Table of Contents

Q 17. 1 What are intrauterine contraceptive devices?

These are objects are placed inside the uterus in order to prevent pregnancy. There is evidence that a variety of ‘devices’ have been used for more than two thousand years. In modern clinical practice, widespread use followed the first International Conference in New York in 1962 when the Lippes loop (IUCD) was introduced.

Q 17. 1 What are intrauterine contraceptive devices?

Q 17. 2 How commonly are IUCDs used?

Q 17. 3 Why is copper used in IUCDs?

Q 17. 4 How effective are IUCDs?

Q 17. 5 How do IUCDs work?

Q 17. 6 Can pregnancy occur after an IUCD is removed if I then use another method of contraception?

Q 17. 7 When should an IUCD be introduced?

Q 17. 8 What happens after an IUCD is fitted?

Q 17. 9 How quickly will an IUCD be effective?

Q 17. 10 Can I use tampons when I have an IUCD?

Q 17. 11 Can any drugs interfere with the action of an IUD?

Q 17. 12 How should my IUCD be monitored?

Q 17. 13 What are the benefits of IUCDs?

Q 17. 14 What problems could I have with an IUCD?

Q 17. 15 What are the risks if a pregnancy occurs in the presence of an IUD?

Q 17. 16 What is pelvic actinomycosis?

Q 17. 17 My smear test shows the actinomyces organism. What should be done?

Q 17. 18 How often should an IUCD be changed?

Q 17. 19 How quickly will my fertility return after removal of an IUCD?

POST-COITAL CONTRACEPTION.

Q 17. 20 What is post-coital (morning-after or emergency) contraception?

Q 17. 21 What methods of post-coital contraception are available?

Q 17. 22 How do post-coital contraceptive methods work?

Q 17. 23 What is the Yuzpe method of post-coital contraception?

Q 17. 24 What is the levonorgestrel method of post-coital contraception?

Q 17. 25 What is the post-coital IUCD?

Q 17. 26 How effective is post-coital contraception?

Q 17. 27 Are there any risks if pregnancy continues after post-coital contraception?

Q 17. 28 Where can I obtain further information about contraception?

Q 17. 29 Could I have some Web sites?

Women’s Health – Home Page

Q 17. 2 How popular are IUCDs?

A survey in 1991 found that 5% of women in the UK chose this method. Currently there are more than 100 million women using IUCDs worldwide.

Q 17. 3 Why is copper used in IUCDs?

Early IUCDs were inert, being made of plastic. With the exception of the LNG-IUS (Q14.26), IUCDs are now contain copper. Copper IUCDs have replaced inert IUCDs as they can be smaller and therefore less likely to cause symptoms, notably pain and bleeding problems. Smaller copper IUCDs can be at least as effective as larger inert IUCDs.

Q 17. 4 How effective are IUCDs?

The quoted range of failure is 0.3-2.0 per hundred woman years – this range is for non-hormonal devices. The LNG-IUS is the most effective contraception currently available (Q13.6).

Q 17. 5 How do IUCDs work?

The IUCDs work in a number of ways. All IUCDs produce an inflammatory response in the fluid of the genital tract that largely prevents fertilisation. Copper, increases this inflammatory response and it is toxic to sperm (spermicidal) and the early embryo. The amount of copper entering the body from copper containing IUCDs is believed to be of no significance as there is very little increase in blood levels of copper. Most of the copper is lost through the fluid in the uterus which passes into the vagina. The LNG-IUS causes the endometrium to be thin so that it is not capable of sustaining embryo implantation. It also results in the cervical mucus being impenetrable to sperm. For some, the question of how the IUCD prevents pregnancy is critical. As inert and copper IUCDs are effective partly after fertilisation and they may not be acceptable in some cultures. The Mirena (LNG-IUS –Q14.26) functions almost entirely by preventing fertilisation.

Q 17. 6 Can pregnancy occur after an IUCD is removed if I then use another method of contraception?

If intercourse has taken place within seven days before IUCD removal conception could occur as there may be sperm or an early embryo in the genital tract.

Q 17. 7 When should an IUCD be inserted?

Many doctors prefer to insert an IUCD during a period as the cervix is more open and there is little chance of a current pregnancy. There is, however, a greater chance of expulsion (the uterus squeezes the device back out) if a device is introduced early in the cycle. It would seem that the best time for insertion is just after the period.

Q 17. 8 What happens after an IUCD is fitted?

There may be some bleeding and pain, which generally settle within a few days. Mild analgesics such as paracetamol may be required.

Q 17. 9 How quickly will an IUCD be effective?

Contraception is immediate, but it is advisable to wait one or two weeks before having intercourse

Q 17. 10 Can I use tampons when I have an IUCD?

External sanitary wear is preferable for a week after an IUCD has been introduced, but subsequently internal tampons are fine.

Q 17. 11 Can any drugs interfere with the action of an IUD?

Steroids reduce inflammatory response and could lead to failure of the IUCD. There are no problems with other medications.

Q 17. 12 How should my IUCD be monitored?

To ensure that the device has not been expelled, you should check that the threads of the IUCD are still present after each period. You should see your doctor if you experience irregular bleeding, pelvic pain or excessive discharge. Most doctors would recommend a pelvic examination within a few weeks of insertion of your IUCD. Most expulsions occur during the first few periods and a further check six months later seems appropriate. Subsequently an annual pelvic examination can be recommended.

Q 17. 13 What are the benefits of IUCDs?

• This method provides a highly effective inexpensive and reversible method of contraception.

• No hormone treatment is involved (except with the LNG-IUS).

• It is always present providing continuous contraception.

• Side-effects are minimal.

• There is no evidence of increased risk of cancer.

Q 17. 14 What problems could I have with an IUCD?

The chances are that you will be happy with an IUCD although, as with anything in life, problems do occasionally arise.

• Your IUCD could result in pelvic pain, irregular vaginal bleeding and heavier periods.

• The device may be expelled by the uterus and, if you are not aware that this has happened, you could inadvertently have unprotected intercourse with the possibility of pregnancy.

• Copper IUCDs are associated with a risk of pelvic infection (Q20.2).

• Very rarely, the device may perforate the uterus and end up inside the abdomen (one in a thousand chance).

Q 17. 15 What are the risks if a pregnancy occurs in the presence of an IUD?

Should a pregnancy occur:

• miscarriage and infection are more likely. If the IUCD is left in place the risk of miscarriage is increased even beyond three months. Whilst there is a chance of miscarriage in association with removing the device, the balance of risks is such that if possible, the IUCD should be removed early in the pregnancy. If the pregnancy is to be terminated, the IUCD can be removed at the same time.

• although overall pregnancy rates are low, there is a slightly higher percentage of ectopic pregnancies (pregnancy outside the uterus, Q12.23) than would otherwise be expected.

• there is no evidence of an increased risk of foetal abnormality.

Q 17. 16 What is pelvic actinomycosis?

Pelvic actinomycosis is a chronic low grade pelvic infection due to organisms called actinomyces. Typically, there may be pelvic symptoms, and clinical examination or pelvic ultrasound shows a swelling in the pelvis. Invariably there is an IUCD present unless it has recently been removed. The diagnosis is often made from tissue samples taken at surgery. Pelvic actinomycosis should respond to antibiotics (usually penicillin) taken over several months.

Q 17. 17 My smear test shows the actinomyces organism. What should be done?

You will need to visit your doctor. Most doctors would suggest that if you have an IUCD it should be removed and either a new IUCD fitted or you should change your method of contraception. Many doctors would recommend antibiotics for about two months although this is not universal.

You will need to visit your doctor. Most doctors would suggest that if you have an IUCD it should be removed and either a new IUCD fitted or you should change your method of contraception. Many doctors would recommend antibiotics for about two months although this is not universal.

Q 17. 18 How often should an IUCD be changed?

Modern copper IUCDs are approved for between three and ten years.

Q 17. 19 How quickly will my fertility return after removal of an IUCD?

Fertility returns immediately to pre-existing levels as soon as your IUCD is removed. There is no medical advantage in waiting before trying for a pregnancy.

Q 17. 20 What is post-coital (morning-after or emergency) contraception?

Post-coital contraception (sometimes called emergency contraception) is a method used after unprotected intercourse with the aim of preventing pregnancy. It takes about five days from ovulation (egg release) to implantation (embedding of the early embryo into the lining of the uterus). Post-coital contraception is essentially preventing implantation rather than fertilisation. This method of contraception may not be acceptable to all cultures. Vaginal douching has been used for centuries although it is quite ineffective, as sperm will reach the protection of the cervical mucus within 90 seconds of ejaculation. Effective post-coital contraception was introduced as recently as the early 1960’s when diethylstilboestrol was first prescribed. This oestrogens, estrogens, however, could have adverse effects on the fetus if the pregnancy continued. Diethylstilboestrol has been replaced by ethinyloestradiol, which is the oestrogen used in most combined pills; it has a proven safe track record.

Q 17. 21 What methods of post-coital contraception are available?

There are three methods.

• The Yuzpe method using combined oral contraceptive pills (morning after pill),

• Levonorgestrel (progestogen-only pill).

• Insertion of an IUCD.

Q 17. 22 How do post-coital contraceptive methods work?

They may:

• delay or prevent ovulation.

• reduce the chance of fertilisation.

• prevent implantation in the unlikely event that fertilisation occurs.

Q 17. 23 What is the Yuzpe method of post-coital contraception?

This is named after the Canadian gynaecologist who first described it. Four tablets of PC4 (post-coital 4 tablets) are prescribed. Each tablet contains ethinyloestradiol 50mg and 250mg levonorgestrel (or Ovran – see Table 16.1). Two tablets are taken immediately and the other two tablets 12 hours later. Nausea occurs in about 25% of cases. There may be a little bleeding two or three days after the treatment. Usually, your doctor will wish to review the situation just after your next period is due.

The term ‘morning after pill’ is inappropriate and misleading as it suggests that the method must be initiated within a few hours of unprotected intercourse. The treatment should be commenced within 72 hours of a single episode of unprotected intercourse. It is less effective if taken later. Sadly many unwanted pregnancies have occurred because the women concerned had assumed that they were too late to use a ‘morning after’ pill.

Q 17. 24 What is the levonorgestrel method of post-coital contraception?

The levonorgestrel method requires one 0.75mg tablet (Levonelle-2) to be taken as soon as possible and within 72 hours of unprotected intercourse and a further tablet to be taken 12 hours later. This method is an alternative for women who cannot be given oestrogen (Q15.8). An additional tablet should be taken if vomiting occurs within 2 hours of taking either tablet.

Q 17. 25 What is the post-coital IUCD?

An IUCD can be inserted at the time of consultation with the doctor provided that this is not more than five days later than the predicted time of ovulation. More than one episode of unprotected intercourse is not a contraindication.

Q 17. 26 How effective is post-coital contraception?

The Yuzpe method has a reported success of 98% (two pregnancies per hundred women). The reported success for the levonorgestrel method is 97% (three pregnancies per hundred women). It may be tried more than 12 hours after intercourse but failure is more likely and data is not available. The IUCD method of post-coital contraception is more than 99% successful (less than one pregnancy per hundred women. An additional advantage is that long-term contraception is provided. From a legal point of view, an IUCD should be introduced not later than 5 days after ovulation (day 19 of a 28 day cycle) as implantation could have taken place after that time and the device would be causing pregnancy termination (abortion).

Q 17. 27 Are there any risks if pregnancy continues after post-coital contraception?

It is possible for the pregnancy to implant in the Fallopian tubes (ectopic pregnancy- Q12.23) so you should see your doctor quickly if pain develops in the pelvic area. If the pregnancy is in the uterus and allowed to continue to term there is inevitably concern that the fetus may have been damaged. Early reports do not suggest a significant increased risk. Certainly there is no support for the concept that pregnancy should be terminated because of failed post-coital contraception.

There are risks associated with insertion of an IUCD (Q17.14) or taking the pill (Q15.6) but these are not specific to the post-coital situation.

Q 17. 28 Where can I obtain further information about contraception?

Some your useful sources of further information can be found at Q13.27.

Q 17. 29 Could I have some Web sites?

Evaluation of the quality of Web sites is discussed in Q4.27. You may find that several general women’s health sites may help you (Q4.28). The following are more specialised Web sites on topics found in this chapter:-

Q 17. 1 What are intrauterine contraceptive devices?

Q 17. 2 How commonly are IUCDs used?

Q 17. 3 Why is copper used in IUCDs?

Q 17. 4 How effective are IUCDs?

Q 17. 5 How do IUCDs work?

Q 17. 6 Can pregnancy occur after an IUCD is removed if I then use another method of contraception?

Q 17. 7 When should an IUCD be introduced?

Q 17. 8 What happens after an IUCD is fitted?

Q 17. 9 How quickly will an IUCD be effective?

Q 17. 10 Can I use tampons when I have an IUCD?

Q 17. 11 Can any drugs interfere with the action of an IUD?

Q 17. 12 How should my IUCD be monitored?

Q 17. 13 What are the benefits of IUCDs?

Q 17. 14 What problems could I have with an IUCD?

Q 17. 15 What are the risks if a pregnancy occurs in the presence of an IUD?

Q 17. 16 What is pelvic actinomycosis?

Q 17. 17 My smear test shows the actinomyces organism. What should be done?

Q 17. 18 How often should an IUCD be changed?

Q 17. 19 How quickly will my fertility return after removal of an IUCD?

POST-COITAL CONTRACEPTION.

Q 17. 20 What is post-coital (morning-after or emergency) contraception?

Q 17. 21 What methods of post-coital contraception are available?

Q 17. 22 How do post-coital contraceptive methods work?

Q 17. 23 What is the Yuzpe method of post-coital contraception?

Q 17. 24 What is the levonorgestrel method of post-coital contraception?

Q 17. 25 What is the post-coital IUCD?

Q 17. 26 How effective is post-coital contraception?

Q 17. 27 Are there any risks if pregnancy continues after post-coital contraception?

Q 17. 28 Where can I obtain further information about contraception?

Q 17. 29 Could I have some Web sites?

Women’s Health – Home Page

Give a Comment