Intra-uterine device (IUD) is The most commonly used effective and safe method among contraceptive methods.
Made of plastic material enforced with radio-opaque material.
Two nylon threads are attached to body, and protrude from cervix with a suitable length:
− Indicate that the I.U.D. is in place.
− Facilitate removal.
Types of Intra-uterine device (IUD) :
I. Inert devices: (Non-medicated):
* Lippes loop is broadly known.
* Double S shaped with 2 nylon threads at its base.
Available in 4 sizes (according to uterine size).
Requires sterilization e.g. aqueous iodine solution for 5 minutes.
Long lasting may be left till menopause.
Withdrawn in 1985 and replaced by recent types.
II. Bioactive devices: (medicated):
* Addition of biologically active substances to ordinary loop provide a new generation with,
– Increased efficacy,
– Reduced side-effects, &
– Improved user-acceptability.
A. Copper-medicated devices:
− Copper increases contraceptive effect & reduces side-effects as well. − The most commonly used in Egypt. − It has different shapes and sizes e.g. – The letter “T” or “7” denoting the shape of the frame, & – The number refers to the surface area of copper in mm².
1- Cooper T200. (Gyne-T):
– A copper wire around the longitudinal limb.
– Releasing about 50 µg/day of CU.
– Provide contraceptive cover for 3 years.
– Copper sleeves on the transverse limbs increases the surface area of copper to 220 mm2.
2- Copper T380.
– Similar to the previous one with a copper surface area of 380 mm2.
– Releases about 100 µg /day. & lasting for 5-7 years.
– Silver may be added to copper reducing fragmentation giving longer life span of loop.
3- Copper 7. (Gravigard):
– Copper wire coiled around vertical shaft.
– Copper surface area of 200 mm2, lasting 3 years.
– Smaller size for nulliparous woman or smaller uteri are available called Minigravigard.
4- Nova-T. (Novagard):
– Modified T device.
– The metal wire is made of alloy of copper and silver with surface area 200 mm² (5 years life span) and is coiled around longitudinal limb.
– Two rounded bulbs at end of transverse protecting uterus from risk of perforation.
5- Multiloaded devices:
– Modified T-device with softer and more flexible transverse limbs.
– Transverse limbs curved downwards with external protrusions to fix it firmly.
– It is the simplest device to insert as it needs no threading into an inserter.
B. Progestogen-medicated system:
♦ ♦♦ ♦ The main value is that it causes significant reduction of menstrual blood loss.
♦ ♦♦ ♦ Progestasert T device:
– Medicated with natural progesterone.
– Contains 38 mg with daily rate of release about 65 µg/day.
– It is effective for 1-2 years. – More risk of ectopic pregnancy;
– Doesn’t inhibit ovulation.
– Decrease tubal motility.
♦ ♦♦ ♦ Mirena device:
– Medicated with Levonorgestrel.
– Contains 60 mg with daily rate of release about 20 µg/day.
– It is effectives for up to 5 years.
♦ ♦♦ ♦ Other benefits of Mirena coil:
1. Treatment of DUB especially D. menorrhagia.
2. Treatment of endometrial hyperplasia.
3. If estrogen HRT is indicated in non hystrectomatized women, as it can decrease the risk of endometrial hyperplasia and endometrial carcinoma.
4. Women with fibroids, as it can shrink the size of fibroid and treat associated menorrhagia.
In Conclusion, it can spare woman a hysterectomy.
C. Anti-bleeding devices:
* IUD mixed with Anti-fibrinolytic agent as trasylol ↓ menstrual blood loss.
Mechanism of action of Intra-uterine device (IUD) :
* Mechanism of loop itself:
1. Works by causing a sterile inflammatory reaction in the uterus, results in,
– Increased osmolality of uterine fluid.
– Increased endometrial release of prostaglandins (PGs).
2. Interferes with sperm transport into the uterine cavity.
* Copper has additional effect:
1. Interferes with sperm capacitation and migration.
2. Affect PG production.
3. Alters endometrial enzymes.
– Inhibit carbonic anhydrase.
– Endometrium turned unsuitable for implantation.
* Progestogens have another additional effect:
1. Can inhibit ovulation 20%.
2. Endometrium show excessive decidualization and exhaustion, unsuitable for implantation.
3. Turns cervical mucous into mucous G, imperceptible for sperms.
N.B. – IUD is not abortifacient.
– Takes action before ova reach uterus.
Indications of Intra-uterine device (IUD) :
1. Parous women, with monogamous sexual relationship.
2. Women, who prefer a long acting, reversible method.
3. When method not related to coitus and does not need continuous motivation desired.
4. Breast-feeding women, as IUD has no effect in lactation.
5. Unfit or unable to use effective alternatives.
Intra-uterine device (IUD) Contraindications:
* Absolute contraindication:
1. Pelvic infection, active or recurrent.
3. Genital or pelvic Cancer.
4. Congenital uterine anomalies e.g. subseptate uterus.
5. Distorted uterine cavity e.g. SMF.
* Relative contraindication:
♦ Temporarily contraindicated until the proper cause diagnosed and cured.
1. Genital tract with;
– Severe dysmenorrhea.
– History of pelvic infection.
– Inflammatory, Cervicitis or severe vaginitis.
– Undiagnosed AUB.
– History of ectopic pregnancy.
2. Woman with;
– Risk of acquiring STDs, (non monogamous women)
– Medical condition e.g. Valvular heart disease and Severe anaemia.
– Nullipara due to:
– Difficult insertion, pin point os.
– Danger of future infertility.
– More liable to side-effects and complications.
3. Loop related contraindications:
– Wilson’s disease, Metabolic disorder in which copper carrier is difficient.
– Women with allergy to copper.
Intra-uterine device (IUD) Insertion process:
* Timing of insertion:
– Post-menstrual, better on last day to exclude pregnancy.
– At the end of puerperium or 2 weeks after abortion to minimize expulsion.
* Technique of insertion:
1. Confirm that your patient is free of any contraindications.
2. Bimanual examination, then inserts a speculum into the vagina to inspect the cervix.
3. Cleans the cervix and vagina with appropriate antiseptic.
4. Insert vulsellum slowly through the speculum and closes it just enough to gently hold the cervix.
5. Pass uterine sound -slowly and gently- through the cervix to measure the depth and position of the uterus.
6. Load the IUD into the inserter while both are still in the unopened sterile package.
7. Slowly and gently insert the IUD and removes the inserter.
8. Cut the strings on the IUD, leaving about 3 cm hanging out of the cervix.
9. After the insertion, the woman rests. She remains on the examination table until she feels ready to get dressed.
N. B. – Multiload loops are inserted much easily, – They are inserted just by pushing the inserter inside uterus with stem only inside it till fundus is reached
* Instructions after insertion:
• Early; menstrual like colic, spotting and discharge may occur.
• Monthly; – Menses following insertion may be heavier than normal (few cycles).
– After end of each menses, assure that the nylon threads are in site.
– Check up examination is essential after one month, then annually.
* Indications of removal:
• End of indication i.e. pregnancy is desired. • End of validity i.e. after 5 years for copper lUDs. • Intolerable complications e.g. persistent bleeding, pelvic infection or perforation.
Intra-uterine device (IUD) Advantages:
• It is cheap, available and effective (low failure rate about 1-2/HWY).
• Safe and not affect lactation.
– No effect on sexual intercourse.
– Does not require intake of drugs.
• Requires little motivation (just one decision).
• Easy to insert and remove.
• Immediately Reversible.
Intra-uterine device (IUD) Disadvantages:
1- Uterine bleeding.
2- Pain, variable types. 3- Perforation.
4- Pregnancy on top of IUD (intrauterine and ectopic).
5- Syncopal attack (during insertion).
6- Expulsion (Shortly after insertion).
7- Missing threads.
8- Pelvic Inflammatory Disease (PID).
9- Vaginal Discharge, excessive.
10- Discomfort of male partner.
11- Difficult removal.
12- Future infertility.
13- Carcinogenicity and teratogenicity.
* Timing and nature:
i. Post-insertion spotting.
ii. Menorrhagia, due to
– Increase levels of PGE2, and fibrinolysins.
iii. Metrorrhagia, due to
– Injured areas of endometrium in contact with IUD.
1. Exclude organic causes of bleeding e.g. cervical polyp.
2. Medical treatment i.e.
– Antiprostaglandins e.g. mefanamic acid.
– Antiftbrinoytics e.g. tranexamic acid.
3. Persistent bleeding indicates removal of IUD and my D&C.
* Mild colic: Usually during 1st month treated by analgesics.
* Severe colic: mainly due to disparity of size or start of expulsion and so removal is indicated.
* Backache: refer to possibility of cervicitis.
* Acute pain: – During insertion may indicate perforation.
– Ectopic pregnancy.
– Pelvic inflammatory disease.
3- Vaginal discharge:
– Physiological watery discharge due to pelvic congestion→ pelvic decongestant.
– Pathological purulent or mucopurulent discharge indicates pelvic infection.
4- Pelvic inflammatory disease:
– IUDs is a risk factor to pelvic infection,
– Organisms ascend to upper genital tract through threads.
– IUD persists in site as a foreign body.
– Treated by antibiotics followed by removal of the IUD.
5- Pregnancy on top of IUD:
* Intrauterine pregnancy:
♦ ♦♦ ♦ Causes:
– Disparity of size.
– Distorted uterine cavity e.g. bicornuate uterus.
– Ill fitting IUD inside the uterus or expulsion.
♦ ♦♦ ♦ Management:
– Remove loop immediately by thread traction, abortion occurs in 25%.
– If the threads are not visible, IUD is left. Abortion occurs in 50%.
* Ectopic pregnancy:
– Most probable with IUS i.e. Progestasert.
6- Spontaneous expulsion:
– Usually during the 1st 3 menstruations after insertion.
♦ Most probable during insertion process.
* If discovered during insertion:
– Stop procedure,
– Observe vital signs,
– If deteriorated, laparotomy is a must.
* If discovered later:
– Non-medicated IUD has no harmful effect so leave it. – Medicated IUD removed by laparoscopy.
8- Difficult removal:
– Non visible threads i.e. cut or retracted.
– Endometrial bridges entangling IUD limbs.
– Primary tubal infertility, rare.
– So, avoid IUD in nullipara.
10- Carcinogenicity and teratogenicity:
– No evidence to prove or exclude neither any increased risk of malignancy nor any teratogenic effect among IUD users.
– Some advocate that IUS can decrease risk of endometrial carcinoma.
11- Male discomfort:
– Pricking pain of male partner referred to threads which can be shortened.
– Stem of the device (improper insertion) may cause pain.
– A vaso- vagal response rarely occurs, especially in narrow os of cervix.
– More common in nulliparae & women with low pain threshold.
13- Missed IUD:
♦ Inability to feel the previously felt threads of an IUD.
2. Uterine perforation, IUD passed outside.
3. Expulsion of the IUD.
4. Threads retracted or adhered to fleshy cervix by cervical mucous
5. Deep vagina or short fingers.
1. Pregnancy test to exclude pregnancy.
2. Gynecological examination to localize the site of IUD.
– Cusco speculum to visualize the cervix and detect threads.
– Sound of cervical canal for exploration.
– Ultrasound to detect if the IUD is intrauterine.
– Hysteroscopy to visualize lUDs in the uterine cavity.
– Pelvi- abdominal X-ray is taken;
– No shadow appears, expulsion is diagnosed.
– IUD shadow appears; it is better to ask HSG.
– HSG; A- P and lateral views are taken
– Shadow disappears in both views = intrauterine device, loop removed vaginally by D&C or hysteroscopy.
– Shadow is still seen outside the uterus = extrauterine device, perforation is diagnosed, removed abdominally.
Intra-uterine device (IUD) Videos:
Intra Uterine Device (IUD) Copper T Animation | ADMAA video
This video shows the complicated process of insertion and removal of CopperT using clean animation with eye-catching details. Primarily outlines the complications related to IUD use. Complications are uncommon outcomes resulting from a procedure or treatment. Complications associated with inserting IUD are rare but possible. Incidents* of complication from interval IUD insertion: Spontaneous expulsion = 2 to 8% Infection = Less than 1% Pregnancy = Less than 1% Perforation = 0.15 to .20%
Intrauterine Device (IUD) Copper T Removal procedure – Patient Education Medical animation video
Intra-uterine device (IUD) PPT (power point presentations):
A short description about IUD, its types, mechanisms of work advantage and side effects. it also provide information about IUD new acceptors in Nepal.