Ultrastructural alterations in human endometrium caused by intrauterine contraceptive devices

Biopsies of endometrium from women using intrauterine contraceptive devices (IUDs) were examined by electron microscopy to elucidate the possible cause of IUD-associated uterine hemorrhage. The findings reveal the presence of degenerated, shrunken cells in the endometrial glands of IUD users. These cells, termed pyknotic or apoptotic, are more prevalent in tissue from women with complaints of excessive bleeding than in cases without such complaints. The pyknotic cells often show discontinuities of the plasma membrane at their luminal pole, from which cell contents stream into the lumen. Sometimes erythrocytes are also observed in the lumen. A second alteration in the ultrastructure of the endometrium is an abnormal increase in microfilaments in the epithelial cells. These two changes, a large number of pyknotic cells on the one hand and increase in microfilaments on the other, are correlated with excessive bleeding but they do not explain in simple terms of outflow of erythrocytes. Probably some inflammatory mechanism is involved. The increased number of microfilaments might be helping the movement of fluid from healthy to pyknotic cells.     

Urgent need to change clinical practices about postpartum contraception

In the United States, maternal mortality and unintended pregnancy rates are increasing. There are growing disparities in maternal health between indigent, minority women and Caucasian women of higher socioeconomic status. Family planning has long been viewed as a solution to these problems. As reliance on permanent contraception has diminished, timely access to highly effective contraceptive methods, namely long acting reversible contraceptives, which includes the contraceptive hormonal implant and intrauterine device- has become even more important. For women in the United States and abroad, the time of delivery is the one reliable opportunity for women to receive medical care. Consistently, research has shown that providing contraception in the immediate postpartum period is safe, effective, feasible and cost effective. However, misperceptions, lack of supplies, and reimbursement issues combine to defeat attempts to provide the most effective methods of contraception during that hospitalization. We believe that it is time to tackle the problem of unintended and rapid repeat pregnancy using an evidence-based, patient-centered paradigm and to eradicate systemic barriers blocking access to contraceptive methods during hospital stay. This editorial will outline some of the more compelling evidence supporting this move and will provide insights from successful programs.     

Implanon: a new contraceptive implant

Women who cannot use hormonal contraception containing estrogen have a variety of progestin-only contraceptive methods from which to choose. Implanon is a new single-rod progestin-only contraceptive implant that is easily inserted and can remain in place for up to 3 years. It is highly effective with a rapid onset of action and an equally rapid return of fertility once removed. Counseling is important to help women decide if this method is appropriate for their needs.     

The intrauterine device: rethinking old paradigms

The United States continues to have one of the highest rates of unintended pregnancy and elective abortion in developed countries. Intrauterine devices (IUDs) available today offer women safe and highly effective contraception along with noncontraceptive benefits, yet IUDs remain underutilized in part because of outdated and biased information about the risks associated with this method of fertility control. New research demonstrates that IUD use does not increase the risk of pelvic infections or subsequent infertility. IUD use decreases the absolute risk of ectopic pregnancies. In light of this data, the IUD should be made available to women at low-risk for sexually-transmitted infections and should not be denied to women on the basis of parity or marital status.     

Long-term use of intrauterine contraceptive devices in a private practice

Clinical experience with 1504 insertions of intrauterine contraceptive devices (Lippes Loop, Dalkon Shield, Cu-7) in a private practice is evaluated. Expulsion rates and removal rates for bleeding and/or pain and personal reasons differed for the three types of devices. Pregnancy rates associated with use of the three types of devices were similar. Pelvic inflammatory disease rates were similar for Dalkon Shield and Cu-7 users but were higher than the rate for Lippes Loop users. Use of intrauterine contraceptive devices did not appear to compromise future fertility based on the experience of women who had the devices removed. The study shows that long-term IUD use (up to 5 years) provides a safe and effective method of contraception.     

Perforation of the bowel from intrauterine contraceptive devices: case series and discussion

The intrauterine contraceptive device is used extensively in the female population. Serious complications are rare, but they do occur. We discuss three cases of bowel perforation caused by these devices following their perforation through the uterine wall. It is important that cases of perforation be recognised swiftly and the possibility of involvement of other organs considered.     

Postpartum intrauterine device contraception: A review

AIM: To review the safety (infection, perforation) and efficacy (expulsion, continuation rates, pregnancy) of intrauterine device (IUD) insertion in the postpartum period. METHODS: MEDLINE, PubMed and Google Scholar were searched for randomized controlled trials and prospective cohort studies of IUD insertions at different times during the postpartum period. Time of insertion during the postpartum period was documented specifically, immediate post placenta period (within 10 min), early post placenta period (10 min to 72 h), and delayed/interval period (greater than 6 wk). Other study variables included mode of delivery, vaginal vs cesarean, manual vs use of ring forceps to insert the IUD. RESULTS: IUD insertion in the immediate postpartum (within 10 min of placental delivery), early postpartum (10 min up to 72 h) and Interval/Delayed (6 wk onward) were found to be safe and efficacious. Expulsion rates were found to be highest in the immediate postpartum groups ranging from 14% to 27%. Immediate post placental insertion found to have expulsion rates that ranged from 3.6% to 16.2%. Expulsion rate was significantly higher after insertion following vaginal vs cesarean delivery. The rates of infection, perforation and unplanned pregnancy following postpartum IUD insertion are low. Method of insertion such as with ring forceps, by hand, or another placement method unique to the type of IUD did not show any significant difference in expulsion rates. Uterine perforations are highest in the delayed/interval IUD insertion groups.Breastfeeding duration and infant development are not affected by delayed/interval insertion of the non-hormonal (copper) IUD or the Levonorgestrel IUD. Timing of the Levonorgestrel IUD insertion may affect breastfeeding. CONCLUSION: IUD insertion is safe and efficacious during the immediate postpartum, early postpartum and delayed postpartum periods. Expulsion rates are highest after vaginal delivery and when inserted during the immediate postpartum period. IUD associated infection rates were not increased by insertion during the postpartum period over interval insertion rates. There is no evidence that breastfeeding is negatively affected by postpartum insertion of copper or hormone-secreting IUD. Although perforation rates were higher when inserted after lactation was initiated. Randomized controlled trials are needed to further elucidate the consequence of lactation on postpartum insertion. Despite the concerns regarding expulsion, perforation and breastfeeding, current evidence indicates that a favorable risk benefit ratio in support of postpartum IUD insertion. This may be particularly relevant for women for whom barriers exist in achieving desired pregnancy spacing.     

Factors influencing discontinuation of intrauterine contraceptive devices: an assessment in the Indian context

Sociocultural and behavioral factors are associated with decision to use and the selection of a contraceptive method, continuation of use and reasons for discontinuation of a contraceptive. This paper tries to distinctly outline the determinants of discontinuation of the intrauterine contraceptive device (IUCD), especially in the Indian context. Data on medical reasons for discontinuation are available through clinical trials. However, sociodemographic studies provide one with a wider spectrum to analyze the factors associated with the discontinuation of IUCDs. Information on service providers can be used to improve the quality of family planning services in the country. In India, a thorough review of birth spacing methods, especially the IUCD, is needed since the surveys show a high rate of discontinuation. The emphasis in this paper is upon compilation of reasons for discontinuation of the IUCD and research thereof. The review of the literature is directed towards giving a new direction to assessment of family planning programs, especially in India where population control is largely dependent upon permanent methods. Delineation of factors is important to improve the family planning program.     

Post-abortion long-acting reversible contraception in a sample of Italian women: intrauterine device versus subdermal implant

Abstract

Long-acting reversible contraceptives (LARC) represent an especially effective kind of post-abortion contraception. We aimed at assessing satisfaction, discontinuation, efficacy, and tolerability associated with either levonorgestrel intrauterine device (L-IUCD), the copper intrauterine device (C-IUCD) and implant (IMP) after termination of pregnancy (TOP). We recorded baseline data about the patients and performed phone surveys at 3, 6 and 12?months after insertion to assess the bleeding profile. Furthermore, women were inquired about possible adverse events, satisfaction, and discontinuation at 12?months after insertion. LARC continuers (>12?months after TOP) were divided into three groups: L-IUCD (n?=?47), C-IUCD (n?=?6) and IMP (n?=?36). Satisfaction rates among L-IUCD users were higher than among IMP users (100% vs. 72.2%, p?<?.05). A higher, yet not significant, share of patients decided to withdraw contraception in IMP group (3.6% in IUCD group and 12.2% in IMP group). The bleeding profile was significantly more favorable among L-IUCD users than among IMP users. Finally, the reported rate of treatment-associated adverse events did not differ significantly among the groups. L-IUCD insertion after TOP is associated with higher satisfaction and lower discontinuation rates than IMP. Such pattern could be attributed to a more favorable bleeding profile.     

Human papillomavirus in cervical smears taken from women wearing an intrauterine contraceptive device

Summary Cervical cells were screened for human papillomavirus (HPV) infections by in situ filter hybridization in 108 patients wearing intrauterine contraceptive devices. The cells were tested for the presence of HPV 6, 11, 16, 18. DNA. In 86 cases (79.6%) no reactions were obtained with³² P-labeled HPV DNA probes. 22 smears (20.3%) were positive for HPV: type 6 and 11 sequences were demonstrated in 17 cases (3 of them carried both). 4 smears hybridized with the probe for oncogenic HPV 16 and one with that for oncogenic type 18. All these five patients had normal smears and no abnormality on colposcopy.     

宫内节育器综合临床评价指标的探讨

本文通过专家咨询（Ｄｅｌｐｈｉ）法，应用常用的宫内节育器单项临床效能指标（Ｉｎｄｉｃａｔｏｒ，Ｉ）研制了一个ＩＵＤ综合临床效能指标（ＣｏｍｐｒｅｈｅｎｓｉｖｅＰｅｒｆｏｒｍａｎｃｅＩｎｄｉｃａｔｏｒ，ＣＰＩ），并对ＣＰＩ的意义、特点及其应用进行了探讨。ＣＰＩ的特点、是全面地反映了ＩＵＤ的临床效能，计算简便。应用ＣＰＩ值可直接全面比较各种ＩＵＤｓ的临床效能，避免了既往那种应用不同的单项效能指标比较会得出不同结论的矛盾。应用本文研制的方法计算的ＣＰＩ值，其范围在２４０～３８０之间，一个综合临床效能较好的ＩＵＤ其ＣＰＩ值应大于３２０。参考有关文献，应用ＣＰＩ试行评价了六种常见ＩＵＤｓ：金属单环、ＴＣｕ２２０℃、宫形铜环、Ｎｏｖａ－Ｔ、ＴＣｕ３８０、ＬＮＧ－ＩＵＤ，结果表明综合临床效能最佳的是宫形铜环、ＴＣｕ２２０Ｃ。本文在国内、外首次探讨了ＩＵＤ综合评价指标，此项研究尚有待于进一步探讨。     

Complications among adolescents using copper intrauterine contraceptive devices

Objective

To evaluate the rate and pattern of complications associated with use of the Copper T 380A intrauterine device (IUD) among adolescents.

Methods

A prospective comparative study of women eligible for IUD insertion who attended the family planning clinic of Sohag University Hospital, Egypt, between July 1, 2008 and December 31, 2010. The participants were categorized as adolescents or adults. The Copper T 380A IUD was inserted in all participants and follow-up visits were scheduled at 1, 3, and 6 months. Odds ratio and χ² square tests were used to compare the rates of complications at each visit.

Results

Of 1512 patients eligible for IUD insertion, 852 met the inclusion criteria: 281 adolescents and 571 adults. The rates of pain, bleeding, displacement, expulsion, and removal of IUDs were significantly higher in adolescents (P < 0.05). The rates of these complications were high in adolescents younger than 16 years; the rates then decreased with age and became comparable with the adult rates at 18 years of age.

Conclusions

IUD-associated complications were high in adolescents up to the age of 17 years. Our data suggest that adolescents younger than 18 years of age should be counseled carefully before IUD insertion, and examined more frequently to detect displacement or expulsion of the device.     

Options for intrauterine contraception

The IUD is a convenient and effective contraceptive option for many women. Currently, there are two different types of intrauterine contraception available to women in North America: the levonorgestrel-releasing intrauterine system and the copper T IUD. A greater understanding of the benefits and limitations of these two contraceptive options will assist women's health care providers to better meet the family planning needs of their patients.     

Long acting reversible contraception

Long-acting reversible contraception (LARC) is the collective name for intrauterine contraception (copper intrauterine devices and levonorgestrel intrauterine systems) and the subdermal contraceptive implant. LARC methods are highly effective, require minimal user effort and do not require regular healthcare appointments; however the insertion and removal procedures can only be undertaken by clinicians trained to do so. The progestogen-only subdermal implant is the most effective method of reversible contraception in the United Kingdom and is licensed for 3 years. The copper intrauterine device is the most effective non-hormonal method of contraception. These devices are licensed for five or 10 years and can also be used as emergency contraception. The levonorgestrel intrauterine systems (LNG-IUS) are licensed for 3, 5, or 6 years. The Mirena LNG-IUS is also licensed for use in treating heavy menstrual bleeding and for endometrial protection as part of hormone replacement therapy.     

Pregnancy during the use of levonorgestrel intrauterine system

OBJECTIVES: This study was undertaken to evaluate the pregnancy rate with the levonorgestrel intrauterine system (LNG IUS) and to analyze the outcome of pregnancies with the LNG IUS in situ in regular use. STUDY DESIGN: Questionnaires from 17,360 users of the LNG IUS were analyzed. With the consent of women reporting pregnancy during the use of the LNG IUS, related hospital records were reviewed concerning the pregnancies. RESULTS: Originally 132 pregnancies were reported. Medical records were reviewed from 108 of these women. In 64 pregnancies, conception occurred with the LNG IUS in situ. Thirty-three pregnancies were ectopic. The 5-year cumulative pregnancy rate per 100 users was 0.5 and the 5-year Pearl rate was 0.11. CONCLUSION: Pregnancy with the LNG IUS in situ is rare. Ectopic pregnancies constitute 53% of all pregnancies. Typical pregnancy symptoms occur during pregnancies with the LNG IUS. The importance to counsel about the risk of pregnancy before insertion is emphasized.     

Lidocaine gel vs lidocaine spray in reducing pain during insertion of the intrauterine contraceptive device

Objectives: The aim of this study was to compare the pain-relieving effect of intracervical lidocaine gel with that of lidocaine spray or no local anaesthesia in decreasing pain during insertion of the intrauterine contraceptive device (IUCD).

Methods: In a prospective multicentre non-randomised comparative study design, 420 women were divided into three groups of 140 and fitted with the same type of IUCD. Group 1 received cervical lidocaine gel, group 2 received cervical lidocaine spray and group 3 received no topical anaesthesia. A visual analogue scale was used to measure the degree of pain experienced.

Results: There were no significant differences between the three groups with regard to baseline characteristics such as age and number of deliveries. Significantly less pain was felt during cervical traction in women using a local anaesthetic. However, there were no significant differences in pain due to IUCD insertion.

Conclusions: Application of a local anaesthetic decreased the pain resulting from cervical traction but not that resulting from IUCD insertion.     

Use of intrauterine contraceptive devices in nulliparous women: personal experience over a 12-year period

Objective To evaluate the use of intrauterine contraceptive devices (IUDs) in nulliparous women compared to their use in parous women.

Methods A comparative cross-sectional study was carried out to determine the reasons for removal of IUDs inserted between 1985 and 1996 in a sample of 227 nulliparous women and 2080 parous women. The statistical analysis was performed using the χ² test; the differences were considered to be significant when p < 0.05.

Results The reasons for removal of IUDs in the two groups were: expiry, 49.1% in the nulliparous group vs. 48.2% in the parous group; planned pregnancy, 21.7% vs. 15.4%; accidental pregnancy, 4.8% vs. 6.3%; expulsion, 1.6% vs. 5.1%; pelvic inflammatory disease, 1.6% vs. 1.1%; pain and/or bleeding, 14.5% vs. 10.2%; other, 6.4% vs. 6.3%; vasectomy or tubal sterilization, 0% vs. 7%.

Conclusion Our data suggest that nulliparity is not a contraindication for the use of an IUD, and that the use of an IUD in nulliparous women is as safe and effective as in parous women.