Intrauterine devices for contraception
The intrauterine device (IUD) is one of the most common forms of reversible contraception for women. IUDs have developed over time from non-medicated plastic frames to copper-bearing devices or IUDs impregnated with hormones. The copper IUDs prevent fertilization by inhibiting sperm mobility and stimulating a cytotoxic inflammatory reaction that is spermicidal. Other IUDs are impregnated with a hormone (progestogen or levonorgestrel) and slowly release the hormones to improve contraceptive action. Three Cochrane Reviews, including a new review published in this month’s Issue 6 (2010), look at the different types of IUDs.
IUDs may be framed or frameless, and each uses a different mechanism to stay in place. The frameless IUDs are the newer form and, as explored in a Cochrane Review, may reduce the risk of expulsion of the IUD, bleeding and pain that can lead to early removal of the IUD, and pregnancy.
There are questions about whether antibiotics reduce infection during insertion and about different times for inserting an IUD, such as after birth or abortion. These have been addressed by three Cochrane Reviews.
IUDs can have unwanted effects, such as pain and bleeding. Fear of pain during insertion is one reason for avoiding this form of contraception, and a Cochrane Review has looked at drugs and other methods to prevent pain. For women using IUDs, pain and heavy bleeding are the commonest reasons for discontinuation, and a Cochrane Review looks at the use of non steroidal anti-inflammatory drugs for treatment of these symptoms.
These Cochrane Reviews of IUDs are a selection of reviews prepared by the Cochrane Fertility Regulation Group. The full list of reviews can be viewed here.
Image credit: John Bavosi/Science Photo Library
Copper containing intrauterine devices
Copper containing intra-uterine devices versus depot progestogens for contraception 
Two common methods of pregnancy prevention are the use of a copper-containing IUD or an injection of a progestogen hormone. This review compares the contraceptive and non-contraceptive benefits and risks of using the copper-containing IUDs versus depot progestogens for contraception. [Download PDF]
Copper containing, framed intra-uterine devices for contraception
The design and copper content of IUDs, as well as the placement of the copper on IUDs, could impact on the benefits and harms of IUDs. This review compares different copper IUDs for their effectiveness and side effects. [Download PDF]
Hormone-impregnated intrauterine devices
Progestogen-releasing intrauterine systems versus other forms of reversible contraceptives for contraception
Hormonally impregnated intrauterine systems add a progestogen to a non-medicated contraceptive device to improve contraceptive action. This review assesses the contraceptive efficacy, tolerability, and acceptability of intrauterine systems versus other reversible contraceptive methods. [Download PDF]
Frameless intrauterine devices
Frameless versus classical intrauterine device for contraception
The early IUDs were non-medicated and consisted only of what is nowadays referred to as the frame of the IUD. Over time, these have been replaced by the more effective copper-bearing devices, which are either framed (T or horseshoe shaped) or frameless. The framed devices stay in place in the uterine cavity due to the extended horizontal 'arms' whereas the frameless ones are anchored to the wall of the uterine fundus. This review examines the hypothesis that the frameless IUD reduces the risk of expulsion and pregnancy, and the problems of bleeding and pain that lead to early removal. [Download PDF]
Using antibiotics to reduce infection during insertion
Routine antibiotics for intrauterine device insertion
Concern about the risk of upper genital tract infection often limits use of the IUD. Since the risk of IUD-related infection is limited to the first few weeks to months after insertion, contamination of the endometrial cavity at the time of insertion appears to be the mechanism, rather than the IUD or string itself. Thus, antibiotic administration before IUD insertion might reduce the risk of upper genital tract infection from passive introduction of bacteria at insertion. This review assesses the effectiveness of prophylactic antibiotic administration before IUD insertion in reducing IUD-related complications and discontinuations within three months of insertion. [Download PDF]
Timing of insertion of intrauterine devices
Immediate postabortal insertion of intrauterine devices
Insertion of an IUD immediately after an abortion has several potential advantages, such as that the woman is known not to be pregnant, which is a major concern for clinicians, and because many clinicians refuse to insert an IUD in a woman who is not menstruating. After induced abortion, a woman's motivation to use contraception may be high. However, the insertion of an IUD immediately after a pregnancy ends carries potential risks, such as an increased risk of spontaneous expulsion due to recent cervical dilation. This review assesses the safety and efficacy of IUD insertion immediately after spontaneous or induced abortion. [Download PDF]
Immediate post-partum insertion of intrauterine devices
Insertion of an IUD immediately after delivery is appealing for several reasons. The woman is known not to be pregnant, her motivation for contraception may be high, and the setting may be convenient for both the woman and her provider. However, the risk of spontaneous expulsion may be unacceptably high. This review assesses the efficacy and feasibility of IUD insertion immediately after expulsion of the placenta. [Download PDF]
Managing unwanted effects during insertion and use
Interventions for pain with intrauterine device insertion
Fear of pain during IUD insertion is a barrier to use of this contraceptive method. Interventions for pain during IUD insertion include non-steroidal anti-inflammatory drugs, local cervical anaesthetics, and cervical ripening agents such as misoprostol. This review assesses all randomized controlled trials that have evaluated a treatment for IUD-related pain. [Download PDF]
Heavy bleeding and pain are the most common reasons why women discontinue IUD. Non-steroidal anti-inflammatory drugs, which inhibit prostaglandin synthesis, have been shown to be effective in reducing menstrual bleeding and pain in women without IUDs. This review summarizes all randomized controlled trials studying use of non-steroidal anti-inflammatory drugs for treatment of bleeding or pain associated with IUD use. [Download PDF]
