Intrauterine contraception

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Intrauterine contraception
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IUD is the official name
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Origins
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Characteristics of LARCs

• Long-acting method (work over gt 1 cycle)
• Reversible
• High efficacy
• Does not need motivation on a daily basis or when
  having sex
• Vanishingly low mortality rate

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Copper IUDs

• The only LARC that is non-hormonal
• Useful for women who have side effects with
  oestrogen/progestogen

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Terminology

• Inert
• Just plastic frame
• Medicated
• Copper bearing (wire or collars)
• Hormone releasing
• Intrauterine system (IUS)

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Prevalence in women aged 15-49 (UN 2001)
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Current use 2004 by women aged 16 - 49

• IUD 4
• IUS 1

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FP10s (000s) for IUD/IUS
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Inert devices
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Copper IUDs

• First generation (200mm2)
• copper 7 and copper T 200
• Second generation (220-250mm2)
• Nova T, Multiload 250
• Third generation (300mm2)
• T380, Multiload 375 and Flexi-T 300

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Gyne-Fix

• Frameless device
• Six copper cylinders on a thread
• Knot embedded in myometrium using a stilette
• Low expulsion rate (but not zero)
• Perforation rate appreciable
• Suitable for nullips
• Suitable for emergency contraception

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Mechanism of action

• All IUDs cause an increase in number of
  leucocytes, in endometrium and in uterine and
  tubal fluid
• The above impedes sperm transport and
  fertilisation. Actual phagocytosis of sperm has
  been reported
• Copper enhances foreign body reaction and causes
  biochemical changes in the endometrium
• Copper ions are also directly toxic to sperm and
  blastocyst

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Effectiveness of IUDs/IUS

• Most effective IUDs contain 380mm2 copper and
  have banded copper on the side arms
• Pregnancy rate with these devices is very low 2
  over 5 years
• Some evidence that IUS is more effective than
  380mm2 copper IUDs, but difference is small and
  of doubtful clinical significance

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Efficacy of IUDs/IUS

• First generation
• lt 2 per 100 woman years
• Second generation
• 1.0 1.5 per 100 woman years
• Third generation (high copper load)
• lt 1 per 100 woman years
• Mirena
• lt 0.5 per 100 woman years

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Efficacy of copper IUDs as emergency contraception

• Very few failures ever reported
• Has been calculated to be 15 times more effective
  than PC4 was
• Method of choice at 72-120 hours and if high
  efficacy is vital

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Lifespans

• The licensed duration of use for use of IUDs
  containing 380mm2 copper ranges from 5 to 10
  years, depending on the type of device
• Women who are aged 40 or over at the time of
  insertion may retain the device until they no
  longer need contraception, even if this is beyond
  the duration of UK Marketing Authorisation

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WHO 4 unacceptable health risk, should not be
used

• Pregnancy
• Unexplained genital tract bleeding
• STI/PID current
• Post-pregnancy sepsis

• Distortion of uterine cavity
• Malignant trophoblastic disease
• Cervical or endometrial cancer
• Known pelvic TB

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WHO 3 risks usually outweigh benefits

• Postpartum insertion 48 hrs to 4 weeks (higher
  perforation rate)

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WHO 2 benefits generally outweigh risks

• Nulliparas
• Age lt 20 years
• Menorrhagia
• Anaemia
• Increased STI risk
• STI/PID in last 3/12
• HIV positive

• Severe dysmenorrhoea
• Anatomical abnormalities/ fibroids not distorting
  cavity
• Complicated valvular heart disease
• lt 48 hrs postpartum insertion

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Medical removals of copper IUDs

• Average menstrual loss increased from 30-40ml to
  70-80ml
• Removal rates for bleeding and/or pain are around
  8 at 3 years
• NSAIDs or tranexamic acid may help

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Expulsion of IUDs

• Risk is around 1 in 20 for copper-bearing devices
• Rate declines after insertion most common in
  first year, especially 1st 3 months
• More likely during a period
• Rate lower in older women and those of higher
  parity
• Teaching women to check threads is important

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Data from RCTs 65,000 woman years
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Ectopic pregnancy

• IUD/IUS more effective at preventing intrauterine
  than tubal pregnancy
• Absolute number of ectopics less in IUD/IUS
  wearers than those using no method
• High-load devices protect against ectopic
  pregnancy
• Risk of ectopic pregnancy with IUD in situ is 1
  per 1000 over 5 years
• If a woman with an IUD in situ becomes pregnant,
  risk of ectopic is 6 and an ectopic should be
  excluded

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Copper IUDs and PID

• 6-7x increase in PID in the 20 days after
  insertion
• No increase in PID thereafter
• No better outcome if prophylactic antibiotics
  given at time of insertion
• Absolute risk of PID after IUD insertion lt 1 in
  women at low risk from STIs

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Copper IUDs and cancer

• At least a 50 reduction in endometrial cancer
  risk
• Note
• Based on systematic review of 7 studies, mostly
  case-control

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IUS (Mirena)

• Releases levonorgestrel for gt5 years lifespan
  possibly to 7 years
• Highest efficacy of any intrauterine device lt1
  over 5 years
• Suppresses endometrium
• Altered bleeding patterns are common

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IUS (Mirena) 2

• Rapid return of fertility
• Low risk of ectopic pregnancy
• Can reduce menstrual blood loss by gt 90
• Possibly small increased risk of functional
  ovarian cysts initially after insertion not
  significantly different from IUDs at 5 years
• Women aged 45 or above at the time of insertion
  may retain their IUS for 7 years

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Uses of the IUS ( licensed)

• Contraception (not EC)
• Menorrhagia (alternative to hysterectomy)
• ? Primary dysmenorrhoea
• ? Fibroids
• ? Endometriosis
• To oppose oestrogen in HRT (4 years only)
• ? Endometrial hyperplasia

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Lifespan of IUS

• RCT of IUS and copper T 380Ag
• No pregnancies with either device in years 6 and
  7
• Cumulative pregnancy rates 1.1 per 100 at seven
  years for IUS and 1.4 per 100 for IUD

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Medical eligibility for IUS

• Current thromboembolism WHO 3
• Current breast cancer WHO 4
• Liver disease WHO 3

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IUS and hormonal side effects

• LNG absorption equivalent to about 2 POPs per
  week (wide interindividual variation in serum LNG
  levels)
• A small minority of women request removal on
  account of progestogenic side effects
  depression, acne, headache, weight gain and
  breast tenderness
• More so in the first 3 months
• Not significantly different from IUDs at 5 years

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Mechanism of action
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Chlamydia testing before insertion

• Involve woman in assessing her own STI risk
• Test at request of woman
• Test if at higher risk of STIs
• sexually active and aged under 25
• age gt25 if have had a new sexual partner or gt1
  sexual partner in last year
• Test for gonorrhoea too if local prevalence high

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Prophylaxis to prevent bacterial endocarditis

• Women with previous endocarditis
• Prosthetic heart valve(s)
• Antibiotic as per BNF
• Intravenous route i.e. hospital setting
• For removals as well as insertions

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Timing of IUD insertion

• Up to 120 hours after UPSI
• Up to 5 days after the calculated earliest day of
  ovulation up to day 19 of a 28 day shortest
  cycle on history
• Any time in cycle if pregnancy has been excluded
• Immediately after suction TOP
• 4 weeks after delivery

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Problems at insertion

• Cervical shock vasovagal attack
• caused by dilatation of the cervix
• bradycardia possible
• usually resolves spontaneously
• if severe, remove device
• resuscitation equipment and drugs ready
• Epileptic fits
• rare
• Hyperventilation

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Perforation of uterus

• Occurs at the time of insertion
• Incidence is lt 1 per 1000 insertions
• Use a tenaculum to straighten cervico-uterine
  angle
• Can be silent
• Copper-bearing devices must be removed by
  laparoscopy

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Lost threads

• Main reasons are
• threads too short or are drawn up into cervical
  canal or uterus
• unrecognised expulsion of the device
• perforation of uterus resulting in translocation
  of device into peritoneal cavity

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Action to be taken in the event of lost threads

• Try to find them in cervical canal with Spencer
  Wells forceps
• Sweep uterine cavity with thread retriever e.g.
  Emmett device (first half of cycle only)
• Ultrasound scan
• X-ray

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Removal of IUDs/IUS

• Easy!
• Beware removal around mid-cycle when woman does
  not wish to become pregnant
• If removing device urgently because of medical
  problems, consider use of hormonal emergency
  contraception
• Wait until period after sterilisation

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Return of fertility after removal of IUD/IUS

• No reduction in fertility compared to those
  stopping other methods
• Mean time to pregnancy following removal is 3
  months

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Actinomyces-like organisms

• ALOs may be detected on cervical smears of
  IUD/IUS users (and non-users)
• If no symptoms, there is no reason to remove the
  device

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Continuation comparative study
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Continuation 5 year follow up of 17,360 IUS users
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