S2k-Guideline Non-hormonal Contraception, Part 2: Intrauterine Devices and Sterilization

Abstract

Aim This official guideline was published and coordinated by the DGGG, OEGGG and SGGG with the involvement of other medical societies. The aim was to provide a consensus-based overview of non-hormonal forms of contraception based on an evaluation of the relevant literature. The first part of these summarized statements and recommendations presents natural family planning methods such as lactational amenorrhea, barrier methods and coitus interruptus. The second part focuses on intrauterine devices and sterilization.

Methods This S2k-guideline was developed by representative members from different medical professions on behalf of the guidelines commission of the DGGG, OEGGG and SGGG using a structured consensus process.

Recommendations The guideline provides recommendations on the indications for, safety of use, benefits, and limitations of the different methods as well as recommendations on providing advice and other aspects of non-hormonal contraception. This summary presents recommendations and statements about intrauterine devices and female and male sterilization.

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)/ AWMF/non-AWMF professional society/ organization/association
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
Standard Days method [10]	12	5
symptothermal method, Sensiplan [4]	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.

Conflict of Interest/Interessenkonflikt

The conflicts of interest of all the authors are listed in the long German-language version of the guideline./Die Interessenkonflikte der Autor*innen sind in der Langfassung der Leitlinie aufgelistet.

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Publication History

Received: 25 April 2024

Accepted: 29 April 2024

Article published online:
06 August 2024