Intrauterine Devices: Effective Contraception with Noncontraceptive Benefits for Adolescents.

Although adolescent pregnancy and birth rates have been declining since the early 1990s, the rate of intrauterine device (IUD) use in adolescents remain low. IUDs are a highly effective contraceptive method with a failure rate of less than 1%. There are currently 5 IUDs available and marketed in the United States: the nonhormonal copper-containing IUD (Paragard Copper T380A; Ortho-McNeil) and 4 hormonal levonorgestrel-releasing intrauterine systems (LNG-IUDs). IUDs can be used in adolescents, and the LNG-IUD has many noncontraceptive benefits including the treatment of heavy menstrual bleeding, dysmenorrhea, pelvic pain/endometriosis, and endometrial hyperplasia/endometrial cancer. In addition, the LNG-IUD is an effective tool for suppression of menses.

Safety of intrauterine devices in MRI.

OBJECTIVES: The paucity of safety information on intrauterine devices (IUD) for magnetic resonance imaging (MRI) examinations is clinically relevant. The aim of this study is to evaluate the MRI safety of clinically used IUDs composed of copper/gold and stainless steel at 1.5T and 3.0T. MATERIALS AND METHODS: We assessed and compared the displacement force, torque effects, presence of imaging artifacts and heating of IUDs composed of copper/gold (western IUDs) and stainless steel (China) on 1.5 and 3.0T MRI systems. RESULTS: Gold/Copper IUDs can show small deflection angles of 7° ± 7° in the worst-case field gradient of 40T/m (equivalent to magnetic force of 0.5 mN), while the stainless steel IUD experienced significant magnetic force and deflection (Force > 7.5 N; deflection angle 90° ± 1°). Manual rotation and suspension method show no torque effects on gold/copper IUDs but high torque effects were observed by manual rotation on the stainless steel IUD. Heating measurements showed a temperature increase (rescaled to a wbSAR of 4 W/kg) of 1.4°C at 1.5T / 3.4°C at 3.0 T (stainless steel IUD), 3.2°C at 1.5 T / 3.8°C at 3 T (copper/gold IUD), 3.3°C at 1.5 T / 4.8°C at 3 T (copper 1), 3.8°C at 1.5 T / 4.8°C at 3 T (copper 2). The visible imaging artifacts of the copper and gold IUDs at 3 T MRI reach a diameter of 4 mm ± 1 mm, while the stainless steel IUD resulted in artifacts measuring 200mm ± 10 mm when using gradient echo pulse sequences. CONCLUSIONS: Standard IUDs (copper/gold) can be considered as conditional for MR safety at 1.5 T and 3.0 T, demonstrating at wbSAR up to 4W/kg and a magnetic field gradient of up to 40T/m with minimal imaging artifacts. The stainless steel IUD, however, induces unacceptable artifacts and is potentially harmful to patients during MRI due to high magnetic dislocation forces and torque (MR unsafe).

ACOG Committee Opinion No. 735: Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices.

The phenomenon of adolescent childbearing is complex and far reaching, affecting not only the adolescents but also their children and their community. The prevalence and public health effect of adolescent pregnancy reflect complex structural social problems and an unmet need for acceptable and effective contraceptive methods in this population. In 2006-2010, 82% of adolescents at risk of unintended pregnancy were currently using contraception, but only 59% used a highly effective method, including any hormonal method or intrauterine device. Long-acting reversible contraceptives (LARC) have higher efficacy, higher continuation rates, and higher satisfaction rates compared with short-acting contraceptives among adolescents who choose to use them. Complications of intrauterine devices and contraceptive implants are rare and differ little between adolescents and women, which makes these methods safe for adolescents. Barriers to use of LARC by adolescents include patients' lack of familiarity with or understanding about the methods, potentially high cost of initiation, lack of access, low parental acceptance, and obstetrician-gynecologists' and other health care providers' misconceptions about the safety of LARC use in adolescents. Because adolescents are at higher risk of sexually transmitted infections (STIs), obstetrician-gynecologists should continue to follow standard guidelines for STI screening. They should advise adolescents who choose LARC methods to use male or female condoms consistently (dual method use) to decrease the risk of STIs, including human immunodeficiency virus (HIV). Obstetrician-gynecologists should counsel all sexually active adolescents who do not seek pregnancy on the range of reversible contraceptive methods, including LARC, and should help make these contraceptives readily accessible to them.

A review of intrauterine contraception in the Asia-Pacific region.

BACKGROUND: Across the Asia-Pacific region, approximately 38% of pregnancies are unintended. Long-acting reversible contraception, such as intrauterine contraception (IUC), is effective in reducing unintended pregnancy. OBJECTIVE: This study aims to review access to, uptake of and influencing factors on IUC use in the Asia-Pacific region. METHODS: We searched PubMed and MEDLINE for articles published between 1990 and 2015. We identified and reviewed primary studies that examined the following points and were relevant to the Asia-Pacific region: available types and utilization rates of IUC and factors that influence these. We also obtained the opinions of local experts to gain a better understanding of the situation in specific countries. RESULTS: Types of IUC used and utilization rates vary widely across the region. Factors influencing rates of utilization relate to healthcare systems, such as government policy on and subsidization of IUC, types of healthcare providers authorized to place IUC and local guidelines on preinsertion screening. Healthcare provider factors include concerns around pelvic inflammatory disease and the suitability of IUC in certain groups of women, whereas end-user factors include lack of awareness of IUC, concerns about safety, cultural or religious attitudes, access to IUC and costs. CONCLUSIONS: Across the Asia-Pacific region, clear data gaps and unmet needs exist in terms of access to and uptake of IUC. We believe that several recommendations are necessary to update future practice and policy for enhanced IUC utilization so that women across this region have better access to IUC.

A Lower-Cost Option for Intrauterine Contraception.

In March 2015, the U.S. Food and Drug Administration approved Liletta (Actavis, Dublin, Ireland), a new intrauterine device for contraception. The Centers for Disease Control and Prevention recommend use of long-acting reversible contraception (LARC) as first-line pregnancy prevention. LARC efficacy rates are similar to those of sterilization, with the possibility for quick return of fertility upon removal of the device. Despite benefits and recommendations for this form of contraception, access and high cost remain barriers to use. Liletta is the first lower-cost option for intrauterine contraception. Available to qualified clinics and health centers at a reduced rate, this device may increase availability and decrease the overall cost to women who desire intrauterine contraception.

A facility birth can be the time to start family planning: postpartum intrauterine device experiences from six countries.

Initiation of family planning at the time of birth is opportune, since few women in low-resource settings who give birth in a facility return for further care. Postpartum family planning (PPFP) and postpartum intrauterine device (PPIUD) services were integrated into maternal care in six low- and middle-income countries, applying an insertion technique developed in Paraguay. Facilities with high delivery volume were selected to integrate PPFP/PPIUD services into routine care. Effective PPFP/PPIUD integration requires training and mentoring those providers assisting women at the time of birth. Ongoing monitoring generated data for advocacy. The percentages of PPIUD acceptors ranged from 2.3% of women counseled in Pakistan to 5.8% in the Philippines. Rates of complications among women returning for follow-up were low. Expulsion rates were 3.7% in Pakistan, 3.6% in Ethiopia, and 1.7% in Guinea and the Philippines. Infection rates did not exceed 1.3%, and three countries recorded no cases. Offering PPFP/PPIUD at birth improves access to contraception.

Reducing barriers to the use of the intrauterine contraceptive device as a long acting reversible contraceptive.

The intrauterine device (IUD) is the oldest long acting reversible contraceptive (LARC) method. There remain widespread barriers to its general acceptance, although some have been overcome, others remain. These stem from a lack of understanding of uterine anatomy and physiology. Uterine measuring techniques did not become popular, probably because of the extra effort required prior to IUD insertion. Unfortunately the information they provided regarding IUD design was also not heeded. In some countries varying sizes of other IUDs (second generation) are now available. The third generation hormonal carrying IUDs have also reduced barriers by lowering side effects and producing added health benefits. Fourth generation IUDs will provide added health benefits in addition to contraception and should further reduce barriers to IUD use. Most remaining IUD barriers are due to provider perceptions. Most are based on psychological, moral and religious prejudices. These should not be allowed to interfere with the provision of LARC methods of contraception. There are also acceptor barriers which can be modified by providing education about the method. The use of the IUD as a LARC method is increasing in many developed and developing countries. New technology should help propel the IUD into a more mainstream contraceptive.

[A multi-center randomized controlled trial of three types of intrauterine device inserted immediately after vacuum aspiration].

OBJECTIVE: To compare the safety and effectiveness of three types intrauterine device (IUD) insertion immediately after vacuum aspiration, and to provide evidence for women fulfilling contraception and reducing repeat abortion. METHODS: A multi-center randomized controlled clinical trial was performed in 12 medical institutions or family planning service stations located in China. Total 1800 eligible women were inserted G-Cu200, TCu380A or active γ-IUD randomly after vacuum aspiration immediately, and they were followed up for 12 months. RESULTS: Except for 2 cases who dropped out (loss rate is 0.11%, 2/1800) and 17 cases who didn't match the including standard, the data of 1781 cases was analyzed. No any uterine perforation or ectopic IUD was found. During followed up 12 months, there was also no any pregnancy or pregnancy with IUD in situ occurred in the three groups. The medical removal rate for bleeding or (and) pain of active γ-IUD was the lowest (1.02/hundred women year) among three groups, and there were significant difference (P = 0.015). The rate of expulsion rate and discontinuation rate of active γ-IUD was 2.73/hundred women year, which was also the lowest among the three IUD, but there was no significantly statistical difference (P > 0.05). CONCLUSIONS: The results showed that there are perfect clinical safety and effectiveness for three types of IUD immediately after vacuum aspiration. Active γ-IUD is superior to other two types IUD for its low medical removal rate which may be worthy to use widely immediately after vacuum aspiration.

[A multicentre comparative clinical study of uterine cavity shaped device Cu300, TCu220C and TCu380A in ten years].

OBJECTIVE: To observe the clinical effects of uterine cavity shaped device (UCD) Cu300, TCu220C and TCu380A in ten years. METHODS: Two thousand, six hundred and ninety-nine rural parous women were randomized into three groups. UCD Cu300 group had 899 cases, TCu220C group and TCu380A group each had 900 cases. Follow-up visits were performed at 3, 6, 12 months and 2, 3, 5, 10 years after insertion. RESULTS: The cumulative pregnancy rates in the 10th year for UCD Cu300, TCu220C and TCu380A were 2.56, 4.82, and 4.01 per 100 women, respectively. UCD Cu300 group was significantly lower than other two groups (P < 0.05). The expulsion rates were 4.54, 5.46 and 9.68 per 100 women, respectively. TCu380A was significantly higher than UCD Cu300 and TCu220C (P < 0.001). The rates of removal for bleeding and pain for UCDCu300, TCu220C and TCu380A were 6.71, 5.58 and 6.80 per 100 women, respectively, no statistical difference was shown. The cumulative continuation rates were 74.86, 66.22 and 63.56 per 100 women at the 10 th year, UCD Cu300 was the highest, TCu380A was the lowest (P < 0.01). CONCLUSIONS: UCD Cu300, TCu220C and TCu380A are effective for long-term contraception. They are worthy of wide spreading in rural areas.

The intrauterine device: still misunderstood after all these years.

The intrauterine device (IUD) is one of the most effective, safe, and economic methods of contraception today. It is used by more women worldwide than any other reversible method of birth control, yet less than 1% of women in the United States use the IUD. Still remembering the tragedy of the notorious Dalkon Shield, American pharmaceutical companies and clinicians have been wary about promoting any IUD, leaving most physicians inadequately trained in the two IUDs available in the United States. Most significantly, misconceptions about the IUD's safety, mechanism of action, complication rates, and liability have severely limited the utilization of the IUD by many practitioners and women in the United States who may greatly benefit from it.

Sonographic characteristics of various types of intrauterine contraceptive devices.

OBJECTIVE: We sought to demonstrate the usefulness of ultrasonography for the in utero identification of different types of intrauterine contraceptive devices. METHODS: We used sonography to differentiate among types of intrauterine contraceptive devices. RESULTS: Each type of intrauterine contraceptive device had typical sonographic characteristics, in most cases, best demonstrated in the axial plane. Photographs of each type are shown and their sonographic appearance is discussed. CONCLUSION: Sonographic identification of intrauterine contraceptive devices is accurate and specific. Sonography may serve as a useful method for determining the time to change the device and to identify those types that are more prone to complications.

Conducta sexual en una población de mujeres usuarias del dispositivo intrauterino asistidas por un servicio de planificación familiar / Sexual conduct in women who use the intrauterine device and attend a family planning service

Con el objetivo de establecer mediante una guía de entrevista estructural la conducta sexual en una población de mujeres usuarias del dispositivo intrauterino (DIU) asistidas por el servicio de planificación familiar del Hospital Materno Infantil "San Lorenzo de Los Mina", Santo Domingo, Distrito Nacional, República Dominicana, se realizó un estudio descriptivo, transversal, de colección retro y prospectiva, con una muestra aleatoria simple de 100 mujeres entre 18 y 39 años de edad, en el período enero-marzo 1995. El 93// de las encuestadas tenía de tres a 14 meses con el DIU y el 7// de 15 a 60 meses; el 52// manifestó tener molestias vaginales luego de dicha implantación; el 53// indicó que conocía el DIU. El 37// consideró que el DIU era bueno; el 29// no tuvo ninguna opinión. El 48// de las encuestadas señaló sentir temores con respecto al dispositivo, otras manifestaron nerviosismo (22//), inquietud (21//), conflictos de pareja (6//). El 36// eligió el DIU por entenderlo como el mejor método anticonceptivo, el 40// no opinó al respecto. El 69// reveló que usó el DIU consciente de que la iba a proteger y el 14// dijo lo contrario. El 72// respondió que el DIU fue insertado por un ginecólogo, y el 12// por un médico general. En cuanto a la conducta sexual: el 47// manifestó vaginismo, el 41// no percepción del placer erótico (a veces), el 36// inhibición de la lubricación en el acto sexual, 38// reducción del deseo sexual (a veces). Asimismo hubo orgasmo inhibido (40//), relación sexual poco satisfactoria (40//). Dispareunia profunda (34//), en el trayecto medio (15//), al inicio (5//). Se precisan de más estudios en interés de continuar estableciendo las posibles causas (patologías médicas, fármaco-socioculturales, conflictos psicosexuales y otras), que pudieran estar influyendo en dicha variabilidad del comportamiento sexual

Modern intra-uterine devices.

Modern intrauterine devices (IUDs) provide effective, safe and long-term contraception and could be recommended to most women. The mechanism of action of an IUD is still not fully understood, but most recent research suggests that copper-IUDs as well as hormone-releasing intrauterine systems (IUSs) prevent conception. In women in mutually monogamous relationships the risk of PID is low and related to the insertion procedure. IUD/IUS use should be discouraged if there is a suspicion of increased risk of sexually transmitted disease. The risk of ectopic pregnancy is extremely low if modern, highly effective IUDs/IUSs are used. Copper-IUDs increase menstrual blood loss by around 50%, whereas hormone-releasing IUSs substantially reduce menstrual blood loss. Careful patient selection and counselling are the most important tools in order to provide acceptable and safe IUD use.

PIP: IUDs have the advantages of being highly effective, safe, long-acting, easy to administer, reversible, and inexpensive. At present, copper IUDs and levonorgestrel-releasing intrauterine systems are the most commonly used and studied. A review of recent clinical and epidemiologic research suggests the following recommendations: 1) the IUD may not be the method of choice for young nulliparous women; 2) the copper IUD is not the first choice for women suffering from heavy menstrual flow given its tendency to increase blood loss by 50%, whereas the levonorgestrel-releasing device may be ideal since it has been associated with dramatic reductions in bleeding; 3) although recent studies have failed to document an increased risk of ectopic pregnancy in IUD users, women with such a history should be given a levonorgestrel IUD or a device with a copper surface that exceeds 300 sq. mm; 4) the levonorgestrel-releasing IUD can be recommended to breast feeding women given the minimal transfer to breast milk; 5) IUD insertion should be preceded by history taking, counseling, and pelvic examination; 6) postpartum insertion of levonorgestrel-containing IUDs should be delayed for six weeks; and 7) a follow-up visit should be scheduled three to six weeks after insertion since this is the risk period for post-insertion infection.

Incidence of actinomycosis associated with intrauterine devices.

The incidence of intrauterine device (IUD)-associated cervicovaginal actinomycosis was evaluated. Papanicolaou-stained cervicovaginal smears from 1,520 women with IUDs were reviewed for the presence of Actinomyces-like organisms. The overall colonization rate was 11.4%. The colonization rates for the Progestasert, plastic IUDs and copper IUDs were 14.3%, 10.8% and 6.69%, respectively. The colonization rate appeared to increase with the duration of IUD use. The relatively high cervicovaginal Actinomyces colonization rate suggests that all patients with IUDs should undergo annual cytologic smears, with specific attention given to the presence of Actinomyces-like organisms.

PIP: A retrospective study of data from the Temple University Hospital Family Planning clinic in Philadelphia, Pennsylvania, for the period 1975-85 was undertaken to evaluate IUD use and the associated rate of cervicovaginal colonization of actinomycosis. All 1745 patients had a cytological smear before IUD insertion, and none showed evidence of Actinomyces-like organisms. During the study period, 1520 patients were followed regularly, and evidence of Actinomyces-like organisms appeared in 173 patients, for a colonization rate of 11.4%. The number of positive smears per user for each type of IUD was as follows: 120/960 for Saf-T-Coil, 17/254 for Copper-7, 7/49 for Progestasert, 8/36 for Lippes Loop, 2/15 for Dalkon Shield, 0/5 for Birnberg Bow, and 19/201 unknown. The type of IUD significantly affected the interval between insertion and detection of colonization, with Progestasert having the shortest duration of use prior to onset. Colonization rates also increased with duration of use for all IUDs, especially after 24 months. In this study, the first evidence of Actinomyces-like organisms occurred after 7 months of use. IUD-associated Actinomyces must be detected and treated promptly to avoid the significant implications of this infection.

Menstrual bleeding pattern and iron status in women fitted with copper and non-medicated intrauterine contraceptive devices.

A prospective study of the menstrual bleeding pattern and iron status was conducted in 42 healthy Nigerian women volunteers before and after being fitted with either a medicated, copper T (TCu.200B) (n = 20) or a non-medicated, Lippes loop (n = 22) intrauterine contraceptive device (IUD). After about six months of use, the mean fasting serum iron and packed cell volume (PCV) were significantly higher (+32% and +6% respectively), mean serum ferritin was significantly decreased (-14%) compared to the pre-insertion levels in the copper T IUD users. In the Lippes loop IUD users, mean fasting serum iron was significantly lower (-11%), mean PCV was higher (+5%). The changes observed in the mean levels of serum ferritin and the duration of menstrual bleeding did not reach a statistical significant level. Among the two groups, only the changes in the mean fasting serum iron was significant (P < 0.01). In all, only the women fitted with Lippes loop IUDs had a decrease in the levels of both serum iron and body iron stores (ferritin), however, no clinical anaemia was observed at six months of use.