1. Newer Intra-Uterine Contraceptive Devices

2. Dr. Mandakini Parihar Director Mandakini IVF Centre, Chembur Associate Hon. Prof. Obs & Gyn K.J.Somaiya Medical College Member Managing Committee, ISAR Member Governing Council, ICOG

3. “ Family Planning alone could bring more benefits to more people at less cost than any other single technology now available to the human race.” UNICEF

4. Contraceptive Use Indian Scenario
There has been consistent improvement in the levels of contraceptive use in the country over time.
However, these changes have not necessarily brought along corresponding decline in fertility levels for various reasons
The data from the NFHS I and II indicate that the contraceptive prevalence rate for India was about 41 per cent during that increased to slightly over 48 per cent by the end of the last century, an increase of 7 per cent points in 6 years which is not significant and is the main reason for our mammoth population growth

5. Unintended vs. Intended Pregnancies
51%
Unintended 49%
Unintended births (22.5%)
Elective abortions (26.5%)
U.S. Pregnancies: Unintended vs. Intended
Unintended pregnancy continues to be a major public health issue in the United States. Each year, half of all pregnancies are unintended. Half of unintended pregnancies – or one in four pregnancies overall – end in abortion. The abortion rate in the United States is the highest of all Western developed countries and Japan.
It goes without saying that effective, accessible contraception is imperative to the health of a society. No single method, however, is universally suitable for all women and many factors affect a woman’s choice of contraception.
Reference:
Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect Jan-Feb;30(1):24-9,46.
POSTED: September 25, 2002
REVIEWED: September 25, 2002
Henshaw SK. Fam Plann Perspect. 1998;30:24-29.

6. Unmet Need in India
Millions of women would prefer to avoid becoming pregnant either right away or ever, but are not using any contraception
These women have an unmet need
Awareness
Access
Availability
Unmet need for family planning (NFHS-3)
Spacing %
Limiting %
Total %
Fact sheet
Table 5.32 (NRT) Table 5.32 (NRT) or table 5.32 (national report-pg 159) or table 28 (SRT)
Unmet need for FP NFHS-2
+ Spacing %
+Limiting %
Total % 6 6

7. Everything changes continually.
What is history but a record of change?
Mahatma Gandhi

8. Evolution of IUCDs 1st generation : Lippes Loop
2nd generation : copper containing
3rd generation : progesterone containing
Progestasert
Levonorgestrel (Mirena)
4th generation : frameless IUD
GyneFix (copper)
FibroPlant ( levonorgestrel)

9. Evolution of Cu-IUCD 2nd generation : copper containing Cu-T 200
Multi-load 250 –375
Nova –T
Newer Cu-380A

10. Currently there are 100 million IUCD users in the world, 80 % of them are in China

11. IUD: Work-up History: STD’s, Sexual History, Ectopic Examination:
Size / Configuration of Uterus
Cervical Cultures
Pap Smear
Counseling

12. IUD: Mechanisms of Action
NOT ABORTIFACIENT!!!!!!!!
Prevents Conception
local Foreign body reaction
Sperm Transport Inhibited
Sperm Survival / Capacitation Diminished
Prevents Implantation

13. Cu IUD
typically comprise a solid plastic frame loaded with copper wire and/or copper sleeves
very effective
(pregnancy rates <2%)
Once inserted, protects for 3-10 years depending on type of IUD
Easy to insert and remove
Does not protect from STDs

14. New Cu-IUD: Overview ParaGard (CuT380A) Very Effective (~ TL)
Reversible
However-
Monogamy Essential
Does Not Protect Against STD’s
Can Remain for 10 Years

15. Cu-IUD: Complications
PID: Usually secondary to Insertional Contamination
– Unproven Role for Prophylactic ABx
Menorrhagia
Expulsion
Perforation (< 0.1%)
Failure: IUD Should be Removed
??Ectopic

16. LNG IUS
pure levonorgestrel in the vertical 20 micrograms per day into the endometrium
approved for five years of use
menstrual bleeding, overall a reduction by 90%

17. LNG – Mechanism of action
Endometrium suppressed
Cervical mucous thickening
Sperm motility and function affected
Weak foreign body reaction
Rare cases inhibits ovulation
Johnson et al , Contra: 1991,43;447
Videla-Ribero et a l, Contra:1997,46;217

18. Randomized studies Luukkainen et al., 1986 5 281 Nova-T 0.1
Years Comparison Pearl index Reference of use n method LNG-IUS
Luukkainen et al., Nova-T 0.1
Sivin et al., Cu T
Faundes et al., Cu T
Andersson et al., Nova-T 0.1
Indian Council, Cu IUDs 0
Wang et al., Norplant 0.3

19. Backman et al. Br J Obstet Gynaecol
Apprehension caused by amenorrhea can be minimized by appropriate counselling User satisfaction strongly correlates with counselling
Backman et al. Br J Obstet Gynaecol
2000;107:

20. LNG counseling – bleeding patterns
1-4 months irregular bleeding
2-6 months amount and duration of bleeding
20% will have amenorrhoea at the end of one year
Overall significant reduction in the bleeding

21. LNG IUS Main reasons for premature removal were
Bleeding problems 5.4 %
Amenorrhea 1%
Pain 2.5%
Acne 1%

22. Benefits of local action of LNG
No significant change in:
Blood pressure
Serum lipids
Coagulation factors
Carbohydrate metabolism
Liver function

25. Pelvic inflammatory disease 5-year cumulative gross termination rates
Age group Nova T Levonorgestrel (years) IUS
≤ *
26–
31– ≥
Total *
*p < 0.01
Andersson et al., 1994

26. Body weight over 5 years of use65 64 63 62 61
Copper IUD
Mirena kg
Months
Andersson et al., 1993

28. LNG – other health benefits
Reduction in
Amount and duration of bleeding
Incidence of ectopic pregnancies
Menstrual cramps
Non-contraceptive benefits
Treatment of DUB and menorrhagia
In HRT for endometrial protection

29. Other newer IUCDs

30. The design characteristics of the frameless IUD
(fixed, frameless and flexible) are responsible for
the low expulsion, high effectiveness and high
continuation rates. Insertion is easy and safe in
the hands of trained providers and appears to be
as reliable and effective as when inserted at
interval

31. GyneFix  
The expulsion rate of 8.4% and removal rate for bleeding and/or pain of 9.0% at 12 months
within acceptable ranges for framed intrauterine devices
does not affect future fertility in nulliparous and parous women
Masters T, et al Eur J Contracept Reprod Health Care 2002 Jun;7(2):65-70

32. Gynefix
The frameless intrauterine device (IUD) dispenses with the frame in the classical IUD and holds the device in the uterus by anchoring one end of a nylon thread in the fundal myometrium, to which copper sleeves are attached
There are insufficient data to show that problems of early expulsions have been overcome with the new introducer used in GyneFix. Apart from that, the frameless device performs similarly to TCu380A, and appears to have a lower pregnancy rate in later years, although the absolute difference is small.

33. Gynefix Insertion

34. Newer IUCD’s To Come
Fibroplant
Gynefix Fibrofix
T shaped LNG

35. FibroPlant
the FibroPlant levonorgestrel intrauterine system (IUS), releasing 14 microg of levonorgestrel/day.
Strong endometrial suppression is the principal mechanism explaining both the effect on menstrual blood loss and the contraceptive performance of the IUS
Eur J Contracept Reprod Health Care 2001
Jun;6(2):93-101

36. Conclusion
Intrauterine contraception is the most cost-effective reversible method of contraception
increasingly attractive
due to the development of new technologies that not only enhance the performance of the intrauterine device (i.e. efficacy is now close to 100%), but also reduce the rate of expulsion and the number of removals for medical reasons
Eur J Contracept Reprod Health Care
2000 Dec;5(4):

37. Technology made large populations possible and large populations make technology indispensable
Joseph Wood Krutch

38. Thanks to all contributors.
Dr Adarsh Bhargava.
Dr Ashwini Bhalerao.
Dr Alka Kriplani.
Dr. Kalpana Apte.
Dr Mala Arora.
Dr.Meenakshi Bharath.
Dr. Mandakini Parihar.
Dr.Nozer Sheriar.
Dr.Parikshit Tank.
Dr. Roza Olyai.
Dr.Sasikala Kola.
Dr.Sujata Mishra.