Type Of IUD Research Articles

The Quality of Family Planning Services for Breastfeeding Women in Senegal

This study examined the management of contraceptive services for lactating women visiting clinics for the first time in Senegal. A situation analysis (SA) was conducted in 1994 among staff at 180 service delivery points for new and family planning (FP) clients. The SA included an inventory of facilities and services at each site observation of service provision exit interviews among first time clients and interviews with providers and program managers. Most staff were midwives. Findings indicate that the mean age of clients was 29 years; parity averaged 3.7 children. Almost all women were Muslim. About 75% were married. 56% of women in exit interviews were breast-feeding. Only 7% of staff said that breast-feeding women would be treated the same when advised about method choice. 66% of providers gave correct information about contraception for lactating women. Almost 40% did not correctly indicate that breast-feeding was a reason not to use combined oral contraceptives. About 25% of providers received training in FP counseling and 66% reported training in clinical FP practice. 75% of those trained considered it inadequate. About 21% of new clients were not asked about their breast-feeding status. Almost 85% of managers indicated that instruction on breast-feeding was provided. Over 33% of breast-feeding women chose combined oral contraceptives. Only 12.5% adopted progestin only pills which were in ample supply. The IUD was the third most common choice but breast-feeding women were less likely to use. Over 75% of clinics had at least one type of IUD in stock.

The Pattern of IUD Use in Vietnam

Fieldwork for the IUD Use Dynamics Study was conducted between March 1 and May 18 1993 in the provinces of Nam Ha Thai Binh and Quang Nam-Da Nang. Questionnaires solicited data on education occupation marital status and number of children. The study examined the pattern of IUD use in the 3 provinces by questioning 2996 women who first used an IUD between 1981 and 1992. 74-78% of all women were using the IUD. Withdrawal was the 2nd most popular method (5-8%) followed by the condom (2-8%) and sterilization (1-4%). High continuation rates ranged from 77% among those who first used an IUD during 1984-86 to 84% among those who started IUD use during 1990-91 for an overall average rate of 81% at 12 months. Women who reported first using an IUD in the period of 1984-86 had the lowest continuation rates. The failure rate was low; about 3% of women experienced accidental pregnancy after 12 months of use. The rates ranged from 2.3 to 4.2 per 100 users at 12 months and from 6.5 to 11.3 at 24 months. Among reasons for termination expulsion was the most common and it was reported more frequently than in other countries; approximately 9% of users said they had expelled their IUD within 12 months. Health problems were the second most common reason cited by about 7% of women who had terminated use. A random sample of 10% of nonpregnant were examined by X-ray to verify whether the IUD was in place. 94% of 258 women who said they were using an IUD were in fact doing so and 21% of the 38 women who said they were not using an IUD also had a device in place. No data were collected on the type of IUD used or on the respondents characteristics at the time of insertion. A larger more carefully drawn sample and more comprehensive analysis would yield results for the continued development of family planning services.

Chlamydial serologic characteristics among intrauterine contraceptive device users: Does copper inhibit chlamydial infection in the female genital tract?

Our objective was to assess the association between copper intrauterine contraceptive device use and the level of antichlamydial antibodies. Fifty-four women (29 with history of ectopic pregnancy, 2 with non-tubal factor infertility, 1 with tubal factor infertility, and 22 with intact intrauterine pregnancies) with current or prior intrauterine contraceptive device use were compared with 60 prenatal control subjects with respect to antichlamydial antibodies. When the intrauterine contraceptive device user group was subdivided into copper users and Lippes Loop device users, a significantly lower geometric mean serum antibody titer among copper intrauterine contraceptive device users was detected. The odds ratio estimates for past chlamydial exposure (> or = 1:64 immunoglobulin G, > or = 1:128 immunoglobulin G) in users of noncopper versus copper intrauterine contraceptive devices were 9.1 (95% confidence interval 1.9 to 43.0) and 10.5 (95% confidence interval 1.5 to 71.8), respectively. The lower geometric mean serum antibody titer of antichlamydial antibody among copper versus Lippes Loop device users and the large association measured between past chlamydial infection and noncopper intrauterine contraceptive device use suggest that copper may have a protective effect against Chlamydia trachomatis infection or a suppressive effect on development of antichlamydial antibodies.

PID Risk for IUD Users Highest in First 20 Days After Insertion; Risk Then Falls Sharply and Remains Low

Researchers analyzed data on 22908 women obtained from randomized WHO studies from 23 countries to determine whether the IUD increases the risk of pelvic inflammatory disease (PID). 35% of the women used the TCu220C IUD 39% other copper releasing IUDs 16% a hormonal IUD and 9% the Lippes Loop. The overall PID incidence rate was 0.4% of all IUD insertions or 1.6 cases/1000 woman years. The incidence was greatest during the 1st 20 days after insertion (9.7 cases/1000 women years) and then declined to 1.4/1000 woman years. In fact the risk of PID was >6 times greater within 20 days after insertion than it was >20 days after insertion. This high risk immediately after insertion was evident in every region where PID existed at all insertion times and in all age groups. The higher risk within the 20 days after insertion was attributed to contamination of the uterus during insertion. Women who had an IUD inserted after 1980 experienced PID 50% less often than those who had had it inserted earlier e.g. the rate ratio for 1977-80 was 1.5 but was 0.5 for 1981-83 and 0.34 for 1984 and after. This may have been due to physicians being more aware of contraindications for IUD use particularly past infection with sexually transmitted diseases )STDs). The rate ratio was higher in Africa (2.6) than it was in Europe (1) but lower in Asia (0.46) and in the Americas (0.39). None of the subjects in China experienced PID. Older women were at lower risk of PID than 15-24 year olds (0.44 for 25-29 year olds 0.38 for 30-34 year olds and 0.35 for =or> 35 year olds). The researchers believed the higher risk life styles of the younger group accounted for this difference. Risk of PID decreased with family size (2.5 for 0 children 0.56 for 2 children and 0.39 for at least 4 children). The risk of PID did not differ with IUD type. The researchers concluded that the major determinant of PID is exposure to an STD rather than type of IUD.

IUD use and endometrial bleeding

Bleeding disturbances account for 41-52% of all IUD discontinuations. These bleeding disturbances include an increase in menstrual blood loss (MBL) intermenstrual bleedings (IMBs) and prolonged duration of menstruation. IUD users experience an increase of MBL of 50-75% which continues throughout the duration of IUD use. MBL decreases after insertion of a progestin-releasing IUD. A progestin-releasing IUD can treat women suffering from excessive bleeding during menstruation. MBL of at least 60-80 ml causes iron deficiency and anemia. Since due to infections and malnutrition iron balance is especially important in women from developing countries copper T IUD use threatens their health. IMBs are most frequent during the first months following IUD insertion. IMBs differ with the IUD type. IMB generally results in minimal blood loss (4-5 ml) which has no negative health effects in IUD users. IUD-induced IMB may keep many women from using the IUD in cultures where irregular bleeding is unacceptable. The copper T IUD prolongs menstruation by about 1 day while the progestogen-releasing IUD prolongs it by about 2 days. Prolongation of menses rarely contributes to discontinuation. Ways to manage bleeding disturbances other than removal include counseling before insertion and when disturbances occur; in cases of heavy blood losses antifibrinolytic agents nonsteroidal anti-inflammatory drugs and iron supplementation; and in cases of IMB changing either the IUD or its location. The most important way to minimize the consequences of IUD-related bleeding problems and increase IUD acceptability is good counseling from professionals with experience confidence and adequate knowledge of the effect of the IUD on bleeding patterns.

Reconsidering the IUD

Critical comment is provided on the risk of pelvic inflammatory disease (PID) with the use of IUDs, and specifically the Dalkon Shield. The reopening of the issue of IUD and PID was precipitated by the reanalysis of the Women's Health Study (WHS) data by Kronmal et al. The focus of the discussion is on the description of an epidemiological case control study, the WHS, assessing the criticisms of the study, the possible biases, and an interpretation of the conflicting analyses. The WHS was conducted in 8 health care centers in the US between 1976-78 and included hospitalized PID cases. Controls were other hospitalized patients. Burkman in 1981 and Lee et al, in 1983 published results of their analyses of the WHS data. Burkman estimated a 1.6 risk of PID among IUd users relative to all other contraceptive users and 1 or 2.1 relative to women with no history of PID. Lee estimated risk among Dalkon Shield users as 8.3 relative to women not using any contraceptive method prior to hospitalization, and 1.6 among users of other IUDs; analysis excluded women with a prior history of PID. Recently Kronmal et al, found fault with the WHS on 10 counts, which are provided in detail. Their reanalysis indicates there is no increased risk of PID for IUd users. However, the question is raised as to the appropriate reference group, -all other users of contraceptives or nonusers. Another question pertains to whether subjects should all, or just those without a prior PID history, be included. Due to the protective effect of oral contraceptives, the reference group should be nonusers of any type as analyzed by Lee et al. Lee et al. also excludes those with a prior PID history, which is the best solution to the 2nd question. The Kronmal analysis allowed those with a prior PID history, and the reference group was all women regardless of use. The Kronmal analysis also describes ways in which selection bias is involved in the higher risk of PID among Dalkon Shield users relative to nonusers. Some of the reasons are that women using the Dalkon Shield may have been less likely to seek early medical care, to have a greater likelihood of having their diseases properly diagnosed, and to identify more easily the Dalkon Shield as their IUD type. This reasoning is found to be excessive and unrealistic to explain a difference between a risk of 8.3 vs. 1.6, and the Dalkon Shield was deservedly removed as an unsafe product. Support for the IUD is better served by discussing the careful selection of users to reduce PID, meticulous insertion techniques, and close monitoring.

Effects of various iuds on the composition of cervical mucus

The influence of three different intrauterine devices on the composition of cervical mucus was studied. The amount of mucin, albumin and immunoglobulin G was estimated. After the insertion of an inert IUD, a decrease in mucin was observed. During copper-IUD use the content of mucin, albumin and IgG was increased in cervical mucus, while weight was not affected. In the levonorgestrel-IUD users, ovulation was inhibited in 2 out of 8 women. Mucus weight was increased. The amounts of mucin, albumin and IgG were not changed. In an in vitro experiment the effect of copper-IUDs on autooxidation of cholesterol was studied. There was an extensive conversion of cholesterol but addition of albumin quenched the oxidation of cholesterol. It is suggested that the increased secretion of albumin induced by copper-IUD users may offer protection against copper-induced cell damage.

IUDs are Contraceptives, Not Abortifacients: A Comment on Research and Belief

No studies show that IUDs destroy developing embryos at rates higher than those found in women who are not using contraceptives. Studies of early pregnancy factors have not shown statistically significant differences in transient levels of hCG between IUD and control groups, a sign of early abortion. The small, careful study by Segal et al. (1985) found no transient rise of hCG in the IUD group. The highly sensitive assay in a larger sample of IUD users, by Wilcox et al. (1985), suggests that an upper limit of only 3 or 4 percent of ovulatory matings with an IUD in situ might show transient rises of hCG. The electron microscopy of Hurst et al. (1980) demonstrated the existence of leukocyte-ridden degenerating embryos in rhesus monkeys fitted with IUDs, but found the same percentage of degenerating embryos in the control group. In this respect, IUDs do no more than nature. The work of Hurst et al. also demonstrates the comparative rarity of fertilized ova in rhesus monkeys fitted with IUDs. Croxatto (1974) and Alvarez et al. (1988) showed that this was also true for humans. A variety of studies demonstrate that IUD use diminishes both the number of sperm reaching the oviduct and their capacity to fertilize ova. Depending on the type of IUD and the drug dose, sperm are hindered from penetrating cervical mucus, are phagocytized by leukocytes, are incapacitated, with head-tail separation in the presence of copper, and suffer other cytotoxic effects in the IUD-altered uterine fluid. In the oviducts of copper-IUD users, ova are found significantly less frequently than in controls.(ABSTRACT TRUNCATED AT 250 WORDS)

The intrauterine device and ectopic pregnancy

Based on data given by case-control and cohort studies the relationships between current and past IUD use, duration of IUD use and the type of IUD were evaluated to determine the risk of ectopic pregnancy among IUD users. The results of this review indicate that current and past IUD users do not have an increased risk of ectopic pregnancy. No relationship was found between the duration of IUD use, for either current or past IUD users, and the risk of ectopic pregnancy. Pooled data from clinical studies of different types of IUD showed that the lowest risk of ectopic pregnancy was for users of copper-bearing IUDs, and the highest risk was for users of progesterone-releasing IUDs. Further research is needed to evaluate the ectopic pregnancy risks to past IUD users, especially in view of recent studies which have shown that these women may be at a higher risk of infertility.

Fertility after intrauterine device discontinuation.

Infertility rates and outcomes of pregnancies were evaluated for 219 former IUD users who had either expelled their IUDs or had them removed for medical or personal reasons other than planned pregnancy. Six women (2.7%) were infertile. Infertility rates were highest for women who used IUDs for more than two years and for women who had expelled their IUDs. Five women (2.3%) had ectopic pregnancies. The type of IUD used (Cu-7, Dalkon Shield, Lippes Loop) was not associated with different infertility rates or outcomes of pregnancies. The study results show that prior IUD use did not appear to impair subsequent fertility or outcome of pregnancy for women who either expelled their IUDs or had them removed for reasons other than pregnancy or planned pregnancy.

Do insertion-related problems affect subsequent IUD performance?

This investigation compares the IUD performance of 372 women who had an insertion-related problem (most with moderate or severe pain) and 372 matched women who had no such problem; all women had interval insertion. A woman in the Problem Cohort and her matched counterpart in the Comparison Cohort were inserted with the same IUD type by the same insertor on the same day or on close dates. The six IUD types used by these women were Lippes Loop D, Copper-7, Copper T-200, Copper T-380 Ag, Multiload Copper 250 and Multiload Copper 375. Cumulative gross life-table rates of the pertinent events (accidental pregnancy, expulsion and medical removal for bleeding and pain), adjusted for age and parity, were calculated. Between the Problem Cohort and the Comparison Cohort, no differences were detected in the event rates that were of either statistical or practical significance. Results from this preliminary study suggest that the insertion-related problems usually encountered during interval insertion such as insertion pain, syncope and/or mild cervical laceration are not associated with an increased risk of IUD discontinuation due to pertinent events.

Time to Conception after IUD removal: Importance of Duration of Use, IUD Type, Pelvic Inflammatory Disease and Age

Abstract Some investigations of IUD use have demonstrated impaired ability to become pregnant after removal, while others have not. None of these studies, however, have adequately considered such potentially influencing variables as age and a history of pelvic inflammatory disease (PID). To study the effect of length of IUD use, IUD type and the modifying influences of age and PID history on time required to conceive, we followed women trying to become pregnant after removal of their IUD. Five hundred forty women in Ljubljana, Yugoslavia who were first fitted with an IUD between 1964 and 1972 and had their IUD removed in order to become pregnant were followed through 1980. We found no relationship between the duration of IUD use or type of IUD used, but increasing age and a history of PID each decreased the montly probability of conception. These findings, along with other recent work, indicate that IUDs are a safe and efficacious contraceptive for women at low risk for sexually transmitted diseases.

Time to conception after IUD removal: Importance of duration of use, IUD type, pelvic inflammatory disease and age

Some investigations of IUD use have demonstrated impaired ability to become pregnant after removal, while others have not. None of these studies, however, have adequately considered such potentially influencing variables as age and a history of pelvic inflammatory disease (PID). To study the effect of length of IUD use, IUD type and the modifying influences of age and PID history on time required to conceive, we followed women trying to become pregnant after removal of their IUD. Five hundred forty women in Ljubljana, Yugoslavia who were first fitted with an IUD between 1964 and 1972 and had their IUD removed in order to become pregnant were followed through 1980. We found no relationship between the duration of IUD use or type of IUD used, but increasing age and a history of PID each decreased the montly probability of conception. These findings, along with other recent work, indicate that IUDs are a safe and efficacious contraceptive for women at low risk for sexually transmitted diseases.

Return to Fertility after IUD Removal for Planned Pregnancy

The ability to conceive after discontinuing contraceptive practice is an important concern for women who have not completed their families. This paper focuses on 576 women who had their IUDs removed for planned pregnancy. The data from this study add further evidence that fertility subsequent to IUD removal is not impaired. Among these women followed-up, 94.3% conceived. The majority of these conceptions (55.9%) occurred during the first three months after IUD removal. In addition to analyzing conception rates, there were four factors that were considered in relationship to return to fertility. These were age at removal, duration of use, type of IUD (medicated vs non-medicated) and timing of insertion (interval vs postabortion). Age at removal was the only variable which seemed to influence conception rates.

The intrauterine device and ectopic pregnancy

Based on data given by case-control and cohort studies the relationships between current and past IUD use, duration of IUD use and the type of IUD were evaluated to determine the risk of ectopic pregnancy among IUD users. The results of this review indicate that current and past IUD users do not have an increased risk of ectopic pregnancy. No relationship was found between the duration of IUD use, for either current or past IUD users, and the risk of ectopic pregnancy. Pooled data from clinical studies of different types of IUD showed that the lowest risk of ectopic pregnancy was for users of copper-bearing IUDs, and the highest risk was for users of progesterone-releasing IUDs. Further research is needed to evaluate the ectopic pregnancy risks to past IUD users, especially in view of recent studies which have shown that these women may be at a higher risk of infertility.

Return to fertility after IUD removal for planned pregnancy

The ability to conceive after discontinuing contraceptive practice is an important concern for women who have not completed their families. This paper focuses on 576 women who had their IUDs removed for planned pregnancy. The data from this study add further evidence that fertility subsequent to IUD removal is not impaired. Among these women followed-up, 94.3% conceived. The majority of these conceptions (55.9%) occurred during the first three months after IUD removal. In addition to analyzing conception rates, there were four factors that were considered in relationship to return to fertility. These were age at removal, duration of use, type of IUD (medicated vs non-medicated) and timing of insertion (interval vs postabortion). Age at removal was the only variable which seemed to influence conception rates.

Clinical experience with intrauterine devices in a private practice.

Clinical experience with intrauterine devices was evaluated, based on 627 insertions over a 14-year period in a private practice. Overall, there were few differences in the event rates leading to IUD discontinuation for the IUDs evaluated, principally Cu-7, Dalkon Shield and Lippes Loop. Pelvic infections were infrequent (0.7-2.2 cases per 100 woman-years of IUD use). The rate of PID in the study population appeared to be similar to that noted in the general population. IUD use did not appear to compromise future fertility, based on evaluations of patients after removal of their IUDs or from their return to fertility following IUD removal. IUD event rates (pregnancy, expulsion, displacement, removal for bleeding and/or pain) were related to the difference between endometrial cavity length and IUD length. A significant increase in the event rates was noted, regardless of the IUD type, when the endometrial cavity length exceeded IUD length by 2.0 cm or more, or when the difference between the endometrial cavity and IUD length was less than 0.5 cm.

Rat uterine tissue and cell responses to the presence of plain and indomethacin-delivering IUDs.

Plain silastic intrauterine devices or those containing 270 micrograms of indomethacin were inserted into the caudal portion of one uterine horn of mature Wistar rats. After a 3-week period animals were fixed by perfusion on the morning of day 2 after estrus. Segments of uterine tissue corresponding to regions adjacent to and cranial to the devices as well as an equivalent portion of the contralateral horn were embedded in glycol methacrylate. A group of control animals without any form of device were treated in an identical manner. Sections cut from these segments were evaluated by grid-point stereology to ascertain changes in tissue volumes and cell populations. It was found that the presence of plain devices induced hypertrophy in the stroma and myometrium of the portion of the uterus adjacent to the device. The presence of indomethacin in such devices prevented stromal hypertrophy. No changes in populations of fibroblasts or areas of glandular or vascular tissue were evident in any treatment group. Cell populations of neutrophils, eosinophils, and mononuclear cells, however, were elevated in the superficial stroma of the horns bearing either type of device; this feature was more pronounced for neutrophils in the presence of the indomethacin devices. Neutrophils, rather than eosinophils, predominated in the epithelia of the uterus bearing either type of IUD. Conversely, eosinophil populations were reduced in the superficial tissues cranial to the devices delivering indomethacin. Neutrophils and mononuclear cells were also found to be elevated in the deep stroma of tissues adjacent to both the plain and medicated device.

Type of IUD and PID risk : Lee N, Rubin G, Ory H, Burkman R: Type of intrauterine device and the risk of pelvic inflammatory disease. Obstet Gynecol 62:1, 1983

Type of IUD and PID risk : Lee N, Rubin G, Ory H, Burkman R: Type of intrauterine device and the risk of pelvic inflammatory disease. Obstet Gynecol 62:1, 1983

Risk of PID 5x Greater from Dalkon Shield Than from Other IUDs

2 recent studies provide evidence that use of the Dalkon Shield creates a considerably greater risk of pelvic inflammatory disease (PID) than does use of other types of IUD. Data from the Women's Health Study reveal that women who use the Dalkon are 5 times more likely than those who use other IUDs to be hospitalized for PID, while a Boston-based study, reported in the Journal of the American Medical Association, reports a 4-6 times higher risk. It is advised that women still using the Dalkon Shield have it removed. Table 1 provides risk estimates of hospitalization for PID by type of contraceptive used. The Women's Health study included 622 women aged 18-44 admitted to hospitals with an initial episode of PID. The data for the Boston study was obtained from interviews with 155 women, all of whom were premenopausal, under 45, and not pregnant. When analyzed by type of IUD, the data strongly confirm the findings of the other study.