Spotters in "Family Planning: Intra-uterine Devices (IUD) Contraceptive Methods" for CFM & MPH students

 First generation IUDs:

Comprise the inert or non-medicated devices, usually made of polyethylene or other polymers. Appeared in different shapes and sizes.

1. Grafenberg rings:

Important points:

• A flexible ring of silk
• Later versions were wrapped in silver wire
• Introduced by German gynecologist Ernst Grafenberg in 1929
• Creates a hostile environment for sperm due to inflammatory response
• Obsolete   

2. Ota ring:

Important points:

• It is a variation of Grafenberg ring
• Developed by Japanese physician Tenrej Ota
• It contained a supportive structure in the center to lower the expulsion rate
• Obsolete

3. Birnberg’s bow:

Important points:

• Figure of 8 shaped
• Made of polyethylene
• Obsolete

4. Lippes Loop:

Important points:

• A double-S shaped device made of polyethylene
• Polyethylene is a non-toxic, non-tissue reactive & extremely durable
• Contains a small amount of barium sulfate to allow X-ray observation
• It has attached threads /tail (nylon) which project into vagina after insertion & makes it easy to remove when desired
• Exists in four sizes A,B,C & D (largest)
• Larger the loops lower expulsion rate, greater anti-fertility effect & higher removal rate
• Mechanism of action: Due to foreign body reaction cellular/biochemical changes in endometrium/uterine fluids, impairs viability of gametes & reduces chances of fertilization rather than implantation
• Pregnancy rate: 3 % (highest)
• Expulsion rate: 12-60 % (highest)
• Removal rate: 12-15 %
• Obsolete now

Second generation IUDs:

These are Bio-active or Medicated IUDs. Metallic ions (Copper) added. Numbers included in the names refers to surface area (in sq. mm) of copper.

Earlier devices:

1. Copper-7:

Important points:

• Shelf life: 3-5 years
• Mechanism of action: Prevents pregnancy by enhancing cellular response in endometrium, affecting enzymes in the uterus & altering cervical mucus thus affecting sperm motility, capacitation & survival
• Advantages: Lower incidence of side effects, easier to fit, better tolerated by nullipara, increased contraceptive effectiveness
• Side effects: Bleeding, pain, pelvic infection, uterine perforation, ectopic pregnancy, spontaneous expulsion
• Contraindications: Absolute- Suspected pregnancy, PID, vaginal bleeding of undiagnosed etiology, cancer of cervix, uterus or adnexa/other pelvic tumors, previous ectopic pregnancy, Relative- Anemia, menorrhagia, h/o PID, purulent cervical discharge, uterine anomaly & unmotivated persons 
• Pregnancy rate: 3%
• Expulsion rate: 6%
• Removal rate: 11%
• Timing of insertion: During/ within 10 days of beginning of menstrual period (best time), during first week after delivery (high chance of expulsion & perforation) , 6-8 weeks after delivery
• Can it be used as emergency contraception: Yes if inserted within 3-5 days of unprotected intercourse

2. Copper T-200:

Important points:

• Shelf life:  4 years
• Mechanism of action: Prevents pregnancy by enhancing cellular response in endometrium, affecting enzymes in the uterus & altering cervical mucus thus affecting sperm motility, capacitation & survival
• Advantages: Lower incidence of side effects, easier to fit, better tolerated by nullipara, increased contraceptive effectiveness
• Side effects: Bleeding, pain, pelvic infection, uterine perforation, ectopic pregnancy, spontaneous expulsion
• Contraindications: Absolute- Suspected pregnancy, PID, vaginal bleeding of undiagnosed etiology, cancer of cervix, uterus or adnexa/other pelvic tumors, previous ectopic pregnancy, Relative- Anemia, menorrhagia, h/o PID, purulent cervical discharge, uterine anomaly & unmotivated persons 
• Pregnancy rate: 3 %
• Expulsion rate: 8 %
• Removal rate: 11 %
• Timing of insertion: During/ within 10 days of beginning of menstrual period (best time), during first week after delivery (high chance of expulsion & perforation) , 6-8 weeks after delivery
• Can it be used as emergency contraception: Yes if inserted within 3-5 days of unprotected intercourse

Newer devices:

3. Copper T-220 C:

Important points:

• Shelf life: 3-5 years
• Mechanism of action: Prevents pregnancy by enhancing cellular response in endometrium, affecting enzymes in the uterus & altering cervical mucus thus affecting sperm motility, capacitation & survival
• Advantages: Lower incidence of side effects, easier to fit, better tolerated by nullipara, increased contraceptive effectiveness
• Side effects: Bleeding, pain, pelvic infection, uterine perforation, ectopic pregnancy, spontaneous expulsion
• Contraindications: Absolute- Suspected pregnancy, PID, vaginal bleeding of undiagnosed etiology, cancer of cervix, uterus or adnexa/other pelvic tumors, previous ectopic pregnancy, Relative- Anemia, menorrhagia, h/o PID, purulent cervical discharge, uterine anomaly & unmotivated persons 
• Pregnancy rate: 3 %
• Expulsion rate: 8 %
• Removal rate: 11 %
• Timing of insertion: During/ within 10 days of beginning of menstrual period (best time), during first week after delivery (high chance of expulsion & perforation) , 6-8 weeks after delivery
• Can it be used as emergency contraception: Yes if inserted within 3-5 days of unprotected intercourse

4. Copper T-380 A or Ag:

Important points:

• Shelf life: 10 years
• Has a silver core over which copper wire is wrapped
• Mechanism of action: Prevents pregnancy by enhancing cellular response in endometrium, affecting enzymes in the uterus & altering cervical mucus thus affecting sperm motility, capacitation & survival
• Advantages: Lower incidence of side effects, easier to fit, better tolerated by nullipara, increased contraceptive effectiveness
• Side effects: Bleeding, pain, pelvic infection, uterine perforation, ectopic pregnancy, spontaneous expulsion
• Contraindications: Absolute- Suspected pregnancy, PID, vaginal bleeding of undiagnosed etiology, cancer of cervix, uterus or adnexa/other pelvic tumors, previous ectopic pregnancy, Relative- Anemia, menorrhagia, h/o PID, purulent cervical discharge, uterine anomaly & unmotivated persons 
• Pregnancy rate: 0.5-0.8 %
• Expulsion rate: 5 %
• Removal rate: 14 %
• Timing of insertion: During/ within 10 days of beginning of menstrual period (best time), during first week after delivery (high chance of expulsion & perforation) , 6-8 weeks after delivery
• Can it be used as emergency contraception: Yes if inserted within 3-5 days of unprotected intercourse

5. Nova-T:

Important points:

• Shelf life:  5 years
• Has a silver core over which copper wire is wrapped
• Mechanism of action: Prevents pregnancy by enhancing cellular response in endometrium, affecting enzymes in the uterus & altering cervical mucus thus affecting sperm motility, capacitation & survival
• Advantages: Lower incidence of side effects, easier to fit, better tolerated by nullipara, increased contraceptive effectiveness
• Side effects: Bleeding, pain, pelvic infection, uterine perforation, ectopic pregnancy, spontaneous expulsion
• Contraindications: Absolute- Suspected pregnancy, PID, vaginal bleeding of undiagnosed etiology, cancer of cervix, uterus or adnexa/other pelvic tumors, previous ectopic pregnancy, Relative- Anemia, menorrhagia, h/o PID, purulent cervical discharge, uterine anomaly & unmotivated persons 
• Timing of insertion: During/ within 10 days of beginning of menstrual period (best time), during first week after delivery (high chance of expulsion & perforation) , 6-8 weeks after delivery
• Can it be used as emergency contraception: Yes if inserted within 3-5 days of unprotected intercourse

Multi-load devices

6. ML-Cu-250:

Important points:

• Shelf life: 3-5 years
• Mechanism of action: Prevents pregnancy by enhancing cellular response in endometrium, affecting enzymes in the uterus & altering cervical mucus thus affecting sperm motility, capacitation & survival
• Advantages: Lower incidence of side effects, easier to fit, better tolerated by nullipara, increased contraceptive effectiveness
• Side effects: Bleeding, pain, pelvic infection, uterine perforation, ectopic pregnancy, spontaneous expulsion
• Contraindications: Absolute- Suspected pregnancy, PID, vaginal bleeding of undiagnosed etiology, cancer of cervix, uterus or adnexa/other pelvic tumors, previous ectopic pregnancy, Relative- Anemia, menorrhagia, h/o PID, purulent cervical discharge, uterine anomaly & unmotivated persons 
• Timing of insertion: During/ within 10 days of beginning of menstrual period (best time), during first week after delivery (high chance of expulsion & perforation) , 6-8 weeks after delivery
• Can it be used as emergency contraception: Yes if inserted within 3-5 days of unprotected intercourse

7. ML-Cu-375:

Important points:

• Shelf life:  3-5 years
• Mechanism of action: Prevents pregnancy by enhancing cellular response in endometrium, affecting enzymes in the uterus & altering cervical mucus thus affecting sperm motility, capacitation & survival
• Advantages: Lower incidence of side effects, easier to fit, better tolerated by nullipara, increased contraceptive effectiveness
• Side effects: Bleeding, pain, pelvic infection, uterine perforation, ectopic pregnancy, spontaneous expulsion
• Contraindications: Absolute- Suspected pregnancy, PID, vaginal bleeding of undiagnosed etiology, cancer of cervix, uterus or adnexa/other pelvic tumors, previous ectopic pregnancy, Relative- Anemia, menorrhagia, h/o PID, purulent cervical discharge, uterine anomaly & unmotivated persons 
• Timing of insertion: During/ within 10 days of beginning of menstrual period (best time), during first week after delivery (high chance of expulsion & perforation) , 6-8 weeks after delivery
• Can it be used as emergency contraception: Yes if inserted within 3-5 days of unprotected intercourse

Newer devices:

8. IUB Ballerine MIDI copper IUD:

Important points:

• Shelf life:  5 years
• Mechanism of action: It works along the same principle as other intrauterine devices and prevents pregnancy locally - within the uterus. The contraceptive effect comes mainly from the copper. It consist of a special shape memory alloy (Nitinol), which has been successfully used in medicine for a long time, e.g. in implants and stents. Several copper pearls are strung on a uterus friendly frame, coated with polymer.
• Advantages: Once the flexible IUB™ Ballerine® frame is released from the insertion tube in the uterus it remembers its 3-dimensional past and coils into a round and smooth shape without sharp edges and corners.
• Side effects: Bleeding, pain, pelvic infection, uterine perforation, ectopic pregnancy, spontaneous expulsion
• Contraindications: Absolute- Suspected pregnancy, PID, vaginal bleeding of undiagnosed etiology, cancer of cervix, uterus or adnexa/other pelvic tumors, previous ectopic pregnancy, Relative- Anemia, menorrhagia, h/o PID, purulent cervical discharge, uterine anomaly & unmotivated persons 
• Timing of insertion: During/ within 10 days of beginning of menstrual period (best time), during first week after delivery (high chance of expulsion & perforation) , 6-8 weeks after delivery
• Can it be used as emergency contraception: Yes if inserted within 3-5 days of unprotected intercourse

Third generation IUDs:

1. Progestasert:

Important points:

• Shelf life: 1-1.5 years
• First hormonal uterine device
• Filled with 38 mg progesterone
• Rate of hormone release- 65 mcg/day
• Mechanism of action: Prevents pregnancy by direct local effect on uterine lining, effect on cervical mucus & effect on sperms
• Advantages: Lesser chances of dysmenorrhoea & menorrhagia
• Disadvantages: Expensive, requires yearly replacement, highest rate of ectopic pregnancy(9-fold higher)
• Contraindications: Absolute- Suspected pregnancy, PID, vaginal bleeding of undiagnosed etiology, cancer of cervix, uterus or adnexa/other pelvic tumors, previous ectopic pregnancy, Relative- Anemia, menorrhagia, h/o PID, purulent cervical discharge, uterine anomaly & unmotivated persons 
• Pregnancy rate: 1.5 %
• Expulsion rate: 3 % (lowest)
• Removal rate: 10 % (lowest)
• Timing of insertion: During/ within 10 days of beginning of menstrual period (best time), during first week after delivery (high chance of expulsion & perforation) , 6-8 weeks after delivery
• Can it be used as emergency contraception: Yes if inserted within 3-5 days of unprotected intercourse

2. Levonorgestrel IUD:

Important points:

• Shelf life:  7-10 years
• Releases 20 mcg of levonorgestrel 
• Mechanism of action: Prevents pregnancy by increasing viscosity of cervical mucus,maintaining high level of progesterone in endometrium hence unfavorable for implantation
• Advantages: Lesser ectopic pregnancy, long clinical experience, lower menstrual blood loss
• Disadvantages: More expensive
• Contraindications: Absolute- Suspected pregnancy, PID, vaginal bleeding of undiagnosed etiology, cancer of cervix, uterus or adnexa/other pelvic tumors, previous ectopic pregnancy, Relative- Anemia, menorrhagia, h/o PID, purulent cervical discharge, uterine anomaly & unmotivated persons 
• Pregnancy rate: 0.2 % (lowest)
• Expulsion rate: 6 %
• Removal rate: 17 % (highest)
• Timing of insertion: During/ within 10 days of beginning of menstrual period (best time), during first week after delivery (high chance of expulsion & perforation) , 6-8 weeks after delivery
• Can it be used as emergency contraception: Yes if inserted within 3-5 days of unprotected intercourse

Ideal candidates for IUD insertion:

As per Planned Parenthood Federation of America (PPFA)

• Who has at least one child
• Has no h/o pelvic disease
• Has normal menstrual period
• Is willing to check the IUD tail
• Has access to follow up and treatment of potential problems
• Is in a monogamous relationship

References:

1. Park, K. (2019). Park's textbook of preventive and social medicine. 25th. Jabalpur, India: M/S Banarsidas Bhanot.
2. Kadri AM. (2019). IAPSM's Textbook of Community Medicine. 1st. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.
3. https://www.jaypeedigital.com/book/9789351526384/chapter/ch24 photo credit
4. https://mhc.andornot.com/en/permalink/artifact9779 photo credit
5. https://obgynkey.com/intrauterine-contraception-2/
6. https://medical-dictionary.thefreedictionary.com/Birnberg%E2%80%99s+bow
7. https://www.medicalexpo.com/prod/medical-engineering-corporation/product-70806-436115.html photo credit
8. https://www.slideshare.net/mohitsatodia/iucd-seminar photo credit
9. https://www.medicalexpo.com/prod/pregna-international/product-69730-462284.html photo credit
10. https://www.jaypeedigital.com/book/9789350904312/chapter/ch15 photo credit
11. https://www.indiamart.com/proddetail/copper-t-380-a-21338631497.html photo credit
12. https://www.medical-world.co.uk/p/family-planning/iucds/nova-t-380-iud-single/1818 photo credit
13. https://scholarsrepository.llu.edu/thomsen-contraceptive/95/ photo credit
14. http://www.mydoctorshop.co.uk/Product/Detail/2432?category=multiload-cu375-iud photo credit
15. https://scholarsrepository.llu.edu/thomsen-contraceptive/index.7.html photo credit
16. https://www.indiamart.com/proddetail/hormonal-intrauterine-system-15184629791.html photo credit
17. https://www.oconmed.com/fileadmin/user_upload/Real_world_experience_with_the_IUB_Ballerine_MIDI_copper_IUD_an_observational_study_in_the_French_speaking_region_of_Switzerland.pdf photo credit
18. https://www.oconmed.com/en/contraception/intrauterine-ball-iub/