Risks of the IUD

IUD use in the Netherlands increased from 92,000 to 352,000 between 1981 due to the pill's unfavorable publicity. Only copper IUDs are used in the Netherlands (copper-covered plastic for increased effectiveness). In 1977, 1/2 of women aged 15-44 used oral contraceptives (OCs); in 1981, this figure was only 1/3. IUD use involves increased risk of salpingitis (1.8-9.3%) and extrauterine pregnancies. Doctors must be aware of these side affects and know how they can be avoided. Pelvic Inflammatory Disease (PID) occurs more frequently in IUD users, especially in nulliparas, than in women who use OCs. PID is more likely to occur after an IUD has been used for 5 years. Promiscuous IUD users are more susceptible to PID, and must be advised to use condoms as protection, though the risk of PID is higher among promiscous OC users. In order to avoid recurrence of the disease, women with diagnosed salpingitis should not use an IUD. Uterine perforations can occur during IUD implantation (8-9/1000 for inexperienced doctors and 1/1000 for experienced doctors). Copper IUDs may have to be removed due to adhesions in the abdominal cavity. All types of IUDs can cause blood loss from the endometrium. 50% of women using IUDs experience heavier menstrual blood loss during the first 3 months after the IUD is implanted, as well as longer menstrual periods and spotting between periods. Some women continue to bleed after the first 3 months and consequently discontinue IUD use. The conclusion is that the risks associated with IUD use are minimal when the device is implanted and used properly in women who do not show a high risk of genital infection. Literature must be provided pertaining to the increased risk of pregnancy compared with OCs, the negative side effects of IUDs, and the positive and negative side effects of the pill.     

Statement on intrauterine devices (IUDs)

Topics covered in this statement on IUDs include: mechanism of action; contraindications; efficacy; duration of use; counseling; IUD selection; insertion; the complications of perforation, bleeding and pain, infection, pregnancy, ectopic pregnancies, and expulsion; removal; and follow-up care. The newer copper- and hormone-releasing IUDs have high continuation rates, and the pregnancy rates are low. The removal in February 1986 of the Lippes Loop, the Copper 7, and the Copper T200 from the US market was for commercial reasons and not because of concerns about safety and efficacy. The Food and Drug Administration (FDA) approves these IUDs, and it is likely that the already FDA-approved Copper T380A will be available in the US during 1988. In its December 1986 meeting, the World Health Organization (WHO) scientific group on the mechanism of action, safety, and efficacy of IUDs concluded that all IUDs stimulate a foreign body reaction in the endometrium which is potentiated by the action of copper, and progestagen-releasing IUDs produce endometrial suppression much as that seen when the drug is administered by other routes. Further, the scientific group indicated that it is unlikely that 1 single mechanism of action accounts for the anti-fertility effect of IUDs. Several absolute contraindications to IUDs are recognized, including: acute or chronic pelvic inflammatory disease (PID); known or suspected pregnancy; abnormal uterine bleeding; confirmed or suspected malignancy of the genital tract; and congenital uterine abnormalities or fibroids distorting the cavity in a manner incompatible with proper IUD placement. The newer copper devices (TCu220C, TCu380Ag, TCu380A, and Multiload 375) have the lowest failure rates. Counseling of the IUD user should include telling her about all alternative family planning methods and advising her of the type of IUD to be inserted and the proper time for replacement if it is a medicated device. The available evidence from many countries suggests that properly trained nonphysicians can insert IUDs as well as doctors. The IUD may be inserted at any time convenient to the user if it can reasonably be determined that she is not pregnant. The medical indications for removal are pregnancy, acute inflammatory disease, endometrial or cervical malignancy, perforation and partial expulsion of the IUD, and abnormal or excessive bleeding. Whenever possible, it is useful to examine IUD users 3 months after IUD insertion, and annual checks are useful to ensure the IUD is in place.     

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.     

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.     

Contraception in women with diabetes mellitus

Oral contraceptive users suffering from diabetes mellitus experience different side effects from other women. The reliability of the pill is also different. 2 studies demonstrated a connection between fatal or nonfatal heart attacks in young women suffering from diabetes mellitus who also were taking the pill. Lower estrogen pills were found to have fewer side effects for this group. The same is true for lower gestagens. 4 pregnancies occurred out of 118 women aged 18-24 with diabetes mellitus type 1 and using IUDs. No pregnancies occurred in the 2nd year. IUD complaints and removals over a 2-year period were the same in the control group of 914 women not suffering from diabetes mellitus. In 1980, much was made of the fact that 11 out of 30 women suffering from diabetes mellitus using IUDs became pregnant within 1 year. IUDs were removed, showing 40% more sulphur chloride, but no copper deterioration. These findings were not conclusive, and there was no reason to advise women suffering from diabetes mellitus against using IUDs. The chances of side effects from the pill and IUD are the same for women who do not suffer from diabetes mellitus. If there is no preference between pill or the IUD, the latter is advised. Only women suffering from diabetes mellitus cannot quit smoking will be advised against using the pill. Patients wishing to become pregnant should consult their doctors so that IUDs can be removed.     

The multiload IUD--a U.S. researcher's evaluation of a European device.

This evaluative review focused on the performance and safety of the Dutch-made Multiload copper IUD, primarily the Multiload-375 (MLCu-375) model which has a longer life expectancy (5 or more years) than the Multiload-250 (MLCu-250) model, usually cited for a life expectancy for three years. This copper-medicated IUD differs from the copper-T IUDs in shape and insertion technique. The review shows that (a) the MLCu-375 IUD seems to be slightly less effective in preventing pregnancies than TCu-380A IUD. Its efficacy is comparable to that of the Nova-T by two to three years of use; (b) the MLCu-250 IUD is similarly effective to TCu-200 but may be slightly less effective than TCu-220C; (c) no consistent differences were detectable in expulsion rates or in removal rates for bleeding/pain between the Multiload IUDs and comparative Copper-T IUDs; (d) the Multiload IUDs may perform better in nulliparous women than the T-shaped devices; (e) no or a very low incidence of uterine perforation is associated with insertions of the Multiload IUD; (f) ectopic pregnancy risks are similarly low in Multiload IUD users as in Copper-T-380A users; and (g) pelvic inflammatory disease (PID) risks are similarly low in Multiload IUD users as in users of T-shaped copper IUDs.     

A new simple contraceptive device. (Preliminary report)

A new IUD developed by the authors and manufactured by them in Hungary because of the expense and difficulty in obtaining IUDs from the West in described. The new loop IUD, kept in a sterile solution until used, is much thinner and more flexible than commercial products and, consequently, assumes the shape of the uterine cavity; it also comes in different sizes. Insertion, which takes only a few minutes, is accomplished with a plastic tube and piston device. This insertion device is based on an idea by Joan Rettie of the IPPF. The bottom of the IUD stays in the upper portion of the cervix without reaching down to the outer orifice. Since March 1965 120 persons have been fitted with the IUD within 5 months, with most being fitted 2 weeks postabortion. The timing of the insertion was later changed to the last days of the first menstruation after an abortion. For those who did not undergo an abortion, the IUD was inserted on the last day of a menstrual period, and for nonmenstruating women (due to lactation) IUD insertion was 6-8 weeks postdelivery. The IUD remained in place for a year, then was removed for a 1-2 week rest period, and then reinserted. There have been 2 cases of bleeding, 1 case of partial extrusion, and 1 with complete loss of the device. Results from an additional fitting of 200 IUDs reveal 1 pregnancy and removal from 10 women because of bleeding. It is thought that the bleeding problem can be solved by decreasing the loop size.     

宫腔镜联合 B超治疗宫内节育器嵌顿103例临床分析

目的：探讨宫腔镜联合B超在宫内节育器嵌顿中的治疗作用。方法回顾性分析2011年12月至2013年12月用宫腔镜联合B超治疗的103例宫内节育器嵌顿临床病例资料。结果期间共取环1509例,其中103例发生节育器嵌顿,各种嵌顿的节育器构成比分别为：金属圆环52例（8．11％）,爱母环47例（17．21％）,T型环2例（1．21％）,宫型环1例（0．47％）,吉妮环1例（1．37％）。节育器嵌顿发生在绝经前50例,绝经2年内10例,绝经2年以上43例。所有嵌顿节育器均在B超监测下宫腔镜下一次成功取出。结论金属圆环及爱母环较易嵌顿,绝经2年以上节育器易于发生嵌顿,应尽可能在绝经后2年内取环。对于嵌顿的宫内节育器,B超监测下宫腔镜检查及镜下取环是一种安全有效的治疗手段。     

Removal of the LNG IUD when strings are not visible: a case series

Objectives

To report length of intrauterine device (IUD) and strings as well as technique for extraction when IUD removal occurs without visible strings.

Study Design

A prospective case series of 29 women who had IUDs removed in-office when strings were not visible at the external cervical os.

Results

One third (n= 11) were found to have a total length of IUD and strings < 7.5 cm. All IUD removals were successfully performed as outpatient procedures.

Conclusion

Removal of IUDs without visible strings can be successfully done as an in-office procedure.

Implications

In-office removal of IUDs without visible strings is effective, safe and economically sound.     

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.     

The forces imposed by the novel T-shape Cu/LDPE nanocomposite intrauterine devices on the simulated uterine cavity

BACKGROUND: A simulated device was designed to study the forces, which are one of the most important factors relevant to the pain caused by the inserted intrauterine devices (IUDs), imposed by the novel T-shape copper/low-density polyethylene nanocomposite IUDs and the existing T-shape copper-containing IUDs (CuT 220C) on the uterine cavity. STUDY DESIGN: Tests were performed in a simulated uterine cavity with the same simulated uterine solution at a constant temperature of 37.0+/-0.1 degrees C. Force and deformation were measured using the Digital Push Pull Force Gauge with a gauge of displacement. RESULTS: The novel T-shape nanocomposite IUD and the existing T-shape Cu-IUD (CuT 220C) have a similar relationship between force and deformation when they are removed from the simulated uterine cavity, but they have a quite different relationship when they are pressed by axial compressive loads. CONCLUSION: It can be surmised that the novel T-shape nanocomposite IUD is superior to the existing T-shape Cu-IUD. It may alleviate the users' pain in future clinical application. Shape is a very important factor that affects the force imposed by the inserted IUDs, and it must be taken into account when a new IUD is designed.     

Inhibition of Chlamydia trachomatis growth in endometrial cells by copper: possible relevance for the use of the copper IUD

There is agreement that the relative risk of developing pelvic inflammatory disease (PID) increases among women who use the intrauterine contraceptive device (IUD). The role of Chlamydia in causing PID among IUD users is not clear. The present study demonstrates that Chlamydia trachomatis growth can be inhibited in cultured human endometrial cells by copper ions at concentrations known to be released by the copper IUDs. More than 98% inhibition was produced with 10(-5) and 10(-6) M of copper. Both C. trachomatis serovar E and a lymphogranuloma venereum Chlamydia serovar L2 (LGV) were inhibited by the copper ions. Although the mechanism of the inhibition is not known, the continuous presence of the copper ions during and after adherence appeared to be necessary for maximal effect. If such inhibition occurs in vivo, it is possible that copper ions released from the copper-containing IUD may partially protect against chlamydial infection.     

知情选择中提供IUD种类与效果关系的分析

目的:探索避孕方法知情选择工作中供选择的宫内节育器(IUD)种类数量与其使用效果间的关系。方法:对9省农村18922例放置IUD妇女的流行病学调查数据进行聚类分析,并进行生存分析和Cox回归分析。结果:IUD种类数量与其使用效果并非线性关系。比较IUD使用失败率,使用IUD>5种的地方(14.31%)明显高于使用IUD≤5种的地方(9.89%)。进一步分层分析和多因素Cox回归分析发现,使用IUD>5种的地方发生使用失败结局的可能性高于使用IUD≤5种的地方。结论:使用IUD的种类数量过多,IUD的使用效果未必好。为了保证IUD的使用效果,应对所提供IUD种类进行合理的选择。     

Comparison of segmented polyether urethane with polyethylene IUDs in rabbits.

A segmented polyether urethane IUD was compared with a polyethylene IUD in rabbits. The contraceptive efficacy of urethane IUDs was excellent. Moreover, the purulent slippery deposit present with the polyethylene IUDs and observed by Davis et al. (1) was absent. Our studies indicate that the polyether urethane IUDs have a high degree of antifertility activity in rabbits and these IUDs have reduced inflammatory response, based on leucocytic infiltration and tissue debris in the uterine lumen. It is suggested that polyether urethane IUDs not requiring copper or other medication can be designed for high contraceptive efficacy, intrauterine compatibility and with the necessary rigidity for proper uterine retention in humans.     

78例宫内节育器断裂事件分析

目的探讨高血压与男性性功能障碍发病风险的关系。方法采用前瞻性队列研究方法,随机抽取2015年中国人民解放军联勤保障部队第九二三医院进行健康体检的30~40岁已婚男性1000例进行基线调查,实际调查892人,有效应答率89.2%,剔除不符合调查条件者78例,最终可纳入研究对象为814例。按基线调查有或无高血压情况分为高血压组和正常血压组。随后开展3年随访,并剔除在随访中新发影响性功能的器质性疾病者、随访期服用降压药者、失访者,共135例。最后可纳入数据统计分析共679例。采用Cox模型分析高血压与男性性功能障碍发病风险比及95%可信区间(95%CI)。结果高血压组177例(26.07%),正常血压组502例(73.93%)。开展3年随访发现高血压组患者的性功能障碍发生率为48.58%,明显高于正常血压组的15.54%,差异有统计学意义(P<0.05)。Cox回归单因素结果显示,高血压组性功能障碍发病风险是正常血压组的2.056倍;调整高血压患者的年龄、BMI、饮酒、吸烟、职业类型、夫妻关系、高血脂症史和糖尿病史因素后,Cox回归多因素分析结果显示,高血压组性功能障碍发病风险是正常血压组的3.133倍。结论高血压是增加男性性功能障碍发生风险的危险因素,临床中应密切关注男性高血压患者的情况,并及早采取措施预防或避免性功能障碍发生。     

A comparative randomized study of three different IUDs in nulliparous Mexican women

With the aim to evaluate the clinical performance of intrauterine devices (IUDs) especially designed for nulliparous women (TCu 380 Nul and ML Cu 375 sl), a prospective randomized, single-blind study comparing them with standard TCu 380 A, was carried out. We included 1170 healthy nulliparous women randomly allocated to receive any of the three types of IUDs and conducted follow-up for 1 year of use. Continuation and termination rates were evaluated by gross cumulative life table analysis and compared by the log-rank test. Continuation rates (95% confidence interval) at the end of the study for TCu 380 A, TCu 380 Nul and ML Cu 375 sl were 29.5% (+/-12.9), 85.9% (+/-5.3) and 85.4% (+/-5.8), respectively (p < 0.001). There were six pregnancies during the first 3 months of use, for a failure rate of 1% (+/-0.6) in the TCu 380 A group, 0.5% (+/-0.3) in TCu 380 Nul, and no pregnancy in ML Cu 375 sl (p < 0.05). Especially designed IUDs for nulliparous women had a better clinical profile compared with the standard IUD. This may improve the use of IUD in this population.     

Six-month and 1-year continuation rates following postpartum insertion of implants and intrauterine devices

ObjectiveStudies show immediate postpartum (PP) insertion increases use of contraceptive implants and intrauterine devices (IUDs). Our objective was to compare the satisfaction and continuation rates of the two types of devices at 6 months and 1 year following PP insertion.Study DesignWe enrolled 133 women in a prospective cohort study following immediate PP insertion of an implant or IUD at two academic hospitals during 8 months of 2011. Subjects completed an enrollment survey during hospital admission and a follow-up phone survey 6 months and 1 year PP.ResultsAt 6 months PP, 72% of subjects provided follow-up information. Implant users were more likely to be using the originally-placed device (40/41, 98% vs. 45/55, 82%, p=0.02); nine women reported IUD expulsions. When accounting for replacement of expelled IUDs, IUD continuation at 6 months was 89% yielding similar continuation rates between groups (p=0.12). At 1 year PP, 51% provided follow-up. Of those, 82% still had a LARC method in place with similar continuation by device type (84% for implants, 81% for IUDs, p=0.96). Overall, satisfaction was similarly high in both groups.ConclusionDue to IUD expulsion, implants had a higher continuation rate than IUDs six months following immediate PP insertion. After replacement of expelled IUDs, continuation and satisfaction were similar for both devices at 6 months and 1 year.ImplicationsPlacement of implants and IUDs immediately PP can lead to high satisfaction. Despite early IUD expulsions, continuation rates were similar to those placed outside of the immediate PP period.     

新型宫内节育器规范化引入性试验的研究

目的:通过新型宫内节育器(IUD)的引入,提高基层计划生育服务质量,提高新技术的可接受性并鼓励更多的人更有效地使用避孕方法。方法:研究分三阶段进行,第一阶段采用定性和定量方法进行引入前需求评估;第二阶段为干预研究:宣传教育、技术培训和引入新型IUD;第三阶段采用定性方法进行干预后评估。研究现场的选择考虑了地区、社会经济和计划生育工作状况的代表性,分别在江苏省、山东省和重庆市各选择了3个县(市),然后在每个县(市)选择3个乡镇。引入的新型IUD为宫药铜300、TCu380A和γ药铜200。结果:被访的市(县)指导站能提供多种避孕方法和相关手术,如口服避孕药、皮下埋植剂、置取IUD、男/女绝育术、人工流产、男用避孕套和外用药以及一些妇科疾病和避孕药具副反应的处理。可提供的IUD种类较多,以TCu220C、药铜165和宫铜IUD为主。政策因素对避孕方法的选择有一定影响,普遍是‘一孩上环,二孩结扎’。不少妇女不知道自己使用IUD种类,相当多的妇女在放置IUD过程中未获得较规范的咨询服务。技术服务人员对性传播疾病的认识仍非常有限。多数技术人员都希望有进修和培训的机会。服务记录过于简单的问题较为突出,如放置IUD仅记录其形状如宫型、圆形或T型,这将可能影响随访和IUD的到期取出,直接影响服务的可持续性?     

Lost levonorgestrel IUD: diagnosis and therapy

A lost intrauterine device (IUD) is an uncommon event. Recently, a new levonorgestrel-releasing intrauterine system was introduced. In view of several cases of an unusual diagnostic discrepancy in the location of a lost levonorgestrel-releasing IUD in our department, we sought to determine if the extrauterine location of lost levonorgestrel-releasing IUDs differs from that of lost copper IUDs. The medical files of all patients with a diagnosis of lost IUD who were admitted to Rabin Medical Center from 2000 to 2003 were reviewed. Fourteen women were identified, 9 with levonorgestrel-releasing IUDs and 5 with copper IUDs. In six of the nine cases of a lost levonorgestrel-releasing IUD, there was a clear discrepancy between the presumed location of the device by diagnostic evaluation and its actual location on surgical extraction. All six devices were embedded in the omentum; four were located in the upper abdomen. No such discrepancies were noted for the copper IUDs (0 vs. 66%, p < 0.05). No significant difference in peritoneal adhesions was noted between the groups (55% vs. 66%, respectively, p = 0.095). It is concluded that lost levonorgestrel-releasing IUDs are associated with a higher rate of localization errors by clinical evaluation than copper IUDs. Lost levonorgestrel-releasing IUDs might be found in the mid-upper abdomen, embedded in omentum tissue, and this area should be explored first during laparoscopy.