Intra Uterine Device

Ruswana Anwar, dr, SpOG(K),MKes

Copper IUDs (Nova-T, Flexi-T and CuT
380 A) and a levonorgestrel-releasing
device (Mirena) are currently available.
Mirena is also referred to as a
levonorgestrel-releasing intrauterine
system (LNG-IUS).
INTRODUCTION
In a large trial:
1. The failure rate of a copper IUD
(Nova-T) was 1.26 per 100 women-
years (WY) and
2. The rate of ectopic pregnancy
was 0.25 per 100 WY.
EFFICACY
The failure rate of the
levonorgestrel-releasing
intrauterine system was
0.09 per 100 WY and
The ectopic pregnancy rate was
0.02 per 100 WY.
EFFICACY
Although the product monograph for the
Nova-T copper IUD suggests that it be
replaced every 30 months, clinical trials
have shown that it is effective for 5 years.
The Flexi-T 300 copper IUD and the LNG-
IUS should be replaced every 5 years.
EFFICACY
CONTRAINDICATIONS
The World Health Organization
(WHO) has developed a list of
absolute and relative
contraindications to use of an
IUD.
ABSOLUTE CONTRAINDICATIONS
1. Pregnancy :current, recurrent, or recent (within past 3
months)
2. Pelvic inflammatory disease (PID) or sexually transmitted
infection (STI)
3. Puerperal sepsis
4. Immediate post-septic abortion
5. Severely distorted uterine cavity
6. Unexplained vaginal bleeding
7. Cervical or endometrial cancer
8. Malignant trophoblastic disease
9. Copper allergy (for copper IUDs)
10. Breast cancer (for LNG-IUS)
RELATIVE CONTRAINDICATIONS
1. Risk factor for STIs or human
immunodeficiency virus (HIV)
2. Impaired response to infection
- in HIV-positive women
- in women undergoing corticosteroid therapy
from 48 hours to 4 weeks postpartum
3. Ovarian cancer
4. Benign gestational trophoblastic disease
SIDE EFFECTS
1. BLEEDING
2. PAIN OR DYSMENORRHEA
3. HORMONAL
4. FUNCTIONAL OVARIAN CYSTS
Irregular menstrual bleeding or an
increase in the amount of bleeding are
the most common side effects of IUDs
in the first months after insertion.
Menstrual blood loss in users of
copper IUDs increases by up to 65%
over non-users.
1. BLEEDING
Use of non-steroidal anti-
inflammatory agents
(NSAIDs) or tranexamic acid
may help to decrease the
amount of menstrual blood
loss.
1. BLEEDING
By contrast, users of the LNG-IUS
experience a reduction in menstrual blood
loss of between 74 and 97%.
Women using the LNG-IUS have an
average of 16 days of bleeding or spotting
at 1 month after insertion, and this
decreases to an average of 4 days by 12
months after insertion.
1. BLEEDING
2. PAIN OR DYSMENORRHEA
Up to 6% of copper IUD and LNG-IUS users will have
discontinued use at 5 years because of pain.
Pain may be a physiological response to the presence
of the device, but the possibility of infection,
malposition of the device (including perforation), and
pregnancy should be excluded.
The LNG-IUS has been associated with a decrease in
menstrual pain.
RISKS
1. UTERINE PERFORATION
2. INFECTION
3. EXPULSION
4. FAILURE
1. UTERINE PERFORATION
Uterine perforation is a rare
complication of IUD insertion, occurring
at a rate of 0.6 to 1.6 per 1000
insertions.
All uterine perforations, either partial or
complete, occur or are initiated at the
time of IUD insertion.
Risk factors for perforation include:
1. Postpartum insertion,
2. An inexperienced operator, and
3. A uterus that is immobile,
4. Extremely anteverted or
5. Extremely retroverted.
1. UTERINE PERFORATION
2. INFECTION
Evidence from large cohort
studies ,case-control studies,
and randomized controlled trials
indicates that any risk of genital
tract infection after the first
month of IUD use is small.
There appears to be an inverse relation
between the risk of infection and the time
since IUD insertion.
The Womens Health Study data showed a
relative risk of PID of 3.8 in the first month
after insertion, reaching baseline risk after
4 months.
2. INFECTION
Investigations by the World Health Organization
found the risk to be highest in the first 20 days
following insertion.
Although insertion of an IUD contaminates the
endometrial cavity with bacteria, the cavity
becomes sterile soon afterwards.
Exposure to STIs, and not the use of the IUD
itself, is responsible for PID occurring after the
first month of use.
2. INFECTION
It remains unclear whether the risk
of PID is reduced in users of the
LNG-IUS compared to users of the
copper IUDs.
IUD users should continue to use
condoms for protection against
STIs.
2. INFECTION
3. EXPULSION
Expulsion of the IUD is most common in the first year
of use (210% of users).
The 5-year cumulative expulsion rate for the copper
IUD is 6.7% and for the LNG-IUS is 5.8%.
Risk factors for expulsion include insertion
immediately postpartum, nulliparity, and previous IUD
expulsion.
A woman who has expelled one IUD has a 30%
chance of expelling a subsequent device.
4. FAILURE
If a woman becomes pregnant with an IUD in situ, the
possibility of ectopic pregnancy must be excluded.
The risk of spontaneous abortion is increased in
women who continue a pregnancy with an IUD in
place.
The UK Family Planning Research Network study
found that 75% of pregnancies aborted if a copper IUD
was left in situ, but that early removal virtually
eliminated the risk of septic abortion.
If the IUD was removed, 89% of women
had a live birth, compared to 25% of
women who left the IUD in place.
Although the risk of spontaneous
abortion appears to be normalized after
IUD removal, the risk of preterm
delivery remains higher.
4. FAILURE
1. Nulliparous women cannot use IUDs.
2. IUDs increase the risk of ectopic pregnancy.
3. IUDs increase the risk of infertility.
4. IUDs increase the long-term risk of PID.
5. IUDs are not effective contraceptives.
MYTHS AND MISCONCEPTIONS
MYTHS AND MISCONCEPTIONS
Nulliparous women cannot use IUDs.
Fact:
Nulliparity is not a contraindication to
IUD use.
In carefully selected nulliparous women,
IUDs may be successfully used.
IUDs increase the risk of ectopic pregnancy.
Fact:
IUDs do not increase the risk of ectopic pregnancy.
Because IUDs work primarily by preventing
fertilization, IUD users have a lower risk of ectopic
pregnancy than women who are not using any form of
birth control (0.020.25/100 WY versus 0.120.5/100
WY).
However, in women who conceive with an IUD in
place, the diagnosis of ectopic pregnancy should be
excluded.
MYTHS AND MISCONCEPTIONS
IUDs increase the risk of infertility.
Fact:
IUDs do not increase the risk of infertility.
Women who discontinue use of an IUD in order
to conceive are able to conceive at the same
rate as women who have never used an IUD.
Copper IUD use is not associated with an
increase in tubal factor infertility in nulliparous
women.
MYTHS AND MISCONCEPTIONS
IUDs increase the long-term risk of PID.
Fact:
The incidence of PID among IUD users is less than 2
episodes per 1000 years of use, similar to that of the
general population.
The increase in risk of PID associated with IUD use
appears to be related only to the insertion process.
After the first month of use, the risk of infection is not
significantly higher than in women without IUDs.
MYTHS AND MISCONCEPTIONS
IUDs are not effective contraceptives.
Fact:
IUDs are a highly effective method of birth
control.
In fact, in long-term users of IUDs, the failure
rate approaches that of tubal ligation.
The LNG-IUS appears to be as effective as tubal
ligation.
MYTHS AND MISCONCEPTIONS
INITIATION
Prior to insertion, informed
consent should be obtained and
the patient should be aware of
the risks, benefits, and
alternative methods of
contraception.
Patients should be counselled regarding
the potential side effects associated with
the IUD of choice, particularly alterations in
the menstrual cycle.
Patients should also be reminded that the
IUD does not protect against STIs or HIV.
INITIATION
The IUD can be inserted at
any time during the
menstrual cycle once
pregnancy or the possibility
of pregnancy can be
excluded.
INITIATION
Although the advantages of inserting the
IUD during or shortly after menses include
ruling out pregnancy and the masking of
insertion-related bleeding, there is no
evidence to support the common practice
of inserting the IUD only during menses.
INITIATION
In fact, infection and expulsion
rates may be higher when inserted
during menses.
The IUD can be removed and
replaced at the same time on any
day of the menstrual cycle.
INITIATION
Postpartum women may be candidates
for immediate IUD insertion (within 10
15 minutes after delivery of the
placenta).
These women are at higher risk of
expulsion and uterine perforation.
INITIATION
In most circumstances, it is best to wait
to insert the IUD until the uterus is
completely involuted, usually at 4 to 6
weeks postpartum.
Women should wait until 6 weeks post-
partum to have the LNG-IUS inserted.
INITIATION
An IUD can be safely inserted
immediately after a first trimester
pregnancy termination.
The cost-effectiveness of screening
for gonorrhea and chlamydia
infection prior to IUD insertion is
unclear.
INITIATION
The cervix should be carefully inspected
prior to IUD insertion, and,
if there is any evidence of mucopurulent
discharge or pelvic tenderness, cervical
swabs should be performed and IUD
insertion delayed until the results are
known.
INITIATION
ANTIBIOTIC PROPHYLAXIS
A Cochrane Collaboration review concluded
that neither doxycycline nor azithromycin
before IUD insertion conferred benefit.
According to the American Health Associations
1997 guidelines for prevention of bacterial
endocarditis (SBE), antibiotic prophylaxis is not
necessary prior to IUD insertion if there is no
obvious infection.
FOLLOW UP
A follow-up visit should be scheduled post-insertion.
This allows for:
1. the exclusion of infection,
2. an assessment of bleeding patterns,
3. an assessment of patient and partner satisfaction, and
4. an opportunity to reinforce the issue of condom use for
protection against STIs and HIV.
After this visit, an IUD user should continue annual
well-woman care as for any sexually active woman.
An IUD user should be instructed to contact her
healthcare provider if any of the following occur:
1. She cannot feel the IUDs threads
2. She or her partner can feel the lower end of the IUD
3. She thinks she is pregnant
4. She experiences persistent abdominal pain, fever, or unusual
vaginal discharge
5. She or her partner feel pain or discomfort during intercourse
6. She experiences a sudden change in her menstrual periods
7. She wishes to have the device removed or wishes to
conceive
TROUBLESHOOTING
1. LOST STRINGS
2. PREGNANCY WITH AN IUD IN PLACE
3. AMENORRHEA OR DELAYED MENSES
4. PAIN AND ABNORMAL BLEEDING
5. DIFFICULTY REMOVING THE IUD
6. STI IDENTIFIED WITH IUD IN PLACE
7. ACTINOMYCOSIS ON PAP SMEAR
1. LOST STRINGS
If an IUD user is unable to palpate the IUD
strings, a speculum exam should be
performed.
If the strings are not seen in the cervical os,
the device
1. May have been expelled,
2. May have perforated the uterine wall, or
3. The strings may have been drawn up into the
cervical canal.
Pregnancy should be excluded.
Once pregnancy is excluded, the
cervical canal should be explored
(with a cotton swab, forceps, or similar
instrument) to see if the
strings can be found.
1. LOST STRINGS
If the strings cannot be found,
ultrasound is the preferred method to
identify the location of the IUD.
If the device is seen within the uterus,
it can be left in situ.
1. LOST STRINGS
If the device is not identified within the
uterus or the pelvis, a plain x-ray of the
abdomen should be performed to
determine whether the device has
perforated the uterine wall.
Both the LNG-IUS and the copper IUD
are radio-opaque.
1. LOST STRINGS
Once she get pregnant, the diagnosis of an
ectopic pregnancy has been excluded,
The IUD should be removed if possible.
If the strings are visible, gentle traction is
applied to remove the device.
If the strings are not visible, gentle
exploration of the cervical canal is
performed.
2. PREGNANCY WITH AN IUD IN PLACE
If no strings are found, the possibility of
perforation must be considered.
This is best excluded by pelvic ultrasound.
Despite reports of successful hysteroscopic
IUD removal during the first trimester, if the
device remains in the uterus then usually no
attempt is made to remove it.
Note should be made of recovery of the IUD at
the time of delivery.
2. PREGNANCY WITH AN IUD IN PLACE
3. AMENORRHEA OR DELAYED MENSES
Pregnancy must be excluded.
Once pregnancy has been excluded, investigation
should be as for a woman without an IUD.
Up to 35% of LNG-IUS users may experience
amenorrhea.
If proper positioning of the LNG-IUS is confirmed, it is
unnecessary to perform repeated pregnancy tests.
If the IUD user is post-menopausal, the device should
be removed.
4. PAIN AND ABNORMAL BLEEDING
Increased menstrual bleeding with or without an
increase in menstrual cramping may occur in
IUD users.
In the event of partial expulsion or perforation,
the device should be removed and
consideration given to inserting another IUD.
In the first few months after insertion, pain and
spotting can also occur between menses.
Once partial expulsion, perforation,
pregnancy, and infection are ruled out,
treatment with NSAIDs may be helpful in
treating these symptoms.
The number of days of bleeding or spotting
usually decreases over time.
If pain or bleeding persists or worsens,
removing the IUD must be considered.
4. PAIN AND ABNORMAL BLEEDING
5. DIFFICULTY REMOVING THE IUD
Grasping the string with a ring forceps and
exerting gentle traction can usually
accomplish removal of an IUD.
If the strings cannot be seen, manoeuvres
such as those described above can be
used to assist in localizing the strings.
If further manoeuvres are needed, a
paracervical block may be considered.
A uterine sound can be passed into the
endometrial cavity to localize the IUD.
Cervical dilation may be required.
Once localized, the IUD can be
subsequently grasped with a small
grasping instrument directed towards
it.

5. DIFFICULTY REMOVING THE IUD
If removal is not easily performed,
direct visualization of the IUD with
ultrasound or hysteroscopy may be
required.
Occasionally general anesthetic
may be needed to carry out IUD
removal.
5. DIFFICULTY REMOVING THE IUD
6. STI IDENTIFIED WITH IUD IN PLACE
Appropriate antibiotic therapy should be
initiated for an IUD user (and her sexual
contacts) found to have chlamydial or
gonoccocal cervicitis.
If there is a suggestion of PID, the device
should be removed after pre-treating the woman
with antibiotics.
She should be counselled regarding the use of
barrier contraceptive methods for STI
prevention.
7. ACTINOMYCOSIS ON PAP SMEAR
Actinomycosis is considered a commensal
vaginal organism but may be associated with
frank infection.
Up to 20% of cervical smears in long-term
copper IUD users show evidence of
Actinomycosis, although this finding is only
noted in up to 3% of LNG-IUS users.
Removal of the device in women with
Actinomycosis on their Pap smear may not be
necessary.
In the asymptomatic woman, it is
reasonable to leave the IUD in place, follow
her with annual Pap smears and pelvic
examinations, and warn her of potential
symptoms of PID.
If the decision is made to treat, antibiotic
therapy with penicillin G, tetracycline, or
doxycycline may be given.
7. ACTINOMYCOSIS ON PAP SMEAR
If the woman is symptomatic, the
IUD should be removed after
antibiotic preloading.
If the infection is severe, she should
be hospitalized, treated for PID, and
investigated for possible abscess.
7. ACTINOMYCOSIS ON PAP SMEAR
SUMMARY STATEMENTS
In women who are at low
risk of acquiring STIs, the
use of an intrauterine
device may be an excellent
contraceptive option.
(Level II)
Efficacy rates for the levonorgestrel-
releasing intrauterine system
approach those of surgical sterilization;
it is therefore an excellent alternative to
surgical sterilization for women who
seek long-term contraception.
(Level II)
The copper IUDs (Nova-T
and Flexi-T 300) and the LNGIUS
(Mirena) provide effective
contraception for 5 years.
(Level I)
The risk of genital tract infection
after the first month of IUD use is
small.
There appears to be an inverse
relation between risk of infection
and time since IUD insertion.
(Level II)
Although the relative risk of pelvic
inflammatory disease (PID) in the first
month after insertion is increased slightly,
the absolute risk is still low.
Exposure to sexually transmitted
infections, and not the use of the IUD itself,
is responsible for PID occurring after the
first month of use.
(Level II)
Both types of IUDs provide excellent
contraceptive efficacy
(Level 1)
In addition, the copper IUD may
decrease the risk of endometrial
cancer
(Level II)
The levonorgestrel releasing
IUS may provide an acceptable
alternative to hysterectomy, by
decreasing menorrhagia and
increasing hemoglobin
concentrations.
(Level I)
RECOMMENDATIONS
Health-care professionals
providing family planning
services should be familiar
with the use of the
intrauterine device (IUD).
(Grade A)
Appropriately trained personnel in
adequately equipped facilities should
be available in order to ensure that
women have access to the IUD if they
desire this method of contraception.
RECOMMENDATIONS
(Grade A)