Summary

Dr. Pankaj Desai discusses intrauterine contraception throwing light on,

• current practices followed for placement and retrieval of IUDs
• IUD role in serving as emergency contraceptives
• newer, frameless versions of intrauterine devices and IUBs

Intrauterine contraceptive devices (IUDs or IUCDs) are a group of very effective and easy to use reversible contraceptive systems, also safe and easily available especially in countries like India, where they are supported by the government which effectively brings down the end-user cost. In fact, IUCDs in government institutes are absolutely free in India.

Contraceptive devices are very competent, reversible systems. Reported failure rates within the first year after insertion have been particularly low, 0.6 to 0.8% for the Copper T, 0.2 to 0.9% for the LNG IUDs.

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What is the right time for insertion of a contraceptive device in regular population as well as in special situations?

Here are the the current practice recommendations for insertion of IUCDs

1. Regular cycle: An IUCD can be placed at any time of the menstrual cycle provided the woman is not pregnant. During active menstruation, no one would like to insert an IUCD. There has been a debate as to whether it can be fitted in the second half of the menstrual cycle. This is because of the possibility of the woman having already ovulated and being pregnant at the time of insertion. To this, the recommendation is that if the lady is reasonably sure that she is not pregnant, it is safe to insert an IUCD.
2. Post-abortion: Contraceptive devices can be safely inserted following an abortion– both spontaneous as well as induced. The only exception is septic abortion. In these cases, it is advisable to wait for three months after the sepsis has cleared.
3. Post-delivery: IUCD insertion is considered safe after both, vaginal delivery as well as after a cesarean section. The current recommendation is after ten minutes of placental delivery. Nevertheless, the risk of expulsion is considerably higher and this is understandable. The size of the uterine cavity and the patulousness of the cervical canal both increase the chances of expulsion. Some changes in the design of IUCDs is recommended.
4. Post-placental: This is defined as intrauterine device (IUD) placement within 10 minutes after delivery of the placenta. It is an appealing strategy for increasing access to postpartum IUDs because it does not require a separate postpartum visit. Postplacental IUD insertion is safe and does not have higher risks of complications than interval insertion. Expulsion rates vary widely across studies, without clear evidence about the factors that may influence expulsion.

Special situations

1. In nulliparous women: Traditionally practitioners do not insert IUCDs in nulliparous women. This is because of some safety concerns. Also, younger nulliparous women seem to have a higher expulsion rate. But, this has been challenged by some studies which actually show a lower expulsion rate (nearly half). It is therefore recommended to individualise the case.
2. In adolescents: They are not popular contraceptive methods for adolescents. This is because of the inherent invasiveness of these devices. Also, in societies like India, the majority of adolescents are not sexually active. Even amongst the sexually active adolescents, IUCDs are not popular due to fear of pelvic inflammatory diseases.
3. Certain medical conditions: Some medical conditions may be deterrents for healthcare providers in soliciting or canvassing an IUCD. A comprehensive list showing details of these conditions is available.

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Frameless intrauterine contraceptive device during Cesarean Section

In the section on “Timing of IUCD Insertion”, post-delivery IUCD has been separately covered. The main reason why some groups advocated the use of IUCDs during cesarean section is the fact that in many societies, patients get lost to follow-up. They may never come for contraception coverage after delivery. Instead, they come with pregnancy in quick succession. Due to this, the possibility of post-delivery and intra-procedural insertion of IUCD is explored. It has been found that the conventional T-shaped IUCD are likely to be expelled or displaced much readily.

As a result, frameless IUCDs have been developed and advocated. The placement technique of a frameless IUCD is apparently simple. Its uterine compatibility is high. As a result, user compliance is good. Because of its small size and fragmented design, frameless IUCDs have minimal patient discomfort. Both agents, copper and levonorgestrel impregnated IUCDs are available and popular in Europe. Immediately post-delivery, the motivation of women for contraception use is the highest and therefore the need for this device is understandable.

Intra-operatively, during c-section, the frameless IUCD, is anchored at the fundus. For this, a special insertion apparatus is available. The IUCD is anchored at the fundus and suspended with delayed absorbable suture material. It is projected as a major advance over the traditional IUCD.

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Efficacy of intrauterine devices as emergency contraceptives

Intrauterine contraceptive devices have been found to be very effective as emergency contraceptives too. Accurately-used IUCDs after unprotected sexual intercourse can prevent conception. IUCDs may not prevent conception but successfully prevent implantation. It is believed that a fertilised ovum on moving to the uterine cavity, finds an IUCD occupying its space and fails to implant.

Copper IUCDs are the first choice of emergency contraceptives. This is because of their rapid action and long-term validity. Copper ions are also said to be detrimental for the viability of the sperms and the ovum. They prove to be lethal for them. When inserted after ovulation, they prevent implantation. However, for them to function as emergency contraceptive agents, copper IUCDs need to be inserted up to five/seven days after unprotected intercourse or up to five days after the earliest expected day of ovulation. IUCDs as emergency contraceptives are very effective. But their popularity for this particular purpose remains limited. This is more so in societies like India where IUCDs are conventionally popular for use in parous women as usual contraceptives.

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Intrauterine Balls (IUBs)

IUBs as Intrauterine Balls have been reported to have fewer side effects and complications than IUCDs. These are so devised that they take the shape of a 3-D ball on insertion. IUBs are expected to reduce the risk of perforation, malposition, and expulsion. Some reports indicate that they may even reduce dysmenorrhea and menorrhagia seen sometimes with conventional IUCDs. Their popularity has indeed remained limited.

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Side effects of IUCDs

1. The main side effect of copper IUCD is increased menstrual bleeding. This may be found even on long term use. However, these side effects are not very common. All types of IUCDs are well tolerated with a continuation of use rate being very high. In practice, IUCD continuation rates are highest amongst all reversible contraceptives in use.
2. Side effects of progesterone IUCDs (LNG-IUCD) are quite like those found with other progesterone-based contraceptives. This includes nausea, headache, hair loss, breast tenderness, decreased libido, and ovarian cysts. Some women (less than 20%) may report amenorrhea or intermenstrual spotting with progesterone IUCD. These complaints disappear on long term use of this system. Copper IUCDs can cause dysmenorrhea and menorrhagia. They can cause pelvic inflammatory disease (PID) in susceptible women.

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Retrieval of intrauterine contraceptive devices with missing strings

1. When IUCD strings are noted to be missing, the first step in management is the use of a cervical cytology brush to sweep strings from the endocervix. This procedure alone is frequently effective and can be performed regardless of the IUCD or pregnancy status.
2. If the strings cannot be swept easily with the brush, an ultrasound examination, if readily available, should be performed to assure intrauterine location.

• When an appropriately located IUCD is confirmed on ultrasound examination and the patient wishes to maintain the IUCD, no further follow up is required until the IUC has to be removed
• If the patient is pregnant or wishes to maintain the IUCD, an ultrasound to assess pregnancy and IUCD location should be obtained
• In non-pregnant patients who desire IUCD removal, it can be easily removed by an IUCD hook or by using artery forceps

3. Ultrasound control may not always be necessary. If removal is difficult as the IUCD is embedded, ultrasound guidance can be of help for precise location and removal.
4. If the IUCD is not in the uterine cavity and has migrated to the peritoneal cavity, laparoscopic removal or laparotomy may be necessary. Though, these are complications that can rarely occur.

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Concurrent practices deemed unnecessary

1. Some practices have been discussed with IUCD insertion. One of them is the use of misoprostol or nitroglycerin gel administration for ease of inserting IUCDs. Both of these practices have been found to be unnecessary and unhelpful. Overall, most studies found no significant differences between women receiving interventions to ease IUD insertion versus controls.
2. There was a recommendation for confirming IUCDs routinely, for proper placement by sonography. It was to be done immediately after IUCD placement. But, this has also been found to be of limited use being confined to those women in whom IUCD insertion was difficult.
3. Administration of prophylactic antibiotics at the time of IUCD insertion has also been found to be unnecessary.

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In conclusion, IUCDs are very popular, very effective, safe, and reversible contraceptives. They have the highest continuation rate of use. They have side effects, but, they are not very common. IUCDs continue to be popular in countries like India where government support and subsidy have made social marketing of IUCDs very successful.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author is a Senior Obstetrician and Gynaecologist.