Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action

The Levonorgestrel-Releasing Intrauterine Device as Emergency Contraception: Re-examining the Data

Emergency contraception methods that also deliver ongoing contraception provide the most effective options for individuals hoping to prevent pregnancy after unprotected intercourse. Although the copper intrauterine device (IUD) provides the most effective option for emergency contraception because the device prevents pregnancy when placed before implantation and offers long-acting contraception, uptake by patients has been limited. Recently, the Society of Family Planning issued new guidance recommending the levonorgestrel IUD (LNG-IUD) as an emergency contraception option along with the copper IUD. Here, we review evidence related to this recommendation and conclude that the available data do not support use of the LNG-IUD for emergency contraception. We discuss the mechanisms of action of emergency contraception methods and how these concepts interface with the current political and social landscape of contraception and abortion care. We describe limitations of the existing evidence supporting use of the LNG-IUD as emergency contraception and highlight the critical research needed to establish the device as a highly effective method of emergency contraception.

Reversible female contraceptives: historical, current, and future perspectives†

Contraception is a practice with extensive and complicated social and scientific histories. From cycle tracking, to the very first prescription contraceptive pill, to now having over-the-counter contraceptives on demand, family planning is an aspect of healthcare that has undergone and will continue to undergo several transformations through time. This review provides a comprehensive overview of current reversible hormonal and non-hormonal birth control methods as well as their mechanism of action, safety, and effectiveness specifically for individuals who can become pregnant. Additionally, we discuss the latest Food and Drug Administration (FDA)-approved hormonal method containing estetrol and drospirenone that has not yet been used worldwide as well as the first FDA-approved hormonal over-the-counter progestin-only pills. We also review available data on novel hormonal delivery through microchip, microneedle, and the latest FDA-approved non-hormonal methods such as vaginal pH regulators. Finally, this review will assist in advancing female contraceptive method development by underlining constructive directions for future pursuits. Information was gathered from the NCBI and Google Scholars databases using English and included publications from 1900 to present. Search terms included contraceptive names as well as efficacy, safety, and mechanism of action. In summary, we suggest that investigators consider the side effects and acceptability together with the efficacy of contraceptive candidate towards their development.

Contraception and Abortion Care for People Living With HIV: A Clinical Guide for Reproductive Health Practitioners

People capable of pregnancy are disproportionately affected by HIV. Family planning needs and services are often unmet in this population, and clinical care guidelines regarding contraceptive options and abortion care are not well elucidated. Individuals living with HIV often face unique barriers in accessing contraception and abortion services due to internalized stigma, medically complex care (eg, drug-drug interactions, adverse effects of antiretroviral therapy), and distrust of health care providers. There is also a lack of clarity among reproductive health, primary, and infectious disease care providers on best-practice contraceptive counseling and contraceptive care for individuals living with HIV, given limited opportunities to enhance expertise in reproductive infectious disease. In this review, we summarize existing and updated evidence and clinical considerations regarding contraceptive counseling and abortion care in this population.

Prevalence of Candida albicans in High-Risk Human Papillomavirus-Positive Women: A Study in Diyarbakır Province, Turkey

The human papillomavirus (HPV) is a significant public health concern due to its association with the development of cervical cancer. Although inflammation caused by Candida spp. has been shown to facilitate oncogenesis, the interactions between HPV and Candida spp. remain unclear. This study aimed to determine the prevalence and genotype distribution of HR-HPV infection HR-HPV-positiveCandida albicans in HR-HPV-positive individuals in Diyarbakır province in Turkey. Cervical samples were taken from 350 participants aged 20-69 years who applied to Diyarbakır Gazi Yaşargil Training and Research Hospital, Gynecology and Obstetrics Clinic. For detection of HPV presence and HR-HPV genotyping, PCR/direct cycle sequencing was used. E6/E7 mRNA expression of HPV-16, -18, -31, -33, and -45 was determined by type-specific real-time NASBA assay (NucliSENS EasyQ(®)HPV v1.1). The presence of Candida albicans in cervical specimens of HR-HPV-positive women was investigated by RAPD-PCR and culture methods. Results. Of the 350 women who participated in the study, 24% were HPV positive and 10.5% were found to be HR-HPV positive. HR-HPV positivity was most frequently detected in the age range of 40-49 years. Among HR-HPV-positive women, C. albicans was found in 59.4%. Conclusion. The most frequent HR-HPV genotype was HPV16, followed by HPV31. Of women who tested positive for HR-HPV, C. albicans was discovered in 59.4%. C. albicans infection may occur when the immune system is weakened or the balance of the vaginal flora is disturbed, increasing tissue damage in the vaginal area and the risk of carcinogenesis of HR-HPV. Therefore, knowing the presence of Candida infection in HR-HPV-positive women is essential to plan the treatment and prevent the risk of secondary disease.

Systems analysis reveals differential expression of endocervical genes in African women randomized to DMPA-IM, LNG implant or cu-IUD

Although effective contraceptives are crucial for preventing unintended pregnancies, evidence suggests that their use may perturb the female genital tract (FGT). A comparative analysis of the effects of the most common contraceptives on the FGT have not been evaluated in a randomized clinical trial setting. Here, we evaluated the effect of three long-acting contraceptive methods: depot medroxyprogesterone acetate(DMPA-IM), levonorgestrel(LNG) implant, and a copper intrauterine device (Cu-IUD), on the endocervical host transcriptome in 188 women from the Evidence for Contraceptive Options and HIV Outcomes Trial (ECHO) trial. Cu-IUD usage showed the most extensive transcriptomic changes, and was associated with inflammatory and anti-viral host responses. DMPA-IM usage was enriched for pathways associated with T cell responses. LNG implant had the mildest effect on endocervical gene expression, and was associated with growth factor signaling. These data provide a mechanistic basis for the diverse influence that varying contraceptives have on the FGT.

Complications of Long-Acting Reversible Contraceptive Modalities

ABSTRACT

Long-acting reversible contraception has risen in popularity in recent decades and is becoming one of the more common modalities of contraception in the United States, with a growing adolescent population among its users. The 2 modalities of long-acting reversible contraception-intrauterine devices and subcutaneous hormonal implants/etonogestrel implants (referred to as Nexplanon in the US)-are beneficial for their excellent effectiveness, ease of use, and safety profile. This article reviews the pharmacology of these modalities, common complications and their presentations, and the initial evaluation and management in the pediatric emergency department setting. Where applicable, attention will be paid to problems unique to the adolescent population.

Long-Acting Reversible Contraception for Adolescents: A Review of Practices to Support Better Communication, Counseling, and Adherence

Long-acting reversible contraception (LARC) methods, including levonorgestrel and copper intrauterine devices (IUDs) and the subdermal contraceptive implant, are the most effective reversible forms of contraception and thus are an important aspect of adolescent pregnancy prevention. While LARC efficacy, safety, and appropriateness are supported by major medical organizations and usage rates are increasing, overall LARC uptake among United States (US) adolescents remains lower than uptake of short-acting contraceptive methods. A better understanding of the barriers affecting adolescent LARC uptake and reasons for discontinuation could help facilitate effective communication. For example, learning how to improve adolescent-centered communication, shared decision-making, and motivational counseling strategies may be the first step to improving utilization rates. This narrative review includes three sections. First, this review will describe the history, mechanisms of action, and epidemiology of adolescent LARC use in the US and globally. Next, this review will describe key factors influencing adolescent LARC uptake, reasons for discontinuation, and multilevel barriers specific to adolescent LARC use. Finally, this review will characterize communication techniques and LARC counseling strategies for adolescents in the context of a reproductive justice approach set in the health belief model framework. The distinction between moving away from a presumptive counseling approach towards an adolescent-centered, shared decision-making approach to encourage parent-adolescent sexual health communication to lay the foundation of empowering adolescent reproductive autonomy should be the underpinning of all effective reproductive communication strategies.

Society of Family Planning Clinical Recommendation: Emergency contraception

Emergency contraception (EC) refers to several contraceptive options that can be used within a few days after unprotected or under protected intercourse or sexual assault to reduce the risk of pregnancy. Current EC options available in the United States include the copper intrauterine device (IUD), levonorgestrel (LNG) 52 mg IUD, oral LNG (such as Plan B One-Step, My Way, Take Action), and oral ulipristal acetate (UPA) (ella). These clinical recommendations review the indications, effectiveness, safety, and side effects of emergency contraceptive methods; considerations for the use of EC by specific patient populations and in specific clinical circumstances and current barriers to emergency contraceptive access. Further research is needed to evaluate the effectiveness of LNG IUDs for emergency contraceptive use; address the effects of repeated use of UPA at different times in the same menstrual cycle; assess the impact on ovulation of initiating or reinitiating different regimens of regular hormonal contraception following UPA use; and elucidate effective emergency contraceptive pill options by body mass indices or weight.

The Effects of Hormonal and Non-Hormonal Intrauterine Devices on Female Sexual Function: A Systematic Review

Objectives

The goal of this paper was to review and synthesize the extant literature exploring the impact, if any, of copper (Cu) and levonorgestrel (LNG) intrauterine devices on female sexual function.

Methods

To review the literature, Medline, PubMed, and PsychINFO, were searched for primary research articles that were available in English and measured female sexual function in Cu- and LNG-IUD users. 35 quantitative and 2 qualitative research papers met criteria for inclusion in this systematic review. The 35 quantitative articles were then rated based on the STROBE statement.

Results

The included articles indicated a positive impact of LNG-IUDs on sexual pain, and a positive-to-neutral effect of IUDs on sexual desire, however more research is warranted. This review also found IUDs to be generally non-impactful on other domains of sexual function, including arousal, lubrication, orgasm, satisfaction, and overall sexual function.

Conclusions

As this review highlights that LNG-IUDs may improve sexual pain, future research should explore this connection further. Additional RCTs should also be conducted to confirm effects on sexual function with little bias. A better understanding of the impact of both Cu- and LNG-IUDs is necessary to expand upon this field of research and uncover any other benefits or detriments from IUDs.

Retained Copper Intrauterine Device Fragment in Pregnancy: A Case Report

Copper intrauterine device (IUD) failure and fragmentation are rare, with minimal documentation on their effects in pregnancy. Recommendations from professional organizations highlight the importance of prompt identification and surgical removal, as case reports have noted various acute and chronic intra-abdominal pathologies. However, limited guidance exists around counseling patients who are pregnant with a retained IUD fragment. Here, we present a case of a normal pregnancy with a retained copper IUD fragment, while reviewing existing data on management and counseling.

Importance of the endometrial immune environment in endometrial cancer and associated therapies

Endometrial cancer is rising in prevalence. The standard treatment modality of hysterectomy is becoming increasingly inadequate due primarily to the direct link between endometrial cancer and high BMI which increases surgical risks. This is an immunogenic cancer, with unique molecular subtypes associated with differential immune infiltration. Despite the immunogenicity of endometrial cancer, there is limited pre-clinical and clinical evidence of the function of immune cells in both the normal and cancerous endometrium. Immune checkpoint inhibitors for endometrial cancer are the most well studied type of immune therapy but these are not currently used as standard-of-care and importantly, they represent only one method of immune manipulation. There is limited evidence regarding the use of other immunotherapies as surgical adjuvants or alternatives. Levonorgestrel-loaded intra-uterine systems can also be effective for early-stage disease, but with varying success. There is currently no known reason as to what predisposes some patients to respond while others do not. As hormones can directly influence immune cell function, it is worth investigating the immune compartment in this context. This review assesses the immunological components of the endometrium and describes how the immune microenvironment changes with hormones, obesity, and in progression to malignancy. It also describes the importance of investigating novel pathways for immunotherapy.

Contraceptive Counseling for the Transgender Patient Assigned Female at Birth

Although almost 0.7% of the Brazilian population identifies as transgender, there is currently no training for healthcare professionals to provide comprehensive care to these patients, including the discussion of reproductive planning. The use of testosterone promotes amenorrhea in the first months of use; however, this effect does not guarantee contraceptive efficacy, and, consequently, increases the risks of unplanned pregnancy. The present article is an integrative review with the objective of evaluating and organizing the approach of contraceptive counseling for the transgender population who were assigned female at birth. We used the PubMed and Embase databases for our search, as well as international guidelines on care for the transgender population. Of 88 articles, 7 were used to develop the contraceptive counseling model. The model follows the following steps: 1. Addressing the information related to the need for contraception; 2. Evaluation of contraindications to the use of contraceptive methods (hormonal and nonhormonal); and 3. Side effects and possible discomfort associated with the use of contraception. The contraceptive counseling model is composed of 18 questions that address the indications and contraindications to the use of these methods, and a flowchart to assist patients in choosing a method that suits their needs.

Ectopic Intrauterine Device Revealed by Ureteral Colic in a 37-Week Pregnant Woman: Case Report

Copper T intrauterine devices (IUDs) are a popular long-acting reversible contraceptive method. The most common reasons for contraceptive failure are expulsion and extrauterine migration. We report a case of a 28-year-old female, G13P3, 37 weeks pregnant, who presented to the hospital for left abdominal flank pain. The patient was admitted for treatment of left ureteral colic. The woman went into labour, and Caesarean Section was performed due to foetal distress. During the surgery, an inspection of the peritoneal cavity revealed a copper IUD embedded in the granulous tissue located in the left lateral abdominal region, which was extracted. No uterine scar tissue could be identified macroscopically. The migration of an IUD in the abdominal cavity is a rare finding, and coexistence with third-trimester pregnancy is an infrequent but serious event due to potential visceral complications. Higher gravidity can be associated with an increased risk of IUD migration in women with a non-scarred uterus.

Beyond the pill: contraception and the prevention of hereditary ovarian cancer

BRCA1 and BRCA2 mutation carriers face an elevated lifetime risk of developing ovarian cancer. Oral contraceptives have been shown to significantly decrease the risk of ovarian cancer by approximately 50% in this high-risk population. Changes in contraceptive formulations and patterns of use over time have introduced lower hormonal dosages, different steroid types and non-oral routes of administration. Specifically, there has been a considerable shift in patterns of contraceptive use and the increase in the uptake of non-oral, long-acting, reversible contraception (e.g., intrauterine devices, implants, injections) has corresponded to a decline in oral contraceptive pill use. Whether or not these other methods confer a protective effect against ovarian cancer in the general population is not clear. To our knowledge, there have been no such studies conducted among BRCA mutation carriers. Furthermore, the impact of these changes on the risk of developing ovarian cancer is not known. In this article, we will review the existing epidemiologic evidence regarding the role of contraceptives and the risk of ovarian cancer with a focus on women with a BRCA1 or BRCA2 mutation. We will discuss recent findings and gaps in the knowledge while extrapolating from studies conducted among women from the noncarrier population.

The Penis, the Vagina and HIV Risk: Key Differences (Aside from the Obvious)

Globally, most Human Immunodeficiency Virus type 1 (HIV) transmission occurs through vaginal–penile sex (heterosexual transmission). The local immune environment at the site of HIV exposure is an important determinant of whether exposure during sex will lead to productive infection, and the vaginal and penile immune milieus are each critically shaped by the local microbiome. However, there are key differences in the microbial drivers of inflammation and immune quiescence at these tissue sites. In both, a high abundance of anaerobic taxa (e.g., Prevotella) is associated with an increased local density of HIV target cells and an increased risk of acquiring HIV through sex. However, the taxa that have been associated to date with increased risk in the vagina and penis are not identical. Just as importantly, the microbiota associated with comparatively less inflammation and HIV risk—i.e., the optimal microbiota—are very different at the two sites. In the vagina, Lactobacillus spp. are immunoregulatory and may protect against HIV acquisition, whereas on the penis, “skin type” flora such as Corynebacterium are associated with reduced inflammation. Compared to its vaginal counterpart, much less is known about the dynamics of the penile microbiome, the ability of clinical interventions to alter the penile microbiome, or the impact of natural/induced microbiome alterations on penile immunology and HIV risk.

Ovarian drilling down-regulates endometrial nuclear factor-κB p65 expression in women with PCOS: A prospective case-control study

Objective:

To investigate the impact of laparoscopic ovarian drilling (LOD) on the expression of endometrial NFκB p65 (Rel A) in women with clomiphene-resistant polycystic ovary syndrome (PCOS).

Materials and Methods:

The study group comprised 25 normal-weight women with PCOS undergoing LOD and 14 control women without PCOS. Endometrial NF-κB p65 levels evaluated before and after LOD following immunohistochemical staining. The semiquantitative method was used to evaluate the intensity of NF-κB p65 levels. NF-κB p65 was found to higher in the endometrium of patients with PCOS compared to controls. LOD leads to significant down-regulation in endometrial NF-κB p65 expression. NF-κB p65 expression of PCOS and fertile control were similar after LOD. After LOD, H-score values decreased approximately 3-fold. The H-score of the control subjects was lower than the preoperative and postoperative H-score values of the control women with ovarian cyst.

Results:

Expression of endometrial NF-κB p65 did not change following ovarian cystectomy. The laterality of the ovarian cyst did not cause any change in preoperative H-score values.

Conclusion:

By downregulating the endometrial NF-κB p65 expression LOD improved physiological inflammation in women with PCOS.

The significance of "atrophic endometrium" in women with postmenopausal bleeding

We evaluated the interpretation of atrophic endometrium (AE) histology as the most common cause for postmenopausal bleeding (PMB). This theory has been accepted for several generations by gynecologists and gynecologic oncologists and has been published in past and current major gynecology textbooks. In our review of the literature, we did not find sufficient histological or clinical proof for this concept. In our view, AE is not a cause of PMB and we back this up with a review of old and current medical literature. The old studies are based on information which was obtained prior to the existence of transvaginal sonogram, sonohysterogram and hysteroscopy. Focal lesions are notorious for being missed by endometrial sampling and curettage. Recent studies show that focal endometrial lesions are a crucial cause for PMB and some of those lesions can harbor cancer. In our opinion, AE is the most common histology found because it is physiologic and a ubiquitous finding in postmenopausal women, but it is not a cause of PMB. Referring to AE as a cause of PMB may result in misdiagnosis of cancer, management delay and unnecessary intervention. To avoid misdiagnosis of cancer, transvaginal sonogram should be considered in all women with PMB and AE on pathology. If endometrial thickness is found, AE is unlikely to be the cause of the PMB and further workup is warranted to reveal the true etiology for the bleeding.

Discontinuation rates of intrauterine contraception due to unfavourable bleeding: a systematic review

OBJECTIVE

Levonorgestrel-releasing intrauterine devices (LNG-IUDs) and copper intrauterine devices (Cu-IUDs) offer long-acting contraception; however, some women may discontinue use within the first year due to bleeding pattern changes, limiting their potential. This systematic literature review investigated whether differences in bleeding profiles influence continuation rates in women in America, Europe and Australia.

METHODS

Searches performed in PubMed and Embase were screened to identify publications describing bleeding patterns and rates of early IUC removal/discontinuation or continuation, descriptions of bleeding patterns, reasons for discontinuation, and patient satisfaction, acceptability and tolerability for LNG-IUDs and Cu-IUDs published between January 2010 and December 2019. The results were further restricted to capture citations related to 'Humans' and 'Females'. The review was limited to studies published from 2010 onwards, as changing attitudes over time mean that results of studies performed before this date may not be generalizable to current practice.

RESULTS

Forty-eight publications describing 41 studies performed principally in the USA (n = 17) and Europe (n = 13) were identified. Publications describing bleeding patterns in LNG-IUD users (n = 11) consistently observed a reduction in bleeding in most women, whereas two of three studies in Cu-IUD users reported heavy bleeding in approximately 40% of patients. Rates of discontinuation for both devices ranged widely and may be as high as 50% but were lower for LNG-IUDs versus Cu-IUDs. Discontinuation rates due to bleeding were consistently higher for Cu-IUDs versus LNG-IUDs.

CONCLUSIONS

Bleeding is a common reason for discontinuation of Cu-IUDs and LNG-IUDs. The more favourable bleeding pattern observed in LNG-IUD users may be associated with a lower rate of early discontinuation of LNG-IUDs versus Cu-IUDs.

The Effect Of Contraception On Genital Cytokines In Women Randomized To Copper Intrauterine Device, Intramuscular Depot Medroxyprogesterone Acetate Or Levonorgestrel Implant

BACKGROUND

The ECHO Trial randomized women to intramuscular depot medroxyprogesterone acetate (DMPA-IM), levonorgestrel implant (LNG-implant), or copper intrauterine device (Cu-IUD). In a sub-study of the ECHO Trial, we tested the hypothesis that contraceptives influence genital inflammation by comparing cervicovaginal cytokine changes following contraception initiation. In addition, we compared cytokine profiles in women who acquired HIV (cases) versus those remaining HIV-negative (controls).

METHODS

Women (n=251) from South Africa and Kenya were included. Twenty-seven cervicovaginal cytokines were measured by Luminex at baseline, 1- and 6-month post-contraceptive initiation. In addition, cytokines were measured pre-seroconversion in HIV cases (n=25) and controls (n=100).

RESULTS

At 6-months post-contraceptive initiation, women using Cu-IUD had increased concentrations of 25/27 cytokines compared to their respective baseline concentrations. In contrast, women initiating DMPA-IM and LNG-implant did not experience changes in cervicovaginal cytokines. Pre-seroconversion concentrations of IL-1β, IL-6, and TNF-α, previously associated with HIV risk, correlated with increased HIV risk in a logistic regression analysis, although not significantly after correcting for multiple comparisons. Adjusting for contraceptive arm did not alter these results.

CONCLUSION

Although Cu-IUD use broadly increased cervicovaginal cytokine concentrations at 6-months post-insertion, these inflammatory changes were found not to be a significant driver of HIV risk.

Contraception Selection, Effectiveness, and Adverse Effects: A Review

IMPORTANCE

Many women spend a substantial proportion of their lives preventing or planning for pregnancy, and approximately 87% of US women use contraception during their lifetime.

OBSERVATIONS

Contraceptive effectiveness is determined by a combination of drug or device efficacy, individual fecundability, coital frequency, and user adherence and continuation. In the US, oral contraceptive pills are the most commonly used reversible method of contraception and comprise 21.9% of all contraception in current use. Pregnancy rates of women using oral contraceptives are 4% to 7% per year. Use of long-acting methods, such as intrauterine devices and subdermal implants, has increased substantially, from 6% of all contraceptive users in 2008 to 17.8% in 2016; these methods have failure rates of less than 1% per year. Estrogen-containing methods, such as combined oral contraceptive pills, increase the risk of venous thrombosis from 2 to 10 venous thrombotic events per 10 000 women-years to 7 to 10 venous thrombotic events per 10 000 women-years, whereas progestin-only and nonhormonal methods, such as implants and condoms, are associated with rare serious risks. Hormonal contraceptives can improve medical conditions associated with hormonal changes related to the menstrual cycle, such as acne, endometriosis, and premenstrual dysphoric disorder. Optimal contraceptive selection requires patient and clinician discussion of the patient's tolerance for risk of pregnancy, menstrual bleeding changes, other risks, and personal values and preferences.

CONCLUSIONS AND RELEVANCE

Oral contraceptive pills are the most commonly used reversible contraceptives, intrauterine devices and subdermal implants have the highest effectiveness, and progestin-only and nonhormonal methods have the lowest risks. Optimal contraceptive selection incorporates patient values and preferences.

Does Obesity Influence Body Mass Index Changes in Nulliparous Adolescent Users of Long-Acting Reversible Contraceptives?

OBJECTIVES

To compare body mass index (BMI) changes in adolescents using long-acting reversible contraceptives (LARCs), specifically, the etonogestrel subdermal implant (ENG-implant), levonorgestrel intrauterine device (LNG-IUD), and copper IUD (Cu-IUD), by initial BMI category from the time of LARC insertion to within 6-18 months after insertion.

DESIGN

This was a single-center retrospective cohort study.

SETTING AND PARTICIPANTS

We reviewed electronic health records from our large health system to identify and follow a cohort of 196 adolescents aged 14-19 years with LARCs inserted from 2010 to 2016. We excluded adolescents with conditions or medications affecting weight, including childbirth.

MAIN OUTCOME MEASURE

BMI change from LARC insertion to first BMI documented after 6-18 months RESULTS: Mean age was 17.2 ± 0.2 years; 59% of the cohort was Hispanic and 29% Black. Mean BMI was 26.4 ± 7.1 kg/m². Of the total cohort of adolescents, 51% were underweight/normal, 24% overweight, and 25% obese. Mean time to first BMI documented after LARC insertion was 10.1 ± 3.2 months. Mean BMI change for the total cohort was +0.73 ± 1.8 kg/m², indicating weight gain. Mean BMI change for the ENG-implant + LNG-IUD users (n = 127) was larger than for Cu-IUD users (n = 69) (+0.92 ± 1.9 kg/m² vs +0.37 ± 1.6 kg/m², respectively, P < .05). Two-way analysis of variance showed that both initial BMI category (P = .001) and type of LARC (P = .011) had an independent significant main effect on BMI change. A significant interaction effect (P = .017) showed that obese adolescents had a larger increase in BMI when they were using a progestin-releasing LARC, either ENG-implant or LNG-IUD, as compared to a Cu-IUD (P < .05).

CONCLUSION

Adolescents using progestin-releasing LARCs had a larger increase in BMI within 6-18 months after device insertion than those using Cu-IUDs. The disproportionate increase in BMI with progestin-releasing LARCs was primarily contributed by obese users.

Rates of pregnancy among levonorgestrel and copper intrauterine emergency contraception initiators: Implications for backup contraception recommendations

OBJECTIVE

This study assessed the timing, frequency, use of backup method and 1-month pregnancy rates among individuals who had an intrauterine device (IUD) placed as emergency contraception and reported intercourse within 7 days post-placement.

STUDY DESIGN

In this secondary analysis of a randomized control trial of IUDs for emergency contraception, 518 individuals reporting unprotected intercourse in the preceding 5 days had a 52 mg levonorgestrel intrauterine system (IUS) or 380 mm2 copper IUD placed outside the first week of their menstrual cycle. All participants were advised to use backup contraception for 7 days. We assessed pregnancy status 1 month after placement by urine testing or, when not available, by survey responses and electronic health record review.  Participants reported whether their first sexual activity after device placement occurred within 7 days of their placement, the frequency of intercourse and whether they used backup contraception.

RESULTS

Rapid return to sexual activity was common and use of backup contraception was rare, regardless of type of IUD placed. Of participants who resumed penile-vaginal intercourse in the first month, most (286/446, 64.1%) participants reported intercourse within 7 days of IUD placement; only 16.4% (74/446) used condoms or withdrawal. No pregnancies occurred among users of the levonorgestrel IUS who reported intercourse within 7 days of placement (0/138, 0.0%, 95% CI 0.0%, 2.6%) nor among users of the 380mm2 copper IUD (0/148, 0.0%, 95% CI 0.0%, 2.5%).

CONCLUSION

Pregnancy rates are low after placement of an IUD for emergency contraception, even among the many who resume intercourse within days following IUD placement without use of backup contraception.

IMPLICATIONS

Clinical guidelines should facilitate access to contraception, including elimination of unnecessary recommendations for backup contraception or abstinence in the 7 days following 52 mg levonorgestrel intrauterine system.

No Association Between Intrauterine Contraceptive Devices and Musculoskeletal Hip Joint Pain

Purpose

To investigate the association between intrauterine device (IUD) use and hip pain, orthopaedic visits for hip pain, and arthroscopic hip surgery.

Methods

This was a retrospective cohort study of patients aged 18-44 years old using either IUDs or subdermal implants for contraception in a large commercial claims database (MarketScan) from 2012 to 2015. All patients had at least 12 months of continuous enrollment both before and after contraceptive placement. Patients with a history of hip pain or surgery were excluded. The primary outcome was new hip pain. Secondary outcomes included visiting an orthopaedic or sports medicine provider for a hip complaint, intra-articular hip injection, and arthroscopic hip surgery. Outcomes were analyzed with Cox proportional-hazard models.

Results

We identified a total of 242,383 patients, including 216,541 (89.3%) with IUDs and 25,842 (10.7%) with subdermal contraceptive implants. In time-to-event analysis, IUDs (vs implants) were not associated with increased risk of new hip pain diagnoses (hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.87-1.03, P = .21). In contrast, both age (P < .001) and region (P < .001) were associated with increased risk of new hip pain. Similar results were seen for the secondary outcomes, including risk of orthopaedic visits for hip complaints (HR 1.06, 95% CI 0.83-1.35, P = .63), intra-articular injections of the hip (HR 0.94, 95% CI 0.63-1.41, P = .77), and hip arthroscopy procedures (HR 1.13, 95% CI 0.53-2.40, P = .75).

Conclusions

In this study, we found no evidence that IUDs were associated with hip pain or surgery.

Level of Evidence

Level III, retrospective cohort.

Contraception in Adolescents

Adolescents are at risk for unwanted pregnancy when they become sexually active, and contraception is an important part of mitigating this risk. Use of contraceptive methods, and long-acting reversible contraceptive methods such as implants and intrauterine devices in particular, has increased among adolescents. Although sexual activity has declined and contraceptive use has increased among adolescents in the United States in recent years, the unintended pregnancy rate remains high. All of the currently available contraceptive methods are safe and effective for adolescents to use; however, adolescents may have specific concerns about side effect profiles and unscheduled bleeding that should be addressed during contraceptive counseling. Healthcare providers should prioritize adolescents' needs and preferences when approaching contraceptive counseling, and also consider the unique access and confidentiality issues that adolescents face when accessing contraception.

PET/CT Variants and Pitfalls in Gynecological Cancers

The role of hybrid imaging with 2-[18F] flourodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT) is continuously evolving and now considered standard practice in evaluation of disease stage, treatment response, recurrent disease and follow-up for numerous primary malignancies. In gynecological malignancies FDG PET/CT plays an important role, not only in the assessment of disease in the pre-and post-therapy setting, but also in radiation therapy (RT) planning by defining the metabolically active gross tumor volume (GTV. The glucose analogue radiotracer, FDG, is by far the most utilized radiotracer in PET/CT and is typically seen with high uptake in malignant cells. The radiotracer FDG has a high sensitivity but low specificity for malignancy, as benign processes with an inflammatory response for example infection, are also FDG-avid. In the evaluation of the female pelvic region an awareness of potential confounding factors in the interpretation of FDG is essential as variations of FDG uptake occur in accordance with the menstrual cycle and the menopausal state. Incidental imaging findings in the female genital can pose differential diagnostic challenges as false-positive and false-negative findings in benign and malignant processes are not uncommon. Gynecological malignancies continue to pose major public health problems with cervical cancer as the fourth most common cancer in women ranking after breast cancer, colorectal cancer and lung cancer. Familiarity with frequently encountered benign and malignant variants and pitfalls in FDG PET/CT in the female pelvic region can aid the reader in differential diagnostic considerations.

Morphogenesis of the human preimplantation embryo: bringing mechanics to the clinics

During preimplantation development, the human embryo forms the blastocyst, the structure enabling uterine implantation. The blastocyst consists of an epithelial envelope, the trophectoderm, encompassing a fluid-filled lumen, the blastocoel, and a cluster of pluripotent stem cells, the inner cell mass. This specific architecture is crucial for the implantation and further development of the human embryo. Furthermore, the morphology of the human embryo is a prime determinant for clinicians to assess the implantation potential of in vitro fertilized human embryos, which constitutes a key aspect of assisted reproduction technology. Therefore, it is crucial to understand how the human embryo builds the blastocyst. As any material, the human embryo changes shape under the action of forces. Here, we review recent advances in our understanding of the mechanical forces shaping the blastocyst. We discuss the cellular processes responsible for generating morphogenetic forces that were studied mostly in the mouse and review the literature on human embryos to see which of them may be conserved. Based on the specific morphological defects commonly observed in clinics during human preimplantation development, we discuss how mechanical forces and their underlying cellular processes may be affected. Together, we propose that bringing tissue mechanics to the clinics will advance our understanding of human preimplantation development, as well as our ability to help infertile couples to have babies.

Risk of precancerous cervical lesions in women using a hormone-containing intrauterine device and other contraceptives: a register-based cohort study from Denmark

STUDY QUESTION

Is the risk of high-grade precancerous cervical lesions and/or is the risk of lesion progression increased in users of a hormone-containing intrauterine device (HIUD) compared with users of other contraceptive methods.

SUMMARY ANSWER

Women starting use of HIUD had the same subsequent risk of cervical intraepithelial neoplasia 3+ (CIN3+) as copper IUD (CIUD) users, and both groups tended to have lower risks than oral contraceptives (OC) users.

WHAT IS KNOWN ALREADY

HIUDs may cause inflammatory and immunosuppressive changes that may potentially affect the risk of persistent human papillomavirus infection and precancerous cervical lesions.

STUDY DESIGN, SIZE, DURATION

A Danish population-based cohort study was conducted using register data from 2008 to 2011 on 26–50-year-old users of HIUD (n = 60 551), CIUD (n = 30 303), or OC (n = 165 627).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Within each user group, women were divided into two groups; normal cytology or abnormal diagnosis before start of contraceptive use (baseline). Follow-up histology and cytology diagnoses were registered during the 5 years after baseline. Adjusted relative risks (aRR) and 95% CI were calculated for precancerous cervical lesions in HIUD users compared with CIUD and OC users.

MAIN RESULTS AND THE ROLE OF CHANCE

Women with normal cytology at baseline: at follow-up HIUD users had the same risk of CIN3 or higher (3+) as CIUD users; aRR 1.08 (95% CI 0.94–1.22). For the HIUD and CIUD groups compared with OCs, the risks of CIN3+ were lower: aRR 0.63 (95% CI 0.57–0.69) and aRR 0.58 (95% CI 0.52–0.65), respectively. The same was observed for CIN2 risks: aRR 0.86 (95% CI 0.76–0.96) and aRR 0.68 (95% CI 0.58–0.79) for HIUD and CIUD groups, respectively. Women with abnormal diagnosis at baseline: a lower progression risk, except for CIN2+ at baseline, was observed in HIUD users compared with OC users. Similar progression risks were found in HIUD and CIUD users. There were no differences between the three contraceptive groups in persistence or regression of present lesions.

LIMITATIONS, REASONS FOR CAUTION

We adjusted for age, education, and region of residence as a proxy for socio-economic factors. Data on smoking and sexual behavior were not available thus we cannot exclude some differences between the three user groups.

WIDER IMPLICATIONS OF THE FINDINGS

These findings suggest that women may safely use HIUDs.

STUDY FUNDING/COMPETING INTEREST(S)

A.P. Møller Foundation for the Advancement of Medical Science, Else and Mogens Wedell-Wedellborgs Fund, Direktør Emil C. Hertz og Hustru Inger Hertz Fund, and the Fund for Development of Evidence Based Medicine in Private Specialized Practices. EL is principle investigator for a study with HPV-test-kits provided by Roche. The other authors have nothing to declare.

TRIAL REGISTRATION NUMBER

N/A.

Effective easing of the side effects of copper intrauterine devices using ultra-fine-grained Cu-0.4Mg alloy

Copper intrauterine device is one of the most adopted contraceptive methods with high effectiveness (over 99 %), low cost, spontaneous reversibility and long-lasting usage. However, the side effects induced from the initial burst release of copper ions (Cu²⁺) hinder the continuation of the Cu-IUD made of Coarse-Grained Copper (CG Cu). We proposed to tailor the bio-corrosion behaviors of better control of Cu²⁺ release via the addition of bioactive Mg into the Ultra-Fine Grained (UFG) Bulk Cu. Thus, UFG bulk Cu with 0.4 wt.% Mg was produced via equal-channel angular pressing. The microstructures of the UFG Cu-0.4Mg was observed using electron backscatter diffraction and transmission electron microscopy techniques. The in vitro long-term corrosion behaviors in simulated uterine fluid, cytotoxicity to four cell lines, in vivo biocompatibility and contraceptive efficacy were all studied on CG Cu, UFG Cu and UFG Cu-0.4Mg materials. The results demonstrate that both the ultrafine grains and the addition of bioactive Mg into Cu contribute to the suppression of the burst release of Cu²⁺ in the initial stage and the maintenance of high level Cu²⁺ in long-term release. Moreover, the UFG Cu-0.4Mg also exhibited much improved cell and tissue biocompatibility from both the in vitro and in vivo evaluations. Therefore, the contraceptive efficacy of UFG Cu-0.4Mg is still maintained as high as the CG Cu and UFG Cu while the side effects are significantly eased, suggesting the high potential of the UFG Cu-0.4Mg alloy as a new upgrading or alternative material for Cu-IUD. STATEMENT OF SIGNIFICANCE: The side effects from burst release of Cu²⁺ at the initial implantation stage of Cu-containing intrauterine devices (Cu-IUD) is one of the main drawbacks of these devices. In this work, an ultra-fine-grained Cu (UFG Cu) alloyed with a low amount of bioactive Mg was used for a Cu-IUD. The UFG Cu-0.4Mg alloy exhibited suppressed burst release of Cu²⁺ at initial implantation, while active Cu²⁺ release for long-term usage was maintained, comparable to coarse-grained pure Cu. Furthermore, the UFG Cu-0.4Mg alloy displayed significantly improved biocompatibility with human uterus cells and a much decreased inflammatory response within the uterus. Therefore, the side effects from Cu-IUD were eased, while high antifertility efficacy of the UFG Cu-0.4Mg alloy was maintained. The UFG Cu-0.4Mg alloy is promising for Cu-IUD.

Uterine synechiae after intrauterine device use: a case series

PURPOSE

The intrauterine device (IUD) is one of the most effective and safe contraceptive methods. Substantial literature suggests an overall return to normal fertility following IUD removal. However, there are no studies to date that evaluate endometrial function specifically in nulliparous women after levonorgestrel IUD use.

METHODS

We present three nulliparous women with a history of levonorgestrel IUD use who were evaluated for uterine dysfunction at the University of California, San Francisco Center for Reproductive Health. These patients had no other known risk factors or history of uterine manipulation, including prior uterine surgery, pelvic radiation, intrauterine infection, hypothalamic amenorrhea, or uterine anomaly.

RESULTS

Upon evaluation, these patients were found to have uterine synechiae concerning for Asherman syndrome. All three patients were eventually able to conceive through assisted reproductive technology or natural conception.

CONCLUSION

This case series is the first to suggest a possible effect of endometrial dysfunction on fertility resumption following levonorgestrel IUD removal in nulliparous patients. It is possible that a small subset of patients may be at risk for Asherman syndrome after IUD use. Larger prospective trials are needed to explore this possible association.

Copper and levonorgestrel containing intrauterine devices: comparison of their effect on oxidative stress markers

We aimed to evaluate the oxidative stress by measuring the thiol-disulfide balance in women who use either T380A or LNG-IUD as a contraceptive method. Material and method: The study included two groups; 30 women with LNG-IUD and 30 women with copper-IUD. Thiol-disulfide homeostasis as a marker of oxidative stress was analyzed before the IUD insertion and on the 6^th month after insertion. Results: The LNG-IUD group had similar native thiol levels with Cu-IUD (293.1 ± 43.5 µmol/l vs. 290.4 ± 42.4 µmol/l respectively, p = 819). In the copper-IUD group total thiol levels were higher than LNG-IUD group (345.5 ± 58.2 µmol/l vs. 319.5 ± 52.4 µmol/l, p = .031). A significant increase was observed after 6 months in LNG-IUD patients in terms of disulfide/native thiol (7.9 ± 4.4% vs. 11.2 ± 2.6%, p = .006), disulfide/total thiol (6.2 ± 1.8% vs. 8.7 ± 1.9%, p = .004) and Native thiol/total thiol (87.1 ± 12.1% vs. 82.3 ± 8.2%, p = .004) levels. After 6 months in copper-IUD patients, disulfide (22.3 ± 7.3 µmol/l vs. 27.5 ± 6.9 µmol/l respectively, p = .006), disulfide/native thiol (7.7 ± 3.8% vs. 9.8 ± 2.4% respectively, p = .007), disulfide/total thiol (6.4 ± 2.03% vs. 8.2 ± 1.8% respectively, p = .007) and native thiol/total thiol (86.3 ± 9.4% vs. 83.8 ± 10.6% respectively, p = .007) levels were increased. Conclusion: An increase in oxidative stress markers were observed in both groups. Studies evaluating the long term subclinical risks of IUD's are needed to understand the outcomes of the increased oxidative stress.

The effect of copper intrauterine device use duration on uterine and ovarian blood flow parameters: A prospective cross-sectional study

PURPOSE

This prospective cross-sectional study aimed to compare uterine and ovarian arterial Doppler signals in regularly menstruating patients who had been using copper intrauterine devices (IUD) for different durations.

METHODS

Four groups of participants were formed (n = 30 for each) depending on the duration of copper IUD use: less than 1 year (group 1), 1 to 3 years (group 2), and over 3 years (group 3). Women without IUDs formed the control group. All participants were called in on the fifth-eighth days of their menstrual cycle for Doppler blood flow assessment. The pulsatility index (PI) and resistance index (RI) values were recorded in uterine and ovarian arteries.

RESULTS

The groups 2 and 3 had significantly higher uterine artery PI and RI values than groups 1 and 4. Furthermore, group 2 had uterine and ovarian artery PI and RI values similar to those of group 3. There was a positive relationship between uterine and ovarian arteries' PI and RI values with the duration of IUD use.

CONCLUSIONS

The presence of an IUD for over a year seems to cause changes in the uterine artery PI and RI values assessed by Doppler ultrasonography.

Long-term Management of the Adult Liver Transplantation Recipients

The survival of liver transplantation (LT) recipients has been improved remarkably in short-term. The major causes of mortality in long-term include nonimmunological causes such as cardiovascular, de novo malignancy, chronic kidney disease, and recurrence of primary disease. Rejection-related mortality is rare in the long-term after LT. We discuss nonrejection causes of long-term morbidity/mortality, risk factors, and management strategies in LT recipients. In addition, we discuss osteoporosis, contraception, and pregnancy in LT recipients.

Contraception for the Cardiac Patient: a Cardiologist’s Primer

Purpose of review

Cardiovascular disease (CVD) is the number one cause of maternal mortality in the USA. There are many cardiac conditions which pose significant risk to maternal health, and these women should be offered options to avoid unwanted pregnancies. Individualized contraceptive counseling focusing on woman’s desire for future pregnancy, comorbid conditions, and desire for hormone or non-hormonal (contraceptive) options is paramount to avoid adverse or unwanted side effects. The purpose of this review is to give general guidance on prescribing both hormonal and non-hormonal contraceptives for providers caring for women with heart disease.

Recent findings

Specific recommendation for the use of either non-hormonal or hormonal contraception requires knowledge of the types of contraceptive options available, cost, failure rates, and contraindications to use. Newer progestin-only options have become available and should be considered first-line therapy for women with cardiovascular disease.

Summary

The physiologic burden of pregnancy on the cardiovascular system can cause significant maternal morbidity and mortality for women with underlying CVD. These women should be offered safe and effective options for birth control, and both cardiology and obstetrical providers alike should possess fundamental knowledge of appropriate options.

A rare case of ovarian ectopic pregnancy with IUD in situ: A case report from Nepal

High index of suspicion of ectopic (much likely ovarian) pregnancy should be considered if a woman with IUD in situ presents with abdominal pain, vaginal bleeding, and positive urine pregnancy test.

Clinical Evaluation of Li Brush Endometrial Samplers for Diagnosing Endometrial Lesions in Women With Intrauterine Devices

Background: For women with intrauterine devices (IUDs), it is difficult to sample the endometrium when abnormal uterine bleeding occurs or when regular screening of endometrial cancer is proposed. The purpose of this study is to evaluate the validity of endometrial sampling using Li Brush in IUD users.

Methods: This study was a prospective cohort study and conducted in two parts. Part I was to assess the impact of Li Brush on the position of IUDs. Transvaginal ultrasound was used to locate IUDs before and after sampling. Part II was to explore the diagnostic accuracy of Li Brush in detecting endometrial lesions. IUD users with irregular uterine bleeding were recruited in the IUD group and IUD non-users who arranged for dilatation and curettage (D&C) were recruited in the control group. The endometrium was sampled by Li Brush for cells and by D&C for tissues in both groups. The satisfactoriness of sampling and validity of Li Brush were evaluated.

Results: Seventeen cases in part I confirmed no significant difference in the position of IUDs before and after sampling (p = 0.20). 112 IUD users and 139 IUD non-users were recruited in part II. Li Brush achieved 94.64 and 92.09% satisfactory sampling rates in the IUD group and control group, respectively, without statistically significant difference between the two groups (p = 0.42). The Sensitivity and specificity of Li Brush for detection of endometrial lesions in IUD group were 95.35 and 87.76% respectively.

Conclusions: Li Brush used for endometrial biopsy did not affect the position of IUDs and had high yield of satisfactory samples and good validity for endometrial diagnoses. It was feasible to screen endometrial lesions by Li Brush for women with IUDs.

Long-acting contraception in adolescents and young women with type 1 and type 2 diabetes

Adolescent pregnancy is a major public health problem worldwide. Adolescents living with diabetes are not aware of the risks of unplanned pregnancy and the high rate of fetal and maternal complications when gestation occurs in women with significant hyperglycemia. These data highlight the significance of pregnancy prevention in young women with diabetes. Long-acting reversible contraceptives (LARCs), which include subdermal progestin implants and hormonal and nonhormonal intrauterine devices (IUDs), have been recommended by the American College of Obstetricians Gynecologists and the American Academy of Pediatrics as a first-line contraceptive option for adolescents and young women. This article reviews LARC options for adolescents and young women with type 1 (T1D) and type 2 (T2D) diabetes as well as the possible complications and side effects.

Management of Intrauterine Device Migrated into the Bladder: A Case Report and Literature Review

Intrauterine device represents the most reversible method of contraceptive worldwide. Its insertion is a medical procedure not free from complication. We report a rare case of intravesical migration of a copper intrauterine device inserted 18 months earlier in a 28-year-old multiparous woman. The patient presented with irritative lower urinary tract symptoms, and she was managed endoscopically. This case underscores the role of cystoscopy in irritative lower urinary tract symptoms post IUD insertion.

C-reactive protein and ART outcomes: a systematic review

BACKGROUND

A dynamic balance between pro- and anti-inflammatory factors contributes to regulating human female reproduction. Chronic low-grade inflammation has been detected in several female reproductive conditions, from anovulation to embryo implantation failure. C-reactive protein (CRP) is a reliable marker of inflammation that is extensively used in clinical practice. Recent studies quantified CRP in the serum of infertile women undergoing ART and suggested its potential for the prediction of ART reproductive outcomes.

OBJECTIVE AND RATIONALE

The first objective of this systematic review of the available literature was to evaluate the association between pre-implantation circulating CRP concentration and pregnancy rates in women undergoing ART. The second objective was to describe serum CRP concentration changes after early embryo implantation. The changes in circulating CRP throughout the ART cycle, clinical implications of CRP quantification for the management of women undergoing ART, and future therapeutic options will also be discussed.

SEARCH METHODS

The MEDLINE database was systematically searched from inception to March 2019 using the following key words: (C-reactive protein) AND (assisted reproductive techniques OR ovulation induction OR insemination OR in vitro fertilization). Only articles in English were considered. Studies were selected based on title and abstract. The full text of potentially relevant articles was retrieved and assessed for inclusion by two reviewers (S.B. and S.H.). The protocol was registered in the International prospective register of systematic reviews (PROSPERO; registration number: CRD148687).

OUTCOMES

In total, 10 studies were included in this systematic review. Most of these studies reported lower circulating CRP values before the window of implantation and higher circulating CRP values during the peri-implantation period in women with successful ART outcome (biochemical or clinical pregnancy) compared to women without a successful outcome. Several lifestyle factors and/or drugs that reduce the concentration of circulating CRP significantly improve ART outcomes. Subgroup analyses according to female BMI and baseline circulating CRP concentration are highly recommended in future analyses.

WIDER IMPLICATIONS

These findings highlight a possible detrimental impact of preconception high circulating CRP concentration on ART outcomes. However, the biochemical or clinical pregnancy rate endpoints used in the studies examined here are insufficient (there were no data on live birth outcome), and the impact of major variables that can influence CRP and/or ART, for example maternal age, BMI, number of transferred embryos, and use of anti-inflammatory drugs, were not considered in the analyses. CRP quantification may be a potential marker of ART outcome, but its predictive value still needs to be investigated in large prospective studies. In future, the quantification of circulating CRP before starting ART could help to identify patients with a poor ART prognosis, leading to ART cycle cancellation or to preconception treatment to minimize the medical risks and costs.

Systematic Review of Postfertilization Effects and Potential for Embryo Formation and Loss during the Use of Intrauterine Devices

Objectives

This review sought to evaluate the evidence for embryo formation during intrauterine device (IUD) use, to articulate how often embryo loss occurs in well-designed studies, and to comment on other bodies of literature suggestive of postfertilization mechanisms of action of IUDs.

Methods

The MEDLINE, EMBASE, and Ovid databases were searched for English-language studies of markers of pregnancy in IUD users in May 2018. Studies of human chorionic gonadotropin (hCG) were subjected to quality assessment based on the US Preventive Services Task Force quality tool. Bias of studies assessing pregnancy in other ways was assessed on a study-to-study basis.

Results

In all, 1,073 studies were identified and 138 were read in detail. Twenty-three studies of β-hCG, 4 studies of direct observation of embryos in fallopian tubes, 2 studies of pregnancy-specific binding globulin (PSBG), and 1 study of heat-shock protein 10 (Hsp10) or chaperonin 10 were included. In all studies considered together, 7.3 percent of IUD users had evidence of fertilization and pregnancy failure. In good-quality studies, 4.5 percent had evidence of fertilization and pregnancy failure.

Discussion

There are no randomized trials of embryo formation and loss in IUD users compared with noncontracepting controls. Studies of β-hCG span a large spectrum of quality, but several good-quality studies exist, which support embryo formation and loss in IUD users. Evidence of embryos found in tubes is moderate and evidence of PSBG and Hsp10 elaboration was limited, but these are also concerning for embryo formation and loss.

Conclusion

There is good-quality evidence of embryo formation and loss in IUD users. Studies are inconsistent, and the stated conclusions of several papers inaccurately diminish postfertilization evidence of embryo formation. To better assess the rate of embryo loss in IUD users compared with non-users, future research should include well-designed prospective trials and less subjective assessments of embryos in fallopian tubes.

Summary

A systematic review was carried out examining the English-language literature in the MEDLINE, EMBASE, and Ovid databases for evidence of embryo formation and loss during IUD use. In all, 1,073 studies were identified and 138 were read. There are no randomized trials and evidence ranges in quality, but evidence for the embryo formation and loss in 4.5 percent of IUD users exists in good-quality research. Further research is needed to compare embryo loss in IUD users to loss in controls.

Differential Effects of the Hormonal and Copper Intrauterine Device on the Endometrial Transcriptome

The contraceptive effectiveness of intrauterine devices (IUDs) has been attributed in part to a foreign body reaction in the endometrium. We performed this study to better understand mechanisms of action of contraceptives of by studying their effects on endometrial and cervical transcriptomes. We collected endometrial and cervical biopsies from women using the levonorgestrel-releasing intrauterine system (LNG-IUS, n = 11), copper intrauterine device (cu-IUD, n = 13) or levonorgestrel-containing combined oral contraceptives (COC, n = 12), and from women not using contraceptives (control group, n = 11). Transcriptional profiling was performed with Affymetrix arrays, Principal Component Analysis and the bioconductor package limma. In endometrial samples from cu-IUD users, there were no genes with statistically significant differential expression compared to controls. In LNG-IUS users, 2509 genes were differentially expressed and mapped predominantly onto immune and inflammatory pathways. The cervical samples showed no statistically significant differential gene expression compared to controls. Hormonal and copper IUDs have significantly different effects on the endometrial transcriptome, with the LNG-IUS transcriptome showing pronounced inflammation and immune activation compared to controls whereas the cu-IUD transcriptome was indistinguishable from luteal phase endometrium. These findings argue against a foreign body reaction as a common mechanism of action of IUDs.

Long-Term Incidence of Infectious-Related Hospitalizations of Offspring Born to Mothers With Intrauterine Device: A Retrospective Population-Based Cohort Study

BACKGROUND

Pregnancy with an Intrauterine device (IUD) is a risk factor for adverse pregnancy outcomes. The purpose of this study was to examine a possible association between presence of IUD during pregnancy and long-term incidence of infectious-related hospitalizations of the offspring.

METHODS

A population-based cohort analysis was performed including all singleton deliveries between 1991 and 2014 at a single tertiary hospital. Primary exposure was defined as delivery of an infant to a mother who conceived with an IUD, that was either removed or retained during pregnancy. Offspring of mothers who conceived without an IUD comprised the comparison group. The main outcome evaluated was infectious-related hospitalizations of the offspring up to the age of 18 years.

RESULTS

The number of deliveries that met the inclusion criteria was 227,431, of which 209 were to mothers who conceived with an IUD that was removed and 52 were to mothers who retained their device. Long-term incidence of infections-related hospitalizations was compared between the groups (12.5% in the retained IUD, 12.9% in the removed IUD and 11.2% in the No-IUD group, P = 0.638). A Kaplan-Meier survival curve did not demonstrate a significantly higher cumulative incidence of infectious-related hospitalizations in offspring of women who conceived with an IUD (log-rank P = 0.340). In a Cox regression model, while controlling for confounders such as maternal age and preterm birth, conceiving with an IUD was not found to be independently associated with long-term incidence of infectious-related hospitalizations of the offspring.

CONCLUSION

Offspring of women conceiving with an IUD are not at increased risk for long-term incidence of infectious-related hospitalizations.

Medical Devices of the Abdomen and Pelvis and Their Complications: A Radiologic Atlas

의료기구들이 발달하면서 복부 및 골반 내에 이식되거나 거치되는 의료기구들이 다양해졌다. 흔하게 사용되는 기구들의 영상의학 소견은 영상의학과 의사들에게 매우 익숙하지만, 상대적으로 사용 빈도가 낮거나 새로운 형태의 기구들의 영상의학 소견은 잘 알려져 있지 않다. 또한 환자에 대한 임상정보가 제한적일 경우 이런 새로운 형태의 의료기구들은 잘못 해석되거나 놓치기 쉽다. 그러므로 복부 및 골반 내 의료기구들의 영상의학 소견을 인지하는 것은 기구들의 올바른 위치를 평가하고, 이와 관련된 합병증을 평가하는데 있어 매우 중요하다. 본 논문에서는 다양한 복부 및 골반 내 의료기구들과 이와 관련된 합병증의 영상의학 소견을 소개하고자 한다.

Practical Tips for Intrauterine Device Counseling, Insertion, and Pain Relief in Adolescents: An Update

The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have endorsed intrauterine devices as first-line contraceptive choices for nulliparous and parous adolescents. Practical concerns about intrauterine devices might be barriers to use for teens and clinicians; this review is devoted to "practical tips" for clinicians, on the basis of an update of the available literature as well as the author's clinical experience. Counseling about contraceptive choices, preventive guidance about possible side effects, informed consent, and pain management are addressed to promote successful use of this long-acting reversible contraption option.

Long-acting reversible contraception: A route to reproductive justice or injustice

This article presents information on unintended pregnancies and the ongoing efforts of policy makers to promote long-acting reversible contraception (LARC) to reduce the numbers of such pregnancies. Also discussed is the tension between the encouragement of LARC to promote the public's interests in achieving that goal versus the need to assure that all women can decide about their bodies and reproductive needs. Our discussion includes information, primarily from the United States, on (a) risks associated with unintended pregnancies, (b) LARC devices approved in the United States (copper intrauterine devices (IUDs), hormone IUDs, and implants), (c) public and social benefits of increasing the use of LARC, (d) disadvantages and barriers to using LARC, (e) dangers of promoting LARC in unjust ways, and (f) the meaning of reproductive justice and its connection to social justice. By sharing the information with the audience of this journal, we hope that it will be integrated into clinical work and research on mental health and development. We also hope that experts in those fields will become discussants in the conversation regarding women's reproductive health and social justice that is taking place in the United States and elsewhere.

Emergency contraception and impact on abortion rates

Emergency contraception (EC) is a drug or a device that is taken after sexual intercourse to prevent unintended pregnancy. The most effective EC is the copper-bearing intrauterine device (Cu-IUD), but oral EC methods are more commonly used and include a single dose of either levonorgestrel (1.5 mg) or ulipristal acetate (30 mg). Although all EC methods are extremely safe, access to EC is often limited due to prevailing misconceptions over how EC works. Although EC can prevent unintended pregnancy for an individual woman, it has failed to make an impact on abortion rates at a population level. This may be because it is not used after every episode of unprotected sex and because existing oral EC methods are only effective if used before ovulation. Future strategies around EC should focus on maximising uptake of Cu-IUD, facilitating initiation of effective regular contraception after EC and developing a more effective oral EC.