1.
The intrauterine device, commonly called the IUD, is one of the most widely used methods
of reversible contraception.
It has many advantages.
Once an IUD is inserted into a woman's uterus, she has very little to do in order to prevent
pregnancy.
But whenever she wishes to become pregnant, the IUD is easily removed.
The IUD is an extremely effective contraceptive.
With most types, pregnancy rates range from less than one, up to three per hundred women
per year.
A further advantage is that the IUD is effective for several years.
The first modern IUDs, the best known of which is a lipis loop, appeared in the early 1960s.
They were made of biologically inert plastic.
For that reason, they are called inert, or non-medicated, IUDs.
In the late 1960s, researchers discovered that adding copper to a plastic IUD frame
increased its effectiveness.
The first copper IUDs were the copper T200 and the copper 7.
These were smaller than the all-plastic devices, so they caused fewer side effects.
But their performance was improved by the development of a second generation of copper
IUDs.
These include the copper T380A, the copper T220, the nova T, and the multi-load 375.
These copper IUDs introduced several innovations.
Four copper wire, copper sleeves, and or a silver core in the copper wire.
These changes increased effectiveness and extended the lifespan of the IUD to at least
four and possibly six years.
Pregnancy rates for these devices are near or less than one per hundred women per year.
Other IUDs contain hormones, which are slowly released into the uterus.
The first one to be marketed was the progester cert, which must be replaced annually.
Hormone releasing and copper-bearing IUDs are known as medicated IUDs.
The trend now is to recommend the newer copper-bearing IUDs, especially the copper T380A, which is
very safe and highly effective.
It is available at special low prices to governments and non-profit-making family planning programs.
What are the advantages of the IUD over other methods of contraception?
Well, Deidre, the IUD is very effective.
It's not only doctors who provide IUD services.
Midwives, nurses, and other health workers do so successfully in many parts of the world.
The skills and care of the provider may be more important than the characteristics of
the IUD in assuring the safety and effectiveness of the method.
Care and sensitivity in counseling, screening, inserting, and follow-up are essential.
Adequate training of those providing an IUD service is therefore crucial.
Like other contraceptive methods, IUDs are not suitable for all women at all times.
Before insertion, one must be certain the woman is not pregnant.
Other absolute contraindications to IUD use include the presence of active pelvic or genital
infection such as endometritis, salpingitis, cervicitis, or acute vaginitis.
Any genital infection should be treated and cured before insertion of an intrauterine
device.
Another contraindication is confirmed or suspected malignancy of the genital tract.
Women with congenital uterine abnormalities or fibroids distorting the cavity should not
receive IUDs.
Any abnormal uterine bleeding should be investigated and treated before fitting an IUD.
A woman without children, a nullipara, is not a good candidate for an IUD, though this
is not an absolute contraindication.
The IUD increases the chance of a woman developing pelvic inflammatory disease which in turn
may produce infertility.
This may happen especially to a woman who is exposed to sexually transmitted infections
like a woman with multiple sex partners or whose partner has many sex partners.
Also the IUD should not be considered the first option for women with a history of ectopic
pregnancy.
The IUD may be inserted at any time during the menstrual cycle at the user's convenience
if it can reasonably be established that she is not pregnant.
There are certain advantages to insertion towards the end of or just after menstruation.
There is less likelihood of inserting the device into a pregnant uterus.
Insertion may be easier and the bleeding associated with insertion is less likely to cause anxiety.
After a full term pregnancy the IUD should ordinarily be inserted at the six weeks post
partum examination or later.
It is possible to fit an IUD immediately after the placenta has been expelled or one to three
days after delivery but the IUD expulsion rate tends to be high.
IUDs can safely be inserted after spontaneous or induced first trimester abortion except
in women with a pelvic infection.
Special care should be taken with post partum or post abortion insertion and insertion during
lactation to ensure proper placement of the device and to avoid perforation.
All potential users of the IUD should be properly counseled about its advantages and disadvantages.
Alternative methods of contraception should be discussed to allow the client to make an
informed free choice.
When discussing an IUD the number of children a woman has had and whether she is at special
risk of sexually transmitted infections must be taken into account.
The equipment needed for insertion of the IUD includes a speculum, long sponge holding
forceps, a uterine sound, a single toothed tenaculum or a small Alice Chalmers forceps,
curved scissors, a bowl of suitable disinfectant fluid such as an aqueous solution of iodine,
two kidney dishes, sterile cotton wool balls and gloves.
All equipment must be sterilised and arranged for use on a table or trolley covered with
a sterile cloth.
The person performing the insertion after washing their hands should do a complete pelvic
examination to determine the size, shape and position of the uterus.
The presence of any contraindication should be ruled out by this examination.
After a careful pelvic examination the cervix is visualised with a speculum and swabbed
with a sterile cotton wool ball dipped in a suitable disinfecting fluid, starting from
the cervical os and working outward.
It is good clinical practice to use a tenaculum or an Alice Chalmers forceps to steady the
cervix and to straighten the cervical canal.
A sterile sound should be inserted to confirm the direction of the uterine canal and to
measure its depth.
Forceps should never be used to insert a sound or an IUD.
Most IUDs are available, together with their inserters, already sterilised in prepack containers.
These pre-sterilised IUDs are preferable to those supplied in bulk because they reduce
the chances of infection from faulty disinfection of the IUD or its inserter.
Sterile instructions are often included with individually packed devices, these should
be followed carefully.
The Colbert T380A is prepared and inserted as follows.
If sterile gloves are not available, the IUD should be prepared for insertion inside the
pre-sterilised package by manipulating the IUD through the clear plastic cover.
Place the package on a clean, flat surface, with the clear plastic side up.
Make sure that the vertical stem of the T is fully inside the insertion tube.
Partially open the end of the package, furthest from the IUD.
Pick up the package holding the open end upward, bend the two flaps away from each other and
remove the solid rod from the package.
Put the rod inside the insertor tube until it gently touches the bottom of the T.
Be careful not to touch the tip of the rod or brush it against a non-sterile surface.
Put the package back on the flat surface.
Through the clear plastic cover, place your thumb and index finger over the arms of the
T. Push the tube and fold the arms of the T against
the sides of the tube.
Pull back the tube slightly.
Push and rotate the insertor tube so that the T becomes trapped inside it.
The uterine depth must now be set.
This is made easier when there is a measuring scale printed on the package.
The distance between the tip of the folded T and the top of the blue depth gauge should
be equal to the depth of the uterus as measured by the uterine sound.
Suppose the depth of the uterus is 7 cm.
Level the top of the blue depth gauge at the 7 cm mark of the scale.
Then hold the depth gauge at that position with one finger while you push or pull the
insertor tube until the tip of the IUD is at the right distance from the depth gauge
at the zero point of the scale.
If there is no scale printed, you can measure by holding the sound next to the IUD package.
If the tip of the folded T isn't lying flat, turn the tube while holding the blue depth
gauge down until gauge and T lie in the same horizontal plane.
Carefully tear the clear plastic cover off the package.
Lift the loaded insertor, taking care that it does not touch any non-sterile surface.
The IUD is now ready to be placed in the uterus.
If sterile latex gloves are worn, the IUD can be prepared for insertion outside the
package.
Do not allow the assembly to touch anything that is not sterile, including the outside
of the package.
The IUD should not be loaded more than 5 minutes before insertion, as the arms of the T can
then lose their ability to spring back.
Having prepared the IUD, pull the tenaculum gently with one hand to align the uterine
cavity and the cervical canal with the vaginal canal.
With the other hand, gently introduce the loaded insertor through the cervical canal,
keeping the blue depth gauge horizontal.
Advance it until the blue depth gauge is in contact with the cervix, or the resistance
of the uterine fundus is felt.
The solid rod should be held stationary with one hand, while withdrawing the inserted tube
with the other hand.
This releases the arms of the copper T high in the uterine fundus.
Then very carefully push the inserted tube forwards until you feel a slight resistance.
This will ensure that if the IUD has been left too low, it will be pushed closer to
the fundus.
Hold the tube stationary while withdrawing the rod.
Gently withdraw the inserted tube from the cervical canal.
Cut the IUD threads so that 3-4 cm protrude into the vagina.
In releasing the copper T inside the uterus, remember to hold the rod stationary while
pulling the tube back as far as the thumb ring of the rod.
This is called the withdrawal technique.
If the wrong technique is used, pushing the solid rod in instead of pulling the inserted
tube out, perforation may be caused.
On the other hand, if the inserted tube is not introduced right up to the fundus, and
then the withdrawal technique is used, the copper T will be placed too low in the uterus.
With other types of IUD, other techniques are required for insertion.
With the multi-load, insertion does not require the use of a solid rod, but uses a hollow
tube alone in which the IUD rests.
With devices like the lipis loop, the introducer is passed just beyond the internal cervical
os, and the device pushed out gently by means of a solid rod, which is pushed up through
the hollow introducer tube.
The person inserting an IUD needs proper instructions about which technique to use with which device.
Training of the health worker is simpler and more effective when only one type of IUD is
provided by the program, or two at the most.
This also reduces the chances of using the wrong technique.
There are a number of possible side effects related to IUD use.
Vaginal discharge commonly occurs during the first few weeks after the insertion of an
IUD, due to the initial reaction of the endometrium to the foreign body.
This should not be a cause for concern.
Particularly during the first few months after insertion, intermenstrual bleeding and excessive
menstrual bleeding may occur. Unless such symptoms are especially severe or appear long-lasting,
the IUD may be left in place. Iron tablets may help to prevent anemia.
Pain, in the form of uterine cramps, occasionally occurs after insertion of an IUD, but should
not persist beyond the first few days.
Pain relief tablets such as aspirin or paracetamol may help to alleviate it.
An IUD can be spontaneously expelled from the uterus, especially during the menstrual
period. The expulsion rate is highest during the first month after insertion and then decreases.
A woman can be unaware of the expulsion of an IUD and conception can then occur.
Women should be instructed on how to check that the IUD is still correctly in place.
This can be done by inserting a finger into the vagina to feel for the IUD threads coming
through the cervix.
If the woman feels that the threads are not there or feels the tip of the IUD at the cervix,
she should consult the clinic to determine the location of the IUD. In the meantime,
she should use another protection against pregnancy, such as a barrier method.
Still other problems can occur after fitting IUDs. In women at risk of sexually transmitted
diseases, IUD use increases the risk of pelvic infection. If pelvic inflammatory disease
occurs with an IUD in place, the IUD should be removed once adequate antibiotic therapy
has been started.
In mutually monogamous sexual relationships, women are very unlikely to develop pelvic
inflammatory disease associated with IUD use.
There is a possibility of the IUD perforating the uterus. This is a rare event. When it
occurs it is usually at the time of insertion. Retrieval of the IUD may necessitate a laparoscopy
or a laparotomy. This should only be attempted by a doctor trained in these techniques.
Medicated IUDs and closed inert devices must be removed. But open inert devices can be
left in the peritoneal cavity unless there are symptoms or the woman requests removal.
After perforation, the woman is no longer protected against pregnancy.
IUDs protect against intrauterine pregnancies better than against ectopic pregnancies. So
when an IUD user does become pregnant, the pregnancy is more likely to be ectopic than
in a non-IUD user. Therefore, any woman who has an IUD and complains of pain with bleeding
and amenorrhea should be seen by a doctor to exclude a possible ectopic pregnancy.
Although rare, if intrauterine pregnancy occurs, potentially severe complications can result.
Medical attention is always needed. Spontaneous abortion is the most frequent complication
of a pregnancy with an IUD in place. Because infection can occur in any pregnancy with
an IUD in place, the IUD should be removed as soon as pregnancy is confirmed. This markedly
lowers the risk of spontaneous abortion and virtually eliminates the risk of septic abortion.
If IUD removal is difficult because the threads of the device are not visible, the woman should
be counseled about the risks of continuing her pregnancy. An IUD left in place during
pregnancy also increases the risk of premature delivery, stillbirth and low birth weight.
Wherever possible, women should have an examination one to two months after the insertion of the
IUD and thereafter every year. The woman should be told clearly which device she has been
given and the date when it should be removed. One major advantage of the IUD is the ease
with which it may be removed, if for example a woman wishes to become pregnant. To remove
the IUD, in most cases it is only necessary to pull the threads using a sponge-holding
or tonsillectomy curved hemostatic forceps. If a woman appears to be unhappy with her
IUD, there is a fine balance between reassuring her and suggesting she should give the device
more time and removing the IUD. The comfort of the woman using the IUD and her own evaluation
of symptoms is greatly affected by the confidence inspired by the health personnel at the clinic
– doctors, nurses, midwives and auxiliary workers can be very supportive if they have
the right attitude. All aspects of the intrauterine device should be explained to the woman carefully
and in simple language. She should be told what to expect in the way of side effects
and what she need or need not be anxious about. She should be made aware that the device will
not in any way interfere with sexual relations. She should be taught how to care for herself,
especially by checking to see if the IUD is still in place. Skill in fitting the IUD is
important but equally so is the relationship between the persons providing the device and