Non-physician insertion of IUDs: Clinical outcomes among TCu380A insertions in three developing-country clinics

Insertion of IUDs by trained non-physicians is increasing. This secondary analysis of TCu380A IUD acceptors collected at clinics in Nigeria, Turkey and Mexico involved 367 women; 193 insertions were performed by physicians and 174 by non-physicians. Women having their IUD inserted by a non-physician were more likely to experience a pain-free insertion, but also likelier to have the IUD removed for bleeding and pain or to experience an expulsion than women who had their IUD inserted by a physician. Early discontinuation rates were similar between the two groups. Overall continuation rates were statistically higher for IUDs inserted by physicians only at the Mexico site. Trained non-physicians can probably safely insert the TCu380A IUD. Appropriate competency-based training is required to limit the number of expulsions and removals for bleeding and pain by non-physicians.     

Transvaginal ultrasonographic assessment of the expulsion rate of intrauterine devices inserted in the immediate postpartum period: a pilot study

OBJECTIVE: To compare the expulsion rates of intrauterine devices (IUDs) inserted in the immediate postpartum after vaginal birth and cesarean section. METHODS: Nineteen patients who had a vaginal birth and 19 patients who had a cesarean section at Hospital de Clínicas de Porto Alegre, Brazil, were selected for copper T 380A IUD insertion. With the aim of detecting clinically unnoticed dislodged devices, ultrasound examinations were performed at 1 month and between 3 and 12 months after delivery. The IUDs were considered completely expelled when found outside the endometrial cavity (e.g., in the cervical canal) or outside the uterus (in the vagina). RESULTS: Expulsion rates were statistically different between the two groups: after a vaginal birth, 50% (ultrasound only) + 27.8% (clinical examination); and post-cesarean section, 0% (p < .001; OR 5.75, 95% CI 2.36-14.01). CONCLUSION: Considering that the contraceptive efficacy of IUDs is associated with their intrauterine location, the high expulsion rates seen when they are inserted immediately after vaginal delivery contraindicate their use in this setting. The use of IUDs immediately after a cesarean section is still a reasonable alternative because its expulsion rate was zero. Ultrasound assessment of IUD positioning performed better than clinical examination, which failed to detect expulsion after postpartum insertion in 75% of the cases (9 from 12 cases).     

Wider opportunities for IUD insertion

The timing of IUD insertion has important implications for those who insert the devices as well as the users. In 1978 the US Food and Drug Administration recommended insertion during menstruation but acknowledged that it is also "necessary and proper" to insert IUDs at other times in the cycle. A 1977 study found that 30% of European and North American obstetricians limited insertion to the time of menstruation. Nearly half those in Africa and the Middle East and 13% of those in Asia followed this practice. Consequently, many women are required to make more than 1 visit to a clinic, meaning inconvenience for both the user and provider and some unintended pregnancies. In developing countries women may depend on mobile clinics or infrequent visits by trained personnel and many seek help without an appointment. 1 reason for insertion at or just after menstruation is to ensure that the woman is not pregnant when the IUD is inserted. 2 recent articles attempt to assess the best time for IUD insertion with regard to IUD performance. White et al. found that women whose Copper T IUDs were inserted on days 1-5 of the menstrual cycle had a lower continuation rate in the 1st few months than did those whose IUDs were inserted at a later time in the cycle. Edelman et al. found that Copper T and Copper 7 IUDs could be inserted at any time during the menstrual cycle without any increased risk of subsequent pregnancy, removal for medical reasons or expulsion during the 1st 12 months after insertion. Pooled International Fertility Research Program (IFRP) data indicate that there is no consistent pattern with regard to the time in the cycle that the IUD is inserted and its later performance. In no case is there a distinct advantage for the 1st 5 days of the menstrual cycle. It is much simpler to offer a woman an IUD when she is first seen, provided she is reasonably sure she is not pregnant. New practices are evolving in relation to recently pregnant women. The postabortal use of IUDs has been extensively researched and is a useful option, using a variety of currently available devices. In regard to the postpartum use of IUDs, some programs have reported a high expulsion rate. Provided proper insertion technique is used, IUDs can be inserted immediately postpartum with a high degree of retention. Another use for copper containing IUDs is insertion within 5 days of unprotected sexual intercourse. In sum, women can be provided with IUDs upon request at any time during the menstrual cycle.     

Spontaneous upward movement of lowly placed T-shaped IUDs

OBJECTIVE: To assess the possible progression of intrauterine devices (IUDs) to a lower or upper position in women. MATERIAL AND METHODS: Thirty-two lowly placed T-shaped IUDs in women with 0-3 children were examined with transvaginal ultrasonography after 2 months of insertion in order to assess the possible progression of the IUDs. Also, the IUDs inserted in women with 0-3, 0-1 and 2-3 children were compared to determine whether this progression was different depending on parity. RESULTS: Intrauterine devices (97%, 100% and 93.7%) in the group of women with 0-3, 0-1 and 2-3 children, respectively, moved upward. The mean decrease in IUD-fundus distance was 6.8, 7.4 and 4.9 mm, respectively. CONCLUSION: Lowly inserted T-shaped IUDs tend to move upward after insertion. Therefore, initial concern about low placement of a T-shaped IUD is not justified as most of them spontaneously readjust their position.     

A clinical trial of the Delta-T intrauterine device: immediate postpartum insertion

The Copper T-220C intrauterine device was modified for use in early postpartum insertions. Biodegradable extensions consisting of No. 2 chromic suture were added to the horizontal arms of the device to enhance retention. This new device, Delta-T IUD, was inserted in 100 patients within 55 hours of the delivery of the placenta. No uterine perforations or cervical lacerations occurred in this study. There was one accidental pregnancy 4 months following the IUD insertion. Seven IUDs were removed for bleeding and pain. There was one case of postpartum endometritis. Seventeen IUD expulsions occurred. Expulsions were more frequent at the beginning of the study and when the IUD was inserted more than 30 minutes after delivery of the placenta. The immediate postpartum insertion of IUDs with the event rates observed in this study is acceptable in situations where alternatives for other family planning modalities or interval insertion of intrauterine devices are not feasible.     

Intrauterine device insertion after medical abortion

Background

Studies comparing immediate intrauterine device (IUD) insertion after first-trimester surgical abortion with interval insertion show similar efficacy and expulsion rates. However, women randomized to interval insertion of an IUD are less likely to return for device placement. An ideal time to insert intrauterine contraception may be the day a woman presents for verification of a completed medical abortion. We examined immediate insertion of IUDs after completed first-trimester medical abortion.

Study Design

This is a prospective, observational clinical study to determine expulsion rates of intrauterine contraception placed immediately after confirmed, completed first-trimester medical abortion.

Results

Of 118 subjects, 78 women had levonorgestrel IUDs placed, whereas 41 women received copper IUDs. Of 97 subjects who completed the study, there were 4 clinical expulsions (4.1%) during 3 months of follow-up. There were no diagnosed pelvic infections, pregnancies, or uterine perforations. The continuation rate at 3 months was 80%.

Conclusion

Intrauterine devices inserted at the time of completed, confirmed first-trimester medical abortion have low rates of expulsion.     

Obstetrician–Gynecologists and contraception: long-acting reversible contraception practices and education

Objectives

Long-acting reversible contraception (LARC) — the copper and levonorgestrel intrauterine devices (IUDs) and the single-rod implant — are safe and effective but account for a small proportion of contraceptive use by US women. This study examined obstetrician–gynecologists' knowledge, training, practice and beliefs regarding LARC methods.

Design

A survey questionnaire was mailed to 3000 Fellows of the American College of Obstetricians and Gynecologists. After exclusions, 1221 eligible questionnaires were analyzed (45.8% response rate, accounting for exclusions).

Results

Almost all obstetrician–gynecologists reported providing IUDs (95.8%). Most obstetrician–gynecologists reported requiring two or more visits for IUD insertion (86.9%). Respondents that reported IUD insertion in a single visit reported inserting a greater number of IUDs in the last year. About half reported offering the single-rod implant (51.3%). A total of 92.0% reported residency training on IUDs, and 50.8% reported residency training on implants. Residency training and physician age correlated with the number of IUDs inserted in the past year. A total of 59.6% indicated receiving continuing education on at least one LARC method in the past 2 years. Recent continuing education was most strongly associated with implant insertion, and 31.7% of respondents cited lack of insertion training as a barrier.

Conclusions

Barriers to LARC provision could be reduced if more obstetrician–gynecologists received implant training and provided same-day IUD insertion. Continuing education will likely increase implant provision.

Implications

This study shows that obstetrician–gynecologists generally offer IUDs, but fewer offer the single-rod contraceptive implant. Recent continuing education strongly predicted whether obstetrician–gynecologists inserted implants and was also associated with other practices that encourage LARC use.     

Postpartum IUD - the suture loop

Postabortal IUD insertion has been well researched and successfully used throughout the world with a wide range of IUDs. Postpartum IUD insertion would be equally successful except that this timing has been associated with high expulsion rates. Extensive IUD design research over more than 10 years has not produced a device superior to the original Lippes Loop. This focuses current research on the conditions under which IUDs are inserted instead of on changes and improvements in design. The International Fertility Research Program (IFRP) in North Carolina is conducting research with a modified Lippes Loop with a view to postpartum insertion. Initial trials with the device have been successful and extended trials are under way. This IUD can be placed by hand or with a simple inserter after expulsion of the placenta. After more experience with the device, it is thought that nonmedical personnel can be trained to insert it.     

Primary healthcare physicians and population have realistic views on IUD contraception

Objectives: The intrauterine device (IUD) is considered as a reliable means of contraception, but due to side effects it is held suspect in some countries. This study examines primary healthcare physicians' and the population's experiences and opinions concerning IUD contraception.

Study design: A questionnaire on family planning was mailed to a random sample of Finnish health centre physicians and a random sample of Finnish women and men. The response rates were 69% for physicians, and among the population 56% for women and 45% for men.

Results: A majority of physicians had recommended IUD contraception and inserted the devices. One third of the women and one third of the male respondents' partners had at sometime used IUDs. Physicians found them more easily available and cheaper than did the population. IUD-users' opinions were closer to those of physicians than were those of non-users.

Conclusion: IUD insertion is familiar to primary healthcare physicians. Both physicians and the population are aware of the side effects related to IUD use, but their opinions are realistic.     

IUD-related knowledge,attitudes and practices among Navajo Area Indian Health Service providers

CONTEXT: The IUD once accounted for about half of contraceptive use among Navajo women but is now little used in this population, which has a high rate of unintended pregnancy. Identifying barriers to use–including those stemming from providers'IUD-related knowledge, attitudes and practices–could help expand use of the method.
METHODS: In 2000, 107 Navajo Area Indian Health Service providers who offer contraceptive services completed a mailed survey. Responses of women's health providers and other types of providers were compared, using the Cochran-Mantel-Haenszel method.
RESULTS: Overall, 69-78% of providers had good factual knowledge about the IUD and felt adequately prepared to insert a device or counsel women about it; considerably larger proportions of women's health providers than of others felt able to counsel about and insert IUDs. Sixty-five percent of providers (88% of women's health providers and 50% of others) currently inserted IUDs, and only 8% (none of them women's health providers) never recommended the method. The main reasons providers cited for not recommending the IUD were concerns about its safety and about side effects (mentioned by 69% and 44%, respectively); these concerns did not differ by provider type.
CONCLUSIONS: Provider education and training should focus on insertion techniques and on the safety of available IUDs. Training should be targeted not only to women's health providers, but to family practice physicians, nurse practitioners and other providers who offer family planning counseling and services.     

Menstrual bleeding with copper-covered ihtrauterine contraceptive devices

The menstrual blood loss before and during three menstruations after insertion of two copper-covered intrauterine devices (TCu 200 and Cu 7 200) was studied in 82 women.

Of 66 women with normal menstruations, 50 were fitted with a TCu 200 and 16 with a Cu 7 200 device. Sixteen women with profuse menstrual bleeding were fitted with a TCu 200 device.

The menstrual blood loss was increased during the first two periods, but by only half of that reported after insertion of other intrauterine contraceptive devices (IUDs), and it was followed by an improvement in the third period. Women with menorrhagia before insertion of the devices had no significant increase in bleeding. The use of copper IUDs reduces the need of medication and control tests.     

江苏省部分农村地区宫内节育器使用状况及避孕效果调查

目的:了解宫内节育器(IUD)的使用状况及其避孕效果与安全性,为提高计划生育服务水平提供依据。方法:在参加2005年国家人口计生委科技司组织的12万例IUD避孕效果抽样调查的江苏省金坛市薛埠镇、高邮市车逻镇、建湖县颜单镇3个样本点,对2005年7月～2008年12月间有放置IUD手术记录的妇女进行IUD放置与使用情况的随访调查。结果:3个样本点育龄妇女使用IUD种类居前5位为TCu220C、元宫型220、TCu380A、宫腔形含铜200和母体乐375IUD,不同地区使用种类存在差异(P<0.01);2005～2008年间放置IUD的3年累计不良停用率较国家人口计生委科技司调查的2000～2005年间的不良停用率增加了5.41%;活性γ型IUD3年续用率为85.74%,高于TCu220C、元宫型220、TCu380A、宫腔形含铜200、母体乐375IUD,3年累计因症取出率低于其他5种IUD(P<0.01),无带器妊娠发生,3年累计脱落率为2.27%。结论:计划生育技术服务机构要重点关注本地区使用较为广泛的IUD可能发生的不良事件,做好IUD不良事件监测与防治;推广应用有效性与安全性较高的活性γ型IUD,并进一步研究其在人群中的使用效果;进一步分析放置IUD因症取出率有所增加的原因。     

Quantitative studies on menstrual blood loss in IUD users

Despite the introduction of new intrauterine devices (IUDs), the most important complication involving their use continues to be excessive menstrual bleeding. IUD use in developing countries with women who are already depleted in body iron stores may prove to be deleterious to their health. Mean amounts of menstrual blood loss (MBL) for women not using contraception in the western world is about 32 ml. This mean is increased to 52-72 ml with use of the Lippes loop and other non-medicated devices up to 24 months after insertion. For the Copper-7 and Copper-T-200 devices this mean increase is to 37-40 ml in the first month, decreasing to 30-38 ml at 12 months after IUD insertion. In the users of the Multiload-250 IUD at one month post-insertion the MBL is from 56 to 63 ml and from 36 to 39 ml at 24 months of use. The mean Multiload-375 device users at one month after insertion lose a mean of 45-73 ml at 24 months, 35-50 ml. With the progestogen-releasing IUD mean MBL is 27-36 ml at 1 month and 9-13 ml at 12 months post-insertion. Intermenstrual blood loss is significant only in the first month of use for all IUDs. Discontinuation rates for pain and bleeding with non-medicated IUDs are from 11.0-19.6 per 100 women per year, and for the copper IUDs 4.4 to 6.8 per 100 women in the first year of use. The main problem with prolonged menstrual bleeding is depletion of the body iron stores; this is highly significant with non-medicated devices, less important with copper devices and conversely, iron stores are increased in users of progestogen-releasing devices. This is based on serum ferritin measured up to 24 months after insertion. The ferritin values correlated well with the volumes of MBL. It is suggested, especially for women with low body iron stores, that there is an order of preference for IUDs to be used. This should be: firstly, the progestogen-releasing devices; secondly, the Copper-T and Copper-7 IUDs; thirdly the larger surface copper devices (Cu-T-220C, Multiload 250 and 375, Cu-T-380). Non-medicated devices are not to be recommended for these women.     

记忆合金药铜IUD对兔子宫内膜及重要脏器的组织形态学影响

目的:研究记忆合金药铜节育器(IUD)对兔子宫内膜及重要脏器的组织形态学影响。方法:将雌性日本大耳白兔随机分为3组,放置记忆合金药铜IUD(实验组)和放置不锈钢药铜IUD(对照组)各18只,空白对照组6只,手术放置IUD于兔子宫腔内,术后1、3、6个月处死兔,取出子宫、输卵管、卵巢和心肺肝脾肾组织,切片HE染色,光镜下进行组织学检查。结果:两置器组IUD直接压迫下的区域,子宫腔扩张,黏膜层变薄,黏膜皱襞减少。空白组子宫壁和两置器组IUD直接压迫区的子宫壁均可见小血管轻度扩张充血,3组比较无明显差异。心肺肝脾肾组织均未见异常。结论:记忆合金药铜IUD与不锈钢药铜IUD对兔子宫内膜及重要脏器的组织形态学影响相似。     

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.     

Consequences of uterine blood loss caused by various intrauterine contraceptive devices in South American women. World Health Organization Special Programme of Research, Development and Research Training in Human Reproduction

Increased menstrual blood loss (MBL) associated with intrauterine device (IUD) use may precipitate or aggravate iron deficiency anaemia, adversely affecting the health of women particularly those from developing countries. Studies were conducted to define the association of MBL and iron status in South American women; to determine the level of MBL induced by IUD use which would result in iron depletion, the length of time for this depletion to occur and, comparing various IUDS, to determine if any currently tested IUDs are suited to long-term use in South American women. A total of 395 women received one of 5 types of IUDs in Santiago, Chile, and Juiz de Fora, Brazil: Lippes Loop, Multiload-250 and Multiload-375 were used in both centres; in Santiago some subjects received the Copper-7 or ProgestasertR devices and in Juiz de Fora, the TCu 200 and the T-Chloroquin IUDs were also tested. MBL and haemoglobin (HGB) were measured for 3 menstrual cycles before insertion, and following insertion, at one, two, four, six, nine, twelve, eighteen and twenty-four months in the majority of cases. Serum ferritin was measured before insertion and at intervals of six months. Mean values of MBL prior to IUD insertion in both centres varied from 21-30 ml. As with previous publications, the use of the Lippes Loop was associated with the greatest increase in MBL which was sustained throughout the 24 months of observation. Women who had one of the two types of Multiload devices inserted also had increased MBL and reduced ferritin for at least 12 months of use. TCu 200 and Copper-7 IUD users had an initial increase in MBL of 1 to 17 ml in the first six months of observation returning to normal levels beyond six months. Serum ferritin levels were lower for one year and then returned to admission values. ProgestasertR users confirmed previous reports of a reduction of 40-50% in MBL and an increase in serum ferritin. Few significant changes in haemoglobin (HGB) concentrations were found. Serum ferritin levels on admission ranged from 7.1 to 16.4 ng/ml in Santiago and from 15.8 to 23.2 ng/ml in Juiz de Fora. Many women were in a marginal state of iron balance as evidenced by lower serum ferritin values. Changes in serum ferritin were very closely related to those in MBL.(ABSTRACT TRUNCATED AT 400 WORDS)     

宫内节育器尾丝与宫颈糜烂关系的临床观察

目的:探讨宫颈糜烂与宫内节育器(IUD)尾丝的关系。方法:采用前瞻性临床研究方法,观察放置有尾丝IUD妇女宫颈糜烂的发病率,并与放置无尾丝IUD妇女进行比较。结果:放置IUD 1年,置入无尾丝IUD者和有尾丝IUD者的宫颈糜烂发生率差异无统计学意义,而放置IUD 3、5和8年,置入有尾丝IUD宫颈糜烂发生率高于无尾丝IUD者,差异有统计学意义(P<0.05)。放置IUD1、3、5和8年,置入无尾丝IUD者和有尾丝IUD者的宫颈糜烂的程度差异均无统计学意义(P>0.05)。结论:尾丝刺激可能是置入有尾丝IUD者宫颈糜烂发生率增高的原因之一。     

Statement on intrauterine devices

These policy statements and guidelines from the International Planned Parenthood Federation's (IPPF) International Medical Advisory Panel (IMAP) concern IUDs. The following contraindications to IUD use are recognized: 1) pelvic inflaminatory disease, 2) known or suspected pregnancy, 3) history of previous ectopic pregnancy, 4) gynecological bleeding disorders, 5) suspected malignancy of the genital tract, 6) congenital uterine abnormalities or fibroids distorting the cavity, and 7) anemia, blood coagulation, severe cervical stenosis, copper allergy, Wilson's disease, and others. Generalities regarding appropriate IUDs are: 1) non-medicated devices (e.g. Lippes Loop) are studied for women who may not return for regular check-ups, 2) smaller medicated devices usually cause less menstrual blood loss than the non-medicated devices, 3) smaller devices are better for a smaller uterus and larger devices for the larger uterus, and 4) when a smaller device is expelled it is advisable to try a larger one and vice versa. Dalkon Shields should not be used by the IPPF system and all women using them should have the device removed. Correct insertion of IUDs is important and should be done by properly trained personnel. The timing of insertion is best during the menstrual period. Withdrawal of the applicator while leaving the device in place is the recommended insertion technique. Sterilization of IUDs should follow instructions on bulk-packaged IUDs. Complications include perforation, bleeding and pain, infection, and ectopic pregnancy. IUD removal should be done during menstruation. Good clinical management and follow-up care are recommended.     

A three-year evaluation of TCu 380Ag and multiload Cu 375 intrauterine devices

A randomized, comparative, multicenter clinical trial of TCu 380Ag and Multiload Cu 375 intrauterine devices (IUDs) was conducted. Safety and acceptability were evaluated through three years following insertion in 884 patients. The two IUDs were similar with respect to all event rates. Thirty-six month life table pregnancy rates were 0.6 per 100 TCu 380Ag users and 1.8 per 100 Multiload Cu 375 users. Continuation rates were 67.4 and 61.4 per 100 users of the respective devices at three years after insertion.