Trailing and treating the wandering IUD

Suggestions on how to manage a missing IUD for current practitioners in the U.S., who may not have any IUD experience, are recommended. It is important to realize that IUDs do not perforate the uterus on their own: they do so at insertion. No one who inserts enough IUDs will never perforate a uterus: the average perforation rate is 3 per 1000. Ultrasound cannot find a lost IUD without reference to some structure, especially if the IUD is free-floating. The best way to ensure that the IUD is not in the uterus use hysteroscopy. Any cystoscope can be converted to a hysteroscope by attaching a glass adaptor, and no distension medium is necessary. If the IUD is not found in the uterus, it can be located in the abdominal cavity by x-ray of the abdomen, including a lateral views. An anterior-posterior view of the pelvis may suggest that the IUD is in the uterus when it is not. If the IUD is in the abdominal cavity, the safest, and most acceptable way to remove it is by laparoscopy. Most lawsuits concerning perforated IUDs were prompted by laparotomy or colpotomy. IUDs in the abdomen, especially copper IUDs, will develop adhesions, any may bear bacteria from the insertion process. Perforated copper IUDs should be removed as soon as possible.     

Intrauterine contraception

Approximately 60 million women worldwide use IUDs. Despite worldwide distribution, the total number of IUD carriers has barely increased since 1970. Due to its risks and side effects there is a retrograding tendency both in West Germany and the US. To generate positive development, 3 basic trends have emerged: 1) Restrictive usage of the pharmacologically inactive, 1st generation IUDs such as the Lippes Loop or the Saf-T-Coil, 2) the increasing usage of small plastic IUDs with bioactive alloys to decrease failure rates such as the copper (2nd generation) or hormone-releasing IUDs, and 3) improvements made by changing its design to reduce side effects without loss of contraceptive effectiveness. Almost all IUDs increase monthly blood loss by 50-100%. The risk of illness for women with IUDs is 2-3 times higher than for a woman without or with other contraceptive methods. About 20% of all expulsions occur unnoticed. There are 2 kinds of perforations: primary (iatrogenic), at time of insertion, and secondary, some time after insertion. The IUD failure rate is about 1-3 pregnancies/100 woman years. In case of pregnancy, the IUD must be removed immediately. IUD insertion requires consent of the woman and can be made to women from 16 years on, presupposing moral maturity. IUD insertion after a miscarriage or abortion does not lead to risks or complications. Due to its corrosive quality, the copper IUD can only remain inside the uterus for a limited time. IUDs could become an excellent contraceptive method if it were possible to decrease bleeding, design easily-removeable IUDs, and prolong their potential for duration in the body.     

Modification of the cervical flora by IUCD

The study objective was to examine the cervical flora during the insertion of an IUD and to determine whether the presence of the device in utero modified this flora. A secondary objective was to determine whether the colonization of the cervix with (occasionally) pathogenic bacteria warrants a prophylactic antibiotic treatment. IUDs were inserted in a group of 20 women, ranging in age from 23-40 years, at the Family Planning Clinic of Meir Hospital in Kfar Saba, Israel. The cervical bacterial flora was examined during insertion and again after a period of 3-12 months with the IUD in situ. None of the women received antibiotic or antifungal treatment for 3 months prior to or 12 months after insertion. The women were divided into 2 groups according to the type of IUD used. Group A consisted of 22 women with nonmedicated IUDs and Group B included 28 women with IUDs medicated with copper. A cervical swab was collected during insertion of the IUD and at 3-12 months afterwards. Of the 50 cervical cultures collected during the insertion, 48 (84%) were sterile, but only 27 of the cultures collected after 3-12 months with the IUD in utero were sterile. The medicated IUD had a more intense bacteriostatic effect on the bacterial cervical flora than the other devices. Among the copper IUDs the best results were obtained with the Nova T type and secondly with the Copper 7 (Gravigard). It is possible that the pathogenic organisms enter the uterine cavity and tubes from the cervix during insertion of the IUD. It may be concluded that during IUD insertion prophylactic treatment with a broad spectrum antibiotic would be indicated, but the study showed that this was not the case. The organisms isolated in the women studied were those normally found in the upper vagina and cervix and only occasionally became pathogenic. Medicated IUDs are preferable because of the bacteriostatic activity of the copper and to the fact that they are normally left in utero for a shorter time than the unmedicated IUDs.     

Intrauterine contraception (author's trans)

Biological and technical research findings have helped to increase the number of acceptors of the IUD in France to nearly 1.5 million in 1983. The endometrial effects of IUDs are better understood at the morphological level through the use of electron microscopy and at the functional level through use of doses of metabolites or hormonal receptors. More precise evaluation of modifications of the composition and biological properties of the uterine environment allow a better understanding of local physiological repercussions of the IUD. Copper IUDs, the most common type in use at present, are produced with numerous variations in size, shape, method of insertion, and other features. Factors conditioning the liberations of copper have not been studied until recently, but appear to depend on the woman herself as well as the quantity, quality, mode of incorporation and location of the device of the copper. There is no consensus as yet as to the optimal amount of copper, duration of the IUD, or role of the copper. Progesterone-freeing IUDs are on the point of being commercialized in France. Unlike copper IUDs, they release the substance at a constant rate over a determined period. The effects include diminution of fibrinolytic activity and liberation of prostaglandins, with consequent reductions in blood loss and menstrual pain. Because the properties of an IUD are modified by such conditions of use as the experience of the inserting physician and patient characteristics, comparison between different devices is difficult. The most important factor affecting performance of the IUD appears to be good adaptation of the device to the configuration of the uterine cavity. Complications are not always avoidable but they can be reduced by better patient selection and good technique of insertion, and their consequences can be limited by early identification and treatment.     

A case of allergy to a copper-medicated IUD. Etiopathogenetic and clinical aspects

The use of copper medicated IUDs has replaced the use of inert IUDs, thanks to their increased effectiveness, a Pearl index of 1% as compared to 2.5%. There are very few reported cases of copper allergy due to IUDs; this article presents 1 such case. A 22 year old healthy woman was inserted with a Cu 250 IUD; 1 week after insertion she presented widespread erythematous patches all over her body, excluding her face. Cortisone and antihistamine treatment were ineffective; the IUD was removed, and all symptoms disappeared in less than 20 days; subsequent tests revealed the patient to be allergic to copper sulphate.     

The effects of TCu-380A on cervicovaginal flora

Objective This study aims to identify the alterations in cervicovaginal flora after insertion of TCu 380A which is a popular type of copper IUD. Study design Among the women who visited the Department of Family Planning in our hospital during 1 month, 100 subjects who preferred IUDs for contraception and who had no history of local or systemic antibiotic use were considered eligible candidates. Results Anaerobic colonies, especially Gram-positive cocci and Gram-negative bacilli were isolated at significantly higher rates after the insertion of TCu-380A. Aerobic colonies were isolated relatively less. Conclusions It can be suggested that copper IUD causes the predominance of anaerobic species in the cervicovaginal flora, which is consistent with the literature. This clinically insignificant condition can be attributed to the copper content or threads of the IUDs. Yet there is no evidence that the prevalance of pelvic infections is influenced by the use of IUDs.     

The intrauterine device, pelvic inflammatory disease, and infertility: the confusion between hypothesis and knowledge.

An earlier editorial made many false claims against the IUD and women. In many cases, the author extrapolated experience from the Dalkon Shield to today's IUDs. He even said the modern contraception has not reduced fertility, but data from at least 7 developing countries clearly refute that statement. Moreover he claims that the most female ambition is motherhood. Thus he blamed women for high fertility rates without acknowledging that women in developing countries have little control over fertility. Husbands determine when and how often to have intercourse and whether to use contraceptives or not. Women do not always have access to contraceptives. The author boldly stated that the IUD poses a threat to future fertility because it causes pelvic infections. The real threat is intercourse by which upper genital tract infections are transmitted. It is these sexually transmitted diseases that cause pelvic infections. The studies the author quoted have been found to have considerable bias and/or methodologic flaws. Some studies used as the comparison group women using contraceptive which lower the pelvic infection risk. Contemporary studies find no increased risk of infertility in copper and hormone IUD users, but instead show increased risk for multiple sex partners. Some studies do indicate an increased risk shortly after insertion which is due to insertion instrumentation used. The author even claimed that a Swedish study concluded that IUDs promote pelvic infection in patients with gonorrhea and chlamydia. But the Swedish study found no difference in pelvic infection risk between IUD and non-IUD, nonhormonal contraceptive users. Based on hundreds of millions of woman-years of worldwide experience, WHO claims modern copper and hormone releasing IUDs, when used as directed, may be the most effective and reliable reversible contraceptive method. This editorial based on flawed conclusions and misinformation does an injustice to the IUD and to women.     

The effect of intrauterine devices containing zinc and copper on their levels in serum

Serum levels of copper and zinc were determined in 11 health women in whom Latex Leaf intrauterine devices (IUDs) containing copper and zinc had been inserted. Patients with low levels of serum copper or zinc before insertion usually had increased levels of either of these metals while using the device, but they did not exceed the upper limits of normal values. When the group was considered as a whole, the serum levels of zinc showed a slight tendency to increase with duration of IUD use, whereas there was no statistical difference between the serum levels of copper before and after insertion of the IUD.     

The effect of intrauterine contraceptive devices on the endometrium

Insertion of an IUD into the uterine cavity is associated with an inflammatory cellular response of the endometrium, which initially is common to all IUDs as the endometrial tissue reacts to the presence of a foreign body. Other types of morphologic modifications specific to different types of IUDs are then observed and may be important in understanding the mode of action of the device and in explaining bleeding patterns associated with IUDs. The endometrial response to inert and copper IUDs is quite similar. The part of the endometrial surface in contact with an inert or copper IUD loses its outer layer of epithelial tissue, exposing the lower layer of basal membrane. The rest of the epithelium in contact with the IUD appears flattened, and some epithelial cells lose their microvilli. Ultrastructural studies have demonstrated a reduction in number of ciliated cells and an alteration of the secretory activity of the surface epithelium and to a lesser degree of the glandular epithelium in reaction to the IUD. Diffuse interstitial bleeding with migration of erythrocytes between the interepithelial spaces has frequently been seen. Ultrastructural studies clearly show that inert IUDs induce lesions and later secondary modifications of the surface epithelium, the superficial vascular epithelium, the glandular epithelium, and to a lesser extent other endometrial cells. With copper IUDs, surface erosions of endometrial epithelium are seen, with much more cellular destruction and signs of bleeding in the part in contact with the copper. As with inert IUDs, the adjacent basal membrane is usually intact. A notable finding in the endometrium is the existence of microthrombosis of stromal capillaries, especially in the portion exposed to the copper. There appears to be a direct relationship between the amount of copper and the degree of ultrastructural modification. The effects of progesterone-releasing IUDs on the surface epithelium, the glands, the stroma, and the vascularization vary as a function of the dose and type of progestin, the proximity of the tissue and the part of the IUD treated, and the time elapsed since insertion.     

In vitro sperm penetration tests and PCTs in fertile women wearing different medicated IUDs (Cu and progesterone)

In order to evaluate the sperm-cervical mucus interactions in women wearing different intrauterine devices (IUDs), a longitudinal study of over 27 months in 7 selected normally fertile couples was made. In vitro sperm penetration tests and PCTs, in the same woman, were carried out in basal conditions and after insertion of IUDs (copper IUD before and progesterone IUD after). The copper IUD induces little modification on the "in vitro" and "in vivo" sperm passage and on the characteristics of the cervical mucus. In contrast, the progesterone IUD is more effective than the copper IUD in inhibiting sperm penetration even with little modofication of the characteristics of the ovulatory cervical mucus. It appears, therefore, that the cervical mucus modifications are less relevant than the toxic effect on the spermatozoa in the mechanism of activity of progesterone IUDs.     

Intrauterine devices. The optimal long-term contraceptive method?

OBJECTIVE: To review selected data on the effectiveness, safety, cost and technical ease of intrauterine device (IUD) use compared with Norplant and surgical sterilization. STUDY DESIGN: Literature review. RESULTS: IUDs are highly effective, safe and relatively inexpensive methods of contraception that may offer advantages for some women over other long-term methods, such as sterilization and Norplant. IUDs provide protection against pregnancy comparable to that provided by female sterilization, and they may be more effective than Norplant. IUDs have a long duration of effectiveness: the copper T 380A (TCu380A) is effective for at least 10 years, and the levonorgestrel (LNg) IUD appears to be effective for at least 7. Norplant is effective for only five years. Both types of IUD can disrupt menstrual bleeding patterns, although the patterns of bleeding are different. Copper IUDs often increase blood loss, whereas the LNg IUD, like Norplant, substantially reduces menstrual bleeding. The most important adverse outcome associated with IUD use is higher rates of pelvic inflammatory disease; careful attention to proper insertion techniques can reduce this risk substantially, and LNg IUDs may cause no increase in risk. IUDs, like both sterilization and Norplant, provide no protection against sexually transmitted disease. The TCu380A IUD is extremely cost-effective. There is as yet no public sector price for the LNg IUD, which has not been approved by the U.S. Food and Drug Administration and is not provided by family planning donor organizations. If it can be made available to the public sector at a price substantially less than its present market price, the LNg IUD would be a useful addition to the contraceptive armamentarium for developing countries. CONCLUSION: Providers, consumers and family planning program managers should begin to see IUDs as potential substitutes for both surgical sterilization and Norplant.     

The IUD and pregnancy after inserting and removing the IUD]

The significance of IUD insertion on pregnancy and the effects of its removal on pregnancy are discussed. IUD insertion has 3 chief implications for pregnancy: 1) the risk of natural abortion increases with the insertion of an IUD, even for an IUD that remains in the proper position; 2) the percentage of women suffering abortions caused by uterine infection is higher among women with IUDs than for women without IUDs; and 3) pregnancy after insertion of an IUD can end in miscarriage or stillbirth, and often produces babies that weigh less than the standard weight for newborns. It is maintained that removal of the IUD has no harmful effects on fertility.     

Future of intrauterine contraception (IUDS)

Performance of IUDs has improved greatly in the past decade. The reasons for improvement include increased copper content and prevention of copper fragmentation, flexible frames that adapt to the endometrial cavity, better evaluation of the endometrial cavity before insertion, simplified insertion, selection of acceptors, and careful follow-up. NO significant modifications in IUD design have occurred since the use of copper was begun in the 1970s except for use of systems-releasing steroids. The use of copper improved efficacy and permitted use of smaller devices, reducing some side effects especially in small uteruses. The duration of use of copper IUDs has increased, and their efficacy has improved at the same time that modifications have permitted greater local tolerance with no increase in expulsion rate. Greater selectivity of IUD users has improved performance, taking into account known risks for major complications such as extrauterine pregnancy and infection. Prior use of IUD and conditions of follow-up should also be considered in candidate selection. The major weaknesses of IUDs at present are related to the introduction of a foreign body into the uterine cavity; IUD insertion entails potential risks of infection and perforation. However, the active substance should not cause damage to the endometrial mucus or induce cycle disturbances or diminished defenses against pain and infection. Research on IUD frames is oriented toward development of a device adaptable to specific conditions such as the postpartum. 1 new device would completely eliminate plastic and the related side effects. A new miniaturized device is under investigation along with a biodegradable device and an intracervical device. New substances under study for a better contraceptive effect include spermicides, immunological substances, and synthetic progestins. An intracervical device emitting a battery-driven weak electric field is intended to immobilize sperm. Most current research has as its goal the reduction of secondary effects of bleeding, pain, or risk of infection. Among the numerous substances utilized have been antifibrinolytics, prostaglandin inhibitors, sexual steroids, and antibiotics. These systems should provide constant release over a prolonged period, a goal not yet attainable for all these substances.     

Copper IUDs (author's transl)

Following initial development of the Grafenberg ring in the 1920's, IUDs fell into disuse until the late 1950s, when plastic devices inserted using new technology began to gain worldwide acceptance. Further research indicated that copper had a significant antifertility effect which increased with increasing surface area, and several copper IUDs were developed and adapted, including the Copper T 200, the Copper T 220C, and the Copper T 380 A, probably the most effective yet. The Gravigard and Multiload are 2 other copper devices developed according to somewhat different principles. Copper devices are widely used not so much because of their great effectiveness as because of their suitability for nulliparous patients and their ease of insertion, which minimizes risk of uterine perforation. Records of 2584 women using Copper IUDs for 7190 women-years and 956 women using devices without copper for 6059 women-years suggest that the copper devices were associated with greater effectiveness and fewer removals for complications. Research suggests that the advantages of copper IUDs become more significant with increased duration of use. Contraindications to copper devices include allergy to copper and hepatolenticular degeneration. No carcinogenic or teratogenic effect of copper devices has been found, but further studies are needed to rule out other undesirable effects. Significant modifications of copper devices in recent years have been developed to increase their effectiveness, prolong their duration of usefulness, facilitate insertion and permit insertion during abortion or delivery. The upper limit of the surface area of copper associated with increased effectiveness appears to be between 200-300 sq mm, and at some point increases in copper exposure may provoke expulsion of the IUD. The duration of fertility inhibition of copper IUDs is usually estimated at 2-3 years, but recent research indicates that it may be 6-8 years, and some devices may retain copper surface for as long as 20 years. Shorter and smaller versions of standard copper IUDs have been tested as they permit easier insertion, but high rates of pregnancy, expulsion, and removal have prevented their wider use. The discovery that the size of the uterine cavity is more important than its length has prompted the development of some promising uterine measuring instruments. Attempts to develop a device appropriate for postpartum use have been disappointing, and expulsion rates remain high. A few promising new forms of copper IUDs have been developed but not yet tested clinically.     

Historical considerations in the development of modern IUD's: patient and device selection and the importance of insertion techniques.

The Cooperative Statistical Program was initiated in 1963, the 1st effort to evaluate a method of contraception by using pooled data from several clinics and a systematic statistical method. Progress reports were issued from 1963 through 1970. The reports provided epidemiological evidence that Lippes Loop D has the best overall performance of all the IUDs studied. Expulsion, pregnancy, and removal rates for bleeding and pain were measured. Performance rates for all these indices are better with the duration of the device. Since 1970, numbers of new IUDs have been designed and tested clinically. The aim was to improve efficacy, to make IUDs suitable for women who had never been pregnant, and to reduce the incidence of pain and bleeding. The T-shaped IUD has been found to cause lowered rates of removal for pain and bleeding. To counteract the higher pregnancy rate with this device, an antifertility agent can be added to the IUD for timed release. Steroids and copper have both been used. Clinics differ in their performance rates due to differing patient populations, differing physician experience, and differing clinic attitudes. The insertion technique is important to long-term performance.     

活性γCu380IUD与TCu380AIUD临床比较性研究

本研究通过增加原γCu 2 0 0 IUD的铜表面积至 3 80 mm2 ,其目的为了进一步降低带器妊娠率 (包括异位妊娠 ) ,以期达到 TCu3 80 A IUD相似的避孕效果 ,而其副反应发生率明显低于 TCu3 80 A IUD。方法 :1 995年 8月～ 1 996年 6月由三个中心参加的随机比较性研究 ,共随访 2 4个月。每个中心分别放置γCu 3 80与 TCu 3 80 A IUD各 1 0 0例 ,共 6 0 0例。结果 :2 4个月末 γCu3 80与 TCu3 80 A IUD脱落率每百妇女分别为 0 .997和 2 .4 70 (P>0 .0 5)。带器妊娠率每百妇女分别为 0 .3 3 2和 2 .4 59(P<0 .0 5)。异位妊娠率每百妇女分别为 0 .1 6 1和 0 .3 3 0 (P>0 .0 5)。因症取出率每百妇女分别为 1 .6 6 1和 5.4 95(P<0 .0 5)。结论 :γCu 3 80 IUD临床避孕效果明显优于 TCu 3 80 A IUD;两种 IUD的异位妊娠率相似 ;γCu3 80 IUD的副反应发生率明显低于 TCu3 80 A IUD。本研究结果证实高铜面积 γCu3 80 IUD是一种优质的 IUD。     

The end of IUD marketing in the United States: what does it mean for American women?

The decision to suspend sale of the copper 7 and Copper T 200 IUDs and the Lippes loop in the US will eventually affect most of the US women using them. Although the Progestasert, a progesterone-containing device manufactured by the Alza Corp, will still be available, the Progestasert accounted for only 3% of IUD sales in 1984 compared to 66% for the 2 copper devices and 31% for the Lippes loops. Ortho Pharmaceutical and Searle, the manufacturers of the discontinued devices, were motivated largely by their difficulty in obtaining liability insurance and their desire to avoid excessive financial risk resulting from lawsuits, especially in view of the large judgements against the makers of the Dalkon Shield. Ortho was also influenced by declining sales of the Lippes loop. The 198 National Survey of Family Growth (NSFG) estimated that in that year some 2,152,900 American women used IUDs, representing 7.3% of the 29.5 million contraceptive users in the US and 10.8% of users of reversible methods. 30% of IUD users had stopped oral contraceptive (OC) use on the advice of their physicians. Slightly over 1/2 of IUD users were 30 years old or over. 63% were currently married. 12.8% had no children. 21.2% had already had an unwanted pregnancy and 54.7% said they wanted no more children. OCs were contraindicated for 56.4% of the IUD users because of age, smoking, or medical conditions. Most IUD users thus belonged to the group for whom the method is most suitable: older married women who have already had children. Lippes loops are inert and users can continue indefinitely with the method, but copper IUDs require periodic replacement, usually after 3 years. Some physicians and family planning programs have advised women using Lippes loops or copper IUDs to have them removed at once. It is difficult to predict what method will be utilized in the future by current IUD users; the near total disappearance of a contraceptive method is unprecedented. 3 estimates of the percentage of current IUD users who will have unwanted pregnancies in the next year under different assumptions about contraceptive choices were compared to the proportion risking unwanted pregnancies assuming continued availability of their IUDs: 4.2%. If all IUD users chose the next most effective method available to them--sterilization for those not wanting more children, OCs for those with no contraindications who might want more children, and condoms for the rest--the pregnancy rate would be 2.4%. The other estimates were 9.2% assuming less resort to sterilization and more to diaphragms and spermicides, and 13.0% assuming that 15% of the women would use no other contraceptive. Current users of IUDs are faced with a difficult choice about future method use, and need clear and reliable information from their physicians and the media on the risks and advantages of other methods.     

Selecting patients and inserting the Progestasert

In this article, the author discusses what is presently known about the Progestasert IUD, a progesterone delivery system. Progestasert delivers progesterone on a daily basis and in continuous fashion into the endometric cavity. It has no systemic effects, although there is increasing evidence of its effects on hypermenorrhea na dysmenorrhea. Evidence suggests that Progestasert may avoid one of the major problems associated with former IUDs (particularly the Dalkon Shield): salpingitis. More than 10 years ago, physicians observed during sterilization procedures that a large number of women wearing inert or copper IUDs had salpingitis. Data from 27 Progestasert users show that none had salpingitis at the time of sterilization. Progestasert may also carry a lower risk of pelvic inflammatory disease associated with IUD use. A study in Helsinki found only 3 cases of pelvic inflammatory disease in 20,000 women years use of progestin (Levonorgestrel) impregnated IUDs, compared to the expected incidence (according to the Center for Disease Control) of 1/100 woman years. Additionally, in a study involving over 300 patients, the use of prophylactic antibiotics after insertion twice a day for 5 days and inserting Progestasert during the time ovulation rather at the time of menstruation produced no cases of the pelvic inflammatory conditions usually associated with the insertion procedure. Concerning the risks of ectopic pregnancy, evidence suggests that progestasert tends towards more ectopics when compared to the copper IUDs, but towards less when compared to not using any contraception. Although Progestasert is not contraindicated in nulliparous patients, caution should be taken with such patients.     

The efficacy of immediate post-abortion intrauterine device insertion

Ovulation returns soon after abortion, with half of the women ovulating by 21 days after the procedure. Immediate post-abortion insertion provides immediate contraceptive protection. Clinicians have feared that rates of uterine perforation due to intrauterine devices (IUDs) and expulsion of IUDs may be higher in the post-abortal uterus due to its softness and enlargement. This study was carried out to assess the safety and efficacy of IUD insertion immediately after induced abortion compared with insertion during the first menstrual cycle after abortion. All women were counseled about a method of contraception, particularly copper T-380A, and divided into two groups: Group 1 included 226 women who preferred immediate IUD insertion, and Group 2 included 100 women who opted for interval-IUD insertion during the first menstrual cycle after abortion. All women were followed-up at two and eight weeks after insertion of the IUDs. Severe bleeding was observed 10.62% in Group 1 and 6% in Group 2. Expulsion rate was 7.08% and 8% in Groups 1 and 2, respectively, which was not statistically significant. Pelvic inflammatory disease (PID) was observed in one case in Group 1. However uterine perforation was not noted in either group. In conclusion, insertion of an IUD immediately after an induced abortion is safe and if a woman asks for a modern contraceptive method it could be offered.