The future of intrauterine contraception

In this review paper some guidelines for IUD use are presented that if followed should reduce the incidence of IUD-related complications. Recent IUD developments are discussed including the levonorgestrel-releasing T, a new variation of the Multiload, and IUDs designed for postpartum insertion. Since significant improvements in IUD safety will most likely result from a better understanding of IUD-related side-effects and adverse reactions, the paper includes recommendations for future IUD research that could enhance the safety, effectiveness and acceptability of available IUDs.

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Resumen En esta revisión presentamos una serie de directrices que si se siguiesen reducirían significativamente la incidencia de las complicaciones referidas al uso del DIU. Actualmente se evestionan los recientes descubrimientos en torno al DIU, incluido el Levonorgestrel-T, una nueva variación del Multiload y DIUs indicados para la inserción postparto. Desde que se efectuaron importantes modificaciones en su utilización, hemos observado un incremento de su inocuidad y un descenso de los efectos indeseables, gracias principalmente a una utilización más oportuna. Ademas nos ha permitido comprener mejor los efectos colaterales relacionados con su uso. Incluimos tambien recomendaciones, para futuros trabajos, que pueden cambiar las directrices seguidas hasta ahora, mejorando la seguridad, efectividad y aceptabilidad de los DIUs.

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Résumé Dans cette communication d'ensemble sont présentés des conseils généraux relatifs à l'utilisation des DIU, qui devraient permettre, s'ils sont suivis, de réduire l'incidence des complications que ces dispositifs peuvent entraîner. Y sont examinés de récents progrès réalisés sur les DIU, et notamment sur le modèle T libérant du lévonorgestrel qui est une variante du modèle Multiload et des dispositifs conçus pour leur insertion après l'accouchement. Etant donné que toutes les améliorations importantes qui seront apportées du point de vue de la sécurité des DIU résulteront probablement d'une meilleure compréhension des effets secondaires et des réactions adverses imputables aux DIU, cette communications inclut des recommandations pour les recherches à venir, qui pourraient rehausser la sécurité, l'efficacité et l'acceptabilité des dispositifs actuellement sur le marché.

     

Microdose intrauterine levonorgestrel for contraception

An intrauterine device (IUD) releasing 2 μg of levonorgestrel per 24 hours was compared in a randomized multicentre clinical trial with two copper IUDs — the TCu 220C and the Nova T. The 2μg levonorgestrel device had statistically significantly higher pregnancy rates (from 390 days of use) and higher expulsion rates (up to 570 days). In addition, the total medical removals and removals for bleeding were significantly higher at all intervals where the data were analysed. Most disturbing was a 6.7 increased relative risk of ectopic pregnancy with the steroid-releasing IUD compared to the combined copper IUD data. It is concluded that the goal of microdose administration of 2μg levonorgestrel to the uterine cavity does not achieve the objectives of a new and improved IUD device which is safe and effective.     

Routine counseling about intrauterine contraception for women seeking emergency contraception

Objective

To compare contraceptive knowledge and use among women seeking emergency contraception (EC) before and after an inner-city clinic began providing structured counseling and offering same-day intrauterine device (IUD) or implant placement to all women seeking EC.

Study design

For 8 months before and 21 months after this change in clinic policy, women aged 15–45 who wanted to avoid pregnancy for at least 6 months were asked to complete surveys immediately, 3 and 12 months after their clinic visit. In addition, we abstracted electronic medical record (EMR) data on all women who sought EC (n= 328) during this period. We used chi-squared tests to assess pre/post differences in survey and EMR data.

Results

Surveys were completed by 186 women. After the clinic began offering structured counseling, more women had accurate knowledge of the effectiveness of IUDs, immediately and 3 months after their clinic visit. In addition, more women initiated IUD or implant use (survey: 40% vs. 17% preintervention, p=0.04; EMR: 22% vs. 10% preintervention, p=0.01), and fewer had no contraceptive use (survey: 3% vs. 17% preintervention, p<0.01; EMR: 32% vs. 68%, p<0.01) in the 3 months after seeking EC. EMR data indicate that when same-day placement was offered, 11.0% of women received a same-day IUD. Of those who received a same-day IUD, 88% (23/26) reported IUD use at 3-months and 80% (12/15) at 12 months.

Conclusions

Routine provision of structured counseling with the offer of same-day IUD placement increases knowledge and use of IUDs 3 months after women seek EC.

Implications

Women seeking EC from family planning clinics should be offered counseling about highly effective reversible contraceptives with the option of same-day contraceptive placement.     

Women's questions after postabortion insertion of intrauterine contraception

Background

Postabortion insertion of intrauterine contraception has the potential to decrease unintended pregnancy and repeat abortions, but little is known about how to ensure that women receive appropriate counseling about this method in this setting. The goal of this investigation was to document women's questions and to assess retention of information provided during contraceptive counseling after immediate postabortion intrauterine contraceptive placement.

Study Design

Women who received postabortion intrauterine contraceptives (IUCs) at an urban, hospital-based abortion clinic were surveyed 2–3 months postabortion to evaluate for expulsion, assess their concerns about IUC and evaluate retention of information provided during contraceptive counseling.

Results

Of 141 women contacted, 121 participated. Almost half of participants (46%) had responses to the question “Do you have any questions or concerns about your intrauterine device?” that fell into the following categories: spotting/bleeding (16%), cramping/pain (15%), string management (10%), expulsion concern (5%). Seventy percent reported less bleeding during menses than prior to IUC placement, and 37% had less cramping. Sixty-three percent were able to accurately report statistics regarding IUC efficacy, 56% recalled common side effects, and 42% remembered what to do if expulsion occurred.

Conclusion

Although IUCs are highly effective and their placement in the abortion setting is safe, women frequently have questions and do not recall critical counseling information about IUCs. In order to improve IUC continuation, techniques to improve both patient knowledge retention and anticipatory guidance should be studied further.     

Current opinion: Consensus statement on intrauterine contraception

Forty-five experts from around the world attended a 1-day seminar in September 2001 in Chapel Hill, North Carolina, USA, to identify ways that they might collaborate to overcome unnecessary barriers to the use of intrauterine devices (IUDs). Seminar participants formed working groups that produced at least three specific recommendations relating to: training/performance improvement; service delivery improvement; general public information; and clinical and programmatic research. Key recommendations included: integrating reproductive health knowledge and skills into curricula for all healthcare professionals; reviewing and reinforcing with providers evidence-based guidelines for IUD use; encouraging evidence-based review of the IUD label and package insert; and conducting further research about IUD client eligibility, potential health benefits, acceptability among clients and providers, and use by HIV-infected women. At the meeting’s conclusion, a number of participants, representing the fields of research, policy, communications, donors, women’s advocacy, and medicine, expressed an interest in refining and acting upon the recommendations. Hosted by Family Health International, the meeting was supported by the Mellon Foundation.     

Current opinion: consensus statement on intrauterine contraception

Forty-five experts from around the world attended a 1-day seminar in September 2001 in Chapel Hill, North Carolina, USA, to identify ways that they might collaborate to overcome unnecessary barriers to the use of intrauterine devices (IUDs). Seminar participants formed working groups that produced at least three specific recommendations relating to: training/performance improvement; service delivery improvement; general public information; and clinical and programmatic research. Key recommendations included: integrating reproductive health knowledge and skills into curricula for all healthcare professionals; reviewing and reinforcing with providers evidence-based guidelines for IUD use; encouraging evidence-based review of the IUD label and package insert; and conducting further research about IUD client eligibility, potential health benefits, acceptability among clients and providers, and use by HIV-infected women. At the meeting’s conclusion, a number of participants, representing the fields of research, policy, communications, donors, women’s advocacy, and medicine, expressed an interest in refining and acting upon the recommendations. Hosted by Family Health International, the meeting was supported by the Mellon Foundation.     

Safety of hormonal contraception and intrauterine devices among women with depressive and bipolar disorders: a systematic review

BackgroundWomen with depressive or bipolar disorders are at an increased risk for unintended pregnancy.ObjectiveTo examine the safety of hormonal contraception among women with depressive and bipolar disorders.MethodsWe searched for articles published through January 2016 on the safety of using any hormonal contraceptive method among women with depressive or bipolar disorders, including those who had been diagnosed clinically or scored above threshold levels on a validated screening instrument. Outcomes included changes in symptoms, hospitalization, suicide and modifications in medication regimens such as increase or decrease in dosage or changes in type of drug.ResultsOf 2376 articles, 6 met the inclusion criteria. Of three studies that examined women clinically diagnosed with depressive or bipolar disorder, one found that oral contraceptives (OCs) did not significantly change mood across the menstrual cycle among women with bipolar disorder, whereas mood did significantly change across the menstrual cycle among women not using OCs; one found no significant differences in the frequency of psychiatric hospitalizations among women with bipolar disorder who used depot medroxyprogesterone acetate (DMPA), intrauterine devices (IUDs) or sterilization; and one found no increase in depression scale scores among women with depression using and not using OCs, for both those treated with fluoxetine and those receiving placebo. Of three studies that examined women who met a threshold for depression on a screening instrument, one found that adolescent girls using combined OCs (COCs) had significantly improved depression scores after 3 months compared with placebo, one found that OC users had similar odds of no longer being depressed at follow-up compared with nonusers, and one found that COC users were less frequently classified as depressed over 11 months than IUD users.ConclusionsLimited evidence from six studies found that OC, levonorgestrel-releasing IUD and DMPA use among women with depressive or bipolar disorders was not associated with worse clinical course of disease compared with no hormonal method use.     

Five years experience of intrauterine contraception with the Nova-T

This study was conducted to evaluate the clinical performance of the Nova-T IUD. The insertion period was from November 1981 to November 1982. Two-hundred-and-one (201) consecutive IUDs were inserted in women attending a family planning clinic and they were followed for a period of 5 years. Most events occurred in the first 2 years of the study and there were no pregnancies in the 3rd, 4th or 5th year. The pregnancy rate after 5 years was 3.2 or a Pearl index of 1.21 which is very good compared to other methods of contraception now available. Our conclusion is that the Nova-T IUD is an excellent method of contraception and it can be left in place for a period of 5 years.     

Anchored IUDs. A new development in intrauterine contraception

The need for IUD removal due to bleeding could be reduced by reducing the size of the device, which could be done if the frame were replaced by threading copper tubules on a nonresorbable string anchored in the fundus of the uterus. Such devices have been designed since 1977, but the most successful one was a temporary device designed in 1984 by D. Wildemeersch to insert a postpartum IUD during the period of uterine involution. A similar device for permanent attachment, the Cu-Fix 390 IUD, consists of 6 copper tubules, each 5 mm long and 2.2 mm in diameter threaded on a polypropylene filament. A knot at the distal end serves as a retention body attached by a loop embedded in the uterine fundus. Insertion is accomplished by a tube and a plunger which carries a stylet for embedding the loop. Between 1985 and 1988, 382 devices were inserted, 38.5% in nulliparas and 53.7% in women under 30. The only problem encountered was some spotting. For postpartum insertion the Gyne-T 380 PP IUD, which is an ordinary T Cu 380 IUD provided with a loop of catgut between 2 knots, is inserted by a tube and plunger device with a pin to insert the knots into the fundus to anchor the IUD. This device may solve the problem of enhanced IUD expulsion after postplacental insertion.