INTRAUTERINE DEVICES

INTRODUCTION AND HISTORY• IUDs are one of the way of long term contraceprion.• used by 15% of women world wide, in INDIA its 11%.• The IUD has had a troubled history. • Its survival has been jeopardized several times from the beginning.• first genuine IUD was devised by Dr Richter in 1909- consisting of silkworm catgut ring with a nickel and bronze wire protruding through cervix, shortly Pust modified the design he combined the ring with button type passary and rplaced the wire with catgut, this IUD was used in Germany during world war II.•In 1920s Grafenberg removed tail and pessary as he belived that it causes infection.• Grafenberg’s ring was associated with high expusion rate.

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• Further many modifications were made as far as size and shape and material is concerned to minimize side effects.• In the 1960s it was 1st time when plastic devices were developed impregnated with barium, The Margulies coil devised by Lazer Margulies was the 1st plastic devise with a memory, which allow the use of inserter and reconfiguration of shape in uterus, the coil was large associated with bleeding and cramping and was withdrawn.• In 1962 Dr J.Lippes presented his experience with his device in front of 1st international conference ‘Lippes loop’which quickly became most widely used IUD.• Further many designs came in between but the addition of copper to IUD was suggested by Dr. Jaime Zipper whose experiments indicate that Cu acted locally on endometrium.• It was Haward Tatum who combined this idea with development of T-shape, 1st copper containing IUD was Cu T 200, also called as Tatum-T.•Followed by further modification to increase efficacy and life span and recently medicated IUD are introduced.

Types of IUDs

Classification• Non medicated IUDs Lippes loop• Medicated copper containing IUDs Cu T 200, Cu T 380 A, Multiload-250,

Multiload-375, Nova T.• Hormone containing IUDs LNG-20

Early IUDs

Lippies Loop Self T Coil Dalkon Shield

Copper containing IUDs

Cu T 200Cu T 220

Copper containing IUD

Multi load 375 Nova T

MECHANISM OF ACTIONNon medicated IUDs – Leads to foreign body reaction (produces

sterile inflammatory response) which is spermicidal.

Copper IUDs- Leads foreign body reaction & in addition produces alteration in cervical mucus & endometrial secretion, and initiates

release of cytokine peptides known to be cytotoxic.

Hormone containing IUD- Levonorgestrel IUD suppresses endometrium leading to atrophy & thickens cervical mucus hindering

penetration

Characteristics of IUDs

• Highly effective and economical• No interference with intercourse• Easy to us• Long acting• Locally acting• easily reversible and quick return to fertility

Copper containing IUDs

• Cu T 200Contains 200 sq mm surface area of wire

containing Cu.Cu wire wounded round the vertical stem,

T shaped frame made of Polyethylene, with polyethylene threads.

life span is 3 yearsFailure rate 3%

• Replaced by modern copper IUDs containing more copper with increased efficacy and life span.

Cu T 380 A

• Holds 380 mm2 of Cu, wire wounded on stem with extra copper sleeves on both arms of T.• “A” indicates Arms, indicating importance of copper sleeve on each arm with introduction of sleeves efficacy and lifespan is increased.• life span 10 yrs• failure rate- 0.3 to 0.8 per HWY• further ball at the bottom of stem reduce risk of perforation and reduces cramp like pain

LNG-20LNG-20 consists of a T-shaped polyethylene frame (T-body) with a steroid reservoir around the vertical stem. The reservoir made of a mixture of levonorgestrel and silicone containing a total of 52 mg levonorgestrel. The reservoir is covered by a semi-opaque silicone membrane. The T-body is 32 mm in both the horizontal and vertical directions. The polyethylene of the T-body is compounded with barium sulfate.The reservoir releases 20mcg per day which declines to half rate after 5 years.Life span- 5 yrs in USA & 7 yrs in Europe

and Asia( has to be changed)Failure rate-0.1 to 0.2 per HWY

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Other uses of LNG 201) Extensively used to treat Heavy menstrual bleeding as n

alternative to hysterectomy.2) Has beneficial effect in menorrhagia from uterine fibroid,

benefit may be diminished with distorting sub mucosal fibroid.

3) The local Progestin effect directed to endometrium can be utilized in patients on tamoxifen, and in women receiving estrogen therapy.

4) Reduces risk of Ca endometrium5) Improvement in symptoms of endometriosis and

adenomyosis.

Who can use IUDs Can be safely used by women who:• are of various age and parity (young and nulliparous women should told about expulsion risk.

• are post partum, post abortion of breast feeding.

• have chronic condition, including Hypertension, cardiovascular disease, diabetes, liver & gall bladder disease.

Contraindications of IUD• Pregnancy• Puerperal sepsis• PID• STDs current or within the past 3 months• Endometrial or cervical cancer• undiagnosed genital bleeding•Uterine anomalies•Fibroid tumors distorting the endometrial cavity• Copper allergy and wilson’s disease Infection with HIV no more contraindication for IUD use as no increase in PID, Female to male transmission, or viral shedding was found among HIV-1 infected women.

Time of Insertion• IUDs can be safely inserted at any time after

Delivery ( Normal or Cesarean)Abortion ( spontaneous or induced)or during the menstrual cycle.

• Expulsion rate were higher when the older, large plastic IUDs were inserted sooner than 8 weeks

but Cu T can be inserted between 4 to 8 weeks postpartum without an increase in pregnancy rates, expulsion, uterine perforation, or removal from bleeding and/or pain.• Post delivery insertion

NOT associated with infection, perforation, PPH, or sub involution, but associated with slightly higher expulsion rate as compare with insertion 4-8 weeks. Cont…….

• IUDs can also be inserted at cesarean section; the expulsion rate is slightly lower than with insertion immediately after vaginal delivery.

• IUDs can be inserted after 1st trimester abortion but after 2nd trimester it is recommended to wait until uterine involution occurs.

• Post menstrual insertion- advantage of open cervical canal and masking of insertion related bleeding

further evidences support that expulsion rate, termination rate, bleeding and pregnancy are lower if insertion is performed after day 11 of menses, and infection rate may be lower with insertion after 17th cycle day.

Screening the patient before IUD insertion• Age and parity are not the critical factors in selection, most of the women are good candidate for IUD.

• Pregnancy to be ruled out.

• Detail history pertaining to sign and symptoms suggestive of PID to be elicited as any current, recent or recurrent PID is a contraindication for IUD use.

• High risk behavior, women with multiple sexual partner, drug or alcohol dependent, not in stable sexual relationship are at greater risk of PID at the time of insertion and at greater risk of acquiring a STD after IUD insertion.

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• Ideal choice for a women with diabetes, specially if vascular disease is present.•Not contraindicated in Heart diseases, patient at risk of endocarditic should be treated with prophylactic antibiotics.• A careful PS and bimanual examination is must

- position of uterus; undetected extreme posterior position is most common reason for perforation.

- A very small or large uterus can preclude insertion, for successful use, the uterus should preferably not sound less than 6cm or more than 9cm.

- also helps to rule out cervical or vaginal infection and any bleeding though OS.

ADVICE after insertion

• Protection against unwanted pregnancy begins immediately after insertion.• Menses can be longer and heavier (except with hormonal IUDs)• IUDs can be spontaneously expelled; monthly palpation of the strings is important, If a string are not felt clinician to be notify further backup contraception should be provided until patient can be examined.

Infections • IUD related bacterial infection are due to contamination of cavity at time of insertion.• The early insertion related infections therefore, are polymicrobial, and derived from endogenous cervicovaginal flora, with predominance of anaerobes.• As per WHO clinical trial data, risk of PID is 6 times higher during 20 days after the insertion compared with later times during follow up, but most importantly PID is extremely rare beyond the first 20 days after insertion.• Risk of PID does not increase with long term use.• The sexual behavior of the patient is one of the strong modifier of the risk of infection- advice a barrier contraception in addition to IUD

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Prevention of Infections• The problem of infection can be minimized with careful screening and by following aseptic techniques.•Doxycycline 200mg or Azithromycin 500 mg orally 1 hour prior to insertion provide protection against PID, but are probably of little benefit for women at low risk for STIs. •IUDs are not contraindicated in women who are at increased risk of bacterial endocarditis• antibiotic prophylaxis of 2 gm amoxyxillin should be given 1 hour prior before insertion or removal.

Treatment of Infections• Asymptomatic IUD users whose cervical cultures showing growth of Gonorrheal or Chlamydia infection should be treated without removal of IUD.• vaginal bacteriosis should be treated without removal of IUD unless pelvic infection is present.•If infection has spread to endometrium, or fallopian tubes IUD should be removed promptly with specific medical management.• If infection is sever as evidence by cervical motion tenderness, abdominal rebound tenderness, adnexal tenderness or masses, or elevated WBC count, and sedimentation rate- parenteral treatment is indicated with removal of IUD

HIV and IUDs

• IUDs are not contraindicated in women with HIV positive status.• does not increase risk female to male transmission.• No grater incidence of complication (including PID).

Actinomyces• Actinomyces are commonly present in vaginal flora.•The only pelvic infection that was unequivocally related to IUD use is Actinomycosis.• Incidence is less than 1% with copper containing IUD.• symptomatic patients should be treated with oral Penicillin G 500 q.i.d. for 1 month or Tetracycline 500 mg q.i.d. , Doxy 100 mg b.d , amoxy/clavulanate 500 mg b.d.

Bleeding with IUDs

• Most common cause of IUD discontinuation- increased uterine bleeding and increased pain during menses.• Bleeding and cramping are most sever in first few months after IUD insertion- NSAID are helpful during menses.• Use of copper IUD leads to increase in menstrual blood loss by about 55%, and this level of bleeding continues for duration of use, however its no so with LNG-20, it leads to oligomenorrhea in 70% of women and in 30-40% amenorrhea (sometimes women wants IUD removal because of lack of periods).

IUDs AND ECTOPIC PREGNANCY• IUDs do not increase the risk of ectopic pregnancy however, if pregnancy occurs, the likelihood of an ectopic pregnancy is high.• A WHO multicentre study concluded that IUD users were 50% less likely to have an ectopic pregnancy when compared with women using no contraception.• This protection is not as great as that achieved by inhibition of ovulation with oral contraceptive.• Risk do not increase with duration of use of Cu T 380 A and LNG-20.

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ECTOPIC PREGNANCY RATE PER 1000 women year

Non-contraceptive users, all ages 3.00-4.50

LNG-20 0.20

Cu T 380A 0.20

• In a 7-year prospective study, not a single ectopic pregnancy was encounter with LNG-20. In 8,000 woman-year of experience in multicentre trials, there has been only a single ectopic pregnancy reported with Cu T 380A.• The protection against ectopic provided by Cu T 380A and LNG-20 makes these IUDs acceptable choices for contraception in women with previous ectopic pregnancy.

Pregnancy with IUDs in situ• Spontaneous miscarriage occurs more who became pregnant with IUD in situ, a rate of 40 to 50%.

• Remove IUD if pregnancy is confirmed provided string is visible, use of instruments inside uterus should be avoided.

• after removal spontaneous abortion rate is 30%.

•If IUD is easily removed without trauma or expelled during the first trimester, the risk of spontaneous miscarriage is not increased. Cont….

• When the string of IUD is not visible-Perform an USG to localize IUD and to determine

whether expulsion has occurred.-if IUD is present, 3 options 1) Therapeutic abortion

2) USG guided removal 3) Continuation of pregnancy with device left in situ.• USG guided removal possible when IUD is not in fundal region, if its in fundal region should be left in situ.• IUD left in situ with pregnancy has higher incidence (4 fold) of PTLP’s with no evidence of risk of congenital malformaiton.

IUDs and uterine perforation• 1 in 1000, risk linked to skill and experience of clinician.

• Most perforation occurs at the time of insertion but migration may occur following initial partial perforation.

•Most perforation go undetected as it leads to transient pain and bleeding at time of insertion, so in case of doubt perform USG to detect position of IUD.

•Suspected when no thread is visible through Ext OS with appearance of pelvic symptoms in women using IUD.

•Further Negative findings on exploration of uterine cavity by a probe is suggestive.

• USG helps in localization of IUD (better than X-ray)

• Cu containing devise if displaced in peritoneal cavity leads to adhesion formation and should be removed via laparoscopy or laparotomy.

Dealing with missing thread…..• 3 Possibilities

• Expulsion.• Displacement (IUD inside uterus but displaced).• perforation and migration to peritoneal cavity.

• All IUDs are radiopaque, but localization with help of X-ray needs 2-3 views and does not allow intrauterine direction of instruments, So USG is best way to locate an IUD.•If IUD is inside uterus an can be grasping with help of forceps under USG guidance, if not possible next is hysteroscopic removal of embedded IUD.• If IUD is identified perforating myometrium or in the abdominal cavity to be removed with help of laparoscopy.• With sighs and symptoms of peritonitis with perforation laprotomy should be done.

IUD as Emergency contraception• Efficacy for emergency contraception is 100% when the device is inserted up to 5 days after intercourse.• and almost 100% up to 7 days after intercourse.• Best is Cu T 380 A• Advantage of using Cu T 380 A as emergency contraception is patient can continue with it for long term contraception making it cost effective.• Whether LNG-20 would work for emergency contraception is not known.