Intrauterine Contraceptive Devices

Ms.
Sarah
Mr. Ten

What is an IUCD?
A device inserted into the uterus (womb) to prevent conception (pregnancy).
A set - and - forget method

Types of IUCD
1) Copper-releasing IUCD
Multiload Cu-250 - emits 60 - 100g copper/day, lifetime up to 3 years
Copper T200 - emits 50g copper per day, lifetime up to 4 years
Multiload - 375 - lifetime up to 5 years
Cu T380A - lifetime up to 10 years
- Failure rate = 0.8%

Who is an ideal candidate for

IUCD
Uniparous
Monogamous
With out any pelvic infection
Who is willing to check the threads every day

Timing of insertion
1. Can be inserted at any time
2. Can be inserted immediately after delivery (Post placental
insertion) or within 48 hours after delivery
3. Preferably 2 - 3 days after the menstrual period is over.
4. Lactation amenorrhea - anytime
5. Postpartum: after 4-6 weeks when uterus in involuted to near normal size
6. Concurrently with I trimester abortion
7. After first period following spontaneous/medical II trimester abortion
8. Within 5 days of unprotected intercourse

Hormone impregnated IUCD

Levonorgestrel-releasing intrauterine system, or LNG-20 IUS
- Contains 52 mg levonorgestrel, released at rate 20g per day
- Lifetime up to 5 years
- Failure rate: 0.2%

Advantages of Copper IUCD

Long term highly effective reversible contraceptive
method
Effective immediately after insertion
Can be replaced without any gap as many times as the
woman desires
One time procedure
Cost effective
Can be used by lactating women
Does not interact with medicines taken by the woman
Fertility returns promptly on removal

Advantages of Hormonal IUCD

More effective than copper bearing IUCDs
Decreases the amount of bleeding
Improves haematocrit
Hence can be used in women with AUB
Reduces pain and cramps in dysmenorrhoea and
endometriosis
Beneficial effects on fibroids

Disadvantages
Very expensive
May not be affordable by many women
Oligomenorrhoea }
Amenorrhoea
} may not be acceptable to many
women
Irregular spotting or bleeding
Insertion requires a special technique

Mechanism of action
1. Biochemical and histological changes in endometrium with non specific
inflammatory reaction - which have gametotoxic and spermicidal
property. Macrophages phagocytize spermatozoa.
2. Tubal motility increases. Quick migration of fertilized ovum into uterine
cavity before the endometrium is suitable for implantation.
3. Impaired sperm ascent

Mechanism of action
4) Copper device - ionized copper prevents implantation and
initiates the release of cytotoxic cytokines
5) Hormone releasing devices - acts by thickening of cervical
mucus inhibits mobility and capacitation of sperms
6) Induce progestational changes that result in endometrial gland
atrophy

Methods of insertion
1. History taking and vaginal examination - exclude contraindications
2. Informed consent prior to procedure
3. NSAID (Ibuprofen 200 400mg) may be given 30 minutes before procedure
4. Strict sterile conditions, female chaperones if male doctor
5. Place device inside the inserter - no touch insertion technique

IUCD loaded into inserter without opening the sterile package

Not to touch IUCD with vaginal wall and speculum when inserting through cervical canal

How to insert
IUCD?

Demonstrate how to insert the

device
Take informed consent prior to procedure
Instruments must be sterile, chaperones needed for male
Patient is placed in lithotomy position
Pick up handle of inserter, with threads released hanging freely
Place thumb on slider
Check arms are horizontal and aligned with the centimeter scale of insertion
tube facing up
Load Mirena , by pulling the threads into the insertion tube
Knobs at the ends of the arms will meet to close the open end of the insertion
tube

Insertion of the IUCD

Check proper loading
Secure threads in the bottom cleft to keep Mirena in loaded position
Grasp a tenaculum forceps with other hand and apply gentle traction to
align the cervical canal with the uterine cavity
Gently insert the insertion tube through cervical canal and into uterine
cavity until flange is 1.5 to 2cm from eternal os. Maintain distance of
flange to allow sufficient space for arms to open (when released) in the
uterine cavity
Release arms of Mirena by pulling slide back until top of slider reaches
the mark
Gently advance the inserter into uterine cavity until flange meets the
cervix and fundal resistance felt

Insertion of IUCD
Release device and withdraw the inserter
While holding the inserter steady, pull slider all the way down to
release device. Threads will release automatically from the cleft
Careful not to pull on threads can cause displacement of device.
Cut threads perpendicular to the thread length, with a curved
scissor, leaving 3 cm visible outside the cervix
Check correct placement of Mirena with a transvaginal ultrasound

Complications
1. Immediate complications:
I) Cramp like pain
Transient, 1/2 to 1 hour
Analgesic or antispasmodic drugs

II) Syncopal attack

Nulliparous
device is large, distend

III. Partial or complete perforation

Faulty technique of insertion
Lactational period when the uterus remains small and soft.

Complications
2) Remote complications:
I.

Pain
proportionate to the degree of myometrial distension

II. Abnormal menstrual bleeding

Excessive bleeding (flow, duration, intermenstrual)
Anaemia -> iron supplement, tranexamic acid

III. Pelvic infection (PID)

The risk is 210 times greater
The risk is more in the first 3 weeks.
Chlamydia, rarely actinomycetes

Complications
IV. Spontaneous expulsion

Usually within few months following insertion

Failure to palpate the thread -> report to doctor
Higher risk following post abortal or puerperal insertions
Markedly reduced in successive years

V. Perforation of the uterus

Incidence: 1 in 1000 insertions
migration may also occur following initial partial perforation with
subsequent myometrial contraction.

 Complete perforation

 Migration into bowel

 Migration into bladder

VI. Pregnancy

Pregnancy rate with the device in situ :

2 per 100 women years of use

Risk of ectopic pregnancy (0.02 %)
If thread visible, remove it to minimise complications like
- Abortion,
- Preterm labour,
- Sepsis,
- LBW baby
If thread not visible: leave it, but counsel about the risk in continuing
pregnancy

Missing Threads
Possible reason
1)
2)
3)
4)

Thread coiled inside

Thread torn through
Device expelled outside unnoticed by the patient
Device perforated the uterine wall and is lying in the
peritoneal cavity
5) Device pulled up by the growing uterus

How to identify missing thread?

1. Exclude pregnancy first
2. Uterine Sound

Instrument used to probe and dilate the uterus

Negative finding on exploration

3. Ultrasonography

4. Hysteroscopy

Direct visualization of the uterine cavity

5. X-ray

If sounding of uterine cavity is negative, do X-ray with

uterine sound in the uterine cavity
AP and lateral view
Reveal the presence of IUCD, existence in or outside uterine
cavity

Removal of
IUCD

Indications for removal:

1.
2.
3.
4.
5.
6.
7.
8.
9.

Persistent excessive regular or irregular uterine bleeding

Flaring up of salpingitis
Perforation of the uterus
IUD has come out of place (partial expulsion)
Pregnancy occurring with the device in situ
Woman desirous of a baby
Missing thread
One year after menopause
When effective lifespan of the device is over.

Removal of
IUCD
ii.

i. Loop Hook

Artery forceps

iii. Uterine curette

iv. Under direct vision by hysteroscopy

 Outside the uterus but inside the abdominal cavity:

1. Laparoscopy
2. Laparotomy (rarely).