Keywords guideline - side effects - alternative contraception - effectiveness - pregnancy -
Pearl Index
I Guideline Information
Guidelines program of DGGG, OEGGG and SGGG
For information on the guidelines program, please refer to the end of the guideline.
Citation format
S2k-Guideline Non-hormonal Contraception, Part 2: Intrauterine Devices and Sterilization.
Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015-095, January
2024). Geburtsh Frauenheilk 2024; 84: 715–736
Guideline documents
The complete long version in German and a slide version of this guideline as well
as a list of the conflicts of interest of all the authors are available on the homepage
of the AWMF: http://www.awmf.org/leitlinien/detail/ll/015-095.html
Guideline authors
See [Tables 1 ] and [2 ].
Author
AWMF professional society
PD Dr. med. Bettina Böttcher
Austrian Society for Gynaecology and Obstetrics [Österreichische Gesellschaft für Gynäkologie und Geburtshilfe e. V. ] (OEGGG)
Prof. Dr. med. Sabine Segerer
German Society for Gynaecology and Obstetrics [Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e. V. ] (DGGG)
Author
Mandate holder
DGGG working group (AG)/
Dr. med. Maria Beckermann
Working Group on Womenʼs Health in Medicine, Psychotherapy and Society [Arbeitskreis Frauengesundheit in Medizin, Psychotherapie und Gesellschaft e. V. ] (AKF)
Barbara Berger
Sexual Health Switzerland [Sexuelle Gesundheit Schweiz ] (SGCH)
PD Dr. med. Bettina Böttcher
Austrian Society for Gynecology and Obstetrics (OEGGG)
Dr. med. Jann Frederik Cremers
German Society for Urology [Deutsche Gesellschaft für Urologie ] (DGU)
Dr. med. univ. Elisabeth DʼCosta
Expert
Dr. med. Petra Frank-Herrmann
German Society for Gynecological Endocrinology and Reproductive Medicine [Deutsche Gesellschaft für Gynäkologische Endokrinologie und Fortpflanzungsmedizin ] (DGGEF)
Dr. med. Tanja Freundl-Schütt
Expert
Dr. med. Cornelia Friedrich
German Society for Sexual Medicine, Sexual Therapy and Sexual Science [Deutsche Gesellschaft für Sexualmedizin, Sexualtherapie und Sexualwissenschaften ] (DGSMTW)
Dr. med. Sören Funck
Professional Association of Gynecologists [Berufsverband der Frauenärzte ] (BVF)
Dr. med. Christine Gathmann
Federal Association pro familia – German Society for Family Planning, Sexual Education
and Sexual Counselling [Bundesverband pro familia – Deutsche Gesellschaft für Familienplanung, Sexualpädagogik
und Sexualberatung e. V. ]
Sabine Goette
Federal Center for Health Education [Bundeszentrale für gesundheitliche Aufklärung ] (BZgA)
Dr. med. Maren Goeckenjan
Pediatric and Adolescent Gynecology Working Group [AG Kinder- und Jugendgynäkologie e. V. ] of the DGGG
Prof. Dr. med. Katharina Hancke
German Society for Reproductive Medicine [Deutsche Gesellschaft für Reproduktionsmedizin ] (DGRM)
Dr. med. Christian Leiber-Caspers
German Society for Andrology [Deutsche Gesellschaft für Andrologie ] (DGA)
Dr. med. Jana Maeffert
German Society for Psychosomatic Gynecology and Obstetrics [Deutsche Gesellschaft für Psychosomatische Frauenheilkunde und Geburtshilfe ] (DGPFG)
Prof. Dr. med. Gabriele Merki
Swiss Society for Gynecology and Obstetrics [Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe ] (SGGG)
Prof. Dr. med. Patricia G. Oppelt
Pediatric and Adolescent Gynecology Working Group of the DGGG
Stefanie Paschke
Federal Center for Health Education (BZgA)
Dr. med. Saira-Christine Renteria
Swiss Society for Gynecology and Obstetrics (SGGG)
Prof. Dr. med. Annette Richter-Unruh
German Society of Pediatrics and Adolescent Medicine [Deutsche Gesellschaft für Kinder- und Jugendmedizin ] (DGKJ)
Dr. med. Sebastian Schäfer
Gynecological Endoscopy Working Group [AG Gynäkologische Endoskopie e. V. ] (AGE) of the DGGG
Dr. med. Anne-Rose Schardt
Professional Association of Gynecologists (BVF)
Nina Schernus
Feminist Womenʼs Health Center Berlin [Feministisches Frauengesundheitszentrum Berlin e. V. ] (FFGZ)
Dr. med. Claudia Schumann-Doermer
German Society for Psychosomatic Gynecology and Obstetrics (DGPFG)
Prof. Dr. med. Sabine Segerer
German Society for Gynecology and Obstetrics (DGGG)
Helga Seyler
Working Group on Womenʼs Health in Medicine, Psychotherapy and Society (AKF)
Christine Sieber
Sexual Health Switzerland (SGCH)
Prof. Dr. med. Barbara Sonntag
German Society for Reproductive Medicine (DGRM)
Gabrielle Stöcker
Federal Association pro familia – German Society for Family Planning, Sexual Education
and Sexual Counselling
Prof. Dr. med. Bettina Toth
Austrian Society for Gynecology and Obstetrics (OEGGG)
Mag.a Angela Tunkel
Austrian Society for Family Planning [Österreichische Gesellschaft für Familienplanung ] (ÖGF)
Dr. med. Lisa-Maria Wallwiener
German Society for Gynecological Endocrinology and Reproductive Medicine (DGGEF)
The following professional societies/working groups/organizations/associations stated
that they wished to contribute to the guideline text and participate in the consensus
conference and nominated representatives to attend the conference.
The guideline was moderated by Dr. Monika Nothacker (AWMF-certified guidelines adviser/moderator).
Abbreviations
ART:
assisted reproductive technology
AWMF:
Association of the Scientific Medical Societies in Germany [Arbeitsgemeinschaft der wissenschaftlichen medizinischen Fachgesellschaften e. V. ]
BZgA:
Federal Center for Health Education [Bundeszentrale für gesundheitliche Aufklärung ]
Cu-IUD:
copper intrauterine device
IUD:
intrauterine device
IUP:
intrauterine pessary
LNG-IUD:
levonorgestrel intrauterine device
PSA:
prostate-specific antigen
STI:
sexually transmitted infection
TESE-ICSI:
testicular sperm extraction with intracytoplasmic sperm injection
WHO:
World Health Organization
II Guideline Application
Purpose and objectives
The aim is to provide evidence-based recommendations for action to advise persons
who wish to practice birth control using non-hormonal forms of contraception.
Targeted areas of care
predominantly outpatient care/if necessary, also day-patient and in-patient care
primary and specialist care
Target user groups/target audience
This guideline is aimed at the following groups of people:
gynecologists, urologists and andrologists in private practice
hospital-based gynecologists, urologists and andrologists
pediatricians
The guideline also provides information for the following target audience:
general practitioners
nursing staff
partners who work together with medical professionals (e.g., specialist healthcare
occupations, funding agencies)
counselling services (e.g., pro familia, Donum vitae, health authorities)
the general public, to inform them about good medical practice
Adoption and period of validity
The validity of this guideline was confirmed by the executive boards/representatives
of the participating medical professional societies, working groups, organizations,
and associations and the boards of the DGGG, SGGG, OEGGG and the DGGG/OEGGG/SGGG Guidelines
Commission in December 2023 and was thereby approved in its entirety. This guideline
is valid from 1 January 2024 through to 31 December 2028. Because of the contents
of this guideline, this period of validity is only an estimate. The guideline can
be reviewed and updated earlier if urgently necessary. If the guideline still reflects
the current state of knowledge, its period of validity can be extended.
III Methodology
Basic principles
The method used to prepare this guideline was determined by the class to which this
guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective
rules and requirements for different classes of guidelines. Guidelines are differentiated
into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined
as consisting of a set of recommendations for action compiled by a non-representative
group of experts. In 2004, the S2 class was divided into two subclasses: a systematic
evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The
highest S3 class combines both approaches.
This guideline was classified as: S2k
Grading of recommendations
The grading of evidence based on the systematic search, selection, evaluation, and
synthesis of an evidence base which is then used to grade the recommendations is not
envisaged for S2k guidelines. The individual statements and recommendations are only
differentiated by syntax, not by symbols ([Table 3 ]).
Description of binding character
Expression
Strong recommendation with highly binding character
must/must not
Regular recommendation with moderately binding character
should/should not
Open recommendation with limited binding character
may/may not
Statements
Expositions or explanations of specific facts, circumstances, or problems without
any direct recommendations for action included in this guideline are referred to as
“statements.” It is not possible to provide any information about the level of evidence for these statements.
Achieving consensus and level of consensus
At structured NIH-type consensus-based conferences (S2k/S3 level), authorized participants
attending the session vote on draft statements and recommendations. The process is
as follows. A recommendation is presented, its contents are discussed, proposed changes
are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes)
is not achieved, there is another round of discussions, followed by a repeat vote.
Finally, the level of consensus is determined, based on the number of participants
([Table 4 ]).
Symbol
Symbol
Symbol
+++
Strong consensus
> 95% of participants agree
++
Consensus
> 75 – 95% of participants agree
+
Majority agreement
> 50 – 75% of participants agree
–
No consensus
< 51% of participants agree
Expert consensus
As the term already indicates, this refers to consensus decisions taken which relate
specifically to recommendations/statements issued without a prior systematic search
of the literature (S2k) or where evidence is lacking (S2e/S3). The term “expert consensus”
(EC) used here is synonymous with terms used in other guidelines such as “good clinical
practice” (GCP) or “clinical consensus point” (CCP). The strength of the recommendation
is graded as previously described in the chapter Grading of recommendations but without the use of symbols; it is only expressed semantically (“must”/“must not”
or “should”/“should not” or “may”/“may not”).
IV Guideline
1 Introduction
In recent years, there has been a clear trend reversal with regards to the choice
of contraception. For many decades, the most commonly used contraceptive method in
Germany was the pill. However, in recent years, hormone-based contraception began
to be viewed more critically and is now being rejected more often. Women are looking
for alternatives, and men are now bearing more responsibility for family planning.
At present, condoms are being used for contraception as often as the pill [1 ].
Doctors therefore need to expand their knowledge of non-hormonal contraceptives. Individual
counselling of couples/users is necessary so they can choose the most suitable contraceptive
method [2 ]. Important selection criteria include effectiveness (reliability of the method),
potential side effects including reversibility of the method, acceptance of the method,
and availability of the method (access to the procedure, costs). Possible impacts
on sexuality and libido play an important role and this is discussed in the individual
chapters. The selection criteria as well as the assessment of what is important and
acceptable with regards to preventing pregnancy can change over the course of a lifetime.
The choice of method often changes accordingly.
If the aim is to reduce the risk of an unplanned pregnancy, especially if pregnancy
would constitute an additional health risk, the effectiveness of the method will be
the most important selection criteria [3 ]. It is important to differentiate between typical use and perfect use [4 ]. Typical use refers to the methodʼs effectiveness when used in real life and includes
typical user-related mistakes (i.e., inconsistent or incorrect use). Perfect use refers
to the methodʼs effectiveness if the method is always used correctly and consistently
[4 ], [5 ]. Sometimes the information provided about the effectiveness of a specific family
planning method does not explicitly state whether the stated effectiveness refers
to typical use or perfect use.
When the chosen contraceptive method is hormonal contraceptives, natural family planning
methods or barrier methods where effectiveness depends on consistent and correct usage,
there is a greater range between the figures reported for typical use and those reported
for perfect use, compared to methods which are effective irrespective of how they
are used. The latter methods include male or female sterilization, placement of an
intrauterine device (IUD) and hormone-releasing implants. There are many factors that
can affect the reliability of use: motivation, quality of the information provided,
how complicated the method is to use, etc.
The efficacy rates of family planning methods are usually reported as rates of unplanned
pregnancies per 100 women per year (both for typical use and for perfect use). Two
methods are used to calculate effectiveness: the Pearl Index and the Life Table . The Pearl Index corresponds to the number of unplanned pregnancies which occur when
100 women use a specific family planning method for one year [6 ]. The Pearl Index has been shown to have some significant inaccuracies and from a
scientific perspective, the Pearl Index should no longer be used. Nowadays, it is
better to use the Life Table to obtain typical-use figures [7 ] and the perfect-use method of Trussell to calculate perfect use [8 ], [9 ]. The cumulative Life-Table figures after 13 cycles correspond to pregnancy rates
per 100 women in one year.
Unfortunately, data on many non-hormonal methods, especially data on barrier methods
used by women, is limited. Most of the data comes from the USA, and there are some
indications that this data cannot be simply transferred to German-speaking countries.
The data on diaphragm use are very heterogeneous, which is why the reported ranges
for unplanned pregnancy rates are quite broad. The data on cervical caps and female
condoms are based only on a small study of moderate quality and should be treated
with caution. Some of the figures presented in international guidelines are only based
on estimates, which is why they have not been included in [Table 5 ]. This particularly refers to the reliability of use of the withdrawal method (coitus
interruptus) and of IUDs. Perfect-use data are lacking for currently available cervical
caps.
% of women with an unplanned pregnancy in the first year of use
Typical use effectiveness
Perfect use effectiveness
No contraception [4 ]
85
85
Spermicide [4 ]
28
18
Natural family planning
12
5
1.8 – 2.3
0.4
Lactational amenorrhea (refers only to a period of 6 months) [10 ]
0.45 – 2.45
0.97 – 1.5
Coitus interruptus (withdrawal method) [11 ]
20
n. s.
Condom [4 ], [11 ]
13
2
Female condom [4 ]
21
5
Diaphragm [12 ], [13 ], [14 ], [15 ], [16 ], [17 ], [18 ], [19 ], [23 ]
12 – 18
4 or 14
Cervical cap (FDA 2003 [P020041b.pdf {fda.gov}])
total 23
no previous vaginal birth 14
previous vaginal birth 29
n. s.
Copper IUD with a copper surface area of ≥ 300 mm2
[20 ], [21 ], [22 ]
0.1 – 1%
n. s.
LNG-IUD [20 ], [21 ], [22 ]
0.06 – 0.12
n. s.
Sterilization (female) [4 ]
0.5
0.5
Sterilization (male) [4 ]
0.15
0.10
Sexual activity also includes the risk of sexually transmitted infections (STIs).
In addition to the efficacy of the contraceptive method, potential protection against
STIs also needs to be considered and users need appropriate information. This is where
condoms have a significant advantage: consistent and correct use of condoms effectively
reduces the risk for HIV or STIs such as chlamydia, gonorrhea or trichomoniasis [24 ].
2 Summary of Recommendations
1. Intrauterine devices
Consensus-based recommendation 5.E23
Expert consensus
Level of consensus +++
Evidence-based information must be provided prior to placement of an IUD. This information
must include a patient information sheet and the written consent of the woman must
be obtained prior to placement.
Prior to placement, care must be taken to ensure that the woman is not pregnant.
Consensus-based recommendation 5.E24
Expert consensus
Level of consensus ++
It is not necessary to take a cytological smear prior to planned placement of an IUD
if the patient undergoes regular screening for cervical cancer.
Consensus-based recommendation 5.E25
Expert consensus
Level of consensus +++
The correct position of the IUD should be checked, e.g., by ultrasound. The initial
inspection should be done 6 weeks after placement, with regular checks carried out
every 12 months thereafter. Women may be made aware of the option that they can also
palpate the retrieval string in the vagina themselves.
Consensus-based statement 5.S21
Expert consensus
Level of consensus ++
A Cu-IUD is a very effective contraceptive method with a low pregnancy rate. The pregnancy
rate depends on the type and copper surface of the IUD. Effective Cu-IUDs have a copper
surface of a least 300 mm2 .
Consensus-based recommendation 5.E26
Expert consensus
Level of consensus +++
Advice on contraceptive methods must also include the possible use of intrauterine
contraception. The advice must include information about the high effectiveness of
intrauterine contraception as well as the fact that the effectiveness is not user-dependent.
Consensus-based statement 5.S22
Expert consensus
Level of consensus ++
In the first weeks after placement of a Cu-IUD, there is a higher risk of ascending
genital infections (pelvic inflammatory disease) as well as a higher risk of STIs.
Consensus-based recommendation 5.E27
Expert consensus
Level of consensus +++
All women who wish to have an IUD must be informed about the symptoms of ascending
genital infection and the risk of STIs. Women with a higher risk of STIs should be
screened for STIs prior to placement of an IUD.
Consensus-based recommendation 5.E28
Expert consensus
Level of consensus +++
General antibiotic prophylaxis must not be given during placement of an IUD.
Consensus-based recommendation 5.E29
Expert consensus
Level of consensus +++
If a symptomatic infection is detected, targeted treatment of the infection should
be carried out prior to placement of an IUD. Depending on the infection, placement
of the IUD may still be carried out, either at the same time or after an interval.
The contraceptive benefit must be weighed up against the risk of an ascending infection
on a case-by-case basis.
Consensus-based statement 5.S23
Expert consensus
Level of consensus +++
Painkillers such as naproxen and tramadol and local administration of a local anesthetic
in the form of higher doses of a gel or creme have an analgesic effect during IUD.
Studies have not provided evidence that the administration of misoprostol prior to
IUD placement generally makes it easier to insert the IUD.
Consensus-based recommendation 5.E30
Expert consensus
Level of consensus +++
Painkillers may be used for pain relief during and after IUD placement. Misoprostol
may be administered prior to repeat placement of an IUD after a previous unsuccessful
attempt at IUD insertion.
Consensus-based statement 5.S24
Expert consensus
Level of consensus +++
The risk of bacterial vaginosis may be slightly higher when using an IUD compared
to the time prior to placement and to other contraceptive methods.
Consensus-based recommendation 5.E32
Expert consensus
Level of consensus ++
Removal of the IUD with a switch to other means of conception may be considered in
cases with recurrent bacterial vaginosis or Candida infection.
Consensus-based statement 5.S25
Expert consensus
Level of consensus +++
In general, immediate removal of an inserted IUD in the event of genital or ascending
genital infection/pelvic inflammatory disease will not necessarily lead to better
healing of the infection or fewer complications.
Consensus-based recommendation 5.E34
Expert consensus
Level of consensus ++
In cases with ascending genital infection/pelvic inflammatory disease, the IUD may
either be removed immediately or only if the infection fails to respond to targeted
treatment.
Consensus-based statement 5.S26
Expert consensus
Level of consensus +++
The risk of perforation during IUD placement is very low. It depends on the experience
and training of the medical staff carrying out the IUD insertion and the presence
of risk factors such as puerperium and breastfeeding.
Consensus-based recommendation 5.E36
Expert consensus
Level of consensus +++
Women must be informed about the risk of uterine perforation prior to placement of
an IUD. If there is a clinical suspicion of perforation, examination by ultrasound
or, if necessary, an X-ray examination must be carried out.
Consensus-based statement 5.S27
Expert consensus
Level of consensus +++
The risk of expulsion is higher in the first 12 months after IUD placement as well
as during the first weeks after giving birth and in women with hypermenorrhea/menorrhagia.
After expulsion of an IUD, repeat placement of a device results in repeat expulsion
in up to 40% of users.
Consensus-based recommendation 5.E38
Expert consensus
Level of consensus +++
Users must be made aware of the risk of expulsion prior to placement of a device.
Consensus-based statement 5.S28
Expert consensus
Level of consensus +++
Studies have not yet identified the optimal approach to take for dislocation.
Consensus-based recommendation 5.E39
Expert consensus
Level of consensus ++
If dislocation occurs or the IUD is low, removal of the IUD may be considered only
after another effective form of contraception is being used.
Consensus-based statement 5.S29
Expert consensus
Level of consensus +++
The rates of early termination of IUD use due to bleeding and pain are comparable
for different Cu-IUDs.
Consensus-based recommendation 5.E41
Expert consensus
Level of consensus ++
If a woman reports that she suffers from dysmenorrhea while she is being advised about
contraceptive methods, she must be made aware that her dysmenorrhea may even increase
following IUD placement and that dysmenorrhea is a common reason for early removal
of an IUD.
Consensus-based recommendation 5.E42
Expert consensus
Level of consensus ++
The 52 mg LNG-IUD may also be used therapeutically to reduce hypermenorrhea and dysmenorrhea,
e.g., in women with endometriosis or adenomyosis.
Consensus-based statement 5.S30
Expert consensus
Level of consensus +++
Pregnancies in women with an IUD are rare. If a pregnancy occurs despite the presence
of an IUD, such pregnancies are more likely to be ectopic. If an intrauterine pregnancy
is maintained, it is not clear whether the risk of complications of pregnancy will
be reduced by removal of the IUD.
Consensus-based recommendation 5.E44
Expert consensus
Level of consensus ++
If a pregnancy occurs despite IUD use, women must be informed about the increased
risks associated with such pregnancies. The IUD may be removed during pregnancy.
Consensus-based statement 5.S31
Expert consensus
Level of consensus ++
According to current data, IUD use does not impair fertility.
Consensus-based statement 5.S32
Expert consensus
Level of consensus +++
Use of a Cu-IUD reduces the risk of cervical cancer. It does not increase the risk
of other malignant gynecological diseases and metabolic disorders.
Consensus-based recommendation 5.E47
Expert consensus
Level of consensus +++
Women with risk factors for or existing metabolic disease may be recommended to use
a Cu-IUD.
Placement of a Cu-IUD may be recommended to women with risk factors for or with existing
cancer with the exception of uterine carcinomas.
Consensus-based statement 5.S33
Expert consensus
Level of consensus ++
The effect of a Cu-IUD on sexuality has not been sufficiently investigated.
Consensus-based statement 5.S34
Expert consensus
Level of consensus +++
The WHOʼs Medical Eligibility Criteria provide information on contraindications for
uterine contraception.
Consensus-based recommendation 5.E50
Expert consensus
Level of consensus +++
Possible contraindications must be reviewed on a case-by-case basis prior to placement
of an IUD.
Consensus-based recommendation 5.E51
Expert consensus
Level of consensus ++
Careful sonographic evaluation of the uterine anatomy which includes assessment of
the cavity of the uterus must be done prior to placement of an IUD.
No IUD should be placed in women with bicornuate uterus or higher-grade subseptate/septate
uterus.
Consensus-based statement 5.S35
Expert consensus
Level of consensus ++
Nulliparity and younger age do not affect the occurrence of complications during IUD
use such as ascending genital infections or perforations. Studies have shown that
placement of an IUD in nulliparous women is associated with higher rates of pain.
Young users, particularly users aged < 20 years, may have a higher risk of expulsion.
Consensus-based recommendation 5.E53
Expert consensus
Level of consensus +++
Intrauterine conception with an IUD must also be offered to young women and nulliparous
women.
Consensus-based statement 5.S36
Expert consensus
Level of consensus ++
The immediate or early placement of an IUD after a termination of pregnancy or miscarriage
is not associated with a higher risk of infection. There is a higher risk of expulsion
if placement is done immediately or very soon after a termination of pregnancy or
miscarriage in the late first or early second trimester of pregnancy. However, the
number of prevented subsequent pregnancies is higher than if IUD placement is delayed.
Consensus-based recommendation 5.E55
Expert consensus
Level of consensus +++
* under the same anesthesia
If a woman chooses an IUD for her contraception, placement of the IUD should be offered
immediately* following a surgical termination of pregnancy or, if the termination
was medically induced, as soon as possible following confirmation of complete termination
of the pregnancy.
The risk of expulsion after early placement must be weighed up on a case-by-case basis
against the higher risk of a repeat unplanned pregnancy.
Consensus-based recommendation 5.E56
Expert consensus
Level of consensus ++
Women who want intrauterine contraception after they have given birth should not undergo
IUD placement in the first 4 weeks following the birth because of the higher risk
of expulsion. If a woman nevertheless requests IUD placement very soon after giving
birth, the placement may be carried out if the woman has been informed about the higher
risk of expulsion.
Consensus-based statement 5.S37
Expert consensus
Level of consensus ++
Cu-IUP is the most effective method of emergency contraception if placement is carried
out within 5 days after unprotected sexual intercourse.
Consensus-based recommendation 5.E58
Expert consensus
Level of consensus ++
Placement of a Cu-IUD for emergency contraception must be offered to all women but
must take any restrictions on the use of this method into account.
Consensus-based statement 4.S38
Expert consensus
Level of consensus +++
MRI examination can be carried out with an IUD in place. Studies have shown that MRI
scans do not affect the position of an IUD.
Consensus-based recommendation 4.E60
Expert consensus
Level of consensus ++
An IUD must not be removed prior to an MRI scan.
Consensus-based statement 5.S39
Expert consensus
Level of consensus +++
There are no indications that the removal of menstrual cups results in (partial) expulsion
of an IUD.
Consensus-based statement 5.E62
Expert consensus
Level of consensus +++
No data is available for recommendations on the safe use of menstrual cups when an
IUD is in place.
2. Sterilization
Consensus-based statement 6.S40
Expert consensus
Level of consensus ++
Careful and detailed information prior to the intervention (if necessary, with the
aid of a translator) is vitally important as it creates the basis for the most satisfactory
adjustment to this permanent form of contraception. The very limited data does not
currently allow any statements to be made favoring a particular sterilization technique.
Consensus-based recommendation 6.E63
Expert consensus
Level of consensus ++
Tubal ligation should be carried out in the follicular phase of the menstrual cycle.
Consensus-based statement 6.S41
Expert consensus
Level of consensus ++
Both tubal ligation (female sterilization) and male sterilization are very effective
contraception methods. Male sterilization is less invasive.
Consensus-based recommendation 6.E64
Expert consensus
Level of consensus ++
Information must be provided about the options with regards to female and male sterilization,
including the safety and effectiveness of the methods, their risks and the side effects.
Consensus-based statement 6.S42
Expert consensus
Level of consensus ++
Female age of less than 30 years, nulliparity, no partner or stressful relationship
with partner, death of a child, a new relationship, psychological disorder, close
temporal association to a prior pregnancy, and insufficient information about alternative
methods of contraception are risk factors for regretting the sterilization at a later
point in time, which is associated with wishing for the restoration of fertility.
Consensus-based recommendation 6.E65
Expert consensus
Level of consensus ++
When a decision is being made to sterilize a nulliparous person, additional information
must be provided where necessary, to ensure that the affected person is aware of all
contraceptive options and, having considered them, is able to make an informed decision
in favor of sterilization.
Consensus-based recommendation 6.E66
Expert consensus
Level of consensus ++
Prior to carrying out a sterilization, information must be provided about alternative
methods of contraception. During the talk, the risk of regretting the sterilization
at a later point in time must be addressed. If there is a suspicion that the person
may be ambivalent or if there are biographical and/or traumatic experiences underlying
the wish for sterilization which explain the lack of wanting to have children, the
person should be offered professional support (counselling services for sexual health
and family planning, psychologyical or psychiatric services). Observing a cooling-off
period with time for reflection after counselling appears to be particularly advisable
in this situation.
Consensus-based statement 6.S43
Expert consensus
Level of consensus +++
Surgery to restore fertility may result in tubal patency. This cannot be equated with
restored fertility.
Consensus-based recommendation 6.E67
Expert consensus
Level of consensus +++
If sterilization was done using tubal implants, ART must be used instead of an operation
to restore fertility.
Consensus-based statement 6.S44
Expert consensus
Level of consensus ++
The probability that sterilization will be regretted increases if the decision for
sterilization is made only a short time after a pregnancy.
Consensus-based recommendation 6.E68
Expert consensus
Level of consensus +++
A person wishing to be sterilized should be advised against sterilization if there
is a direct and recent temporal assocation between the wish for sterilization and
a recent pregnancy. If a person requests sterilization after a recent pregnancy, they
must be informed about alternatives and explicity be made aware of the increased risk
of regretting the sterilization.
Consensus-based statement 5.S45
Expert consensus
Level of consensus ++
Sterilization does not change the pattern of menstrual bleeding. No hormonal changes
have been observed following sterilization.
Consensus-based statement 6.S46
Expert consensus
Level of consensus ++
A careful genital examination together with information and advice about the procedure
and the consequences of the intervention (if necessary, with the help of a translator)
is crucial to create the basis for an informed decision on the part of the patient
and for their adjustment to this permanent method of contraception.
Consensus-based statement 6.S47
Expert consensus
Level of consensus +++
Non-scalpel vasectomy (NSV) procedures appear to be associated with lower complication
rates and shorter operating times.
Consensus-based recommendation 6.E69
Expert consensus
Level of consensus +++
A vasectomy procedure may consist of ligation and excision of the vas with tissue
interposition and/or intraluminal cauterization of the vas. If cauterization is carried
out, it is important to be aware of the longer length of the scar which can make it
significantly more difficult to potentially carry out microsurgery to restore fertility.
Consensus-based statement 6.S48
Expert consensus
Level of consensus +++
There are no indications that male sterilization increases the risk of later cardiovascular
events or disease.
Consensus-based statement 6.S49
Expert consensus
Level of consensus +++
There are no indications that male sterilization increases the risk of developing
malignant testicular cancer.
Consensus-based statement 5.S50
Expert consensus
Level of consensus +++
There are some indications that male sterilization could slightly increase the risk
of prostate cancer later on.
If the factor “PSA-based screening” is taken into account, there are no clear indications
for an association between undergoing vasectomy and later development of aggressive,
advanced or fatal prostate cancer.
But a conclusive statement on this issue is not possible because of the current lack
of scientific data.
Consensus-based statement 6.S51
Expert consensus
Level of consensus +++
Peri- and post-operative complications related to male sterilization are very rare,
especially if non-invasive surgical methods (e.g., non-scalpel vasectomy [NSV]) are
used.
Consensus-based recommendation 6.E70
Expert consensus
Level of consensus +++
Information about alternative contraceptive methods must be provided prior to sterilization.
The risk of regretting the sterilization at a later point in time must be addressed
during the discussion. It is advisable to have a cooling-off period with time for
reflection after counselling.
Professional psychological support should be offered if ambivalence is suspected or
if the wish for sterilization is due to traumatic experiences which explain the lack
of a desire to have children.
Consensus-based recommendation 6.E71
Expert consensus
Level of consensus ++
Prior to male sterilization the man must be informed that even when vasectomy has
been carried out correctly, there is still a minimal residual risk (ca. 1 : 2000)
of a later unplanned pregnancy and that therefore follow-up examinations to check
whether the operation was successful are advised.
Consensus-based statement 6.S52
Expert consensus
Level of consensus ++
The technical and organizational conditions for an appropriate laboratory which is
able to provide post-vasectomy check-ups with semen analysis (spermiogram) are given
in the current edition of the WHO Laboratory Manual for the Examination and Processing
of Human Semen.
Consensus-based recommendation 6.E72
Expert consensus
Level of consensus +++
The patient must be informed about the fact that directly after vasectomy, protection
against unplanned pregnancy is not yet reliable and that another form of contraception
must be used until the success of the operation has been properly established by the
surgeon or delegated physician.
Consensus-based recommendation 6.E73
Expert consensus
Level of consensus ++
The patient may be informed that regular postoperative ejaculation will probably reduce
the time until the desired azoospermia is achieved.
Consensus-based recommendation 6.E74
Expert consensus
Level of consensus ++
The first required control spermiogram may be carried out from 8 weeks after the vasectomy.
Consensus-based recommendation 6.E75
Expert consensus
Level of consensus ++
A spermiogram which shows azoospermia or very few immotile sperm (< 100000 immotile
sperm/ml) is sufficient for the vasectomy to be considered a success if the spermiogram
is done by a qualified certified laboratory using fresh, previously centrifuged ejaculated
sperm. Men with large numbers of immotile sperm (> 100000/ml), a number of motile
sperm in the first spermiogram, no opportunity to obtain ejaculated sperm close to
the time of sperm analysis or where there are indications that the quality of the
spermiogram analysis was deficient should subsequently have a second sperm analysis
to confirm the success of the vasectomy.
Consensus-based statement 6.S53
Expert consensus
Level of consensus +++
No hormonal changes have been observed following male sterilization.
Consensus-based statement 6.S54
Expert consensus
Level of consensus ++
Around 6 percent of all men later go on to doubt their vasectomy. Risk factors for
this are poor communication with their partner, conflicts or dominance by the partner
when making the decision, and younger age of the man.
Consensus-based statement 6.S55
Expert consensus
Level of consensus ++
If a person wishes to have children after vasectomy, surgical restoration of fertility
to recover procreative capacity or enable TESE-ICSI is possible.
In Germany, Austria, and Switzerland, however, this involves financial costs for the
patient as well as medical risks associated with repeat surgery and/or reproductive
medicine procedures which are associated with risks for the partner.
Consensus-based recommendation 6.E76
Expert consensus
Level of consensus ++
* Switzerland
A decision to sterilize a person who is incapable of consent/lacks the ability to
make a sound judgment* must only be taken after interdisciplinary consultation.
