Intrauterine device quo vadis? Why intrauterine device use should be revisited particularly in nulliparous women?

Figures & data

Table 1 Estimates of the prevalence of congenital uterine anomalies

Prevalence of uterine anomalies in unselected population
Arcuate uterus	3.9%
Subseptate and septate uterus	2.3%
Bicornuate uterus	0.4%
Unicornuate uterus	0.1%
Uterus didelphys	0.3%
Overall	5%–7%

Note: Data from Chan et al²⁴ and Jurkovic et al.²⁵

Figure 1 Classification of main uterine anomalies.

Notes: Schematic representation (left); three-dimensional sonographic images (right). Adapted from Grimbizis GF, Gordts S, Di Spiezio A, et al. The ESHRE/ESGE con sensus on the classification of female genital tract congenital anomalies. Human Reproduction. 2013;28:2032–2044.²⁶
Abbreviations: ESHRE, European Society of Human Reproduction and Embryology; ESGE, European Society of Gynecological Endoscopy.

Figure 2 Hysteroscopic picture of Jaydess/Skyla causing pain complaints due to the too long transverse arm in a nulliparous woman.

Figure 3 3D ultrasound in nulliparous women.

Notes: Screening three-dimensional (3D) ultrasonography performed in women desiring intrauterine contraception with measurement of the fundal transverse width (upper row); uterine cavities of nulliparous women fitted with a frameless copper IUD. The transverse width of the uterine cavity is indicated below each figure (lower row).
Abbreviation: IUD, intrauterine device.

Figure 4 A narrow uterine cavity fitted by a trimmed T-shaped IUD with transverse arm length of 18 mm.

Abbreviation: IUD, intrauterine device.

Figure 5 An experimental LNG-IUS capable of adaptation to the individual width of uterine cavity.

Abbreviation: LNG-IUS, levonorgestrel intrauterine system.

Table 2 Monthly cost for financing IUD/IUS

Cost of IUD/IUS in Euro (€350)	Financing period (months)
	6	12	18
Monthly cost	€58.33	€29.60	€20.51

Note: Data from Medipay (https://www.medipay.de).⁷⁹

Abbreviations: IUD, intrauterine device; IUS, intrauterine system.

Table 3 Comparison of the cost of various forms of contraception in Germany in 2014

Method	Total cost	Cost per month
Condom	0.30–1€ per unit
Combined oral contraception pill	–	€5–12
3-monthly injectable	–	€10
Subcutaneous progestin implant	€350–450	€9–13
Vaginal ring	–	€13–20
IUD/IUS	€150–350	€3–8

Abbreviations: IUD, intrauterine device; IUS, intrauterine system.

Table 4 Myths and misconceptions that still exist related to intrauterine contraception

Myths and misconceptions	Reality
IUDs cause abortion	IUDs do not terminate a pregnancy. The primary contraceptive effect of intrauterine contraception is the prevention of fertilization and implantation by interfering with sperm motility and survival. The reaction of the intrauterine foreign body with the endometrium activates the release of leukocytes and prostaglandins which act not only in the uterus but also in the oviduct and cervix to impede sperm and egg development
IUDs cause pelvic inflammatory disease	The issue of increased risk or greater severity of sexually transmitted infection (STI) among IUD users has been a prominent concern. However, the rate of PID is low, with cases concentrated in the first 20 days after insertion. The reason for the increased risk during the first weeks after insertion is that bacteria in the vagina and cervix can be transported through the cervical canal into the uterine cavity. It is important to tell the IUD user that for the majority of the users, fertility is restored immediately after removal of the device; irrespective of whether the IUD was used for a few months or for many years
IUDs cause ectopic pregnancy	The risk of ectopic pregnancy in IUD users has been thoroughly investigated. The risk is ten times lower in IUD/IUS users than in the general population of women using no contraception (0.0–0.5/1,000 women vs 3.25–5.25/1,000 women). This finding has been confirmed by a meta-analysis of 16 case–control studies.^Citation80 A previous ectopic pregnancy is not a contraindication for the use of an IUD/IUS
IUDs cannot be used by nulliparous women	Another myth is that women over 25 years or older are the best candidates for IUD use, and that women over 35 are the ideal candidates. This belief, based on the fear of pelvic infection (PID) and the potential for resulting infertility, is no longer justified. There is no biological reason to conclude that a young woman is at higher risk than an older woman provided they have similar sexual behaviors
IUD insertion is painful	One of the reasons of the underuse of the IUD is the fear of insertion pain. The insertion of an IUD is not usually a painful procedure. However, many women, nulliparous women in particular, fear insertion and this may be an important reason not to select an IUD. Several measures can be used to reduce patient discomfort during the insertion and removal of the IUD: premedication, local anesthesia, and cervix relaxing agents, and anxious patients should ask for it. Should physicians pay attention to pain relief, it is likely that many more women will request IUDs as their method of contraception. Taking care of pain relief is important. When counseling, the provider should inform the woman about the insertion procedure and about the measures he/she will take to make insertion less uncomfortable^Citation81
IUDs cause pain and embedment	IUDs do not necessarily have to cause pain during use if properly fitted in the uterine cavity. Providers should select a particular IUD/IUS based on an estimation of the size of the uterine cavity. A standard IUD size will not fit cavities of every size and shape. Frameless IUDs are particularly useful for use in nulliparous and adolescent women as they are flexible and do not cause any distention of the uterus. IUDs that are too big will often embed in the uterine wall. Each woman should request her doctor to select an IUD/IUS that fits into her uterus
IUDs are not effective	IUDs protect 20 times better than the pill, the contraceptive patch, and the vaginal ring against intrauterine and ectopic pregnancy, in contrast with the general belief. The commonly held opinion is that oral contraceptives are more effective than IUDs. Similarly, physicians and the general public are often poorly informed about the effectiveness of IUDs and the effectiveness of contraceptives in general
IUDs are expelled and cause perforation	Total expulsion of a conventional IUD occurs in 5%–10% of women during the first year of use, with an increased risk in nulliparous women. The majority of expulsions occur during the first months after insertion, with 1%–2% per year thereafter. Frameless, anchored IUDs reduce the risk of expulsion approximately five–tenfold, on condition that the IUD is properly inserted. The overall risk of perforation with IUD insertion is around 1–2/1,000 women. Perforation is often caused by unskilful insertion, poor technique due to the absence of training, and lack of attention to contraindications. Women should discuss these issues with their providers. IUDs that do not fit can progressively migrate through the uterine wall due to forceful contractions of the uterus
IUDs cause abnormal and heavy menstrual bleeding	Erratic and heavy menstrual bleeding is the most common cause for IUD discontinuation. The impact on menstrual blood loss with copper IUDs can be minimized by reducing the surface area of the foreign body. The small frameless GyneFix 200 IUD, releasing copper ions from the outer as well as inner surface of the copper tubes, does not increase menstrual blood loss in contrast to all other copper IUDs simply because it is much smaller. On the other hand, all hormone-releasing intrauterine systems strongly reduce menstrual blood loss. Many users of hormonal IUDs develop amenorrhea (have bleed-free periods). In many countries, this is becoming a trend. Several measures are possible to manage erratic menstrual bleeding and spotting if present

Notes: This is a list of the most frequent myths and misconceptions. Data from WHO Scientific Group on the Mechanism of Action Safety and Efficacy of Intrauterine Devices,³⁸ Center for Disease Control and Prevention,³⁹ Wildemeersch et al⁴⁰ and Ortiz et al.⁴¹

Abbreviations: IUD, intrauterine device; PID, pelvic inflammatory disease; IUS, intrauterine system.

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