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

2. 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

3. 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)

4. 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

5. 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.

6. Parts of IUDs (TCu 380A) Copper sleeves/Arms Copper wire/Stem
String/Thread

7. 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 This slide is available at
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

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

9. 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

10. 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)

11. 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

12. 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

13. Eligibility

14. 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

15. 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 This slide is available at

16. 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 This slide is available at
Would you consider IUD?

17. 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

18. 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

19. 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

20. 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 This slide is available at

21. 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 This slide is available at
Copper-T IUD is an option

22. To be continued…