Intrauterine Contraception

Table of Contents

History 

Safe and very successful is intrauterine contraception. With few exceptions, women of different ages and parities can use the LARC procedure. There are two categories of intrauterine devices:

  1. Copper-bearing (Cu-IUD)
  2. Levonorgestrel-releasing (LNG-IUS)

Although framed devices are more common, unframed ones are also offered. 

Cu-IUD

Worldwide availability of several devices is shown in Figure:

Typically, a T-shaped plastic frame coated with copper wire makes up a Cu-IUD. Additionally, accessible are other device types and frameless alternatives, such Gynefix®. The best models have 380 mm2 of copper and arms (along with the stem) that are copper-banded. 

Mode of action

Mainly, the mode of action is to prevent fertilization. Sperm and eggs both suffer when copper ions are released into the uterus. Variations in cervical mucus, copper content can restrict sperm penetration and trigger an endometrial inflammatory response that has an anti-implantation effect. Abortion is not induced by the copper IUD. 

Duration of use

Depending on the kind of equipment, the use period ranges from five to ten years. Using devices with a longer action time first is recommended to reduce problems after IUD insertion. A ‘gold standard’ device in the UK has copper sleeves, 380 mm2 of copper, and a 10-year lifespan; one example is the TT 380 Slimline. It is now advised that women over 40 keep using a Cu IUD until menopause is confirmed. 

Effectiveness

It is quite successful to avoid pregnancy with the LARC method. After five years of use, there is less than a 2% failure rate. For LNG-IUS, the TCu380A and TCu380S outperform conventional Cu-IUDs, according to a Cochrane review. 

LNG-IUS

The LNG-IUS consists of a steroid (LNG, Levonorgestrel) reservoir encircling the vertical stem of a T-shaped polythene frame. At first, the system releases 20 micrograms of LNG daily.

The Method of Action

The main contraceptive action of the LNG-IUS is to stop implantation. It causes alterations to the stroma and atrophy of the endometrium. Changes to the cervical mucus also limit sperm penetration. Most women who take the LNG-IUS keep ovulating (more than 75%) and their blood estradiol levels stay the same. 

Duration of use

If implanted after 45 years of age, it can be used off-label for up to 7 years or till menopause if amenorrheic ; if used as part of HRT, it must be updated every 5 years.

Performance

With a five-year failure rate of less than 1%, the LNG-IUS is on par with female sterilization. 

Non-contraceptive uses

LNG-IUS is the initial course of treatment for heavy menstrual bleeding (HMB). After a year of therapy, claims suggest it reduces bleeding by up to 95%. Authorities permit its use as a progestogenic agent in conjunction with hormone replacement therapy (HRT). It can treat endometrial hyperplasia and function as an adjuvant to tamoxifen to prevent abnormalities of the endometrium. The pain from endometriosis and PMS symptoms may go away with this treatment.

Benefits 

  • High efficacy. 
  • The success of the method depends on little compliance because it is “fit and forget” for the user. 
  • Not many contraindications. 
  • One year of use later, intrauterine contraception is still less expensive than COC. 
  • Reversible: No waiting to start being fertile again after taking out intrauterine contraception. 
  • The LNG-IUS has non-contraceptive benefits (see above) 
  • The Cu-IUD is a very effective emergency contraceptive. 

Shortcomings 

Bleeding patterns and pain

In the first three to six months following implant, Cu-IUDs may result in painful menstrual cycles, intermenstrual spotting, and heavier and/or longer periods. This is not risky and might go away in due course. Of IUS users, 65% have amenorrhoea or mild bleeding during the first year. But irregular bleeding and spotting are common throughout the first six months of treatment. Bleeding and pain are common reasons for stopping intrauterine methods. Similar discontinuation rates are for LNG-IUS and Cu-IUD. 

Ovarian cysts

Ovarian cysts may result with LNG-IUS. Small follicular cysts usually go away on their own, without causing any symptoms or being significant clinically. Among women using an LNG-IUS, they are an uncommon source of symptoms. 

Hormonal Adverse Reactions:

The LNG-IUS absorbs progestogen, but women who use it and those who use the Cu-IUD had no appreciable difference in acne, headaches, mood, libido, weight, or breast soreness.

Expulsion

 In about 1 in 20 women, the body expels intrauterine contraception, with similar rates for the LNG-IUS and Cu-IUD. Most expulsions occur within the first three months of insertion, and throughout the first year thereafter. Menstruation often results in expulsion, particularly with heavy menstruation. Expelled women run a threefold greater chance of being expelled again.

Perforation

Uterine perforations are rare, happening in less than 2 out of 1000 insertions. The physician’s skill in inserting the device might affect the rate of perforation.

Pelvic infection

The risk is still low overall even if pelvic infection rates increase six-fold in the first 20 days after intrauterine device insertion. Experts believe that microbes injected into the uterus after implantation cause infection. The risk relates to the STI (Sexually transmitted infection) risk in general. We recommend screening women at higher risk of STIs before using intrauterine contraception. Doctors may advise antibiotic prophylaxis if the STI screen results are not available before the surgery .Depending on the local prevalence, use a regimen that works well against both C. trachomatis and N. gonorrhoeae.

Women with symptomatic pelvic infections

In women with symptomatic pelvic infections, Even if the procedure has shown temporary bacteraemia. NICE recommends against administering prophylactic antibiotics to avoid bacterial endocarditis during insertion or removal of intrauterine contraception, even if temporary bacteraemia has been seen during procedures. This is particularly true for women who have heart valve replacements or past infections that raise their risk of infected endocarditis. 

Contraindications 

Protocol for Insertion 

Usual specifications

You should have an aid present and emergency equipment available when inserting. Every employee need to have basic life support training. You should discuss options for pain management, including intracervical anesthetic, before implanting.

Arranging the insertion

 If the practitioner is certain the woman is not pregnant after completing a pregnancy risk assessment, You can implant a Cu-IUD or LNG-IUS during the menstrual cycle. The LNG-IUS needs extra precautions for seven days if implanted during the first seven days of the menstrual cycle, however the Cu-IUD gives quick contraception. The Cu-IUD can be implanted up to 5 days following the first episode of UPSI or the earliest anticipated ovulation date if UPSI occurs before implantation. As the LNG-IUS takes seven days to start working, it cannot be used in these situations.

After induced abortion, miscarriage or postpartum

You should implant intrauterine contraception within 48 hours of pregnancy or delayed until 4 weeks to reduce the chance of perforation during an induced abortion, miscarriage, or postpartum. For a reduced risk of an unplanned second pregnancy, an experienced practitioner may advise insertion between 48 hours and 4 weeks after the abortion. Day 28 is the earliest predicted ovulation date postpartum, hence there is no need to take any precautions when placing a Cu-IUD currently. After day 28 postpartum, an LNG-IUS insertion calls for extra care or a seven-day fast. Intrauterine contraceptives are unlimitedly usable by nursing mothers. 

Insertion method:

No research exists to support washing the ectocervix before surgery, and if a “no-touch” approach is used—that is, introducing objects into the uterine canal using only the handle—sterile gloves are not required. Using a single-toothed tenaculum or similar forceps on the cervix, stabilize the uterus following a bimanual assessment of its size, movement, location, and form. The uterine cavity should be sounded to find out its length. This guarantees correct fundal location of the device and lowers the risk of perforation Cut the threads and insert the device as directed by the manufacturer. Give the woman follow-up instructions and with documentation of the type and duration of the device used. The threads of an intrauterine contraceptive device should be checked by women, who should also be urged to seek advice and exercise caution if any are absent or the stem is perceptible. 

Afterwards

After the installation of the device, women should be scheduled for a follow-up visit three to six weeks later. By now, perforation, infection, and device expulsion have been ruled out by inspection. If a woman has any questions about the process, she should come in, although yearly check-ups are not advised. 

Removal of intrauterine contraception 

Anytime throughout the menstrual cycle, an intrauterine device can be removed if a pregnancy is planned. Fertility returns fast once intrauterine contraception is removed. Women should employ a barrier method for seven days before removal in order to prevent conception. As an alternative, take the device out in the first few days of the menstrual cycle. It is advised to get preconceptionally guidance for intended pregnancy. 

Management of lost IUD threads

Three reasons exist if the uterine device threads are not apparent upon examination

1. Correctly placed device: the threads are either dragged into the uterus or are short. 

2. Expulsion: The uterus has been empty of the device. 

3. Perforation: The gadget is now outside the uterus after it perforated. 

Presence of actinomyces-like organisms (ALO)

Actinomyces israelii is a commensal of the vaginal tract that can occasionally be identified by swabs. IUDs should not be removed from asymptomatic ALO women. 

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