Intrauterine Contraceptive Devices

CLASSIFICATION:

Copper-carrying devices:

• Copper T 200, Copper 7, Multiload Copper 250, Copper T 380, Copper T 220(pregnancy rate of lippes loop and Cu-T 200 are similar) and Nova T.
• Effective life of about 3–5 years.
• Cu 7380A have memory of  5 minute & life span is  10 year

Progestasert 

• Progestasert is a T-shaped device carrying 38 mg of progesterone in silicon oil reservoir in the vertical stem.
•  It releases 65 mcg of the hormone per day.
• The hormone released in the uterus forms a thick plug of mucus at the cervical os which prevents penetration by the sperms and thus exerts an added contraceptive effect
• Menstrual problems like menorrhagia and dysmenorrhoea noticed with Copper T are less with this device (40% reduction).
• Expensive
• Requires yearly replacement

Levonova Mirena:(5 years)(32 3 32 mm) contains 52 mg LNG, eluting 20 mcg daily

• Contains 60 mg of levonorgestrel (LNG) and releases the hormone in very low doses (20 mcg/day). 
• Longer acting (5 years)
• Ectopic pregnancy is sixfold to ninefold higher in women who do become pregnant with progestogen IUCD as compared to failures amongst Copper T users.
• Cumulative 5-year pregnancy rate for LNG-IUD (levonorgestrel intra-uterine device) is 0.5 %.
• Frameless IUCD: Contains several copper cylinders tied together on a string, and it is anchored 1 cm deep into fundus

INDICATION:

• Monogamous relationship
• Multiparous woman
• Desirous of long-term reversible method of contraception, but not yet desirous of permanent sterilization
• Unhappy or unreliable users of oral contraception or barrier contraception
• Low risk of STD

USES:

• Contraception
• Postcoital contraception
• Hormonal IUCD (Mirena) in menorrhagia and dysmenorrhoea, and hormonal replacement therapy in menopausal women
• Following excision of uterine septum, Asherman syndrome
• IUD can be used for Emergency Contraception within 5 days

CONTRAINDICATIONS:

• Suspected pregnancy
• Pelvic inflammatory disease (PID)
• Undiagnosed vaginal bleeding
• Fibroids
• Menorrhagia and dysmenorrhoea after use of Cu T
• Severe anaemia
• Diabetic women
• Heart disease—risk of infection
• Previous ectopic pregnancy
• Scarred uterus
• Preferably avoid its use in unmarried and nulliparous patients because of the risk of PID and subsequent tubal infertility
• LNG IUCD in breast cancer
• Abnormally shaped uterus, septate uterus

 TECHNIQUE OF INSERTION:

In calendar method of contraception, first day of fertile period is 10th day of shortest menstural cycle

Push-in technique

•  Grasp cervix is with a vulsellum or Allis forceps
• Device mounted on introducer 
• Stop of introducer is adjusted to uterine cavity length
• Introducer is then passed through the cervical canal and the plunger is pressed home 

Withdrawal technique

• Rod containing IUCD is inserted up to the fundus
• Outer rod withdwawn followed by inner rod
• The nylon thread is cut to the required length
• The forceps and the speculum are removed and the patient is then instructed to examine herself and feel for the thread every week.

MECHANISM OF ACTION:

• Foreign body in the uterine cavity renders the migration of spermatozoa difficult
• Foreign body within the uterus → prostaglandin release & increases the tubal peristalsis → uterine contractility  → fertilized egg is propelled down the fallopian tube→ reaches the uterine cavity before the development of chorionic villi→ unable to implant.
• The device in situ →leucocytic infiltration in the endometrium. The macrophages engulf the fertilized egg if it enters the endometrial tissue.
• Copper T elutes copper → enzymatic and metabolic changes in the endometrial tissue which are inimical to the implantation of the fertilized ovum.
• Progestogen-carrying device→ alteration in the cervical mucus →prevents penetration of sperms & endometrial atrophy.
• It prevents ovulation in about 40%.

COMPLICATIONS:

Immediate

• Difficulty in insertion
• Vasovagal attack
• Uterine cramps(most common during removal)

Early

• Bleeding(Most common side effect )
• Expulsion (2–5%)(Lippes loop)
• Perforation (1–2%)
• Spotting, menorrhagia (2–10%)
• Dysmenorrhoea (2–10%)
• Vaginal infection
• Actinomycosis

Late

• PID—2–5%. IUCD does not prevent transmission of HIV
• Pregnancy—1–3 per 100 woman years (failure rate)
• Ectopic pregnancy
• Perforation
• Menorrhagia
• Dysmenorrhoea
• Hypofibrinogenimia (Most common)