7.1 Types of IUDs Intrauterine device (IUD) is a small, flexible plastic frame to be inserted into the uterine cavity. Inert or non-medicated These devices are made of plastic or stainless steel only. Lippes loop made of plastic (polyethylene) impregnated with barium sulphate is still used in many parts of the world. Stainless steel rings are widely used in China only. Copper IUDs Copper wire or copper sleeves are put on the plastic frame (polyethylene frame). Examples include Copper T, CuT380 A, Multiload 375 etc. The various types of Copper IUDs differ from each other by the amount of copper. The initial Copper IUDs were wound with 200-250 mm2 wire (CopperT 200). The modern copper containing devices contain more copper and a part of copper in the form of solid tubal sleeves rather than wire. This increases the efficacy and lifespan (Cu T-380 A).  CuT 380A - It is a T shaped device with a polyethylene frame holding 380 mm2 of exposed surface area of copper. The IUD frame contains barium sulfate thus making it radio-opaque.  CuT-380Ag - It is identical to 380 A except that the copper wire on the stem has a silver core to prevent fragmentation and extend the life span of the copper.  CuT 380 slimline - It has copper sleeves flushed at the ends of horizontal arms to facilitate easier loading and insertion. The performance of CuT-380 Ag and the CuT-380 slimline is equal to that of CuT-380 A.  Multiload 375 - It has 375 mm2 of copper wire wound around its stem. The flexible arms are designed to minimize expulsions. The multiload 375 and T cu-380 A are similar in their efficacy and performance.  Nova T - It is similar to the CuT-200, containing 200 mm2 of copper. However, the Nova T has a silver core to the copper wire, flexible arms, and a large flexible loop at the bottom to prevent cervical perforation. Hormone-Releasing IUDs  Progestasert - It is a T shaped IUD made of ethylene and vinyl acetate copolymer containing titanium dioxide. The vertical stem contains a reservoir of 38 mg progesterone together with barium sulfate dispersed in silicone fluid. The progesterone is released at the rate of 65 µg per day.  LNG - 20 (Mirena) - This T shape & device has a collar attached to vertical arm containing 52 mg of levonorgestrel dispersed in poly dimethyl siloxane. It releases 15µg of levonorgestrel per day in vivo and is effective for 7-10 years.. 7.2 Mechanism of action IUD mainly work by changing the intra-uterine environment and making it spermicidal. Non-medicated IUD cause a sterile inflammatory response by producing a tissue injury of minor degree but sufficient enough to be spermicidal. Copper containing IUD, in addition, release free copper and copper salts that have both a biochemical and morphological impact on the endometrium and also produce alteration in cervical mucus and endometrial secretions. No measurable increase in serum copper is observed. Hormone releasing IUD add progesterone effect on endometrium to the foreign body reaction. The endometrium becomes decidualized with atrophy of glands. The progesterone IUD does not increase the serum progesterone level

and mainly acts by inhibition of implantation, sperm-capacitation and survival. Levonorgestrel IUD produces serum concentrations of the progestin half those of Norplant and therefore, ovarian follicular development and ovulation is

not inhibited. The LNG-20 IUD decreases the blood loss (by about 40-50%) and dysmenorrhoea. 7.3 Efficacy Table II. First year clinical trial experience in parous women8

Device Pregnancy

rate (%) Expulsion

rate (%) Removal

rate (%) Lippes Loop 3 12-20 12-15 CuT-200 3 8 11 CuT-380 A 0.5-0.8 5 14 Progesterone IUD 1.3-1.6 2.7 9.3 Levonorgestrel IUD 0.2 6 17 7.4 Contraindications  pregnancy  puerperal sepsis or immediate post septic abortion  distorted uterine cavity (congenital or acquired)  unexplained vaginal bleeding  suspected genital malignancy  high-risk candidate for STI  genital tuberculosis  active Pelvic Inflammatory Disease (PID) + Specific contraindications to LNG-20 IUD  current deep vein thrombosis/pulmonary embolism  current or past history of ischaemic heart disease  migraine with focal neurological symptoms (at any age)  current and past history of breast cancer  active viral hepatitis, cirrhosis of liver and benign or malignant liver tumors 7.5 Timing of Insertion After childbirth  immediately after delivery of placenta

(post-placental insertion)  four to six weeks after childbirth After spontaneous or induced abortion  immediately after 1st trimester abortion (aseptic).  after 2nd trimester abortion it is advisable to wait till involution of uterus is complete. Menstrual cycle  can be inserted any time, during menstrual cycle, if reasonably sure that woman is not pregnant and has not been having sex without contraception.  insertion during menstruation offeres following advantages :  pregnancy is ruled out  insertion is easier due to open cervical canal  any minor bleeding caused by insertion is less likely to upset the client 7.6 Information to the client after Copper T insertion  she can expect some cramping for a day or two after insertion, vaginal discharge for a few weeks after insertion and slightly heavier menstrual period with possible bleeding between the menstrual periods during first few months after insertion  follow-up visit after 3-6 weeks or after next menstrual period to ensure that IUD is in place and no infection has developed.  information about kind of IUD and when to have her IUD removed or replaced. + when she should see a nurse or doctor after IUD insertion?  missed menstrual period  lower abdomen pain / vaginal discharge / fever  missing IUD string  very heavy and prolonged bleeding that bothers her Emergency Cotraception should be used as ‘back up’ if IUD is expelled or misplaced.