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Newer Intra-Uterine Contraceptive Devices

Newer Intra-Uterine Contraceptive Devices. Dr. Mandakini Parihar Director Mandakini IVF Centre, Chembur Associate Hon. Prof. Obs & Gyn K.J.Somaiya Medical College Member Managing Committee, ISAR Member Governing Council, ICOG.

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Newer Intra-Uterine Contraceptive Devices

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  1. Newer Intra-Uterine Contraceptive Devices

  2. Dr. Mandakini PariharDirectorMandakini IVF Centre, Chembur Associate Hon. Prof. Obs & GynK.J.Somaiya Medical CollegeMember Managing Committee, ISARMember Governing Council, ICOG

  3. “ Family Planning alone could bring more benefits to more people at less cost than any other single technology now available to the human race.”UNICEF

  4. Contraceptive UseIndian Scenario • There has been consistent improvement in the levels of contraceptive use in the country over time. • However, these changes have not necessarily brought along corresponding decline in fertility levels for various reasons • The data from the NFHS I and II indicate that the contraceptive prevalence rate for India was about 41 per cent during 1992-3 that increased to slightly over 48 per cent by the end of the last century, an increase of 7 per cent points in 6 years which is not significant and is the main reason for our mammoth population growth

  5. Unintended vs. Intended Pregnancies Intended 51% Unintended 49% Unintended births (22.5%) Elective abortions (26.5%) Henshaw SK. Fam Plann Perspect. 1998;30:24-29.

  6. Unmet Need in India Millions of women would prefer to avoid becoming pregnant either right away or ever, but are not using any contraception These women have an unmet need Awareness Access Availability Unmet need for family planning (NFHS-3) Spacing 7.3% Limiting 7.3% Total 14.6%

  7. Everything changes continually. What is history but a record of change? Mahatma Gandhi

  8. Evolution of IUCDs • 1st generation : Lippes Loop • 2nd generation : copper containing • 3rd generation : progesterone containing • Progestasert • Levonorgestrel (Mirena) • 4th generation : frameless IUD • GyneFix (copper) • FibroPlant ( levonorgestrel)

  9. Evolution of Cu-IUCD • 2nd generation : copper containing • Cu-T 200 • Multi-load 250 –375 • Nova –T • Newer Cu-380A

  10. Currently there are 100 million IUCD users in the world, 80 % of them are in China

  11. IUD: Work-up • History: • STD’s, Sexual History, Ectopic • Examination: • Size / Configuration of Uterus • Cervical Cultures • Pap Smear • Counseling

  12. IUD: Mechanisms of Action • NOT ABORTIFACIENT!!!!!!!! • Prevents Conception • local Foreign body reaction • Sperm Transport Inhibited • Sperm Survival / Capacitation Diminished • Prevents Implantation

  13. Cu IUD • typically comprise a solid plastic frame loaded with copper wire and/or copper sleeves • very effective • (pregnancy rates <2%) • Once inserted, protects for 3-10 years depending on type of IUD • Easy to insert and remove • Does not protect from STDs

  14. New Cu-IUD: Overview • ParaGard (CuT380A) • Very Effective (~ TL) • Reversible However- • Monogamy Essential • Does Not Protect Against STD’s • Can Remain for 10 Years

  15. Cu-IUD: Complications • PID: Usually secondary to InsertionalContamination – Unproven Role for Prophylactic ABx • Menorrhagia • Expulsion • Perforation (< 0.1%) • Failure: IUD Should be Removed • ??Ectopic

  16. LNG IUS • pure levonorgestrel in the vertical stem @ 20 micrograms per day into the endometrium • approved for five years of use • menstrual bleeding, overall a reduction by 90%

  17. LNG – Mechanism of action • Endometrium suppressed • Cervical mucous thickening • Sperm motility and function affected • Weak foreign body reaction • Rare cases inhibits ovulation Johnson et al , Contra: 1991,43;447 Videla-Ribero et a l, Contra:1997,46;217

  18. Randomized studies Years Comparison Pearl index Reference of use n method LNG-IUS Luukkainen et al., 1986 5 281 Nova-T 0.1 Sivin et al., 1991 7 1124 Cu T 380 0.2 Faundes et al., 1993 7 581 Cu T 380 0 Andersson et al., 1994 5 1821 Nova-T 0.1 Indian Council, 1989 3 475 Cu IUDs 0 Wang et al., 1992 3 100 Norplant 0.3

  19. Apprehension caused by amenorrhea can be minimized by appropriate counsellingUser satisfaction strongly correlates with counselling Backman et al. Br J Obstet Gynaecol 2000;107:335-339

  20. LNG counseling – bleeding patterns • 1-4 months irregular bleeding • 2-6 months amount and duration of bleeding • 20% will have amenorrhoea at the end of one year • Overall significant reduction in the bleeding

  21. LNG IUS Main reasons for premature removal were • Bleeding problems 5.4 % • Amenorrhea 1% • Pain 2.5% • Acne 1%

  22. Benefits of local action of LNG No significant change in: • Blood pressure • Serum lipids • Coagulation factors • Carbohydrate metabolism • Liver function

  23. Pelvic inflammatory disease5-year cumulative gross termination rates Age group Nova T Levonorgestrel (years) IUS ≤ 25 5.6 0.3 * 26–30 3.0 1.4 31–35 1.4 0.7 ≥ 36 0 0.3 Total 2.2 0.8 * *p < 0.01 Andersson et al., 1994

  24. Body weight over 5 years of use 65 64 63 62 61 Copper IUD Mirena kg 0 12 24 36 48 60 Months Andersson et al., 1993

  25. LNG – other health benefits Reduction in • Amount and duration of bleeding • Incidence of ectopic pregnancies • Menstrual cramps Non-contraceptive benefits • Treatment of DUB and menorrhagia • In HRT for endometrial protection

  26. Other newer IUCDs

  27. The design characteristics of the frameless IUD (fixed, frameless and flexible) are responsible for the low expulsion, high effectiveness and high continuation rates. Insertion is easy and safe in the hands of trained providers and appears to be as reliable and effective as when inserted at interval

  28. GyneFix   • The expulsion rate of 8.4% and removal rate for bleeding and/or pain of 9.0% at 12 months • within acceptable ranges for framed intrauterine devices • does not affect future fertility in nulliparous and parous women Masters T, et al Eur J Contracept Reprod Health Care 2002 Jun;7(2):65-70

  29. Gynefix • The frameless intrauterine device (IUD) dispenses with the frame in the classical IUD and holds the device in the uterus by anchoring one end of a nylon thread in the fundal myometrium, to which copper sleeves are attached • There are insufficient data to show that problems of early expulsions have been overcome with the new introducer used in GyneFix. Apart from that, the frameless device performs similarly to TCu380A, and appears to have a lower pregnancy rate in later years, although the absolute difference is small.

  30. Gynefix Insertion

  31. Newer IUCD’s To Come T shaped LNG Fibroplant GynefixFibrofix

  32. FibroPlant • the FibroPlant levonorgestrel intrauterine system (IUS), releasing 14 microg of levonorgestrel/day. • Strong endometrial suppression is the principal mechanism explaining both the effect on menstrual blood loss and the contraceptive performance of the IUS Eur J Contracept Reprod Health Care 2001 Jun;6(2):93-101

  33. Conclusion • Intrauterine contraception is the most cost-effective reversible method of contraception • increasingly attractive • due to the development of new technologies that not only enhance the performance of the intrauterine device (i.e. efficacy is now close to 100%), but also reduce the rate of expulsion and the number of removals for medical reasons Eur J Contracept Reprod Health Care 2000 Dec;5(4):295-304

  34. Technology made large populations possible and large populations make technology indispensable Joseph Wood Krutch

  35. Thanks to all contributors. Dr Adarsh Bhargava. Dr Ashwini Bhalerao. Dr Alka Kriplani. Dr. Kalpana Apte. Dr Mala Arora. Dr.Meenakshi Bharath. Dr. Mandakini Parihar. Dr.Nozer Sheriar. Dr.Parikshit Tank. Dr. Roza Olyai. Dr.Sasikala Kola. Dr.Sujata Mishra.

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