Intrauterine Devices (IUD) - Part I Lia Tadesse gebremehdin, Md, mha Program director, cirht

Objectives Describe the types of Intrauterine Devices (IUDs) Describe the efficacy of IUDs Discuss the mechanism of action of IUDs Discuss the advantages and disadvantages of IUDs Describe the common misconceptions attributed to IUDs Identify eligible and not eligible clients for IUD

Intrauterine Devices (IUD) Globally, the 2nd most commonly used modern method Very low use in Sub-Saharan Africa (Ethiopia, 2%) Small flexible plastic devices Two kinds: Copper-containing Hormone-containing 14% next to female sterilization (19%) with >140 million users worldwide Sub-Saharan Africa (0.9%, WHO) and in Ethiopia (2% EDHS 2016, from 0.1% in 2000)

Duration and Efficacy of IUDs Copper-releasing Progestin/Levonorgerstrel-releasing Duration 12 yrs (Paragard Copper T 380A)* 5 yrs (Mirena) Perfect user failure rate 0.6% 0.1% Typical user failure 0.8% 0.2% The widely used type in Ethiopia is the Copper IUD *Multiload 375 MLCu-375 and Nova T copper IUDs last 5yrs Failure rates are all in first year and perfect use is based on clinical trials

Percentage of women pregnant in first year of use Pregnancy Rates by Method Spermicides Female condom Diaphragm w/spermicides Male condom Oral contraceptives Depo-Provera IUD (TCu-380A) This is to demonstrate the high effectiveness of long term methods of contraceptives vs. short term methods Rate during perfect use Female sterilization Rate during typical use Norplant 5 10 15 20 25 30 Percentage of women pregnant in first year of use Source: Hatcher, 2004.

Parts of IUDs (TCu 380A) Copper sleeves/Arms Copper wire/Stem String/Thread http://stellingdames.nl/wp-content/uploads/2015/10/paraguard-copper-t-iud-birth-control-method1.jpg1.jpg http://www.bleedingfeminism.com/2012/11/long-term-methods-of-birth-control-iuds.html

Mechanism of Action Mechanism of Action Copper T IUD LNG IUD Primary Prevents fertilization Reduces sperm motility and viability Impairs oocytes Inhibits fertilization Causes cervical mucus to thicken Inhibits sperm motility and function Secondary Inhibits implantation Original content for this slide submitted by ARHP’s Clinical Advisory Committee for A Clinical Update on Intrauterine Contraception in March 2007. This slide is available at www.arhp.org/core. Foreign body effect: Spermicidal (hostile) environment with sterile inflammatory reaction Copper ions also appear to be toxic to oocytes, thus lessening or inhibiting their ability to be fertilized. Inhibition of implantation would explain the high effectiveness of the Copper T IUD [Paragard®] to act as emergency contraception. The endometrial suppression as a consequence of the high endometrial levels of LNG leads to a substantial decrease in menstrual flow and absence of bleeding in some women who use this form of IUC. No post-implantation effect

Benefits of Copper IUDs Highly effective Long term Do not require ongoing effort Effective immediately after insertion Cost-effective Fast return to fertility

Benefits of Copper IUDs (con’t) Do not affect breastfeeding Not user/partner dependent Can be used for emergency contraception (EC) within 120 hours of unprotected intercourse Lack of hormonal exposure, continued menstrual cyclicity Some protection against endometrial cancer

Disadvantages/Side Effects of Copper IUDs No protection against upper genital tract infections and HIV Average monthly blood loss increased by up to 50% with spotting and cramping in first few weeks of insertion Improves after 6 months Psychological discomfort of foreign body inside Trained provider dependent Risk of PID increased with recent STI or high-risk lifestyle Syncope/vasovagal episode during insertion (rare)

Rare Complications (to be discussed in part II) Missing strings/Expulsion of IUD Pregnancy (intrauterine or ectopic) Perforation (< 1/1000 cases) PID with or without tubo-ovarian abscesses

Myths and Misperceptions Unsafe: Infection Infertility Ectopic pregnancy Pain Abortion Anemia Requires restriction of physical activity Cannot be used by nulliparous or adolescent women Will migrate to the abdomen or will get buried in the uterus May increase HIV transmission to partner or PID if used by HIV positive woman In World Health Organization’s IUD clinical trial Farley et al found that the rate of PID in nearly 23,000 IUD insertions was the same as the baseline risk in the population without an IUD: The risk of infection was found to be higher only in the first 20 days post-insertion indicating it is strongly related to the insertion process and to background risk of sexually transmissible disease. IUDs lower the risk of ectopic pregnancy just as they decrease the risk of pregnancy overall. In the unlikely event that a woman becomes pregnant using an IUD, she may have an increased likelihood of having an ectopic pregnancy Misconceptions exist in providers as well:  A National survey of OBGYNs in US showed 84% thought that a woman in a polygamous relationship was not a candidate for an IUD and 81% thought that a woman with a history of PID was not a candidate

Eligibility

Categories of Medical Eligibility Criteria for Contraceptive Use Category Eligibility 1 A condition for which there is no restriction for the use of the contraceptive method. 2 A condition for which the advantages of using the method generally outweigh the theoretical or proven risks. 3 A condition for which the theoretical or proven risks usually outweigh the advantages of using the method. 4 A condition that represents an unacceptable health risk if the contraceptive method is used. *WHO

Case: Nulligravida Adolescent 17-year-old high-school senior Has been sexually active with a boyfriend for 3 months Has been using condoms for birth control Does not want to use hormonal method of contraception Original content for this slide submitted by ARHP’s Clinical Advisory Committee for A Clinical Update on Intrauterine Contraception in March 2007. This slide is available at www.arhp.org/core.

Case: Nulligravida Adolescent 17-year-old high-school senior Has been sexually active with a boyfriend for 3 months Has been using condoms for birth control Does not want to use hormonal method of contraception Original content for this slide submitted by ARHP’s Clinical Advisory Committee for A Clinical Update on Intrauterine Contraception in March 2007. This slide is available at www.arhp.org/core. Would you consider IUD?

Who Can Use IUDs (Categories 1 and 2) Any parity Any age Immediately after abortion or delivery/c-section Not yet sure about permanent method (VSC) HIV positive Emergency contraception Women who cannot use hormonal methods (Copper IUD) Women with previous STI can use unless they are currently at high risk

Who Should Not Use IUDs (Categories 3 and 4) Pregnant (known or suspected) Unexplained vaginal bleeding Post partum: Between 48 hours-4 weeks Post partum/post abortion with sepsis Current PID, STI (purulent cervicitis) Women with high risk of STI

Who Should Not Use IUDs (Categories 3 and 4) (con’t) Women living with severe or advanced HIV clinical disease (WHO stage 3 or 4) Current pelvic tuberculosis Gestational trophoblastic disease or cervical/endometrial cancer Severe uterine cavity distortion from myoma or congenital abnormalities

Case: Nulligravida Adolescent 17-year-old high-school senior Has been sexually active with a boyfriend for 3 months Has been using condoms for birth control Does not want to use hormonal method of contraception Original content for this slide submitted by ARHP’s Clinical Advisory Committee for A Clinical Update on Intrauterine Contraception in March 2007. This slide is available at www.arhp.org/core.

Case: Nulligravida Adolescent 17-year-old high-school senior Has been sexually active with a boyfriend for 3 months Has been using condoms for birth control Does not want to use hormonal method of contraception Original content for this slide submitted by ARHP’s Clinical Advisory Committee for A Clinical Update on Intrauterine Contraception in March 2007. This slide is available at www.arhp.org/core. Copper-T IUD is an option

To be continued…