Intrauterine Contraceptive Devices(IUCDs)

Lavina Belayutham

Classification

• Non- medicated IUCDs: Lippes loop• Medicated copper containing IUCDs :

Cu T-380 A, Multiload – 375, Cu T-200, Multiload – 250

• Hormone containing IUCDs : Levonorgestrel intrauterine system (LNG – IUS), progestasert

What are the types of IUCD

that you know????

1. A 32 year old woman, P2L2 has come to the hospital for advice on contraception. She is a model and couldn’t tolerate excessive weight gain. When asked about her menstrual history, she says that she soaks through a pad every 2 to 3 hours and she has to get up in the middle of the night to change her pad. She also has severe cramps. She said she doesn’t prefer taking pills because she has never been able to remember to take a pill daily.

What is the best method of contraception?

a)Depot- medroxyprogesterone acetate

b)Progestin- only pill (minipill)

c) Combined oral contraceptive pills

d)Levonorgestrel - IUS

2. A 26 year old woman, G3P3 comes to the hospital to get a copper T inserted. On examination, she is found to have ascites and splenomegaly. Signs of chronic liver disease were also found. On slit lamp examination :

Would you proceed with the copper T insertion?

3. Lalitha is a married 30-year-old mother of one infant child. She and her husband both wish to delay having a second child. Lalitha is currently breastfeeding. She had an occurrence of pelvic inflammatory disease (PID) in her early-20’s. She heard about IUCDs from a community health worker and has come to the clinic to learn more about them.

During your meeting, Lalitha wants to learn more about IUCDs and asks the following question:

a)Is it safe to use copper IUDs while

breastfeeding? Why?

Answer : Yes. No hormones.

b)Does her previous history of PID affect

her eligibility for IUCDs?

Answer : No.

Ideal candidate for IUCD

• Normal uterus• Parous• Low risk for STD• Monogamous • Don’t wish to have baby for few years• Want to avoid surgical sterilisation • Willing to check IUCD thread• Assess – follow up, treatment

1. Pregnancy

2. Abnormalities of uterus resulting in uterine cavity distortion

3. Acute PID or h/o PID unless there has been a subsequent uterine pregnancy

4. Postpartum endometritis or infected abortion in the past 3 months

5. Undiagnosed genital tract bleeding

6.Untreated acute cervicitis, vaginitis, including bacterial vaginosis, until infection is controlled

7. STIs – current or within 3 months

8. History of ectopic pregnancy

9. Immunosupression

Contraindications for copper T 380A

1. Wilson’s Disease

2. Copper allergy

Contraindications for LNG-IUS

1. Hepatic tumor or hepatocellular disease

2. Current breast cancer

4. It is now 6 months since Yamuna had her IUD inserted. During a visit 3 months ago, Yamuna had complained of a heavy bleeding and cramping during menses. She was also concerned about the IUD expulsion. You had examined her and confirmed that the IUD is still in place and reassured her about the side effects. Today, she has returned to the clinics and complains of fever, purulent vaginal discharge, lower abdominal pain, and pain during sexual intercourse. She has checked the threads after each menses since her last visit and had felt them each time.

a)What is the likely cause of Yamuna’s

symptom?

Answer : Pelvic Inflammatory Disease

b)Does she need to have the IUD

removed? Why or why not?

Answer : Yes. Foci of infection.

c)What is your plan of action?

Antibiotics

Ceftriaxone (250mg IM)

+

Doxycycline (100mg bid oral)

for 14 days

d)What other counselling advice

would you offer and why?

Answer :• Complication if untreated • Partner also treated• Abstinence from sexual intercourse until

treatment completed• Use other contraceptive method

5. Sudha, a P1L1 has had her IUCD for three months. She is returning to the clinic and complains that she still has cramping, especially during menses, and heavy bleeding during her periods.

a)Is heavy bleeding normal with IUD

use?Answer : Common (temporary)

b)What would you advise Sudha to do

about her bleeding?

Answer :• Reassure

• Reassure

c) What would you advise Sudha to do about her cramps?

Answer :

• Reassure• Analgesics• Underlying cause• Remove IUCD ( if persists)

Complications of IUCD

1.PAIN AND INCREASED MENSTRUAL BLEEDING

2. PELVIC INFECTION(PID)

Risk :• Low overall• Higher (first 20 days)• Extremely rare (> 20 days)• Gonorrhea/chlamydia• Similar to risk of PID

in women with

gonorrhea and chlamydia

who are not using IUCD

How to reduce the risk of PID?

• Don’t insert IUCD if :- High risk of STIs- Clinical symptoms and signs of STI • Aseptic technique• Follow-up visit at 3 to 6 weeks

3. Perforations

Perforations

• Incidence 1 in 1000• IUCD, the inserter tube, the sound, or other

gynecological instrument • Withdrawal technique (less common)• Postpartum between 72 hours and 6 weeks

4. Expulsions

• During menstruation• Factors contributing to expulsion :

1.Provider’s skill

2.Age, parity

3.Time since insertion

4.Timing of insertion

5. Intrauterine Pregnancy

Intrauterine Pregnancy

• Spontaneous abortion (most common)• Removed• Increase risk of preterm labour (if left in place)

6. Ectopic Pregnancy

Ectopic Pregnancy

• Risk much lower than noncontraceptive users• IUCD user pregnant, mostly ectopic• Lowest rate : copper T 380A, levonorgestrel

IUCD• Higher rate : progestasert (action limited to

local effect on the endometrium)