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Intra- Uterine Contraceptive Device

The intra-uterine device (IUD) is the second most commonly used family planning method, after voluntary female sterilization.

The IUD is one of the best methods of contraception during lactation because of its high efficacy and its lack of effect on breast milk or infant growth.


Generations of IUD:

  1. First: inert devices e.g., Lippes loop
  2. Second: all the copper-containing devices
  3. Third: hormonal devices e.g., Progestasert and Mirena

Mechanism of Action


The precise mechanism of action of the IUD is still unknown.

  1. New studies prove that the IUDs act mostly by preventing sperms from fertilizing ova. The primary mechanisms of action of copper-releasing IUD are by impeding sperm transport and inhibiting their capacity to fertilize ova.
  2. All unmedicated and copper devices produce an inflammatory or foreign body reaction, which in turn causes cellular and biochemical changes in the endometrium and in uterine and tubal fluids. Prostaglandin level increase and the fibrinolytic mechanism needed for hemostasis are affected. Numerous polymorphs, giant cells, mononuclear cells, plasma cell, and macrophages appear in the endometrium as well as in the uterine and tubal fluids. These cells engulf or consume sperms and ova by the process of phagocytosis and thus prevent fertilization. Besides, normal cyclical changes in the endometrium may be delayed or deranged by the inflammatory reaction and liberation of prostaglandins, making it inhospitable for implantation of the blastocyst.
  3. When inserted postcostally, IUDs can prevent implantation of the fertilized ovum.
  4. Copper causes more intense inflammatory reaction and interferes with enzymes in the uterus, the amount of DNA in endometrial cells, glycogen metabolism, and estrogen uptake by the uterine mucosa.
  5. Sperm motility, capacitation, and survival are also affected by the biochemical changes in the cervical mucus produced by copper.
  6. IUDs containing progesterone prevent sperm passing through the cervical mucus and maintain high progesterone level and, in consequence, relatively low estrogen levels locally. They, thereby, keep the endometrium in a state in which implantation is hindered.
  7. In Cu T 200 the copper portion has an exposed surface area of 200 mm2.
  8. The Multiload Cu 250 has a recommended life span of 3 years, and the Multiload Cu 375 of 5 years.

Copper T 380A (Ca T 380A), Ca T 380 Ag, and Cu T 380S (Slimline)


They are T-shaped, look almost alike, and are made of polyethylene impregnated with barium sulfate. They have 314 mm2 copper wire on the vertical stem and two 33 mm2 copper sleeves on each of the two transverse arms. The wire in the 380 Ag has a sliver core. The approved life span of the Cu T 380A is 10 years.


Progesterone IUD (Progestasert)


The vertical shaft is fitted with a capsule containing 38 mg of progesterone dispensed in silicone oil. It delivers progesterone to the uterus at the rate of 65 μg/day.


The US Food and Drug Administration (USFDA)-approved effective life is only 1 year.


The contraceptive effectiveness of the Progestasert is similar to that of Cu IUDs; it reduces menstrual loss, but has to be replaced every year, and possibly increases the risk of ectopic pregnancy (as it decreases tubal motility).


Mirena/LNG IUD/LNG 20/Levonova/LNG IUS


Mirena contains a total of 52 mg levonorgestrel (LNG). LNG is released into the uterine cavity at a rate of approximately 20 μg/day. The L IUD is about as effective as sterilization, but, unlike sterilization, it is easily reversible.


These devices act mainly by local progestogenic effects and act for up to 5 years. Pearl index after 5 years is 0.09/100 women-years (most effective reversible contraception available today). The ovarian functions are not disturbed by LNG 20.

Advantages and Noncontraceptive Benefits

Health benefits of Mirena include:

  1. Reduction of blood loss, which benefits patients with anemia and dysfunctional uterine bleeding
  2. Reduction of pain and dysmenorrhea in endometriosis and adenomyosis
  3. Beneficial effect on fibroids
  4. The advantage that IUDs introduced 6 weeks after delivery do not influence lactation or affect infant growth & development.
  5. Can be used in prevention and treatment of endometrial hyperplasia.
  6. Decreases the risk of endometrial cancer.
  7. Decreases the risk of Plf) and hence protects against ectopic pregnancy.


  1. Irregular bleeding and oligomenorrhea, which happen quite commonly in the first 3-4 months
  2. Amenorrhea, which affects up to 20-50% cases by 1 year. But this is not at all harmful as it is a progesterone- induced amenorrhea.
  3. Difficulty of introduction, needing local anesthesia in many cases
  4. Slightly higher rates of minor side effects such as acne, dizziness, headaches, breast tenderness, nausea and vomiting, and weight gain

Pearl Index of IUD


IUDs can be divided into three groups according to the pregnancy rate, indicating their contraceptive efficacy:

  1. Group I (pregnancy rates greater than 2.0 per 100 women-year): Lippes loop, Cu 7 T 200
  2. Group II (pregnancy rates less than 2.0 but more than 1 per 100 women-year): Nova T, ML Cu 250, and Cu T 220C
  3. Group III (pregnancy rates less than 1 (mostly less than 0.5) per 100 women-year): Cu T 380A, Cu T 380S, ML Cu 375 & LNG 20

Recent Advances

PP IUCD (Post Placental IUCD) Insertion


IUCD can be inserted immediately after vaginal delivery or during LSCS before closure of the uterus.


WHO Category 4: absolute contraindications for use of IUD:


  • Immediate postseptic abortion
  • Pregnancy
  • Vaginal bleeding suspicious/unexplained
  • Puerperal sepsis
  • Cervical cancer
  • Endometrial cancer
  • Uterine anomaly
  • Pelvic tuberculosis
  • Current pelvic inflammatory disease (PID)/Current STDs
  • Malignant trophoblast disease

Current STDs


Uterine fibroids with distortion of uterine cavity


NOTE: Nulliparity, heart disease, fibroids with no cavity distortion and past history of PID are relative contraindications.

Insertion of ML Cu 250 and ML Cu 375: This is done by the withdrawal method without plunger.


Complications of IUD

  1. Increased bleeding is the greatest disadvantage of IUDs and, along with pain, accounts for their removal in 2-10 per 100 users in the first year.
  2. Misplaced IUD: If the device is detected inside the peritoneal cavity, it should be removed as early as possible. Copper devices produce irritative reactions, inflammations, and a lot of adhesions.
  3. Copper devices in the peritoneal cavity usually need laparotomy for their removal, as they produce a good amount of adhesions, although it is possible to remove them by laparoscopy Perforation occurs rarely, not more than 1.2 per 1000 insertions.
  4. The device may migrate into the peritoneal cavity or become embedded in the uterine musculature. Most perforations occur at the time when insertion technique is followed.
  5. The copper T devices are known to produce omental masses and adhesions, and progesterone devices can cause intraperitoneal bleeding and should always be removed urgently.
  6. Infections: Doxycycline 200 mg or, better still, azithromycin 500 mg, administered orally 1 h before insertion, reduces chance of infection.
  7. The presence of actinomyces has been found to increase with duration of use, especially after use of inert-tailed devices.
  8. The infection in IUD users can be prevented by (a) proper selection of patients, excluding those cases who have active infection or are likely to have infection from the husband or other partners, (b) prophylactic antibiotic course, and (c) proper disinfection and the practice of aseptic techniques.
  9. Pregnancy: As soon as pregnancy is confirmed, the IUD should be removed, if it can be done easily, to reduce the risk of pelvic infection and miscarriage-the most frequent complication of pregnancy with an IUD in place.
  10. If the IUD cannot be removed easily, it can be left in situ.
  11. There is no risk at all of any congenital malformations if IUD is left in situ.
  12. Ectopic pregnancy: Several studies, including a WHO multicenter study, have found that IUD users are 50% less likely to have ectopic pregnancy than women using no contraception. The chance of ectopic pregnancy in IUD users is rare and varies from 0.25 to 1.5 per 1000 women-year. However, when pregnancy occurs, the chance of ectopic pregnancy is higher (about 30%) than in general population (about 0.~.8%) of all pregnancies.

Newer IUDS

  1. Cu-Fix IUD (Flexi-Gard): This is frameless IUD consisting of six copper sleeves (300 mm- of copper) strung on a surgical polypropylene nylon thread, which is knotted at the upper end.
  2. Cu Safe IUD: The device has a T-shaped radio-opaque plastic body. The ends of the flexible transverse arms are inwardly bent, providing a nonirritating, fundus-seeking mechanism.

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