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A bill of health for the IUD: where do we go from here?

Although intrauterine devices (IUDs) are a highly cost-effective contraceptive method, they have been unfortunately associated with increased risk of pelvic inflammatory disease (PID). However, new studies, including a 1992 World Health Organization (WHO) report, have demonstrated that there is little evidence of a causal link between IUD use and PID. IUD-related risk of PID is increased only during a short period following insertion, and exposure to STDs is probably the major determinant of PID risk for IUD users. Furthermore, no increased risk of PID use has been demonstrated with long-term IUD use. This paper examines the evidence, focusing on the 1992 WHO study, and looks to the future with suggestions for IUD research and programmatic approaches in the hope of vindicating the IUD's reputation and broadening the indications for its use.

Female↗

The morphologic changes of endometrial spiral arterioles in IUD-induced menorrhagia.

To investigate the relationship between IUD-induced menorrhagia and spiral arteriolar function, we examined the endometrium under light and electron microscope on samples obtained within 24 hours after the onset of premenstrual spotting. These samples included an IUD bleeding group (20 cases), an IUD non-bleeding group (20 cases) and an IUD non-user group (10 cases) as controls. Compared with the IUD non-user group the degenerative changes of spiral arteriolar wall were more severe and dilation of the spiral arteriolar lumen was more obvious, especially in the spongeous layer. In the IUD non-user group these changes were mild, suggesting that IUD-induced menorrhagia might be correlated with poor contractility of spiral arterioles in the spongeous layer.

Adult↗

Second-trimester spontaneous abortion, the IUD, and infection.

Nineteen cases of spontaneous second-trimester abortion associated with the intrauterine device (IUD) are reviewed and compared to 30 cases of spontaneous second-trimester abortion not associated with the IUD. Fifteen of the IUD's were Dalkon shields and four were Lippes loops. 16 of the 19 IUD-associated abortions began either with prolonged rupture of membranes or signs and symptoms of infection. Infection occurred in 18 or 19 of the cases (95%) but only 30% of the comparison group. Eleven major complications occurred in eight patients in the IUD group but only 8 complications occurred among 7 patients in the comparison group. It is suggested that when the IUD remains in utero during pregnancy, it may be a causal factor in second-trimester spontaneous abortion, and that intrauterine infection is the distinguishing characteristic of such cases. Mechanisms are suggested by which the IUD might cause infected abortion.

Abortion, Septic↗

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.

Animals↗

TCu 380A IUD: a reversible permanent contraceptive method in women over 35 years of age.

OBJECTIVE: The objective of the study was to evaluate the performance of the TCu 380A IUD in women who had been using the device for more than 10 years and who were 35 years of age or more on completion of the 10th year of IUD use. METHODS: A total of 228 women who had an IUD inserted between 1987 and 1992 were included in the study. The cutoff date for analysis was January 31, 2004. Clinical performance was evaluated by life-table analysis. The mean age of women at 10 years of use was 38.8+/-0.4 years and mean parity was 2.2+/-0.08 (mean+/-SD). The duration of follow-up beyond 10 years ranged from 1 to 72 months. No pregnancy was observed in 366 woman-years of observation beyond 10 years of use. The main reason for discontinuation was removal of the device because the clients had previously been informed that the IUD was not approved for use beyond 10 years. This reason accounted for a gross cumulative 6 years discontinuation rate of 42.5 per 100 women beyond 10 years. The other main reasons for discontinuation beyond 10 years of use were surgical sterilization, menopause and expulsion with gross cumulative 6-year termination rates of 19.2, 11.0 and 21.2 per 100 women, respectively. The cumulative continuation rate beyond 10 years was 67.0 at the end of the first year of follow-up and 21.2 at the end of the sixth year. CONCLUSION: We found no evidence that the TCu 380A IUD loses its effectiveness after 10 years of use. RESULTS: The concept that women who have insertion of a TCu 380A IUD at the age of 25 years or older could use this IUD as a reversible but permanent method of contraception up to the menopause continues to be supported by the accumulation of evidence, although definitive evidence remains to be obtained.

Adult↗

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.

Adult↗

Comparison of weight increase in users of depot medroxyprogesterone acetate and copper IUD up to 5 years.

The objective of this study was to evaluate retrospectively the weight variation in long-term users of depot medroxyprogesterone acetate (DMPA) compared to users of the TCu380A intrauterine device (IUD). A cohort of 206 healthy women allocated in two groups of 103 women according to the contraceptive method used was evaluated through 5 years. Each user of DMPA was paired with an IUD user by age (+/- 1 year) and weight (+/- 1 kg) at the beginning of the study. Weight was evaluated yearly during 5 years. The mean age at the beginning of the study was 33.1 years in both groups, and the mean weight was 59.4 kg in the IUD users and 60.4 kg in the DMPA group. Both cohorts of women presented significant weight increase at the end of the 5 years of observation (p < 0.001). However, DMPA users presented higher weight increase when compared to IUD users from the second through the fifth year of observation. The DMPA users increased weight by 4.3 kg during the 5 years, and IUD users increased 1.8 kg. In conclusion, DMPA users had a significantly higher weight increase when compared to IUD users. In addition, this cohort of women increased weight throughout the 5 years with the use of DMPA or IUD.

Adult↗

Uterine factors and risk of pregnancy in IUD users: a nested case-control study.

Scarce data are available on the relation between the effectiveness of intrauterine device (IUD) and the gynecologic features of a woman. A nested case-control study was conducted to determine whether the uterine position and hysterometry affect the pregnancy rate of copper IUD. Seventy-one cases (pregnant women with IUD) and 284 matched controls (1:4) were included. Matching criteria were date of IUD insertion and duration of use. Data were analyzed by conditional logistic regression modeling that considered age, parity and copper surface of IUD as potential confounders. When cases were compared to nonpregnant controls with IUD, the results showed that uterine position and hysterometry were not associated with an increased risk of pregnancy. The findings suggest that the gynecological characteristics of the woman analyzed should not be a criterion for the selection of potential IUD users.

Adolescent↗

Pregnancy despite IUD: adverse effects on pregnancy evolution and fetus.

INTRODUCTION: In this retrospective study, we describe cases of pregnancy initiated despite an intrauterine device (IUD), which occurred in our setting in the last 10 years (from January 1992 to December 2001), aiming to point out the effects of IUD in terms of miscarriage or fetal problems. METHODS: Histopathologic reports of IUD pregnancies at any gestational age were found by computer search and analyzed. The characteristics of embryo-fetuses and of decidua-placenta were recorded and compared. RESULTS: Ten IUD pregnancies were found: 3 ended with first-trimester voluntary termination of pregnancy, 2 with second-trimester elective abortions, 2 were miscarried during first trimester (spontaneous abortions) and 3 were carried to term. No relevant abnormalities were found in the development of the embryo-fetuses, except for one case of a newborn with upper lip lesion and a mild deviation of nasal septum. Alterations of the placenta and adnexa were found only in the two miscarriage cases. CONCLUSIONS: The small number of cases found reflects the very low incidence of pregnancies initiated despite an IUD, although an increasing trend has been recorded in the last 5 years, probably concurrently with an increasing immigration flow into our area. Our findings suggest that if the embryo, despite the IUD, can reach a firm attachment during the first weeks of gestation, the pregnancy usually continues to term. It is notable that in this case series a major lip defect occurred in 1 of 10 described cases (10%), suggesting that although pregnancies with IUD are exceptional, fetal abnormalities seem not.

Abortion, Induced↗

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.

Adult↗

Microbiology profile in women with pelvic inflammatory disease in relation to IUD use.

OBJECTIVE: To study the microbial characteristics of patients with pelvic inflammatory disease (PID) and the possible impact of an intrauterine device (IUD) on the microbial environment in women presenting with PID. METHODS: Case-control study, investigating 51 women with acute PID and 50 healthy women. Endocervical specimens for microbiological investigation were obtained at gynaecological examination. RESULTS: IUD users with PID had significantly more Fusobacteria spp. and Peptostreptococcus spp. than non-IUD users with PID. The finding of combinations of several anaerobic or aerobic microbes was associated with a significantly increased risk of PID and with complicated PID. In IUD users, the combinations of several anaerobic/aerobic microbes were associated with an increased risk of PID, irrespective of duration of IUD use. Long-term IUD use appeared to be associated with an increased risk of a PID being complicated. CONCLUSION: The finding of several anaerobic or aerobic microbes appears to be associated with PID in users of IUD.

Adult↗

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.

Clinical Competence↗

Complications of intrauterine contraceptive device (IUD) use at the University of Ilorin Teaching Hospital, Ilorin.

BACKGROUND: The use of Intrauterine Contraceptive Device (IUD) has increased steadily worldwide over the years. METHODS: This is a retrospective study of 602 women who had IUD insertions at the Family Planning Unit of the University of Ilorin Teaching Hospital between January- December 1995 and the study was undertaken to study the complications associated with the IUD use at the University of Ilorin Teaching Hospital. RESULTS: There was 85.55% continuation rate after a year, 81.06% of patients were without complications, 0.33% had Pelvic Inflammatory Disease (PID) and no perforation was reported. Expulsion was also low. Mean duration of use was 14.06 +/- 4.46 months. There was no statistical difference in timing of insertion in those with or without complications (p = 0.781); however, a significant difference becomes noticeable in the duration of use of the IUD in the two groups (p = 0.001). IUD was acceptable to most patients (85.5%). There was no significant difference with respect to level of education (p = 0.064) and type of previous contraception practised (p = 0.022) in those with or without complications. IUD complications were commonest within the first 3 months of insertion; involving a third of those lost to follow-up compared with about 15% of those not lost to follow-up (p = 0.001). CONCLUSIONS: At the University of florin Teaching Hospital, Ilorin, IUD use is safe and effective with minimal complications.

Adolescent↗

Cytologic and histologic findings in women using an IUD.

The present study was undertaken to determine the source of atypical squamous metaplastic cells that are found in large numbers in smears from women with an intrauterine contraceptive device (IUD). The cytologic data are obtained from a population screening program totaling 61,151 women, of which 1401 were using an IUD. Histologic data comprise findings from curettings on removal of an IUD and scrapes from the removed IUD in 102 women. These implicate the endometrial surface epithelium as the main source of the atypical cells in cervical smears from IUD users. As this epithelial atypia frequently disappears upon removal of the IUD, conservative follow-up of women with cytologic metaplastic atypia in cervical smears during IUD use is strongly recommended.

Adult↗

Bacterial infection in relation to pain and irregular bleeding in women using IUD.

Pain and metrorrhagia in women using IUDs are often the reason for removing the IUD. In 54 women where the IUD was removed, uterine fluid for bacteriologic cultures was taken from the removed IUD. There was a correlation between positive cultures and symptoms of pain and metrorrhagia. Spotty bleeding caused by microtraumata and increased fibrinolytic activity of the IUD might thus consitute a substrate for bacterial invasion resulting in endometritis and in turn increased bleeding and pain. In 18 male consorts of females with positive cultures, asymptomatic bacteriospermia was found. Treatment offered alleviated symptoms. Removal of the IUD need thus not be necessary.

Bacterial Infections↗

The influence of copper surface area on menstrual blood loss and iron status in women fitted with an IUD.

The influence of copper surface area on menstrual blood loss (MBL) was evaluated in 34 healthy women (mean age 36.4 +/- 1.4 yr, range 27-46 yr), who were fitted with a Multiload intrauterine device (IUD) with either 250 mm2 (MLCu-250) or 375 mm2 (MLCu-375) copper wire. MBL prior to IUD insertion was 54.4 +/- 10.3 ml for women subsequently fitted with a MLCu-250 and 56.9 +/- 6.9 ml for women fitted with a MLCu-375. An increase (p less than 0.01) in MBL was recorded 3 months after IUD insertion for both the women fitted with a MLCu-250 (86.4 +/- 10.3 ml) and a MLCu-375 (81.1 +/- 8.3 ml). This increase in MBL remained unchanged throughout the study period of one year. At no point were there any significant differences in MBL or increase in MBL between women fitted with a MLCu-250 or MLCu-375. There were no significant differences in serum ferritin, blood hemoglobin, hematocrit or erythrocyte indices before IUD insertion in the women grouped according to type of IUD, nor were any significant changes recorded in any of these parameters after IUD insertion. Thus, our findings that the increase in copper surface area from 250 mm2 to 375 mm2 had no effect on MBL were also substantiated by the hematological findings.

Adult↗

Lack of interaction between magnetic resonance imaging and the copper-T380A IUD.

To determine if the CuT380A (ParaGard) IUD is affected by magnetic resonance imaging (MRI), in vitro studies utilizing a CuT380A IUD (ParaGard), a copper-bearing IUD, and a Signa 1.5T HR system were used to evaluate whether the dynamic magnetic forces generated by the MRI resulted in movement, torque, or heat when the IUD was exposed to the magnetic field generated by the MRI. There was no deflection, turning motion (torque), or temperature change when the IUD was exposed to a magnetic field. There appears to be no reason to exclude women with IUDs of the type examined from an MRI system or its environs.

Adult↗

Menstrual problems and side effects associated with long-term TCu 380A IUD use in perimenopausal women.

The study assessing menstrual problems and side effects associated with long-term TCu 380A intrauterine device (IUD) use in perimenopausal women is reported. Fifty perimenopausal TCu 380A IUD acceptors who had IUD inserted after age 40 and used IUD at least 36 months were recruited. The mean age of acceptors at time of insertion was 44.2 years with an average parity of two live births. The mean body weight at insertion was 62.13 kg. Most of the bleeding patterns were regular cycles. Intermenstrual bleeding and pelvic pain were side effects most often reported. No pregnancies, pelvic inflammatory disease, or IUD expulsions occurred during the follow-up period. This study suggests that the use of TCu 380A IUD in perimenopausal women is safe and effective.

Adult↗