The IUCD: Tales of Misconception and Missed Contraception

Margaret Burnett MD, FRCSC

April 19, 2012

DisclosureBayer is one of the sponsors of

our annual resident retreat and has provided models for our simulation program

The views I express regarding IUCD use are my own, based on my interpretation of the scientific literature and may be at odds (or perhaps just “odd”) with the manufacturers’ product monographs

Learning ObjectivesPrescribe the IUCD more often in

a wider range of patientsEducate colleagues and counsel

patients regarding IUD facts versus myths

Leave IUDs in situ unless there is a compelling reason for removal or replacement

IUCD Myths IUDs cause PIDIUDs work by causing abortionIUDs increase the risk of ectopic

pregnancyNulliparous women should not be

offered IUCDsIUDs need to be changed every few

yearsA malpositioned IUD needs to be

removed

History

First IUDs appear in the scientific literature in the early 1900’s

Originally made of steel, silkworm gut, etc.

Plastic IUDs became commercially available in 1960s (Lippes Loop)

Copper coils were added in 1970s for improved efficacy and more comfortable insertion

History

Dalkon Shield was linked to septic abortion and pelvic inflammatory disease

Resulting law suits in North America led to a dramatic decrease in the popularity of the IUCD during the 1980s

Most IUCDs were removed from the Canadian market

IUCD TodayMost commonly used reversible

method of contraception in the world

13% of couples worldwide50% of couples in ChinaLow uptake in North America with

only 2.1% of contracepting couples using it

Recent Canadian data suggest that there has been a slight increase within the past 5 years

IUDs Licensed for Use in Canada

Nova T or Liberté

Mirena IUS

Flexi T

IUCDs Available in Canada

IUCD Type Pearl Index

Advantages Disadvantages Cost

Mirena IUS®

0-0.6 Decreased menorrhagia

Irregular menses, complicated insertion

$350

Nova T® 0.6-1.5 Non-hormonal Menorrhagia, Dysmenorrhea

$180

Flexi-T 380®

0.1-1.4 Simple insertion, non-hormonal, high Cu content

Menorrhagia, Dysmenorrhea

$85

Flexi-T 300+®

0.6-1.5 Simple insertion, non-hormonal

Menorrhagia, Dysmenorrhea

$85

Liberté UT380®

0.1-1.4 Non-hormonal, high Cu content

Menorrhagia, Dysmenorrhea

$50

Cost/Benefit Analysis of Long Acting Reversible Contraceptives (LARC)

Comparison of Cu IUD, LNG-IUS, implant, DMPA versus COC and sterilization

LARC methods clearly superior to the OC even within the first year of use

Tubal ligation>LARC>Oral Contraceptive

Cu IUD was the most economical LARC method

Mavranzouli I. The cost-effectiveness of long-acting contraceptive methods in the UK: analysis based on the decision-analytic model developed for a National Institute for Health and Clinical Excellence (NICE) clinical practice guideline. Human Reprod 2008;23(6):1338-1345.

Reasons for IUCD failureVoluntary discontinuation

(abnormal uterine bleeding, amenorrhea, dysmenorrhea, pelvic pain)

ExpulsionYoung (uber fertile) womenUnrecognized perforation at time

of insertionMalposition within the uterus or

cervixFortney JA, Feldblum PJ, Raymond EG. Intrauterine devices: The ultimate long-term contraceptive? J Reprod Med 1999;44:269-74

Cu IUCD: Mechanism of Action

SpermicidalInhibits sperm migrationPrevents implantationPrimary mechanism is

prevention of fertilizationProvides effective emergency

contraception when inserted up to 7 days post coitus

Adverse EventsExpulsion: 1-6 per 100 insertions

◦Highest in the first year after insertionUterine perforation: 1-2 per 1000

insertions◦Operator dependant◦Increased in immobile or retroverted

uteri◦More common with stenotic cervix◦Most are unrecognized at the time of

insertion

Pelvic Inflammatory Disease

Uterine cavity is routinely contaminated at the time of insertion

WHO analysis concluded that the rate of PID was 9.68 per 1,000 woman-years in the first 20 days after insertion and 1.39 per 1,000 woman-years thereafter

PID is related to insertion as opposed to the presence of the IUCD

Pelvic Inflammatory Disease

Cervical cultures prior to insertion are recommended but not required

Consider antibiotic prophylaxis in high risk groups

Counsel re: condom useCervicitis/PID can be treated

successfully with IUCD left in place

Ectopic Pregnancy (EP)Baseline rate in women using no

contraception = 3-4.5 per 1,000 woman-years

Cu T 380 ectopic rate = 0.2 per 1,000 woman-years

Therefore, the IUCD actually prevents EP

However, 6% of pregnancies occurring with Cu IUCD in place will be EP

Pregnancy with IUCD in situThink ectopic!Spontaneous abortion occurs in 40-

50%If strings are visible, the IUCD should

be removed to decrease spontaneous abortion to 20% and reduce the risk of chorioamnionitis and preterm birth

No evidence of teratogenesis in infants born to women with IUCD in situ

Brahmi D. et al. Pregnancy outcomes with an IUD in situ: a systematic review. Contraception 2012 Feb;85(2): 131-9

Malpositioned IUCDPrevalence of 10.4% by ultrasoundMost were located in the cervix or lower

uterine segmentNo pregnancies occurred in those women

who opted to have IUCD left in situ Only 30% of those having the IUCD

removed opted for a highly effective method

Pregnancy rates were significantly higher in those women who chose to have it removed

Braaten KP et al. Malpositioned intrauterine contraceptive devices. Obstet Gynecol 2011;118:1014-20.

What about nulliparous women???Many wish to avoid hormonal side effectsDesire for more convenience, complianceInsertion is possible in most cases

although dilators may be necessary (three times more likely than in multiparas)

Efficacy is comparable to multiparous women for LNG-IUS

Bahamondes ML, et al. Insertion and clinical performance of the levonorgestrel-releasing system in nulligravidas. Contraception 2011;84:e11-6Weibe ER, Trouton KJ, Dicus J. Motivation and experience of nulliparous women using intrauterine devices. J Obstet Gynecol 2010; 32(4):335-8.

IUCD: Duration of Action

LGN-IUS (Mirena®) = at least 7 years

Cu IUCD = at least 10 yearsInert IUCD…..unlimited?

How long can an IUD be left in?

Cu IUCDs studied 20 years in situ

No failuresNo increased number

of infections or other adverse events

Conclusion: Women may gain excellent long-term contraception at a bargain price by choosing a copper IUD

Sivin I. Utility and drawbacks of continuous use of a copper T IUD for 20 years. Contraception 2007;75(6 Suppl):S70-5

ConclusionsThe IUD is an economical,

effective, long acting contraceptive that got a bad rap

Adverse events are minimal, virtually all are related to insertion

Any IUD can (should) be left in place indefinitely unless pregnancy is desired or has already occurred

References Burkman RT. Intrauterine devices and pelvic inflammatory

disease: evolving perspectives on the data. Obstet Gynecol Surv 1996 Dec:51(12 Suppl):S35-41.

Fortney JA, Feldblum PJ, Raymond EG. Intrauterine devices: The ultimate long-term contraceptive? J Reprod Med 1999;44:269-74

French R et al. Hormonally impregnated intrauterine systems versus other forms of reversible contraceptives as effective methods of preventing pregnancy. Cochrane Database Syst Rev 2001;(2):CD001776.

Kaneshiro B, Aeby T. Long-term safety, efficacy, and patient acceptability of the intrauterine Copper T-380A contraceptive device. Int J Womens Health 2010;2:211-220.

Mansour D et al. Efficacy of contraceptive methods: A review of the literature. Eur J Contracept Reprod Health Care. 2010;15(1):4-16

The IUCD: Anytime at All?