If a client believes they are pregnant, they should return to a provider trained to offer the hormonal IUD. Removal of the hormonal IUD following confirmation of pregnancy is preferred, if still physically possible, but may result in the termination of early-stage pregnancy. Providers should outline the risks and benefits of both removal and non-removal to clients and support their decision-making regarding both continuing/terminating the pregnancy and removing/retaining the hormonal IUD. If a client wants to continue their pregnancy and opts to retain their hormonal IUD, they should be counseled on risks (see below) and considered at elevated risk for miscarriage and ectopic pregnancy. Close follow-up during their pregnancy to monitor for these complications is necessary.

Pregnancy during use of a hormonal IUD is a significant medical event and should be addressed promptly. Pregnancies occurring while a hormonal IUD is placed are more likely to be ectopic and more likely to result in miscarriage or pre-term birth if the hormonal IUD is not removed. Infection risk is also elevated if a pregnancy is continued without hormonal IUD removal. These pregnancies should be considered high risk and should be monitored closely.

Hormonal IUDs can be inserted either immediately post-partum (within 48 hours of childbirth) or any time after the uterus has returned to its pre-pregnancy size and shape, typically 4-6 weeks following birth. They should not be inserted after 48 hours but before 4 weeks. Post-partum insertion is associated with slightly higher risk of expulsion and perforation, but the overall risk of these complications remains extremely low. Providers should discuss their clients’ plans and preferences for post-partum contraception during their routine prenatal check-ins.

Yes, because almost all of the levonorgestrel in the hormonal IUD is released and absorbed directly into the uterus and cervix, and very little enters the bloodstream, it is safe to breastfeed while using a hormonal IUD. Clinical evaluation of hormonal IUD use 6+ weeks following childbirth has not shown any adverse effects on milk quantity/quality or infant growth and development. Breastfeeding is associated with a modestly increased risk of uterine perforation during insertion, but this risk remains extremely low overall. Providers should take extra caution during hormonal IUD insertion to ensure the method is place correctly.

No, the hormonal IUD does not cause blood clotting and is safe to use by individuals at elevated risk of developing clots. The hormone in the hormonal IUD, levonorgestrel, is a synthetic form of the hormone progesterone, which has no association with blood clotting. This is different from contraceptives that contain the hormone estrogen, like the combination pill or many implants, which increase risk of blood clots.