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

2. 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

3. 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

4. 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

5. 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Originally made of steel, silkworm gut, etc.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

6. 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

7. 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

8. IUDs Licensed for Use in Canada
Flexi T
Nova T or Liberté
Mirena IUS

9. 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®
Non-hormonal
Menorrhagia, Dysmenorrhea
$180
Flexi-T 380®
Simple insertion, non-hormonal, high Cu content
$85
Flexi-T 300+®
Simple insertion, non-hormonal
Liberté UT380®
Non-hormonal, high Cu content
$50

10. 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):

11. 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

12. 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

13. Adverse Events Expulsion: 1-6 per 100 insertions
Highest in the first year after insertion
Uterine perforation: 1-2 per insertions
Operator dependant
Increased in immobile or retroverted uteri
More common with stenotic cervix
Most are unrecognized at the time of insertion

14. 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

15. 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

16. Ectopic Pregnancy (EP)
Baseline rate in women using no contraception = 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

17. 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):

18. 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:

19. 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.

20. IUCD: Duration of Action
LGN-IUS (Mirena®) = at least 7 years
Cu IUCD = at least 10 years
Inert IUCD…..unlimited?

21. How long can an IUD be left in?
Cu IUCDs studied 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

22. 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

23. 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):CD
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:
Mansour D et al. Efficacy of contraceptive methods: A review of the literature. Eur J Contracept Reprod Health Care ;15(1):4-16

24. The IUCD: Anytime at All?