INTRAUTERINEDEVICES

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 warII.
•In 1920s Grafenberg removed tail and pessary as he belived
that it causesinfection.
• Grafenberg’s ring was associated with high expusion rate.
cont…
•Further many modifications were made as far as size and shape
and material is concerned to minimize sideeffects.
•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withdrawn.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 ‘Lippesloop’
which quickly became most widely usedIUD.
•Further many designs came in between but the additionof
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 T200, also called as
Tatum-T.
•Followed by further modification to increase efficacy andlife
span and recently medicated IUD are introduced.
 Types of IUDs
Classification
• Non medicated IUDs
Lippes loop
• Medicated copper containing IUDs
Cu T200, Cu T380 A, Multiload-
250, Multiload-375, Nova T.
• Hormone containing IUDs
LNG-20
 Early IUDs

Lippies Loop Self TCoil Dalkon Shield

 Copper containing IUDs

Cu T 220
Cu T 200
 Copper containing IUD

Multi load375 NovaT

 MECHANISM OF ACTION
Non 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
•CuT200
Contains 200 sq mm surface area of wire
containing Cu.
Cu wire wounded round the vertical
stem, Tshaped frame made of Polyethylene, with
polyethylene threads.
life span is 3 years
Failure rate 3%
•Replaced by modern copper IUDs containing
more copper with increased efficacy and lifespan.
Cu T380A

•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 oneach
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 andreduces
cramp like pain
LNG-20
LNG-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 theT-body
is compounded with barium sulfate.
The reservoir releases 20mcg per day
which declines tohalf 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 perHWY
cont…
Other uses of LNG20
1) Extensively used to treat Heavy menstrual bleeding asn
alternative to hysterectomy.
2) Has beneficial effect in menorrhagia from uterine
fibroid, benefit may be diminished withdistorting sub
mucosal fibroid.
3) The local Progestin effect directed to endometriumcan
be utilized in patients on tamoxifen, and in women
receiving estrogen therapy.
4) Reduces risk of Caendometrium
5) Improvement in symptoms of endometriosisand
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 breastfeeding.

• have chronic condition, including

Hypertension, cardiovascular disease, diabetes, liver &
gall bladder disease.
 Contraindications of IUD
• Pregnancy
• Puerperal sepsis
• PID
• STDscurrent or within the past 3months
• Endometrial or cervicalcancer
• undiagnosed genital bleeding
•Uterine anomalies
•Fibroid tumors distorting the endometrialcavity
• 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-1infected women.
 Time of Insertion
• IUDs can be safely inserted at any time after
Delivery ( Normal or Cesarean) Abortion (
spontaneous or induced) or during the
menstrualcycle.
•Expulsion rate were higher when the older, large plasticIUDs
were inserted sooner than 8weeks
but Cu Tcan be inserted between 4 to 8 weeks
postpartum without an increase in pregnancy
rates, expulsion, uterine perforation, or removal frombleeding
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 cervicalcanal

and masking of insertion relatedbleeding
further evidences support that expulsion
rate, termination rate, bleeding and pregnancy are lower if
insertion is performed after day 11 of menses, andinfection
rate may be lower with insertion after 17th cycleday.
 Screening the patient before IUDinsertion
•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 suggestiveof

PID to be elicited as any current, recent or recurrent PID is a
contraindication for IUDuse.

•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 STDafter IUD insertion.
cont……
•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 prophylacticantibiotics.
•A careful PSand bimanual examination is must
- position of uterus; undetected extremeposterior
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 lessthan
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 provideduntil
patient can be examined.
 Infections
•IUD related bacterial infection are due tocontamination of
cavity at time ofinsertion.
•The early insertion related infections therefore, are
polymicrobial, and derived from endogenouscervicovaginal
flora, with predominance ofanaerobes.
•As per WHO clinical trial data, risk of PID is 6 times higher
during 20 days after the insertion compared withlater 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 termuse.
•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
Cont……
 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 1hour
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 areat
increased risk of bacterial endocarditis
•antibiotic prophylaxis of 2 gm amoxyxillin should be given
1 hour prior before insertion orremoval.
 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 medicalmanagement.
•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 maletransmission.
•No grater incidence of complication (including
PID).
 Actinomyces
•Actinomyces are commonly present in vaginalflora.
•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 G500 q.i.d. for 1 month or Tetracycline 500
mg q.i.d. , Doxy 100 mg b.d , amoxy/clavulanate 500 mgb.d.
 Bleeding with IUDs
•Most common cause of IUD discontinuation- increased
uterine bleeding and increased pain duringmenses.
•Bleeding and cramping are most sever in first fewmonths
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 continuesfor
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 ECTOPICPREGNANCY
•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 nocontraception.
•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 T380 Aand
LNG-20.
cont….
 ECTOPICPREGNANCYRATEPER1000 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 T380A.
•The protection against ectopic provided by Cu T380A and LNG-
20 makes these IUDs acceptable choices for contraception in
women with previous ectopicpregnancy.
 Pregnancy with IUDs in situ
•Spontaneous miscarriage occurs more who becamepregnant
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 beavoided.

•after removal spontaneous abortion rate is30%.

•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 USGto localize IUD and to determine
whether expulsion hasoccurred.
-if IUD is present, 3 options
1) Therapeutic abortion
2) USGguided removal
3) Continuation of pregnancy with device leftin
situ.
•USGguided removal possible when IUD is not infundal
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 partialperforation.

•Most perforation go undetected as it leads to transient pain

and bleeding at time of insertion, so in case of doubt
perform USGto detect position of IUD.

•Suspected when no thread is visible through Ext OSwith

appearance of pelvic symptoms in women usingIUD.
•Further Negative findings on exploration of uterine cavity by a
probe is suggestive.

• USGhelps 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 missingthread…..
•3 Possibilities
• Expulsion.
• Displacement (IUD inside uterus butdisplaced).
• perforation and migration to peritonealcavity.
•All IUDs are radiopaque, but localization with help of X-ray
needs 2-3 views and does not allow intrauterine direction of
instruments, SoUSGis best way to locate anIUD.
•If IUD is inside uterus an can be grasping with helpof
forceps under USGguidance, if not possible next is
hysteroscopic removal of embeddedIUD.
•If IUD is identified perforating myometrium or in the
abdominal cavity to be removed with help of laparoscopy.
•With sighs and symptoms of peritonitis withperforation
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 T380 A
•Advantage of using Cu T380 A as emergency
contraception is patient can continue with it for long term
contraception making it costeffective.
•Whether LNG-20 would work for emergencycontraception
is not known.