Intra Uterine Contraceptive Device (IUCD)

One of the main contraceptive methods in use worldwide .It is the insertion of inert material inside the uterus to prevent pregnancy. . .

HISTORY

In 1909_Ralph Richter from Germany showed the efficacy of mechanical contraception by inserting silk warm gut suture in the endometrial cavity.

Between 1928_1930 Granfenberg from Berlin presented three reports on silk star devices and he is known as the pioneer of IUCD

Ishehama from Japan used the ohta ring made first of gold and later from plastic.

In early 1960s Lippes loop and Margolines spiral made of biologically inert polyethylene appeared.

In 1970s Hormone releasing IUDs developed but their real use started in 1995.

TYPES

1. Medicated IUCD:

Those IUCDs that carry biologically active agents into the uterine cavity like levonorgestrel releasing device [MIRENA]. It is an intrauterine system (LNG_IUS) that has sleeves of levenorgestril 52mg around its stem releasing 20microgram/day and lasting for at least 5 years. The advantage of medicated IUCDs is that the carrier part of the devices is smaller and less traumatic.

2. Non medicated IUCD:

No drugs are added to the matrix or plate form of the IUCD. It consists of plastic polyethylene and cupper. There are so many types of this group, the most commonly used are cupper T, TCU 380A, Multiload 375 and Nova T

Newer developments aim to reduce side effects and decrease expulsion rate by producing smaller and lighter IUCDs.

MECHANISM OF ACTION OF IUCDs

1. Prevent implantation of the fertilized oocyte

2. Produce a local sterile inflammatory reaction in the endometrium as a result of presence of foreign body causing spermicidal effect and the presence of cupper increases this reaction and also increases  the local release of prostaglandins thus decreasing the rate of pregnancy

3. They diminish sperm transport through the cervix to the oviduct by increasing the thickness of the cervical mucous (this happens with the hormonal IUCD).

4. Steroid releasing devices induce progestational changes that result in endometrial gland atrophy& Inhibit further development of the ova.

TIME OF INSERTION

The optimal time for insertion of IUCD is during the menstrual cycle at any day of the week following menstruation which indicates that the woman is not pregnant.

After delivery either vaginally or by caesarian section; an eight week delay seems to be adequate .IUDs specifically designed for immediate post partum insertion are now available.

An IUCD can be inserted immediately after spontaneous or therapeutic abortion but the risk of expulsion is increased in the second trimester abortion.

REMOVAL OF IUCD

Unless pregnancy is desired, removal should only be undertaken in the late luteal phase of the cycle or the first 7days of the cycle.

In menopausal women IUD should be left in situ for one year after the last menstrual cycle.

If the thread is not visible, IUD should be removed using a specially designed hook or a pair of artery forceps preferably under ultra sound guidance.

UNDESIRABLE EFFECTS OF IUCD

1. MENSTRUAL DISTURBANCES:

This includes both regularity and the amount of blood loss i.e. menstrual cycles become prolonged and heavier (menorrhagia) and also may cause dysmenorrhea.

In contrast levenorgestril releasing IUDs decrease the monthly blood loss.

2. PERFORATION

This can occur at the time of insertion .It occurs in 1.3 of every 1000 insertion. It may be best prevented by straightening the uterine axis through pulling the tenaculum which holds the cervix and  by performing a bimanual examination to check if the uterus is anteverted or retroverted before attempting to insert the IUCD.

3. EXPULSION

Rate of expulsion varies from 1_7/100 women in first year of use. Expulsion is commoner in the first 3 months of use so every woman should be examined frequently and should be taught to feel the thread of the IUD vaginally frequently.

4. PELVIC INFECTION

This is caused by bacteria carried into the uterus during the procedure. However the development of pelvic inflammatory disease after insertion usually results from a sexually transmitted pathogen. Salpingitis, tubo- ovarian abscess or pelvic peritonitis and tubal blockage could be the consequences of these bacterial infections. Symptomatic pelvic inflammatory disease is frequently treated with antibiotics without removing the IUD until the patient becomes symptom free, then a new IUD should be inserted under aseptic technique.

5. PREGNANCY ON TOP OF IUCD
    This occurs if the IUCD is not in its proper place in the endometrial cavity (slightly low or tilted) so an intra uterine pregnancy may ensue.

ECTOPIC PREGNANCY

Because IUCD prevents intrauterine pregnancy but not ectopic pregnancy, the relative incidence of ectopic could be higher in IUD users.

SPONTANEOUS ABORTION

A spontaneous abortion rate of up to55% has been reported in women becoming pregnant on top of IUD which is not removed after the diagnosis of pregnancy. However if IUD appendage is visible it should be removed or spontaneously expelled, abortion rate diminish significantly thereafter. If it is not visible, it is not advisable to perform uterine probing because of the possibility of abortion, perforation and/or sepsis.

PREMATURITY

Preterm deliveries have been reported in pregnant patients with an IUCD in situ.

EFFICACY

Throughout the years, pregnancy rate among IUD users have been steadily dropping .Non medicated IUDs and copper IUDs (up to 200) had up to 3% pregnency rates.

CONTRA INDICATIONS FOR THE USE OF IUCD

RELATIVE CONTRAINDICATIONS

1. Nulliparity
2. Valvular heart disease and cardiomyopathy
3. Previous ectopic pregnancy
4. Moderate to severe anemia
5. Hypermenorrhea or menorrhagia
6. Wilson's liver disease
7. Copper allergy
8. AIDS
9. High risk of STD

ABSOLUTE CONTRAINDICATIONS

1.Cardiomyopathy
2.Recent acute pelvic inflammatory disease
3.Chronic or recurrent PID
4.Recent septic abortion
5.Acute cervical or vaginal infection
6.Congenital uterine anomalies
7.Uterine tumors
8.Undiagnosed uterine bleeding

Appropriate Candidates  for Intrauterine Contraception

Women of any reproductive age seeking long-term, highly effective contraceptive

CONCLUSION

The benefit of IUCD use surpasses its risks and these are the risks of unwanted pregnancy. IUCDs are highly recommended for most women seeking contraception in developing countries because it has the highest continuation rate and the lowest cost…….

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