The IUCD: Tales of Misconception and Missed Contraception Margaret Burnett MD, FRCSC April 19, 2012

Disclosure Bayer 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 Objectives Prescribe the IUCD more often in a wider range of patients Educate 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 PID IUDs work by causing abortion IUDs increase the risk of ectopic pregnancy Nulliparous women should not be offered IUCDs IUDs need to be changed every few years A 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History First IUDs appear in the scientific literature in the early 1900’s Originally made of steel, silkworm gut, etc.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 Today Most commonly used reversible method of contraception in the world 13% of couples worldwide 50% of couples in China Low 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 Flexi T Nova T or Liberté Mirena IUS

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 $85 Flexi-T 300+® Simple insertion, non-hormonal Liberté UT380® Non-hormonal, high Cu content $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 failure Voluntary discontinuation (abnormal uterine bleeding, amenorrhea, dysmenorrhea, pelvic pain) Expulsion Young (uber fertile) women Unrecognized perforation at time of insertion Malposition within the uterus or cervix Fortney JA, Feldblum PJ, Raymond EG. Intrauterine devices: The ultimate long-term contraceptive? J Reprod Med 1999;44:269-74

Cu IUCD: Mechanism of Action Spermicidal Inhibits sperm migration Prevents implantation Primary mechanism is prevention of fertilization Provides effective emergency contraception when inserted up to 7 days post coitus

Adverse Events Expulsion: 1-6 per 100 insertions Highest in the first year after insertion Uterine 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 use Cervicitis/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 situ Think 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 IUCD Prevalence of 10.4% by ultrasound Most were located in the cervix or lower uterine segment No 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 effects Desire for more convenience, compliance Insertion 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:e11-6 Weibe 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 years Inert IUCD…..unlimited?

How long can an IUD be left in? Cu IUCDs studied 20 years in situ No failures No 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

Conclusions The 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?