1. History of IUCD.
•
•
•
•
•
•
•
•
•
•
•
First IUCD.--- Stones in the uterus of camels
Hippocrates --- used lead tube
Cervico-uterine stem pessaries----late 1800s.
Graffenberg---- silver wire rings 1930s.
Lippes loop ---- New York 1962
Copper added to Lippes loop 1971
Tcu.200 --------- Tcu.380a
Progestogen releasing IUS 65 ugm./day
LNG-IUS 20ugms/day
Dalkon shield – pelvic infection and disrepute.
Now--- CuT380, GynFix, LNG-IUS-- the
best.

2. Mode of Action of IUCD and IUS
•
•
•
•
•
•
•
•
•
•
•
•
•
Mechanism not exactly clear, but all types cause marked increase in
leucocytes in endometrium and utero-tubal fluid – a typical F.B. reaction
This interferes with gametes, fertilisation and implantation
actual phagocytosis of sperm occurs
-------------------------------------Cu - enhances the FB reaction
- causes endometrial changes(enzyme systems,hormone-receptors)
- probably directly toxic to sperm and ova
-------------------------------------Progesterone releasing IUS
- alter endometrial histology with decidual change and glandular
atrophy, blocking O and P receptors
-markedly reduce sperm permeability of mucus to sperm
-have an anti-implantation effect
-can prevent ovulation

3. Types of Device
• Inert
• Copper containing
• Progestogen containing
------------------------• Framed
• Frameless
------------------------• Design all important
• Implantable GyneFix very promising

5. Advantages of IUCDs.
•
•
•
•
•
•
•
•
•
•
Effective
Safe
Independent of coitus
No effort required.
Motivation necessary only at time of insertion
Relatively cheap and easy to distribute
Does not influence milk volume/composition
Method is under woman’s control
Continuation rates are high
Nearly always reversible

6. Disadvantages
• Intrauterine Pregnancy –with increased rate of
miscarriage and infection.
• Extrauterine pregnancy – but no increase in overall
population risk
• Expulsion with risks of pregnancy
• Perforation – with risks of pregnancy
•
uterine perf.
•
surgery
• Malposition of device - causing pain and bleeding
• “Lost threads”
• Pelvic infection/salpingitis - ? Infertility

7. •
•
•
•
•
•
•
•
•
•
•
•
Contraindications to the IUCD.
Absolute (Temporary)
Undiagnosed vaginal bleeding
Suspected pregnancy
Current pelvic infection
Malignant trophoblastic disease with uterine wall
involvement.
Significant immunosuppression
---------------------------Absolute (Permanent)
Markedly distorted uterine cavity or <5cms.
Known true allergy
Wilson’s Disease
Past attack of bacterial endocarditis or the presence
of a prosthetic valve replacement

8. Relative Contrainds. to IUCD use
•
•
•
•
•
•
•
•
•
•
•
•
•
•
48hrs.
4 weeks post partum
Known HIV or AIDS
Recent exposure to high risk of STD
Valve heart lesion but no past history of bacterial
endocarditis
Past history of ectopic in nullipara
Trophoblastic disease while blood hCG still detectable
Previous pelvic infection
Nulliparity
Diabetes Mellitus
Fibroids or congenital abnormality (?not GynFix)
Severely scarred uterus
Severe cervical stenosis
After endometrial ablation/resection
Memorrhagia/Dysmenorrhoea (not LNG-IUS)

10. Common Problems with IUCDs.
•
•
•
•
•
•
•
•
•
Intrauterine pregnancy with IUCD in situ
IUCD and ectopic pregnancy
Expulsion of IUCD
Uterine perforation by IUCD
Missing threads
Pelvic infection and IUCD
Actinomyces like organisms(ALOs) and IUCD
Menorrhagia
Pain

11. Causes of Failure
• Incorrect Insertion and Malposition
• Age of patient ---- over 35,first year failure
rate is very low (reduced fertility)
• Failure rates lower with increased duration
of use
• Wrong timing of removal
• Wrong timing of insertion

12. Intrauterine Pregnancy with
IUCD in situ
• No evidence for increased risk of Fetal
abnormality
• 50% miscarry if IUCD left in situ
• Remove IUCD if possible
• Do US – if IUCD above sac - ? leave
• If low and threads still accessible - remove

13. IUCD and Ectopic pregnancy
• Copper IUCDs do not increase the overall risk of
ectopics in a population(due more to pre-existing
tubal damage)
• IUCDs do not prevent ectopics as well as they do
intrauterine pregnancy
• The risk of ectopics increases with the duration of
use and is associated with age
• Every IUCD user with pelvic pain and menstrual
irregularity has an ectopic until proved otherwise
• IUCD is contraindicated in a patient who has had
a previous ectopic – an anovulatory method is
required

14. Expulsion of IUCDs
• For framed IUCDs, occurs 3-15/100 women by
one year
• Most common during 1st. or 2nd.menses after
insertion
• Unnoticed expulsion causes 1/3rdof pregnancies in
the first IUCD year
• With proper instruction, this should not happen
• Nulliparous women have higher expulsion rates
• Lower in>30s – half the rate
• Expulsion rates associated with precise fit or
otherwise of IUCD within uterine cavity
• GynFix appears to have solved this problem

15. Uterine Perforation by IUCD
• Most perforations first present in pregnancy as “lost
threads”.
• If device is bioactive – leads to adhesion formation –
may penetrate bowel or bladder
• “Closed” devices associated with possible bowel
strangulation
• Removal is indicated
• Occurs with frequency of 1 in 1000
•
-- insertion during the puerperium
•
-- push technique insertions
•
-- linear devices ; loss of plastic menory
•
-- operator experience ; R/V uterus ; mobile
•
cervix

16. Missing Threads
•
•
•
•
•
•
•
•
IUCD users with lost threads are either ------ already pregnant
or ------ at increased risk of pregnancy
The IUCD ---- will be in the uterus
-- have been unknowingly
expelled
-- or will have perforated the uterus
Establish whether pregnant and if so treat the
pregnancy
• If not pregnant – remove and replace the IUCD

18. P.I.D. and IUCDs.
• IUCD related bacterial infections are now
believed to be due to contamination of the
endometrial cavity at time of insertion, from
pre-existing infection, rather than to type of
IUCD
• WHO data base-the risk of PID was 6 times
higher during the 20 days after the
insertion, compared with later
• Infertility is a major source of concern
• 3 episodes of pelvic infection carry a 50%
risk of tubal infertility

19. • Compared with the protection offered by the
OCP against STD/PID, inert/copper IUCDs
do not protect against STD/PID
• LNG-IUS has a protective action against
pelvic infections
• High risk IUCD users must be advised to use
barrier methods during coitus

20. IUCD and Pelvic Infections
• Asymptomatic IUCD users, whose cervical
cultures show gonorrhea or chlamydia
infection, should be treated with
recommended drugs
• Removal of the IUCD is usually not
indicated
• If however there is clinical evidence of
ascending infection, the IUCD should be
removed promptly

21. IUCD and Pelvic Infection
• IUCD insertion is contraindicated in the
presence of current acute or chronic pelvic
infection
• If PID developes parenteral antibiotic
treatment should be instituted and IUCD
removed – but only when the serum
antibiotic levels are adequate

22. IUCD and Pelvic Infection
• Infections that occur 3-4 months after IUCD
insertion, are considered to be due to acquired
STD infection and not to the direct result of the
IUCD
• In patients at high risk for STDs – Doxycycline
200 mg or Azythromycin 500 mg orally should
be prescribed one hour before insertion.

23. IUCD and Pelvic Infection
• There is no evidence that the prevalence of
bacterial vaginosis is influenced by IUCD
use.
• Bacterial Vaginosis should be treated but
the IUCD need not be removed unless
pelvic inflammation is present.

24. Actinomyces Like Organisms. –
(ALOs) and IUCDs.
• Normally ALOs are harmless commensals in the
mouth and GI tract.
• Very seldom detected in the genital tract unless an
FB present
• After one year of IUCD, 1-2% of smears are
+ve.for ALOs.
• After 5 years, 20% of smears are positive.
• Frank Actinomycosis is rare.
• The significance of smear ALOs is uncertain.

25. IUCD and ALOs.
• If ALOs are present on the cervical smear of an
asymptomatic woman, there are two different
approaches•
1)remove / change the IUCD - in six
months if the cervical smear is negative, replace
the IUCD .It is not necessary to administer an
antibiotic.
• Or
2)leave the IUCD insitu
• Warn the patient to report any symptoms and
follow up carefully.
• If uterine tenderness or a pelvic mass is present,

26. IUCD and Menorrhagia
• Inert and copper containing IUCDs
associated with increase in menstrual blood
loss (55% with Cu IUCD)
• Best treated with NSAIDS
• Menstrual blood loss is reduced if device is
impregnated with progesterone

28. Levonorgestrel IUS (LNG –IUS)
• Nova T shaped disc – releases 20µg/ 24 hours of
LNG from its reservoir through a rate limiting
membrane over at least 5 years.
• Acts locally by – endometrial suppression
- changes in cervical mucus and
and utero-tubal fluid which
impairs sperm migration
• Blood levels of LNG are about ¼ peak levels of
POP
• Most women continue to ovulate.

31. Disadvantages of LNG-IUS
• Same problems as Nova-T
•
expulsion, perforation, malposition
• High incidence in first few months of uterine
bleeding
• Though mainly local in action it is also hormonal
with incidence of steroidal side effects
• Functional ovarian cysts more common –
• - usually asymptomatic
• Uncertainty about harm to foetus – no data

32. Absolute Contraindications
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
IUCD
Current pelvic infection
Recent STD
Severely distorted cavity
Previous bacterial endocarditis
Prosthetic Valve present
Severe Immunodeficiency
Suspected pregnancy
Irregular vag. Bleeding
Allergy to constituent
Progesterone
Active hepato-cellular disease
Active arterial disease Active trophoblastic disease with raised hCG.
(no evidence that enzyme inducing drugs weaken contraceptive
effect)
(may be used during breast-feeding)

33. Advantages of the LNG-IUS
•
•
•
•
•
•
•
•
•
•
•
•
It has unsurpassed efficacy
Rapid complete return of fertility after removal
Highly convenient with few adverse side effects
Also has some beneficial side effects :- dramatic reduction of menses
- improvement in dysmenorrhoea
- reduced PMS
- provides progestogenic protection of uterus
HRT
- appears to reduce frequency of clinical PID
- shows a reduction in extra as well as intra-ut
erine pregnancy

52. •
•
•
•
•
•
•
•
•
•
•
•
•
Insertion Procedure
Timing
“Pre-op” ---- cx screening for STDs
if nec. make cx favourable
Requirements – couch, light, equipment,
emergency tray
Well-trained Doc – “dry-runs”with plastic model
Technique – pain relief
uterine sound
antisepsis
IUCD “memory”
Perforation paranoia
Vaso-vagal attack – emergency-tray
Follow - up advice