertility despite the fact that the brand of IUD that was known to lead to PID (the Dalkon Shield) has been off the market for over 30 years. The study notes that “this misperception is a particular barrier to IUC use in nulliparous women, especially if they are single or have several sexual partners” even though modern IUDs do not carry the same risks.
For detailed evidence-based guidelines on IUDs, visit the U.S. Selected Practice Recommendations for Contraceptive Use, 2016.
Are adolescent or teen clients too young to receive an IUD?
The reality is that teens have sex and should have the option to prevent pregnancy using their contraceptive method of choice, including an IUD. ACOG and the American Academy of Pediatrics endorse the use of long acting reversible contraception (LARC), including IUDs for teens. A study in the journal Contraception found that a majority of adolescents preferred LARC methods over non-LARC methods when offered LARC methods and cost was removed as a barrier. A subsequent study also found high rates of satisfaction and continuation with LARC, including IUDs, among young people. According to ACOG, previous concerns around expulsion, pain with insertion or PID are outdated and uncommon in clients of all ages.
Do clients have to be menstruating in order to have a LARC inserted?
According to the CDC’s U.S. Selected Practice Recommendations for Contraceptive Use, LARC’s can be inserted at any point during a person’s menstrual cycle, if the provider can be reasonably certain the client is not pregnant. Requiring clients to be on their period for insertion is a barrier to contraceptive access.
To learn more about how to provide contraceptive methods at any point during a client’s menstrual cycle, visit the Reproductive Health Access Project’s Quick Start Algorithm resource.
If a client requests the removal of a LARC device prior to its expiration, should providers provide more counseling to encourage keeping the device in longer?
Since LARCs are “provider controlled” contraceptive methods, providers must not implicitly or explicitly coerce clients to continue an unwanted method the client cannot discontinue without provider assistance. Research[SL1] has shown “providers preferred IUD continuation and often encouraged patients to continue with the IUD if they thought it was in the patient's best interest” and “providers reported being more likely to agree with IUD removal when they felt it was a ‘good’ reason, or when they felt that the patient had already tried hard enough”. Likewise, research shows that clients reported their provider minimized experiences of side effects such as heavy cramping and bleeding, “particularly if those side effects led women to request the removal of the LARC device”.
Providers may feel compelled to provide additional counseling to encourage clients to give their LARC another chance, perhaps because of how much it costs to stock these methods or because the client is at a higher risk for unplanned pregnancy. However, ACOG opposes coercive practices that “construct barriers to autonomous decisions to discontinue contraception” and providers must ensure their own biases are not impacting a client’s autonomy around contraceptive use.
Rather than encourage unwanted, continued LARC use; providers should focus on person-centered contraceptive counseling at method initiation that includes comprehensive education on method side effects. The CDC and the U.S. Office of Population Affairs’ Providing Quality Family Planning Recommendations (QFP) notes that “side effects are a primary reason for method discontinuation” and directs providers to discuss ways the client may deal with potential side effects as well as how the client may follow up with concerns.
Finally, a training for providers regarding discontinuation of LARCs can be found on the National Clinical Training Center for Family Planning.
Does a client that identifies as a lesbian really need to use a contraceptive method?
Providers must not withhold information or limit the types of contraceptive methods offered based on assumptions the client may not need contraception due to their sexual orientation. Some clients may need a contraceptive method to prevent pregnancy and others to benefit from the positive hormonal side effects some methods provide. ACOG recommends gynecological services, including family planning, be provided to clients who identify as lesbian. ACOG also offers specific suggestions to changing the patient care setting so providers can better care for lesbian clients.
Providers should never assume pregnancy risk based solely on a client’s sexual identity but instead should conduct a comprehensive, person-centered sexual health assessment to better understand a client’s specific needs and preferences.
The National LGBT Health Education Center’s sexual history toolkit is a great resource for providers and notes that “how a person identifies their sexuality (e.g., “I am gay, bisexual, lesbian, straight, queer”) does not always tell you who they have sex with or who they are attracted to.” The toolkit shares the following considerations for providers:
- Some people who have same-sex partners refer to themselves as heterosexual.
- Some people who identify as lesbian/gay have a recent history of sex with opposite sex partners.
- Some people do not like to use labels to describe their sexual orientation or gender identity.