Intrauterine Device

Aka: Intrauterine Device, IUD, Paragard, Copper T-380A IUD, Progestasert, Mirena

1. Contraindications: Absolute
   1. Undiagnosed Abnormal Uterine Bleeding
   2. Uterine abnormality that distorts endometrial cavity
   3. Current intrauterine infection
   4. Unresolved abnormal Pap Smear
   5. Current endometrial or Cervical Cancer
   6. Findings suggestive of trophoblastic disease
   7. Wilson's Disease or copper allergy (Copper-T IUD)
2. Contraindications: Historical that are no longer contraindications (restrictions loosened by FDA in 2010)
   1. Nulliparity
      1. More difficult to place if no prior pregnancy
      2. Must be able to sound Uterus to 6 cm or greater
   2. Sexually Transmitted Disease history or multiple sexual partners
      1. PID may now be lower risk with modern IUDs
   3. Ectopic Pregnancy
      1. Ectopic risk is not increased with IUD use
      2. However, if breakthrough pregnancy occurs, it is much more likely to occur as an Ectopic Pregnancy
3. Risks
   1. Pelvic Inflammatory Disease
   2. Tubal Infertility
      1. Cohort Study (n=4185)
         1. Primary (Nulliparous) Tubal Infertility Risk
            1. Dalkon Shield relative risk: 3.3
            2. Lippes Loop or Saf-T-Coil relative risk: 2.9
            3. Copper-T IUD relative risk: 1.6
            4. Having only one sexual partner: No increased risk
         2. Secondary (Multiparous) Tubal Infertility Risk
            1. Copper-T IUD relative risk: 1.5 (not significant)
            2. Non-Copper IUD relative risk: 2.8
      2. References
         1. Cramer (1985) N Engl J Med, 312(15): 941-7
4. Adverse Effects
   1. First 3 months after IUD insertion
      1. Perception of vaginal infection
      2. Changes in menstrual flow (30%)
         1. Dysmenorrhea or prolonged flow
         2. Results in 10-15% discontinuation in first year
         3. Reduced with NSAIDs taken 2-3 days with flow onset
   2. Pelvic Inflammatory Disease risk
      1. Risk increases in first 20 days
      2. Risk is <1 per 1000 insertions
      3. Use of prophylactic antibiotics not warranted
   3. Expulsion in first 2 months
      1. Days 1-5: 5% expulsion rate
      2. Days 6-12: 3% expulsion rate
      3. Days >12: 2% expulsion rate
5. Types
   1. Copper T-380A IUD (Paragard): 10 year copper device
      1. First year failure rate: 0.7%
      2. Cumulative ten year failure rate: 2.1%
      3. Recent studies indicate efficacious 12 years
      4. Reduces Ectopic Pregnancy rate significantly
      5. Barium impregnated
   2. Mirena: 5 year Progesterone (Levonorgestrel) device
      1. First year failure rate: 0.1%
         1. Of pregnancies, 50% will be ectopic
         2. Better efficacy than Copper-T IUD
      2. Polyethylene-barium T-shape 52 mg Levonorgestrel
      3. Releases 20 mcg/day of Levonorgestrel
      4. Progesterone adverse effects may occur
         1. Headache
         2. Acne Vulgaris
      5. Conception occurs for 80% within 12 months of removal
      6. Mechanism (Primarily spermicidal)
         1. Thins endometrium and thickens Cervical Mucus
         2. Inhibits sperm movement and function
         3. May also suppress Ovulation
      7. Reduces Menstrual Bleeding
         1. Consider for Dysfunctional Uterine Bleeding
         2. Irregular bleeding may occur in first 6 months
         3. Amenorrhea at one year of use if common (20%)
   3. Progestasert: 1 year Progesterone device
      1. First year failure rate: 2%
      2. Ethylene/vinyl acetate T-shape 38 mg Progesterone
      3. Higher rate of ectopic compared with Copper IUD
      4. Less bleeding complications
      5. Progesterone adverse effects may occur
6. Indications: Prophylactic Antibiotics on insertion
   1. Routine prophylaxis no longer indicated
      1. No difference in outcomes
   2. Prior indications for antibiotic prophylaxis
      1. History of Bacterial Vaginosis
      2. Difficult insertion
      3. SBE Prophylaxis (not indicated in IUD insertion)
7. Procedure
   1. See IUD Insertion
8. Protocol: Switching between contraceptives
   1. Switch to Mirena IUD from pill, patch, ring
      1. Use pill, patch, ring, or barrier protection for the first 7 days after Mirena insertion
      2. Switch may be made before the scheduled end of use of the prior contraceptive
   2. Switch to Mirena IUD from Copper-T IUD
      1. Use barrier protection for first 7 days
   3. Switch to Depo Provera from Copper-T IUD
      1. Give first injection 7 days prior to Copper-T-IUD removal (or use barrier contraceptive for 1 week)
   4. Switch to Implanon (Progestin implant) from Copper-T-IUD
      1. Implanon should be inserted 4 days prior to Copper-T IUD removal (or use barrier contraceptive for 4 days)
   5. Switch to contraceptive pill, patch or ring from the IUD
      1. Start the new contraceptive 7 days before IUD removal
   6. Switch to Copper IUD from other methods
      1. Insert Copper-T IUD no more than 5 days after stopping other contraceptive (or 16 weeks after last Depo Provera injection)
9. Management: Complications
   1. Sexually Transmitted Infection without signs of Pelvic Inflammatory Disease
      1. IUD may be left in place and STD treated
10. References
    1. (2001) Med Lett Drugs Ther 43(1096):7-8
    2. Andersson (1994) Contraception 49:56
    3. French (2000) Br J Obstet Gynaecol 107:1281
    4. Herndon (2004) Am Fam Physician 69(4):853-60