An IntraUterine System (IUS) or IntraUterine Drug Delivery System (IUDDS) is a small object that is placed inside the uterus above the endometrium and is active or medicated when it contains a therapeutic agent. It is a small string that is inserted through the cervix and placed in the uterus to prevent pregnancy. It is a small string that hangs down from the IUD into the upper part of the vagina. IUD is not noticeable during intercourse.

1. Intrauterine Drug
Delivery System
By: Abhilash Poudyal
GOVERNMENT PHARMACY COLLEGE,SAJONG,RUMTEK.

2. Introduction
❏ An IntraUterine System (IUS) or IntraUterine Drug Delivery System (IUDDS) is a small object that is placed inside
the uterus above the endometrium and is active or medicated when it contains a therapeutic agent. ❏ It is a small string
that is inserted through the cervix and placed in the uterus to prevent pregnancy
❏ It is a small string that hangs down from the IUD into the upper part of the vagina.
IUD is not noticeable during intercourse.
❏ It can show pharmacological efficacy for about 1- 10 years
❏ They work by changing the lining of the uterus and fallopian tube affecting the
movements of egg and sperm so the fertilization do not occur.

3. ●
Anatomy of Uterus
The uterus is a thick-walled muscular organ capable of expansion to
accommodate a growing fetus. It is connected distally to the vagina, and
laterally to the uterine tubes.
Normal uterus is about inches long and 2 inches wide
3 .
The uterine cavity is normally triangular in shape and flattened anterio
-posteriorly.
The wall of uterus consists of 3 layers
1) Endometrium- a) straight arteries b) coiled arteries
2) Myometrium
3) Peritoneum

4. ●
●
History of IUDs
● The first IUD was developed in 1909 by the German physician Richard Richter, of Waldenburg. His device was made
of silkworm gut and was not widely used.
● Ernst Gräfenberg, another German physician (after whom the G-spotis named), created the first Ring IUD,
Gräfenberg's ring, made of silver filaments.
● The invention of the copperIUD in the 1960s brought with it the capital 'T' shaped design used by most modern IUDs.
The hormonal IUD was also invented in the 1960s and 1970s.

5. ● Progestasert was manufactured until 2001.One commercial hormonal IUD which is currently available, Mirena, was
also developed by Luukkainen and released in 1976
.
Development of IUDs
● Development of IUDs began in the 1920s, withfirst
generationIUDs constructedfrom silkworm gut and flexible
metal wire. Eg. Grafenbergstar and Ota ring.
Frequent insertionandremoval causing pain and bleeding
● Plastic IUDs of different shapes and sizes were made available using various inert , biocompatible, polymeric
materials ( polyethylene, EVAs, silicone elastomers) were used.

6. Endometrial
compression, myometrial distensioncausinguterine
Cramps, bleeding, expulsionof IUDs.
Development of IUDs
● Researchers developed IUDs in last 30 years with aim to add 1. Antifertility agent 2. Make device smaller 3. Enhance
effectiveness 4. Add Antifibrinolytic agents( e-aminocaproic acid and tranexamic acid to larger IUDs) .
● Tatum developed a T- shaped device to improve patient compliance and reduce side effects.

7. ★ Zipper in 1968 added contraceptive metals (Cu) and Doyle and Clewe developed Progestin releasing IUDs
New era of R & D for long term I.U. contraception, leading to
generation of recent IUDs
● Copperbearing IUDs, such as Cu-7 and progesterone releasing IUDs such as Progestasert thus evolved

8. Inserting method of IUDs

9. Types of IUDs available in market
According to mode of action 1. Non- medicated IUDs : eg ring shaped IUDs of
stainless steel, plastic IUDs, Lippes Loop,
Dalkon Shield, Saf-T-Coil.

10. 2. Medicated IUDs : eg. Copperbearing IUDs,
Progesterone releasing IUD.
Two types
A. CopperBearing IUD
B. Hormone bearing IUDs-
a) Progesterone releasing IUD- progesert
b) Levonorgesterone IUD - MIRENA
According to Generation
1. First generation IUD-
Non hormonal/ inert/ non medicated IUDS: eg.
Lippes Loop
2. Second generation IUD-
Non Hormonal/ meddicated IUD: eg.ParaGard,
copper-7.ML- Cu-250, ML- Cu- 375.
3. Third generation IUD:

11. Hormonal/Medicated IUD: eg progesterone,
LevonorgestrelIUD
Brands: Progestasert,Mirena, Liletta and Skyla.

12. Lippes Loop Plastic IUDs
Progesterone
EXAMPLES

13. Non-medicated IUDs
● These type of IUDs show their contraceptive action via producing sterile inflammatory responsein the endometrium
by its mechanical action.
● They retard the sperm mortility so they fail to reach the egg or producespermicidal effect that kills sperm.
● They do not possessany therapeutic action.
● Examples include ring shaped IUDs of stainless steel
, plastic IUDs, Lippes Loop, Dalkon Shield, Saf-T-
Coil.

14. Medicated IUDs
● These type of IUDs are able to deliver pharmacologically active antifertility agents.
● They releases certain hormones which alter the hormonal balance inside the woman’s bodyto avoid conception.
● These are of two types
❏ CopperBearing IUD
❏ Hormone bearing IUDs-
1. Progesterone releasing IUD-
progesert
2. Levonorgesterone IUD - MIRENA

15. 1.Copper bearing IUDs
● This device uses copperwire wound to the stem
● This device is made of T shaped polyethylene plastic.
● There are various grades as per the surface area of Cu-wire such as Cu-T-30, Cu-T-200, Cu-T-380.
MOA
● At a high concentration copperis cytotoxic and enhances spermicidal and
spermato depressive action of an IUD.
● Cupric ion (Cu+) is a competitive inhibitor of progesterone.
● Evoke sterile inflammatory responsein the endometrium.

16. Multiload Cu IUDs
● There are various grades as per the surface area of Cu-wire such as Cu-T-30, Cu-T-
200, Cu-T-380.
● Surface area of 250 sq mm, blunt apex fits in the vault of uterine cavity. ● Low
expulsion rate
● Various surface areas such as 250 minimum, 325 medium and 375 large for different

17. ●
●
Side effects of Copper bearing IUD
EXPULSION.
● About 2-10% of IUDs are expelled from the uterus. This usually happens in the first few months of use.
● It is more likely when the IUD is inserted right after childbirth or in a nulliparous woman.
MENSTRUALPROBLEMS
uterine capacity
Releases Cu for about 5 years of about 2.5 mcg/ day.
Tissue compatibility improved by hydrogel coat.

18. About 12% of women have CopperT 380-A IUD removed because of increased menstrual bleeding or cramping.
PERFORATION.
● In 1 out of 1000 women, the IUD will get stuck in or puncture the
uterus.
● Although its rare it almost always occurs during insertion.
2.Hormone Releasing IUDs
A. Progestasert (Progesterone releasing IUD)
This device has a solid poly Ethylene-vinyl acetate side arms and a hollow
core. The microcrystalline
progesterone in the core in the
silicone oil with barium sulphate.
It is 0.25 mm thick, release via diffusion through rate limiting
membrane
It is loaded with 38 mg of Progesterone, releasing rate 65 mcg/day
Approved by USFDA in 1975 for 12 months contraceptive use

19. Pregnancy rate is 1.8/100 for parous women and 2.5/100 for nulliparous women.
It does not inhibit ovulation but interfere with implantation in endometrium, thickening of cervical mucus
ADVANTAGE
Increased effectiveness, lower menstrual blood flow, decreased dysmenorrhea.
DISADVANTAGE : Need to be replaced yearly, intermenstrual bleeding, ectopic bleeding.
MOA of Progesterone releasing IUDs
● They diminish sperm transport through the cervix to the oviduct by increasing the thickness of the cervical
mucus
● Steroid releasing devices induces progestational changes that results in endometrial gland atrophy and inhibit
further development of the ova.

20. ● Endometrial hypomaturation is unfavorable for implantation of blastocysts. Thus contraceptive action is
seen.
Clinical effectiveness
Contraceptive efficacy was related with daily dose of progesterone release from
device
Dose ( mcg/day) % pregnancy
10 5.2
25 2.7
65 1.1
120 0.6
B. Levonorgesterone IUD - MIRENA

21. ● The levonorgestrel-releasing intrauterine device LNg IUD is a new contraceptive method that combines the
advantages of both hormonal and intrauterine contraception.
● It is an intrauterine system that has sleeves of levonorgestrel 52mg around its stem
● It is composed ofa polyethylene stem covered by matrix Silastin:LNg (2:1) and side arms
● Releases 20 mcg/day lasting for 5 years. Initial release is fast then after 60%
drug release rate reduces to 16 mcg/day
● Supresseses endometrium and ovulation

22. MOA of Levonorgesterone IUD
● Prevents fertilization by damaging or killing sperm and making mucus thick and sticky, so sperm can't get
through mucus.
● It also keeps endometrium from growing very thick, making lining poorplace for a fertilized egg to implant the
grow.
● It may relieve irregular menstrual bleeding and cramping
● Comparative clinical trials with the LNg IUD cover more than 10,000 women-years of follow-up during use over
five to seven years. The Pearl pregnancy rate in studies has been 0.0–0.2 per 100 women-years. The overall
ectopic Pearl pregnancy rate is 0.02 per 100 woman-years. The LNg IUD is marketed in Denmark, Finland,
Norway, Sweden and in the United Kingdom.
Disadvantage
● It may cause non cancerous growth called ovarian cyst, which gradually go away on their own.
● It can cause hormonal side effects such as breast tenderness, mood swings, headaches, and acnae which usually
goes away after few months

23. Advantages of IUDs
● It is highly effective, with a 98-99 percent success rate over five years of IUD use
● It can be used by almost any woman including nulliparous
● Its action lasts for ten years if it is not removed in between
● The onset of action is immediate
● It is independent of sexual activity
● It doesn’tinterfere with intercourse
● It is suitable for lactating women
● Fertility returns promptly on discontinuation
● It can be used by women who are on any type of medication
● It is not associated with cancer of any organ unlike hormonal contraception
● It does not cause weight gain
● It does not usually affect mood or sex drive

24. Disadvantages of IUDs
● It doesn’toffer any protection against sexually transmitted infections (STIs)
● There is a slight risk (1 percent) of acquiring uterine infection during IUD insertion within 20 days of the
procedure. This is increased if the woman is prone to STIs. Women should be tested for gonorrhea or chlamydia
before insertion, and for any other organism if they so request. Fortunately, pelvic infections with the IUD in
utero can be treated adequately without removing the device
● If a woman becomes infected with an STIwith an IUD in situ, pelvic inflammatory disease may result without
adequate treatment
● Expulsion of the IUD may occurespecially following or during the periods in the first three months. This is more
commonly the case in nulliparous women, or those who had it inserted immediately post-partumor post-abortion.
The risk is approximately 5 percent. If the device is expelled and the loss is noticed only after a few days, backup
contraception should be immediately adopted
● Uterine perforation may occurin 0.1 percent of women during insertion. This may manifest as lower abdominal
pain. Perforation will require surgical removal

25. Contraindications of IUDs
An IUD might not be a goodoption for you if you have:
● a uterus that is not the usual
shape ● a current pelvic
infection.
The hormonal IUD might not be a goodoption for you if you have:
● been treated for breast cancer ●
severe liver disease.
The copperIUD might not be a goodoption for you if you have:
● heavy periods
● low iron levels ●endometriosis.

26. Reference
● Andersson, K., Ryde-Blomqvist, E., Lindell, K., Odlind, V., & Milsom, I. (1998). Perforations with intrauterine
devices: report from a Swedish survey. Contraception, 57(4), 251-255.
● Hubacher, D., Chen, P. L., & Park, S. (2009). Side effects from the copper IUD: do they decrease over time?.
Contraception, 79(5), 356-362.
● Barbosa, I., Bakos, O., Olsson, S. E., Odlind, V., & Johansson, E. D. (1990). Ovarian function during use of a
levonorgestrel-releasing IUD. Contraception, 42(1), 51-66.
● Xiong, X., Buekens, P., & Wollast, E. (1995). IUD use and the risk of ectopic pregnancy: a meta-analysis of
case-control studies. Contraception, 52(1), 23-34.
● Luukkainen, T., & Toivonen, J. (1995). Levonorgestrel-releasing IUD as a method of contraception with
therapeutic properties. Contraception, 52(5), 269-276.
● Bednarek, P. H., Creinin, M. D., Reeves, M. F., Cwiak, C., Espey, E., & Jensen, J. T. (2011). Immediate versus
delayed IUD insertion after uterine aspiration. New England Journal of Medicine, 364(23), 2208-2217.
● Bednarek, P. H., Creinin, M. D., Reeves, M. F., Cwiak, C., Espey, E., & Jensen, J. T. (2011). Immediate versus
delayed IUD insertion after uterine aspiration. New England Journal of Medicine, 364(23), 2208-2217.
● Kapp, N., & Curtis, K. M. (2009). Intrauterine device insertion during the postpartum period: a systematic
review. Contraception, 80(4), 327-336.
● Bayer, L. L., Jensen, J. T., Li, H., Nichols, M. D., & Bednarek, P. H. (2012). Adolescent experience withintrauterine device
insertionand use: a retrospective cohortstudy. Contraception, 86(5), 443-451.

27. Reference
● Levi, E., Cantillo, E., Ades, V., Banks, E., & Murthy, A. (2012). Immediate postplacental IUD insertionat cesarean delivery: a
prospective cohort study. Contraception, 86(2), 102-105.
● Gupta, B. K., Gupta, A. N., & Lyall, S. (1989). Return of fertility in various types of IUD users. International journal of
fertility, 34(2), 123-125.
● Zhou, S. W., & Chi, I. C. (1991). Immediate postpartum IUD insertions in a Chinese hospital—a two year follow-up.
International Journal of Gynecology & Obstetrics, 35(2), 157-164.
● GENTILE, G. P., & SIEGLER, A. M. (1977). The misplaced or missing IUD. Obstetrical & gynecological survey, 32(10),
690.
● Ke-juan, F., Jun-hang, C., Ming-hui, W., Hui-ming, F., & De-wei, Z. (1996). A Multicentre Comparative Clinical Study of
Three Types of IUD (Ten Years Follow up). REPRODUCTION AND CONTRACEPTION, 01.