Intrauterine devices (IUDs) are small flexible plastic devices inserted into the uterus to prevent pregnancy for long periods. There are three main types - copper IUDs, which are the most widely used in Kenya, hormonal IUDs like Mirena which release progestin, and non-medicated IUDs. IUDs work mainly by interfering with sperm transport and inhibiting implantation. Copper IUDs also impair sperm viability and function. When used correctly, IUDs have a failure rate of less than 1% per year. IUDs can be safely inserted immediately postpartum or postabortion, or at any other time if pregnancy can be ruled out. Common side effects

1. Intrauterine Contraceptives
Devices
STEVEN AKACH
MED VI

2. Definition
• Intra uterine device is a small flexible plastic device that is inserted
into the uterine cavity to prevent pregnancy.
• It provides long term protection against pregnancy.

3. TYPES

4. Classification 1
• 1st generation: Non-medicated; inert. Made of polyethylene & BaSO4
• 2nd generation: Cu based; In Kenya, the most widely used copper-
bearing IUCD is Copper T380A.
• 3rd generation: Hormone filled; T shaped; release the hormones
slowly into the uterus.

5. Classification 2
• Hormonal vs Non-hormonal
• Cu-based vs Hormonal.
Kenya
• Cu-based – T380A is widely used.
• Hormone releasing devices – Not widely used; Mirena(LNG-20 IUS) is
the most common. LNG based. Also Lingus and Liletta brands
available in Kenya.

6. Cu-IUCD vs Mirena

7. MOA(general)
• Changes in cervical mucus that inhibit sperm transport (eg, increased
copper concentration, thickening, glandular atrophy or
decidualization).
• Chronic inflammatory changes of the endometrium and fallopian
tubes, which have spermicidal effects and inhibit fertilization and
implantation.
• Thinning and glandular atrophy of the endometrium, which inhibits
implantation.
• Direct ovicidal effects.

8. Specific MOA (Cu-IUCD)
• Copper IUD – The addition of copper provides further contraceptive
benefits.
• Copper enhances the cytotoxic inflammatory response within the
endometrium;
• impairs sperm migration, viability, and acrosomal reaction;
• and impairs implantation

9. Specific MOA(Mirena)
• Levonorgestrel IUDs – The addition of LNg provides further
contraceptive benefits.
• Progestins thicken cervical mucus, which acts as a barrier to the
upper genital tract, causing endometrial decidualization and glandular
atrophy that impairs implantation and may inhibit the binding of the
sperm and egg by increasing glycodelin A production

10. Effectiveness
• IUCD is 99% effective if used correctly and consistently.
• Copper IUCD: Less than 1 pregnancy per 100 women using an IUD
over the first year (6 to 8 per 1,000 women).
• Hormone releasing IUCD: Less than 1 pregnancy per 100 women
using an LNG-IUD over the first year (2 per 1,000 women).

13. Indications
Cu IUCD
• 10-12 years contraception;
• Emergency contraception (off label use):within 5 days of unprotected
sex.
Mirena
• Strengths: 13,5mg, 19.5mg & 52mg
• 52mg device - treatment of menorrhagia and endometrium
protection during hormone replacement therapy.
• 13.5 mg IUD is approved for use for up to 3 years, while the 19.5 mg
and 52 mg IUDs are approved for up to 5 years

14. Contraindications
 Pregnancy, or suspected pregnancy
 Sexually transmitted infection at the time of insertion, including cervicitis, vaginitis, or any other lower
genital tract infection
 A congenital uterine abnormality that distorts the shape of the uterine cavity making insertion difficult
 Acute pelvic inflammatory disease
 History of pelvic inflammatory disease, unless a subsequent successful intrauterine pregnancy has occurred
 History of septic abortion or history of postpartum endometritis within the last 3 months
 Confirmed or suspicion of uterine or cervical malignancy/neoplasia
 Abnormal uterine bleeding of unknown origin
 Any condition that increases the risk of pelvic infection
 History of previously inserted IUD that has not been removed
 Hypersensitivity to any component of the device

15. Specific Contraindications
Levonorgestrel IUD/Mirena
• Confirmed or suspicion of breast malignancy or other progestin-
sensitive cancer
• Liver tumors, benign or malignant
• Acute liver disease
Copper IUD
• Wilson disease
• Sensitivity to copper

19. LORRAINE CHEPNGENO
MED VI

20. Time of insertion
(a) Interval
• When the insertion is made in the interconceptional period beyond 6
weeks following childbirth or abortion
• It is preferable to insert 2–3 days after the period is over.
• It can be inserted any time during the cycle even during menstrual
phase which has certain advantages (open cervical canal, distended
uterine cavity, less cramp).
• During lactational amenorrhea, it can be inserted at any time.

21. Interval ctn..
• IUDs may be placed immediately post-partum within 10 minutes of
delivery of the placenta,
• delayed post-partum within 4-6 weeks of delivery, and post-
abortion, so long as it was not a septic abortion (Lanzola & Ketvertis,
2020).
• 12 days from the start of menstrual cycle or
• Anytime within the cycle as long as pregnancy has been ruled
out(Kenya National Family Planning Guideline, 2016 p. 138).

23. (b) Postabortal —
The additional advantage of preventing uterine synechia can help in
motivation for insertion.
(c) Postpartum — It has a high rate of expulsion, its therefore
preferable to withhold insertion for 6 weeks when the uterus will be
involuted to near normal size.
(d) Postplacental delivery — Insertion immediately following delivery
of the placenta could be done. But the expulsion rate is high.

25. COMPLICATIONS
Immediate:
Cramp like pain — It is transient but at times, severe and usually lasts
for 1/2 to 1 hour. It is relieved by analgesic or antispasmodic drugs.
Partial or complete perforation — It is due to faulty technique of
insertion.

26. Remote:
Pain .
Abnormal menstrual bleeding —increased menstrual blood
loss, prolongation of duration of period and intermenstrual
bleeding.
The patient may become anemic. Iron supplement is
advocated.
Tranexamicacid may be given for short-term relief

27. Spontaneous expulsion—Usually occurs within a few months following
insertion, more commonly during the period.
Failure to palpate the thread which could be felt before, is an urgent
ground to report to the physician. The expulsion rate is about 5
percent.
The rate is, however, more following postabortal or puerperal
insertions.
The expulsion rate is markedly reduced in the successive years.

28. Perforation of the uterus—The incidence of uterine perforation is
about 1 in 1000 insertions.
Most perforations occur at the time of insertion but the migration may
also occur following initial partial perforation with subsequent
myometrial contraction

30. MANAGEMENT OF COMMON PROBLEMS ASSOCIATED
WITH IUCD USE

31. Indications for removal:
(1) Persistent excessive regular or irregular uterine bleeding
(2) Flaring up of salpingitis
(3) Perforation of the uterus
(4) IUD has come out of place (partial expulsion)
(5) Pregnancy occurring with the device in situ
(6) Woman desirous of a baby
(7) Missing thread
(8) One year after menopause
(9) When effective lifespan of the device is over.
IUD removal is simple and can be done at any time.It is done by pulling the strings
gently and slowly with a forceps.

32. References
• Lanzola, E. L., & Ketvertis, K. (2020). Intrauterine Device (IUD). In
StatPearls [Internet]. StatPearls Publishing.
• National Family Planning Guidlines for Service Providers. (2018).
National Family Planning Guidlines for Service Providers [Pdf] (6th ed.,
pp. 129-138). Nairobi: Reproductive and Maternal Health Services
Unit (RMHSU).