CHAPTER 145 Intrauterine Device Insertion

The intrauterine contraceptive device (IUD) has been in use for over five decades and is the most commonly used method of reversible birth control, with current use estimated at over 160 million women worldwide. In the United States, two types of IUDs are available: the ParaGard T380A, a copper IUD containing no hormones that may be left in place for 10 years; and the Mirena Levonorgestrel Intrauterine System (LNG IUS), a progesterone-secreting device that is effective for 5 years. The primary mode of action for IUDs is through inhibition of sperm function (thus preventing ova fertilization) through release of endometrial prostaglandins and leukocytes, enzymes, and copper ions. As a secondary effect, the endometrium is typically rendered inhospitable to embryonic implantation. The LNG IUS has additional effects related to hormonal suppression of the endometrium, thickening of cervical mucus, and inhibition of ovulation.

Although IUDs fell out of favor in the United States many years ago after a reported increase in the incidence of pelvic inflammatory disease (PID) and the highly publicized Dalkon Shield lawsuits, contemporary IUDs have reemerged as an excellent option for reversible, long-term birth control owing to their well-demonstrated safety and potential therapeutic effects (Tables 145-1 and 145-2). Numerous studies demonstrate that the risk of PID and upper genital tract infection is low in properly selected patients. Features that make the IUD an attractive form of birth control for many women are an efficacy rate that rivals sterilization, favorable safety profile, ease of use once inserted, and relative lack of systemic effects. Disadvantages include altered bleeding patterns (especially in the first few months after IUD placement), the need for a procedure to place and remove the device, cramping and pain at time of insertion (as well as possibility of increased dysmenorrhea with copper IUDs), risk of expulsion of the device (2% to 10% in first year), and the risk of uterine perforation at the time of the procedure (risk is 1 per 1000 in experienced hands).

TABLE 145-1 Rate of Continuation of Contraceptive Method at 1 Year

Method	Continuing Method after 1 Year
Mirena intrauterine device (IUD)	81%
ParaGard Copper IUD	78%
Oral contraceptive pill	68%
Depo-Provera	56%
Condom	53%
Diaphragm	57%
Spermicide	42%

Data adapted from Trussell J, Kowal D: The essentials of contraception: Efficacy, safety and personal considerations. In Hatcher RA, Trussell J, Stewart F, et al (eds): Contraceptive Technology. New York, Ardent Media, 1998, pp 211–247.

TABLE 145-2 Annual Failure Rates for Birth Control Methods

Method	“Typical Use” Failure	“Ideal Use” Failure
Sterilization
Male sterilization	0.15%	0.1%
Female sterilization	0.5%	0.5%
Hormonal Methods
Implanon	<0.1%	<0.1%
Hormone shot (Depo-Provera)	3%	0.3%
Combined pill (estrogen/progestin) and minipill	8%	0.3%
Intrauterine Devices
Copper T	0.8%	0.6%
LNG 20	0.1%	0.1%
Barrier Methods
Male latex condom*	15%	2%
Diaphragm^†	16%	6%
Vaginal sponge (no previous births)^‡	16%	9%
Vaginal sponge (previous births)^‡	32%	26%
Cervical cap (no previous births)^†	16%	9%
Cervical cap (previous births)^†	32%	26%
Female condom	21%	5%
Spermicide (Gel, Foam, Suppository, Film)	29%	18%
Natural Methods
Withdrawal	27%	4%
Natural family planning (e.g., calendar, temperature, cervical mucus)	25%	1%–9%
No Method	85%	85%

* Used without spermicide.

† Used with spermicide.

‡ Contains spermicide.

Indications

• The ideal candidate for an IUD is a parous woman in a stable, mutually monogamous relationship, with no sexually transmitted infection (STI) risk factors who is looking for long-term but reversible birth control. The patient should be willing to check for the presence of IUD threads on a monthly basis.

• The IUD is especially appropriate for women who have difficulty remembering to take oral contraceptives or are intolerant to them, who wish to maintain fertility, and who want to avoid systemic hormones.

• Women older than 35 years of age who are smokers and others with increased risk of thromboembolic events, cardiac disease, hypertension, or other contraindications to hormonal therapy are also good candidates.

• Although not listed as an indication by the company, the LNG IUS may be a preferred contraceptive method in women with endometriosis, dysmenorrhea, hypermenorrhea, or significant anemia given that menstrual bleeding and cramping generally decrease significantly within 3 to 6 months. Overall blood loss drops approximately 90% and some 20% of women experience absence of bleeding because of the localized progestin effect. Other possible off-label uses of the LNG IUS are to treat endometrial hyperplasia and for postmenopausal women on hormone replacement who are intolerant to oral progestins. The progesterone component provides endometrial lining suppression, decreasing the risk of endometrial hyperplasia and uterine cancer.

• The IUD is also acceptable for women who were once considered poor candidates for the device, including adolescents, nulliparous women, women in nonmonogamous relationships, and those with a history of PID or ectopic pregnancy. Use of the IUD in these populations is reasonable in the context of appropriate screening and counseling regarding side effects and STI prevention (Table 145-3).

• Emergency contraception may be provided with the copper IUD only.

TABLE 145-3 Special Populations and Considerations

Population	Considerations
Adolescents	Despite increased risk of pregnancy, expulsion, and removal for bleeding or pain, the IUD is still more effective than other forms of reversible contraception in this age group, and age should not be the primary determinant of candidacy for the device. Rates of infection are similar to those in adults.
Nulliparous women	Nulliparous women have similar rates of infection and efficacy with IUD use compared to multiparous women; however, higher rates of expulsion and discomfort can limit tolerance for the device.
Fertility	Most women, including nulliparous patients, can expect a rapid return to fertility after discontinuing copper or hormone-releasing IUDs. Contrary to common belief, use of a copper IUD does not appear to increase the risk of tubal infertility in nulligravid women in the absence of chlamydial infection.
Prior ectopic pregnancy	The IUD is protective against ectopic pregnancy and is appropriate for women with a history of an ectopic pregnancy.
Insertion after abortion	IUD insertion is safe immediately after spontaneous or induced abortion and is not associated with an increased risk of perforation or infection. Expulsion rates are higher when inserted immediately after second-trimester abortion.
Insertion postpartum	Postpartum insertion appears to have a higher rate of expulsion, but no increase in perforation or infection. Expulsion is less likely when insertion is performed within 10 minutes of delivery of the placenta compared to 1 to 2 days postpartum. If immediate postpartum insertion is not done, then waiting 4 to 6 weeks is advisable. Only the Paragard Cu380A has approval for immediate postpartum insertion. The LNG IUS can be inserted at the 6-week postpartum visit. Breast-feeding women can safely use either device.
Use for emergency contraception	The ParaGard IUD can be inserted within 120 hours of unprotected intercourse for emergency contraception with an efficacy of 98.1% in parous women and 92.4% in nulliparous women.
Valvular heart disease	There is no contraindication to use of the IUD in women with uncomplicated valvular heart disease (including mitral valve prolapse and aortic stenosis). Even in women with complicated valvular heart disease, the benefits an IUD generally outweigh risks. Advantages include avoidance of pregnancy risks and those associated with estrogen-containing contraceptives. Prophylactic antibiotics are recommended at the time of insertion to prevent infective endocarditis in those with high-risk valvular heart disease.
Coexistent gynecologic conditions	There is no contraindication to use of the IUD in women with irregular menses, vaginitis, cervical dysplasia or cervical ectropion, a history of benign ovarian cysts, past PID with a subsequent pregnancy, or prior cesarean delivery. In some situations, such as menorrhagia, use of the LNG IUS is therapeutic. The cause of any abnormal bleeding should be defined prior to insertion. It is best to evaluate significant abnormal Pap smears prior to insertion since performing a LEEP procedure can be difficult if not impossible to do with the strings in place.
Coexistent chronic medical conditions	There is no contraindication to use of the copper IUD in women with diabetes mellitus, cardiovascular disease, migraine headaches, breast cancer or benign breast disease, smoking, obesity, epilepsy, or liver, gallbladder, or thyroid disease. There is no increased risk of pelvic infection in women with diabetes mellitus. Neither the copper IUD nor LNG IUS adversely affects glycemic control in diabetic patients.
Immunocompromise	IUD use does not enhance the risk of HIV acquisition over that in users of other contraceptives. Limited data suggest no increased risk of PID in HIV-positive IUD users. In conjunction with appropriate condom use, the IUD may be safely used in women with or at risk for HIV infection. However, for women at risk of HIV and other sexually transmitted infections, hormonal contraception may be preferable due to protection against ascending infections.
Cancer	The copper IUD use has been associated with lower risks of endometrial and cervical cancer. The LNG IUS likely reduces the risk of endometrial cancer but may increase risk of breast cancer.
Menopausal women	An IUD inserted for contraception should be removed one year after the last menstrual period in menopausal women.