Intrauterine device quo vadis? Why intrauterine device use should be revisited particularly in nulliparous women?

Abstract

Background: Long-acting reversible contraceptive (LARC) methods, including intrauterine devices (IUDs) and the contraceptive implant, are considered the best methods for preventing unintended pregnancies, rapid repeat pregnancy, and abortion in young women. An opinion paper of 2012 by the American College of Obstetricians and Gynecologists recommends Mirena and Paragard for use in nulliparous and adolescent women. However, these IUDs are not designed for young women and are not optimal as they often lead to early discontinuation.

Objective: This article was written with the objective to respond to the urgent need to improve intrauterine contraception as it is likely that the objectives of LARC will not be met without significant improvement of IUD design. Anatomical variations in size and shape of the uterus are not sufficiently considered, producing harm and suffering, which often lead to early removal of the IUD.

Proposed problem solving: The article describes why IUDs should be revisited to meet the challenge of LARC and proposes how to solve these problems. The opinion statement presented here may be considered provocative but is based on hundreds of women with IUD problems who consult or are referred to the practices of the authors of this article due to the disproportion between the IUD and their small uterine cavity. The solution is simple but requires a revision of the current design of IUDs. One-dimensional (longitudinal) IUDs are likely to be the first option. Framed devices with shortened transverse arm and IUDs which adapt to the width of the given uterus are viewed as second best.

Conclusion: One of the reasons of the high unintended pregnancy rate in the USA may be the paucity of suitable IUDs. Also, the legal climate in the USA seems to be a problem for developers as many lawsuits have recently been reported. Clinical studies conducted in young nulliparous and adolescent women suggest that IUDs that fit well in the uterine cavity, like a shoe, result in better tolerance, less side effects, and last but not least, higher use continuation rates.

Keywords: IUD screening; adapted IUDs; continuation rate; counseling; efficacy; frameless IUD/IUS; tolerance.

Figure 1

Classification of main uterine anomalies. Notes: Schematic representation (left); three-dimensional sonographic images (right). Adapted from Grimbizis GF, Gordts S, Di Spiezio A, et al. The ESHRE/ESGE con sensus on the classification of female genital tract congenital anomalies. Human Reproduction. 2013;28:2032–2044. Abbreviations: ESHRE, European Society of Human Reproduction and Embryology; ESGE, European Society of Gynecological Endoscopy.

Figure 2

Hysteroscopic picture of Jaydess/Skyla causing pain complaints due to the too long transverse arm in a nulliparous woman.

Figure 3

3D ultrasound in nulliparous women. Notes: Screening three-dimensional (3D) ultrasonography performed in women desiring intrauterine contraception with measurement of the fundal transverse width (upper row); uterine cavities of nulliparous women fitted with a frameless copper IUD. The transverse width of the uterine cavity is indicated below each figure (lower row). Abbreviation: IUD, intrauterine device.

Figure 4

A narrow uterine cavity fitted by a trimmed T-shaped IUD with transverse arm length of 18 mm. Abbreviation: IUD, intrauterine device.

Figure 5

An experimental LNG-IUS capable of adaptation to the individual width of uterine cavity. Abbreviation: LNG-IUS, levonorgestrel intrauterine system.