Intrauterine devices were first mentioned in 1909, when Richter was able to describe in detail ring-shaped device, which in those days was made of Bombyx mori. Although first in history IUD was known in ancient times, you should not consider such devices at this time. Currently there are various forms of intrauterine contraceptives, including «umbrella», «loop», «T letter», devices in the form of spiral or IUD as a ring.
Now for IUD production there is used a variety of innovative materials, which include plastic, silver and copper. In our time in global gynecology Copper-T 380A device is most often used, which contains copper. Intrauterine contraceptives are the most relevant in China, where such devices are now the main method of contraception. Among the most frequently used forms of IUDs there should be noted ring without filaments, with one curl, which is made of stainless copper. This form of rings gradually replacing previously popular Mahua ring made with two symmetrical swirls.
According to statistics, currently IUDs around the world are used by 85 million women, more than 60 million are in China. This method of protection against unwanted pregnancy is now in second place, and in the first place there is still voluntary surgical sterilization.
IUD contraceptive capabilities, mainly based on particular impact on female ovum, have effect on of sperm cells migration, implantation and fertilization processes as well as directly on uterus. But, unfortunately, exact IUDs mechanism of action is not fully understood by scientists, and is not determined yet. It is believed that such contraceptives affect uterus and cause constriction ability and its changing activity. Perhaps their use leads to inflammation of aseptic nature, wherein an endometrium enzymatic system changes its activity, and fallopian tubes peristalsis is accelerating. Therefore, sperm cells migration, which fertilizes female egg, varies considerably, they quickly get to uterine cavity, and then die before they reach their target.
By studying possible properties and different mechanisms of action of modern uterine contraceptives, it is possible determine the following possible effects:
- on sperm cells as well as slowing their migration to fallopian tubes of woman’s vagina;
- on fertilized egg, thus accelerating its subsequent passage into uterus through fallopian tubes;
- on fertilization – a significant slowing down process of fertilizing the egg;
- on implantation – subsequent death of blastocysts as a result of reaction to presence of foreign body in uterus and significant development of inflammatory processes;
- possible abortifacient IUD influence because of rejection of already fertilized egg from endometrium;
- on endometrium as a result of carbonic anhydrase activity and alkaline phosphatase reduction. This is achieved by copper chemical reaction, which intrauterine devices are made of.
Important conditions when selecting IUDs are not only their shape and size, progestins level in spiral and copper content, but also woman’s age, number of her previous pregnancies or childbirth. If medical IUDs are used correctly, frequency of unwanted pregnancies is around 0,1 – 1,5%, and for a typical use of non-medicinal intrauterine devices, this indicator rises to the level of 2-3%. Among women in older age as a rule IUDs are less effective as performance indicators directly linked to woman’s age. Statistics show that least effective are IUDs made in form of a ring with copper content.
Pregnancy rate can be minimized by using the following means:
- IUDs, with copper, progestin or pregesteron content in their structure;
- IUDs, which are characterized by large surface area;
- IUDs with low expulsion frequency;
- IUDs, introduced in full and settling at the bottom of uterus;
- IUDs, which total or partial expulsion is detected in time.
Non-contraceptive intrauterine device properties:
- IUDs with progestin can reduce dysmenorrhea and menstrual hemorrhages intensity;
- IUDs, often used for Asherman’s syndrome – adhesive process that occurs in the uterus – prevention and treatment.
Intrauterine Devices Types
- To neutral IUDs type «Lipps loop» can be attributed, which is divided into four types depending on size. They are sold in pharmacies either in sterile packaging, or in inexpensive packages that require subsequent sterilization in special antiseptic solution containing benzalkonium. As a rule, «Lipps Loop» is introduced into uterine cavity by inserting rod – a special medical instrument.
- Modern IUD in the form of stainless steel ring with one curl is characterized by filaments absence. This intrauterine device is most often used in China, curls diameter is 18 – 24 millimeters. First, with the help of uterine probe there should be determined length of uterine inner cavity, and then necessary size of ring.
- The most common IUD now is Copper-T 380A, released in sterile packaging. It is a copper wire, wound on vertical plastic rod. Copper-T 380A is inserted into uterine inner cavity using special conductor, and this IUD type in the case of proper implantation and lack of negative effects can be worn during five year period.
- Copper-T 200 is designed for contraception for a period of four years, it comes in sterile package and is most often used in Mexico and China. This type of IUD is introduced into uterus curled by using special conductor.
- Such kind of IUD as Copper-7 is sold in modern sterile packaging and conductor is already included in package. In this case, IUD is introduced into uterine space by «outtake» or «push» in the middle of the uterus. After it «opening» you can often hear a click, and only after that conductor is removed.
- IUD type Multiload-375 and 250 are sold already inserted in conductor and it is put in sterile package. This intrauterine device is available in three sizes and is administered by retraction method.
- Medical IUD type Progestasert-T containing progesterone is produced in sterile package, progesterone hormone itself is gradually released after entry into endometrial cavity from the bottom of miniature intrauterine device with constant frequency. This type of IUD is easily inserted into uterus by outtake method.
- Nova-T – is IUD type, made in the form of «T» letter. It is characterized by containing levonorgestrel, which is released after entering from the bottom of device with constant frequency.
IUD can not be applied in the following cases:
- too high risk of various infections and their subsequent sexual transmission;
- inflammatory diseases of various pelvic organs, as well as post-abortion or postnatal endometritis;
- acute purulent cervicitis, chlamydia or gonorrhea;
- present or suspected pregnancy.
Thus intrauterine devices can be used as postcoital contraceptive for five days elapsed after unprotected intercourse. However, IUDs are not allowed to be used for women diagnosed with endometrial cancer, vaginal hemorrhages of pathological character, as well as those that have uterus cancer.
Selecting IUD should be especially careful for women suffering from leucorrhoea without cervicitis or severe vaginal infection in relapse stage, purulent infectious cervicitis. Also, IUDs are not recommended for childless women with high risk of sexually transmitted infections. Another relative contraindication for IUDs – AIDS or other diseases that cause unstable state of immune system, and such disease as anemia, although IUDs , containing progestins, can significantly reduce menstrual blood loss. Intrauterine devices are not recommended for women with painful or heavy menstrual periods, small in size uterus, suffering from cervical stenosis, as well as those who have already had one ectopic pregnancy.
Before IUD introduction, it is desirable to carry out gynecological examination which may reveal contraindications to IUD use such as abnormal uterine structure or biomes.
Principles of Intrauterine Device Application
If pregnancy is excluded, intrauterine devices can be administered at any time during menstrual cycle. In cases of suspected pregnancy, it is recommended to wait for next menstrual cycle onset. The most common intrauterine devices are introduced into woman’s uterus for 3 – 8 days, at the beginning of menstrual cycle or after a certain period after abortion. After childbirth, it is recommended to wait a few months and only then enter the IUD.
IUD is administered in the following situations in absence of pregnancy:
- during first ten minutes after labor since after this period it is risky to enter IUD due to uterine contractions and there is a significant risk of expulsion;
- six months after birth, if new pregnancy is excluded, and a woman all this time either abstained from sexual intercourses or used condoms or vaginal spermicides;
- immediately after abortion if it was carried out earlier than 12 weeks after conception, if legal artificial or spontaneous abortion is not characterized by complications;
- on any day of menstrual period, if pregnancy is completely excluded, and woman permanently used any contraceptives before that.
IUD Introduction and Preventive Antibiotics
Currently, preventive antibiotics are appointed in cases when women are at greater risk of sexually transmitted infections. If antibiotics are appointed, the following factors must be considered:
- woman in this period should not suffer from acute infectious diseases as well as has no contraindications to antibiotics and IUD;
- oral doxycycline administration is recommended;
- during breast-feeding period woman is recommended to take erythromycin.
As a rule, intrauterine devices are introduced immediately after physiological labor, if they went without complications, and uterine contractions are normal in nature, with excluded risk of uterine hemorrhages. After placenta release, intrauterine devices are sequentially entered by hand, their introduction is a convenient and safe method, with no infection risk. To prevent development of inflammatory complications, it is necessary to strictly observe the asepsis rules, which include mandatory use of long sterile gloves.
This method of IUD introduction has side effect – high frequency of intrauterine devices expulsion.
Possibility of expulsion decreases in the following cases:
- intrauterine device is inserted into uterus during the first ten minutes after placenta release;
- you need to manually clear uterine cavity from accumulated blood clots;
- IUD should be introduced by hand into uterine cavity;
- IUD must be placed at the bottom of uterus, high in its cavity;
- IUD must be introduced by experienced doctor;
- it is necessary to intravenously administer drugs that cause uterine contractions.
Many women immediately after intrauterine device introduction observe significant nausea or pain, so it is recommended to come to health clinic with spouse or partner who may take woman home after this procedure.
After IUD introduction it is necessary to check filaments position before you leave doctor’s office. Learn how to determine filaments length. If at palpation of already entered IUD you can feel their plastic parts or palpation is impossible, risk of unwanted pregnancy significantly increases. Filaments are advised to check regularly for a few months after introducing IUD in uterine cavity, and it is recommended until the next visit to doctor to use additional contraception in case of detecting their position violations.
Do not forget about possibility of various inflammatory processes development, as well as infection risk. In case abdominal pains, fever, various secretions from vagina, immediately consult a specialist. Remember that these inflammatory diseases – a direct path to infertility or chronic pelvic pains.
Be sure to follow all changes in menstrual hemorrhages and menstrual cycle violations, in timely manner contact a gynecologist at slightest worries about health condition. Pay attention to symptoms such as heavy vaginal mucous or blood-tinged discharges, increased pain during menstruation, occurrence of menstrual hemorrhages. Remember that IUD can be removed at any time, it is just enough to see a doctor. Do not forget that unpleasant symptoms when using this method for birth control appear, usually during the first two or three months after IUD introduction and then disappear at many women.
Do not attempt to remove IUD yourself as it will be safer for you intrauterine contraceptive is removed by experienced doctor, and only in a sterile clinical environment. Always follow manifestations of the following symptoms:
- missed menstrual period – this may indicate pregnancy;
- hemorrhages or spotting;
- low abdominal pains, as well as pains during sexual intercourse;
- abnormal discharges, infections and inflammations;
- general uneasiness, including such symptoms as chills, fever, fatigue;
- inability to palpate IUD filaments, their lengthening or shortening.
Among all cases of IUD removal in 5 – 15% the direct cause is occurrence of hemorrhages or blood-tinged discharges, especially during first year of using these means of preventing unwanted pregnancy. Symptoms for removing IUD may be general fatigue, pale skin, blood clots release in period between two menstrual periods, sustained and prolonged hemorrhages. In any case, in presence of hemorrhages IUD is recommended to remove, even if administration is not the cause of the problem.
If you have problems of various kinds, follows these guidelines:
- even before intrauterine contraception introduction it is necessary to carry out probe with utmost caution, it is important to choose proper probe of desired size;
- in case of severe pain during IUD introduction or during any subsequent two-day period and during menstruation, it is recommended to remove intrauterine device; if pains are not severe, you can relieve them with the help of aspirin;
- if there is partial intrauterine devices expulsion, it is necessary to remove, and then in absence of pregnancy, unless there are inflammatory processes, it is recommended to install new IUD;
- in case of inflammatory diseases in pelvic it is necessary to remove IUD, carry out appropriate treatment, duration of which is not less than three months, and then enter a new contraceptive intrauterine device;
- in case of severe pains immediately after introduction, loss of consciousness, cardiac arrest, seizures, vaso-vagal reactions, it is required to intramuscularly administer atropine or any anesthetic in order to maintain heart tone, in severe cases, be sure to remove IUD;
- if IUD causes discomfort due to large size, it can easily be removed and replaced by IUD of smaller size;
- in case of spontaneous abortion it is necessary to first diagnose pregnancy, then remove IUD, then evacuate uterus to exclude ectopic pregnancy; if ectopic pregnancy is diagnosed, a woman should be sent to emergency surgery;
- in case of improper disclosure IUD must be removed, and then a new device should be introduced.
IUD complications manifest in spontaneous expulsion of the device, which occurs in about 2 – 8% of cases. Typically it occurs during the first year of use. Its symptoms include: unusual vaginal discharges, low abdominal pains, inter-menstrual hemorrhages. After sexual intercourse in case of expulsion there may be experienced spotting, symptoms of dyspareunia, patient should pay attention to filaments lengthening, as well as feeling of intrauterine device in cervix or uterine cavity. Remember that expulsion can not only cause discomfort for woman, but also cause irritation of her partner’s penis.
If you do not see evident expulsion symptoms, pay attention to its possible indirect consequences, including inability to palpate internal filaments, pregnancy, menstruation delay.
You can determine the following objective signs of expulsion:
- IUD location in vagina or in cervix;
- in case of partial IUD expulsion, there observed filaments lengthening;
- in case of complete IUD expulsion, filaments are not visible;
- during probe, X-ray or ultrasound examination of abdomen and pelvic IUDs do not show up.
If diagnosed partial expulsion, IUD should be necessarily removed, and then if there is no inflammation and pregnancy has not occurred, a new IUD can be inserted immediately after withdrawing the old one, or wait until the next menstrual period. If there is a complete expulsion and no contraindications, you can enter another uterine contraceptive. Statistics show that expulsion of IUDs containing progestin happens most rarely.
Women often complain on gradual shortening of filaments, inability to palpate them, as well as on the fact that the increasing of filaments length leads to irritation of spouse or partner’s penis. These facts indicate either IUD expulsion or its transition into abdominal cavity, so examination is necessary to determine filaments position. The best technique – ultrasound – allows observing filaments location with great accuracy.
To restore IUD filaments normal position coil is often used. In rare cases, cervix is examined using narrow forceps, with the help of which experienced doctor can easily locate intrauterine contraceptive filaments. Such devises can not only be found, but also quickly removed with a variety of medical instruments, including hooks and forceps used in hysteroscopy.
In case when IUD filaments are in the inner space of uterus, it is recommended to remove contraceptive, and then introduce a new one – identical to the old one or of another type.
About 30% of unwanted pregnancy during IUD use are directly related to IUD expulsion, but pregnancy occurs even in presence of such means in uterine cavity. If pregnancy has still occurred, intrauterine device requires urgent removal by pulling filaments or by careful traction.
Women willing to keep pregnancy, you should remember the following:
- in this case, miscarriage risk is twice increased;
- risk of ectopic pregnancy is increased;
- in case of spontaneous abortion risk of subsequent infection greatly increases.
In case of IUD introduction, uterine perforation rate is about 0,04 – 1,2%, and data indicator is directly related to shape and type of intrauterine device, techniques of administration, anatomical features of uterine cavity, IUD position, as well as doctor’s competence. At uterine perforation there are pains during IUDs insertion, then there is gradual filaments disappearance, regular uterine hemorrhages, and then possible pregnancy.
Quite often diagnostics is significantly impeded as outward signs of uterus perforation may be completely absent. This fact may indicate such objective reasons absence of filaments inside cervical canal, inability to remove IUD even in case of its detection, shifted IUD observed during hysteroscopic, ultrasound or x-ray examination.
Cervical perforation is often caused by IUD expulsion. During gynecological examination gynecologist detects contraceptive in any of vaginal vault. In case of cervical perforation, IUD is first to be transferred into intrauterine space, and then removed with narrow forceps from cervix. In case when intrauterine device transmits into cervix, IUD is removed by conventional techniques. When contraceptive is located outside uterus, its removal is performed by laparotomy or laparoscopy.
IUD complications include exacerbation of chronic uterus diseases. Acute inflammatory processes at parous women occur in 1,5 – 7%, and among nulliparous this figure is about 10%. Presence of inflammatory processes during IUD use is quite often the result of a variety of infections, which are usually transmitted by sexual contact, including gonorrhea and chlamydia. The risk of infection when using IUDs is much higher than with other methods of contraception. In any case, diagnosis of a variety of inflammatory diseases, IUD should be immediately removed, then within two weeks suitable antibacterial therapy and subsequent examination should be carried out.
If IUD is in uterine cavity, inflammatory processes treatment in organs located in pelvic area is not recommended, as you first need to remove intrauterine contraceptive. Otherwise there is a high possibility of abscess, sepsis, peritonitis, and fallopian tubes obstruction. Before inserting new IUD after elimination of inflammatory process and its reasons it is recommended to wait three months.
Methods of IUD Introduction
Modern IUDs introduction method is quite simple, it is carried out only under aseptic ambulance conditions. The doctor must first conduct a thorough gynecological examination to accurately exclude possibility of pregnancy and verify absence of inflammation, as well as detect presence of uterine perforation. If uterus is retrograde, it will require a more thorough examination.
Cervix and vagina are to be cleaned with antiseptic solution, including iodine or benzalkonium chloride solutions. Sensitive women need intracervical anesthesia, after that cervical forceps must be applied to cervix, on its upper lip, and then slowly closed. Further, uterine probe is introduced gently into uterine cavity when it reaches uterine cavity bottom, sterile cotton swab is applied to cervix and removed simultaneously with the probe.
Intrauterine contraceptive device is inserted into conductor and then prepared construction through cervical canal is inserted into uterine cavity. Gynecologist should perform every action very slowly, observing utmost caution. When IUD is introduced, it remains only to cut its filaments, and patient can be recommended to perform IUD filaments palpation immediately to know specification for contraceptive location. In this case, woman will then easier be able to determine expulsion, if it occurs.
Methods of IUD Removal
IUD removal depends on its type, but usually this means is necessary to remove after three or four years. IUD is best to remove during menstruation onset, as in this case, procedure is performed relatively easily and painlessly as possible. IUD removal should be slow by constant light traction, in case of natural resistance it is necessary to make uterine cavity probe, then properly turn the probe by 90°C, to expand the cervix.