Editing Copper IUD (section)

== Side effects and complications ==

=== Complications ===
The most common complications related to the copper IUD are expulsion, perforation, and infection. [[Infertility]] after discontinuation and [[Breastfeeding difficulties|difficulty breastfeeding]] during use are not associated with the copper IUD.<ref name=":2" /><ref name="Dean 2011" />

Expulsion rates can range from 2.2% to 11.4% of users from the first year to the 10th year. The TCu{{Nbsp}}380A may have lower rates of expulsion than other models,  and the frameless copper IUD has a similar rate of expulsion to models with frames.<ref>{{cite journal | vauthors = O'Brien PA, Marfleet C | title = Frameless versus classical intrauterine device for contraception | journal = The Cochrane Database of Systematic Reviews | issue = 1 | pages = CD003282 | date = January 2005 | pmid = 15674904 | doi = 10.1002/14651858.CD003282.pub2 | collaboration = Cochrane Fertility Regulation Group }}</ref><ref name="Kane2010">{{cite journal | vauthors = Kaneshiro B, Aeby T | title = Long-term safety, efficacy, and patient acceptability of the intrauterine Copper T-380A contraceptive device | journal = International Journal of Women's Health | volume = 2 | pages = 211–220 | date = August 2010 | pmid = 21072313 | pmc = 2971735 | doi = 10.2147/ijwh.s6914 | doi-access = free }}</ref> Expulsion is more likely with immediate or early postpartum or post-abortal placement.<ref name=":10" /><ref name="Averbach et al 2020">{{cite journal | vauthors = Averbach SH, Ermias Y, Jeng G, Curtis KM, Whiteman MK, Berry-Bibee E, Jamieson DJ, Marchbanks PA, Tepper NK, Jatlaoui TC | title = Expulsion of intrauterine devices after postpartum placement by timing of placement, delivery type, and intrauterine device type: a systematic review and meta-analysis | journal = American Journal of Obstetrics and Gynecology | volume = 223 | issue = 2 | pages = 177–188 | date = August 2020 | pmid = 32142826 | pmc = 7395881 | doi = 10.1016/j.ajog.2020.02.045 }}</ref> In the postpartum period, expulsion is less likely when the device is placed less than ten{{Nbsp}}minutes after the placenta is delivered, or when inserted after a [[Caesarean section|cesarean delivery]].<ref name=":3" /> Unusual vaginal discharge, cramping or pain, [[Intermenstrual bleeding|spotting between periods]], postcoital (after sex) spotting, [[Dyspareunia|pain during intercourse]] (dyspareunia), or the absence or lengthening of the strings can be signs of a possible expulsion.<ref name="Dean 2011" /> As with intentional removal, the device is immediately ineffective after expulsion. If an IUD with copper is inserted after an expulsion has occurred, the risk of re-expulsion has been estimated in one study to be approximately one third of cases after one year.<ref>{{cite journal | vauthors = Bahamondes L, Díaz J, Marchi NM, Petta CA, Cristofoletti ML, Gomez G | title = Performance of copper intrauterine devices when inserted after an expulsion | journal = Human Reproduction | volume = 10 | issue = 11 | pages = 2917–2918 | date = November 1995 | pmid = 8747044 | doi = 10.1093/oxfordjournals.humrep.a135819 }}</ref> [[Magnetic resonance imaging]] (MRI) may cause dislocation of a copper IUD, and it is therefore recommended to check the location of the IUD both before and after MRI.<ref name="Berger-KulemannEinspieler2013">{{cite journal | vauthors = Berger-Kulemann V, Einspieler H, Hachemian N, Prayer D, Trattnig S, Weber M, Ba-Ssalamah A | title = Magnetic field interactions of copper-containing intrauterine devices in 3.0-Tesla magnetic resonance imaging: in vivo study | journal = Korean Journal of Radiology | volume = 14 | issue = 3 | pages = 416–422 | year = 2013 | pmid = 23690707 | pmc = 3655294 | doi = 10.3348/kjr.2013.14.3.416 }}</ref>

[[File:Perforated IUD.jpg|thumb|[[Transvaginal ultrasonography]] showing a perforated copper IUD as a [[hyperechoic]] (rendered as bright) line at right, 3 centimeters away from the [[uterus]] at left. The IUD is surrounded by a hypoechoic (dark) [[foreign-body granuloma]].]]

Perforation of the device through the uterine wall typically occurs at the time of placement, though it may occur spontaneously during the period of use. Estimates of the rate of perforation vary from 1.1 per 1000 to 1 per 3000 copper IUD insertions.<ref name="Good2010" /><ref name=":2" /> Perforation may be slightly more common in people using the copper IUD while breastfeeding.<ref>{{cite journal | vauthors = Berry-Bibee EN, Tepper NK, Jatlaoui TC, Whiteman MK, Jamieson DJ, Curtis KM | title = The safety of intrauterine devices in breastfeeding women: a systematic review | journal = Contraception | volume = 94 | issue = 6 | pages = 725–738 | date = December 2016 | pmid = 27421765 | pmc = 11283814 | doi = 10.1016/j.contraception.2016.07.006 }}</ref>

Due to its inflammatory mechanism of action, a copper IUD that has completely perforated typically requires surgical removal due to the formation of dense [[Adhesion (medicine)|adhesions]] around the device. A device embedded in the uterine wall may be removed [[Hysteroscopy|hysteroscopically]] or surgically.<ref name="Good2010" /><ref name=":3" />

The insertion of a copper IUD poses a transient risk of [[pelvic inflammatory disease]] (PID) for 21{{Nbsp}}days, though this is almost always in the setting of undiagnosed [[gonorrhea]] or [[chlamydia]] infection at the time of insertion. This occurs in less than 1 in 100 insertions. Beyond this time frame there is no increased risk of PID associated with copper IUD use.<ref name=":3" /><ref name="Moh2006" /><ref name=":2" /><ref name="USAID">{{Cite web |title=Infection Prevention Practices for IUD Insertion and Removal |url=http://www.maqweb.org/iudtoolkit/service_delivery/infectionprevention.shtml |archive-url=https://web.archive.org/web/20100101152205/http://www.maqweb.org/iudtoolkit/service_delivery/infectionprevention.shtml |archive-date=January 1, 2010}} By the United States Agency for International Development (USAID). Retrieved on February 14, 2010</ref><ref name="Dean 2011" /> Postpartum insertion of a copper IUD is not associated with increased risk of infection, provided that the delivery was not complicated by an infection such as [[chorioamnionitis]].<ref name=":3" />

=== Side effects ===
The most common side effects reported with use of the copper IUD are increased menstrual bleeding and menstrual cramps, both of which may remit after 3–6 months of use. Less frequently, [[intermenstrual bleeding]] may occur, especially in the first 3–6 months of use.<ref name=":2" /><ref name="Dean 2011" /><ref>{{cite journal | vauthors = Costescu D, Chawla R, Hughes R, Teal S, Merz M | title = Discontinuation rates of intrauterine contraception due to unfavourable bleeding: a systematic review | journal = BMC Women's Health | volume = 22 | issue = 1 | pages = 82 | date = March 2022 | pmid = 35313863 | pmc = 8939098 | doi = 10.1186/s12905-022-01657-6 | doi-access = free }}</ref> The increase in menstrual blood volume varies in different studies but is reported to be as low as 20% and as high as 55%; however, there is no evidence for a concomitant change in [[ferritin]], [[hemoglobin]], or [[hematocrit]].<ref name="Good2010" /><ref name=":2" />

[[Heavy menstrual bleeding|Menorrhagia]] (increased menstrual bleeding) and [[dysmenorrhea]] (painful menstrual bleeding) are typically treated with NSAID medications including [[naproxen]], [[ibuprofen]], and [[mefenamic acid]].<ref>{{cite journal | vauthors = Christelle K, Norhayati MN, Jaafar SH | title = Interventions to prevent or treat heavy menstrual bleeding or pain associated with intrauterine-device use | journal = The Cochrane Database of Systematic Reviews | volume = 2022 | issue = 8 | pages = CD006034 | date = August 2022 | pmid = 36017945 | pmc = 9413853 | doi = 10.1002/14651858.CD006034.pub3 | collaboration = Cochrane Fertility Regulation Group }}</ref><ref name=":3" />

=== Contraceptive failure ===
[[File:Ultrasonography of IUD with copper.jpg|thumb|[[Transvaginal ultrasonography]] visualizing an IUD with copper in the optimal location within the uterus.]]

The absolute risk of [[ectopic pregnancy]] with IUD use is lower than with no contraception due to the dramatically decreased rate of pregnancy overall. However, when pregnancy does occur with a copper IUD in place, a higher percentage of those pregnancies are ectopic, from 3% to 6%, a two to sixfold increase. This corresponds to an absolute rate of ectopic pregnancy in copper IUD users of 0.2–0.4 per 1000 person-years, compared to 3 per 1000 person-years in the population using no contraception.<ref name=":4" /><ref name=":2" /><ref name="Good2010" />

If a pregnancy continues with the IUD in place, there is an increased risk of complications including preterm delivery, [[chorioamnionitis]], and spontaneous abortion. If the IUD is removed, these risks are lower, especially the risks of bleeding and miscarriage; the rate of miscarriage approaches that of the general population depending on study population.<ref name=":4">{{cite journal | vauthors = Molino GO, Santos AC, Dias MM, Pereira AG, Pimenta ND, Silva PH | title = Retained versus removed copper intrauterine device during pregnancy: An updated systematic review and meta-analysis | journal = Acta Obstetricia et Gynecologica Scandinavica | date = January 2025 | pmid = 39868878 | doi = 10.1111/aogs.15061 | doi-access = free | pmc = 11981102 }}</ref><ref name="Good2010" /><ref name=":2" />

Overall failure rates with the copper IUD are low, and are mainly dependent on the surface area of copper in the device. After 12 years of continuous use, the TCu{{Nbsp}}380A device has a cumulative pregnancy rate of 1.7%.<ref name="Good2010" /> The TCu 380A is more effective than the MLCu375, MLCu350, TCu220, and TCu200. The TCu 380S is more effective than the TCu 380A.<ref>{{cite journal | vauthors = Kulier R, O'Brien PA, Helmerhorst FM, Usher-Patel M, D'Arcangues C | title = Copper containing, framed intra-uterine devices for contraception | journal = The Cochrane Database of Systematic Reviews | issue = 4 | pages = CD005347 | date = October 2007 | pmid = 17943851 | doi = 10.1002/14651858.CD005347.pub3 | collaboration = Cochrane Fertility Regulation Group }}</ref> The frameless device has similar failure rates to conventional devices.<ref name=":9" />

=== Contraindications ===
The copper IUD is considered safe and effective during lactation and in those who have never been pregnant. In the [[World Health Organization]] (WHO) ''Medical Eligibility Criteria for Contraceptive Use'', category 3 contraindications (risk typically outweighs benefit) and category 4 contraindications (unacceptable health risk) are listed for the copper IUD. Category 3 contraindications include untreated [[HIV/AIDS]], recent and recurrent exposure to gonorrhea or chlamydia without adequate treatment, benign [[gestational trophoblastic disease]], and [[ovarian cancer]]. Category 4 contraindications besides pregnancy and active genital tract infections (e.g. [[Tuberculosis|pelvic tuberculosis]], sexually transmitted infections, [[endometritis]]) include malignant gestational trophoblastic disease, [[abnormal uterine bleeding]], active [[cervical cancer]], [[Wilson's disease]], and active [[endometrial cancer]]. HIV infection is not itself a contraindication, as long as it is treated. There are no known drug interactions between the copper IUD and anti-retroviral medications.<ref name=":3">{{Cite book |title=Williams Gynecology |date=2016 |publisher=McGraw-Hill Education LLC |isbn=978-0-07-184909-8 | veditors = Bradshaw KD, Corton MM, Halvorson LM, Hoffman BL, Schaffer M, Schorge JO |edition=3rd |series=McGraw-Hill's AccessMedicine |location=New York, N.Y }}</ref><ref>{{cite journal | vauthors = Jatlaoui TC, Riley HE, Curtis KM | title = The safety of intrauterine devices among young women: a systematic review | journal = Contraception | volume = 95 | issue = 1 | pages = 17–39 | date = January 2017 | pmid = 27771475 | pmc = 6511984 | doi = 10.1016/j.contraception.2016.10.006 }}</ref><ref name="WHOMEC">{{Cite book |author-link=World Health Organization |title=Medical eligibility criteria for contraceptive use |vauthors=((World Health Organization)) |publisher=World Health Organization |year=2015 |isbn=9789241549158 |edition=5th |location=Geneva |hdl=10665/181468 |hdl-access=free}}</ref>