Intrauterine device
The modern intrauterine device (IUD) is a form of birth control in which a small 'T'-shaped device, containing either copper or progesterone, is inserted into the uterus. IUDs are a form of long-acting reversible contraception, which is the most effective type of reversible birth control.[1] As of 2002, IUDs were the most widely used form of reversible contraception, with nearly 160 million users worldwide.[2]
Types
The types of intrauterine devices available and the names they go by differ by location.
In the United States, there are two types available:[3]
In the United Kingdom, there are over 10 different types of copper IUDs available. In the UK, the term IUD refers only to these copper devices. Hormonal intrauterine contraception is considered to be a different type of birth control and is labeled with the term intrauterine system (IUS).[4][5]
However, the WHO/ATC labels both copper and hormonal devices as IUDs.
Copper
Copper IUDs primarily work by disrupting sperm mobility and damaging sperm so that they are prevented from joining with an egg. Copper acts as a spermicide within the uterus, increasing levels of copper ions, prostaglandins, and white blood cells within the uterine and tubal fluids.[6][7] The increased copper ions in the cervical mucus inhibit the sperm's motility and viability, preventing sperm from traveling through the cervical mucus or destroying it as it passes through.[8] Copper IUDs have a first year failure rate ranging from 0.1 to 2.2%.[9]
Most non-hormonal IUDs have a plastic T-shaped frame that is wound around with pure electrolytic copper wire and/or has copper collars (sleeves). The arms of the frame hold the IUD in place near the top of the uterus. The Paragard TCu 380a measures 32 mm (1.26") horizontally (top of the T), and 36 mm (1.42") vertically (leg of the T).
Copper IUDs containing noble metals are becoming increasingly popular because they are more resistant to corrosion. In the "Gold T IUD", which is made in Spain and Malaysia, there is a gold core, which further prevents the copper from fragmenting or corroding. GoldringMedusa is a differently-shaped German version of the Gold T [10]. Another form of AuCu IUD is called Goldlily which is made by the Hungarian company, Radelkis. Goldlily consists of a layer of copper wires wrapped around an original layer of gold wires, and it provides electrochemical protection in addition to ionic protection.[11]
Silver IUDs also exist. Radelkis also makes Silverlily, which is similar to Goldlily, and GoldringMedusa is available in an AgCu version as well. Nova-T 380 contains a strengthening silver core, but does not incorporate silver ions themselves to provide electrochemical protection.
[4][12] Other shapes of IUD include the so-called U-shaped IUDs, such as the Load and Multiload, and the frameless IUD that holds several hollow cylindrical minuscule copper beads. It is held in place by a suture (knot) to the fundus of the uterus. It is mainly available in China, Europe, and Germany, although some clinics in Canada can provide it.
Advantages of the copper IUD include its ability to provide emergency contraception up to five days after unprotected sex. It is the most effective form of emergency contraception available.[13] It contains no hormones, so it can be used while breastfeeding, and fertility returns quickly after removal.[14] Copper IUDs are also available in a wider range of sizes and shapes than hormonal IUDs. Disadvantages include the possibility of heavier menstrual periods and more painful cramps.[6]
In addition to copper, noble metal and progestogen IUDs, patients in China can get copper IUDs with indomethacin. This non-hormonal compound reduces the severity of menstrual bleeding, and these coils are popular.[15]
Hormonal
The hormonal I.U.D. (brand name Mirena) does not increase bleeding as copper-containing IUDs do. Rather, they reduce menstrual bleeding or prevent menstruation altogether, and can be used as a treatment for menorrhagia (heavy periods).
Use of Mirena results in much lower systemic progestogen levels than other very-low-dose progestogen-only hormonal contraceptives.
As of 2007, the LNG-20 IUS – marketed as Mirena by Bayer – is the only IntraUterine System available. First introduced in 1990, it releases levonorgestrel (a progestin) and may be used for five years per its label but 7 years per researchers/clinicians (?who). With use of Mirena, the hormones are localized to the uterine area unlike oral contraceptives and other systemic contraception (e.g. depot medroxyprogesterone, etonogestrel implant).
Mechanism
IUDs primarily work by preventing fertilization.[16] The very high effectiveness of copper-releasing IUDs as emergency contraceptives implies they may possible also act by the prevention of implantation.[17][18][19]
Side effects
Regardless of containing progestogen or copper, potential side effects of intrauterine devices include expulsion, uterus perforation, pelvic inflammatory disease (especially in the first 21 days after insertion), as well as irregular menstrual pattern. A small probability of pregnancy remains after IUD insertion, and when it occurs there's a greater risk of ectopic pregnancy.
Substantial pain that needs active management occurs in approximately 17% of nulliparous women and approximately 11% of parous women.[20] In such cases, NSAID are evidenced to be effective.[20] However, no prophylactic analgesic drug have been found to effective for routine use for women undergoing IUD insertion.[20]
Also, IUDs with progestogen confer an increased risk of ovarian cysts, and IUDs with copper confer an increased risk of heavier periods.
History
The history of IUDs dates back to the interuterine devices of the early 1900s. Unlike IUDs, interuterine devices crossed both the vagina and the uterus, causing a high incidence of pelvic inflammatory disease in a time period when gonorrhea was endemic. The first IUD was developed by the German physician, Dr. Richter of Waldenburg. His device was made of silkworm gut and was not widely used.[21]
Dr. Ernst Gräfenberg, another German physician after whom the G-spot is named, created the first Ring IUD, Gräfenberg's ring, made of silver filaments. His work was suppressed during the Nazi regime, when contraception was considered a threat to Aryan women.[21] He moved to the United States, where his colleagues Dr. H. Hall and Dr. M. Stone took up his work after his death and created the stainless steel Hall-Stone Ring. A Japanese doctor named Tenrei Ota also developed a silver or gold IUD called the Precea or Pressure Ring.[21]
Dr. Jack Lippes helped begin the increase of IUD use in the United States in the late 1950s. In this time, thermoplastics, which can bend for insertion and retain their original shape, became the material used for first-generation IUDs. Lippes also devised the addition of the monofilament nylon string, which facilitates IUD removal. His trapezoid shape Lippes Loop IUD became one of the most popular first generation IUDs. In the following years, many different shaped plastic IUDs were invented and marketed.[21] These included the infamous Dalkon Shield, whose poor design caused bacterial infection and led to thousands of lawsuits. Although the Dalkon shield was removed from the market, it had a lasting, negative impact on IUD use in the United States.[22]
The invention of the copper IUD in the 1960s brought with it the capital 'T' shaped design used by most modern IUDs. US physician, Dr. Howard Tatum determined that the 'T' shape would work better with the shape of the uterus, which forms a 'T' when contracted. He predicted this would reduce rates of IUD expulsion.[21] Together, Tatum and Chilean physician Jaime Zipper discovered that copper could be an effective spermicide and developed the first copper IUD, TCu200. Improvements by Dr. Tatum led to the creation of the TCu380A (ParaGard), which is the current gold standard for copper IUDs.[21]
The hormonal IUD was also invented in the 1960s and 1970s. The first model, Progestasert, was conceived of by Dr. Antonio Scommengna and created by Dr. Tapani J.V. Luukkainen, but the device only lasted for one year of use.[22] Progestasert was manufactured until 2001.[23] The only commercial hormonal IUD still currently available, Mirena, was also developed by Dr. Luukkainen and released in 1976.[21] The manufacturer of the Mirena, Bayer AG, became the target of multiple lawsuits over allegations that Bayer failed to adequately warn users that the IUD could pierce the uterus and migrate to other parts of the body.[24]
References
- ^ Winner B, Peipert JF, Zhao Q, et al. (May 2012), "Effectiveness of long-acting reversible contraception", N. Engl. J. Med. 366 (21): 1998–2007, doi:10.1056/NEJMoa1110855, PMID 22621627
- ^ World Health Organization (2002). "The intrauterine device (IUD)—worth singing about". Progress in Reproductive Health Research (60): 1–8.
- ^ Treiman K, Liskin L, Kols A, Rinehart W (1995), "IUDs – an update" (PDF), Popul Rep B (6): 1–35, PMID 8724322, retrieved 2006-01-01
- ^ a b "Contraceptive coils (IUDs)". NetDoctor.co.uk. 2006. Retrieved 2006-07-05.
- ^ French R, Van Vliet H, Cowan F, et al. (2004). "Hormonally impregnated intrauterine systems (IUSs) versus other forms of reversible contraceptives as effective methods of preventing pregnancy". In Sorhaindo, Annik M. Cochrane Database of Systematic Reviews (3): CD001776. doi:10.1002/14651858.CD001776.pub2. PMID 15266453.
- ^ a b Grimes, DA, MD (2007), "Intrauterine Devices (IUDs)", in Hatcher, RA; Nelson, TJ; Guest, F; Kowal, D., Contraceptive Technology (19th ed.), New York: Ardent Media
- ^ "Mechanisms of the Contraceptive Action of Hormonal Methods and Intrauterine Devices (IUDs)". Family Health International. 2006. Retrieved 2006-07-05.
- ^ Oritz ME, Croxatto HB (2007). "Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action". Contraception 75 (6 Suppl): S16–S30. doi:10.1016/j.contraception.2007.01.020. PMID 17531610.
- ^ Kulier R, O'Brien PA, Helmerhorst FM, Usher-Patel M, D'Arcangues C (2007), "Copper containing, framed intra-uterine devices for contraception", Cochrane Database Syst Rev (4): CD005347, doi:10.102/14651858.CD005347, PMID 17943851
- ^ http://www.viomed.de/de/medusa
- ^ http://www.radelkis.hu/en/orvos/huv/frames.html
- ^ Schering (May 13, 2003). "Nova T380 Patient information leaflet (PIL)". Retrieved 2007-04-27.
- ^ Cleland K, Zhu H, Goldstuck N, Cheng L, Trussell J (July 2012), "The efficacy of intrauterine devices for emergency contraception: a systematic review of 35 years of experience", Hum. Reprod. 27 (7): 1994–2000, doi:10.1093/humrep/des140, PMID 22570193
- ^ Belhadj H, Sivin I, Diaz S, et al. (September 1986), "Recovery of fertility after use of the levonorgestrel 20 mcg/d or Copper T 380 Ag intrauterine device", Contraception 34 (3): 261–7, doi:10.1016/0010-7824(86)90007-7, PMID 3098498
- ^ Li Y, Zhang SM, Chen F, et al. (December 2011). "[A multi-center randomized controlled trial of intrauterine device use in Chinese women]". Zhonghua Yi Xue Za Zhi (in Chinese) 91 (45): 3172–5. PMID 22333096.
- ^ al.], [edited by] Steven G. Gabbe ... [et. Obstetrics : normal and problem pregnancies (6th ed. ed.). Philadelphia: Elsevier/Saunders. p. 528. ISBN 9781437719352.
- ^ Trussell, James; Schwarz, Eleanor Bimla (2011). "Emergency contraception". In Hatcher, Robert A.; Trussell, James; Nelson, Anita L.; Cates, Willard Jr.; Kowal, Deborah; Policar, Michael S. Contraceptive technology (20th revised ed.). New York: Ardent Media. pp. 113–145. ISBN 978-1-59708-004-0. ISSN 0091-9721. OCLC 781956734. p. 121:
Mechanism of action
Copper-releasing IUCs
When used as a regular or emergency method of contraception, copper-releasing IUCs act primarily to prevent fertilization. Emergency insertion of a copper IUC is significantly more effective than the use of ECPs, reducing the risk of pregnancy following unprotected intercourse by more than 99%.2,3 This very high level of effectiveness implies that emergency insertion of a copper IUC must prevent some pregnancies after fertilization.
Emergency contraceptive pills
To make an informed choice, women must know that ECPs—like the birth control pill, patch, ring, shot, and implant,76 and even like breastfeeding77—prevent pregnancy primarily by delaying or inhibiting ovulation and inhibiting fertilization, but may at times inhibit implantation of a fertilized egg in the endometrium. However, women should also be informed that the best available evidence indicates that ECPs prevent pregnancy by mechanisms that do not involve interference with post-fertilization events.
ECPs do not cause abortion78 or harm an established pregnancy. Pregnancy begins with implantation according to medical authorities such as the US FDA, the National Institutes of Health79 and the American College of Obstetricians and Gynecologists (ACOG).80
Ulipristal acetate (UPA). One study has demonstrated that UP can delay ovulation.81... Another study found that UPA altered the endometrium, but whether this change would inhibit implantation is unknown.82
p. 122:
Progestin-only emergency contraceptive pills. Early treatment with ECPs containing only the progestin levonorgestrel has been show to impair the ovulatory process and luteal function.83–87
p. 123:
Combined emergency contraceptive pills. Several clinical studies have shown that combined ECPs containing ethinyl estradiol and levonorgestrel can inhibit or delay ovulation.107–110 - ^ RCOG Faculty of Sexual & Reproductive Healthcare, Clinical Effectiveness Unit (January 2012). Clinical guidance: emergency contraception. London: Royal College of Obstetricians and Gynaecologists. ISSN 1755-103X. Retrieved 2012-04-30. p.3:
How does EC work?
In 2002, a judicial review ruled that pregnancy begins at implantation, not fertilisation.8 The possible mechanisms of action should be explained to the patient as some methods may not be acceptable, depending on individual beliefs about the onset of pregnancy and abortion.
Copper-bearing intrauterine device (Cu-IUD). Copper is toxic to the ovum and sperm and thus the copper-bearing intrauterine device (Cu-IUD) is effective immediately after insertion and works primarily by inhibiting fertilisation.9–11 A systematic review on mechanisms of action of IUDs showed that both pre- and postfertilisation effects contribute to efficacy.11 If fertilisation has already occurred, it is accepted that there is an anti-implantation effect,12,13
Levonorgestrel (LNG). The precise mode of action of levonorgestrel (LNG) is incompletely understood but it is thought to work primarily by inhibition of ovulation.16,17
Ulipristal acetate (UPA). UPA’s primary mechanism of action is thought to be inhibition or delay of ovulation.2 - ^ Speroff, Leon; Darney, Philip D. (2011). "Special uses of oral contraception: emergency contraception, the progestin-only minipill". A clinical guide for contraception (5th ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 153–166. ISBN 978-1-60831-610-6. p. 155:
Emergency postcoital contraception
Levonorgestrel
Mechanism and efficacy
There is strong evidence that treatment with emergency contraception acts primarily by preventing or delaying ovulation and by preventing fertilization.22–26 Studies have indicated that emergency contraception does not prevent implantation.27–29 Experiments in monkeys and rats could detect no effect of a high dose of levonorgesterel administered postcoitally once fertilization had occurred.30,31 The evidence indicates that a postfertilization effect does not contribute to the efficacy of emergency contraception.25,30–33 Clinicians, pharmacists, and patients can be reassured that treatment with emergency contraception is not an abortifacient.
p. 157:
The use of progesterone receptor modulators for emergency contraception
Mifepristone. In randomized trials, 10 mg mifepristone was as effective as 25, 50, or 600 mg. preventing about 80-85% of expected pregnancies (the same efficacy and side effects as with the levonorgestrel method), with a slight decrease in efficacy when treatment was delayed to 5 days after intercourse.16,52–54
Ulipristal Acetate. Ulipristal acetate (ellaOne) has similar biologic effects as mifepristone and is approved for emergency contraception in Europe and is expected to become available in the U.S.in a single oral dose of 30 mg. Randomized trials demonstrated that ulipristal acetate is slightly more effective than the single 1.5 mg dose of levonorgestrel when used within 72 h after sexual intercourse and even between 72 h and 120h.55,56 … Progesterone receptor modulators like ulipristal acetate and mifepristone suppress ovarian follicular growth and also delay endometrial maturation, manifested in a delay in menstruation after treatment. Ovulation can be temporarily postponed.
Other methods
Another method of emergency contraception is the insertion of a copper IUD, anytime during the preovulatory phase of the menstrual cycle and up to 5 days after ovulation. The failure rate (in a small number of studies) is very low, 0.1%.34,35 This method definitely prevents implantation, but it is not suitable for women who are not candidates for intrauterine contraception, e.g., multiple sexual partners or a rape victim. The use of a copper IUD for emergency contraception is expensive, but not if it is retained as an ongoing method of contraception. - ^ a b c Gemzell-Danielsson, K.; Mansour, D.; Fiala, C.; Kaunitz, A. M.; Bahamondes, L. (2013). "Management of pain associated with the insertion of intrauterine contraceptives". Human Reproduction Update 19 (4): 419. doi:10.1093/humupd/dmt022.
- ^ a b c d e f g Thiery M (March 1997), "Pioneers of the intrauterine device", Eur J Contracept Reprod Health Care 2 (1): 15–23, doi:10.1080/13625189709049930, PMID 9678105
- ^ a b Thiery M (June 2000), "Intrauterine contraception: from silver ring to intrauterine contraceptive implant", Eur. J. Obstet. Gynecol. Reprod. Biol. 90 (2): 145–52, PMID 10825633
- ^ Smith (pseudonym), Sydney (March 8, 2003). "Contraceptive Concerns". medpundit: Commentary on medical news by a practicing physician. Retrieved 2006-07-16.
- ^ http://newsandinsight.thomsonreuters.com/Legal/News/2013/05_-_May/Judge_calls_for_female_lawyers_on_plaintiffs__committee_in_Mirena_MDL/
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