Intrauterine contraception

Abstract

Currently 85 million women use an intrauterine device (IUD), making it the most widely used, reliable, reversible contraceptive method worldwide. Although the exact mechanisms by which copper-bearing IUDs produce contraceptive action are not completely defined, recent evidence indicates that they act primarily to prevent sperm from fertilizing ova. The future of the IUD is brighter than it has been for the past 20 years. The latest generation of IUDs, such as the TCu 380A (Paragard, GynoPharma, Somerville, NJ), are safer and more effective than ever. In World Health Organization large, multicenter trials, pregnancy rates for the TCu 380A are 1.0, 1.4, 1.6, and 1.8 at 3, 5, 7, and 9 years of use, respectively. The ectopic pregnancy rates and removal for pelvic inflammatory disease are very low. The device may soon be the major IUD available in most countries. The acceptability of IUD use can be increased by good clinical management, sympathetic counseling, careful client selection, proper device selection, careful insertion, timing of insertion, and regular follow-up with quick access to medical care.

PIP: 85 million women worldwide use IUDs. Most live in China (60 million), with another 14 million living in other developing countries and the remaining 11 million living in developed countries. It appears that IUDs mainly prevent pregnancy by causing a foreign body response in the myometrium which consists of increased vascular permeability, edema, and stromal infiltration of leukocytes, neutrophils, mononuclear cells, and macrophages. Another possible mechanism is biochemical changes. Each family planning provider should ask a client about her contraceptive needs, obtain a social and medical history, and inform her about various contraceptives. If the client chooses the IUD, the provider should provide her with her all the relevant information (e.g., insertion procedure, side effects, warning signs of grave complications, time for IUD replacement, and return visits). This helps her to relax during insertion and makes insertion less painful., The IUD is best suited for women who have at least 1 child and access to medical care, are in a monogamous relationship, and whose menstrual period is normal. Copper releasing IUDs, especially the TCu 380A has the lowest pregnancy and expulsion rates and is effective for 6-8 years. Only trained health workers should insert IUDs and, in many developing countries, lower level health workers insert them. A training program developed by the Johns Hopkins Program for International Education in Gynecology and obstetrics and tested in Thailand achieves competent insertion by nurse-midwives after only 5 insertions. IUD insertion can occur at any time during the menstrual cycle. Postpartum insertion is safe, effective, acceptable, and does not affect lactation. Expulsion is more likely with postpartum insertion than with interval insertion, however. Proper IUD placement is high in the fundus. Good IUD clinical management also includes sympathetic follow-up care.