No relationship between the IUD position evaluated by ultrasound and complaints of bleeding and pain

The contradictive findings between ultrasound, hysteroscopy and cytokines in women with nonhormonal IUDs suffering from menorrhagia: a prospective study

PURPOSE

The objective of this study is to assess the correlation between bleeding irregularities and the accurate placement of the intrauterine device (IUD) device in the uterine cavity, determined through transvaginal ultrasonography and hysteroscopy. In addition, the study aims to examine the cytokine profile in the uterine cavity and serum of patients experiencing bleeding irregularities after the insertion of nonhormonal IUDs.

METHODS

A prospective cohort study was conducted at a single tertiary medical center, wherein patients experiencing intermenstrual bleeding and spotting after the insertion of nonhormonal IUDs were enrolled. The study involved hysteroscopic and sonographic assessments of the uterine cavity and IUD placement, along with the analysis of blood and uterine cavity cytokine profiles.

RESULTS

During the period between July 2019 and February 2020, a total of eight patients who experienced intermenstrual bleeding and spotting after the insertion of nonhormonal IUDs were enrolled the study. One case was excluded since a progestative device was detected by ultrasound. Out of the five cases that underwent a thorough ultrasonographic assessment, three cases (60%) showed an embedded IUD. However, these findings were excluded by the hysteroscopic evaluation.

CONCLUSION

The results suggest that ultrasonographic assessment may lead to an overdiagnosis of IUD mispositioning compared to hysteroscopy. In addition, both ultrasound and hysteroscopy have limitations in diagnosing the cause of bleeding in most cases. The role of local reactive inflammatory cytokines should be further studied.

Uterine dimensions and intrauterine device malposition: can ultrasound predict displacement or expulsion before it happens?

OBJECTIVE

Intrauterine devices (IUDs) are the most commonly used method of long-acting reversible contraception. IUD malpositions are described as expulsion, embedding, displacement, and perforation, which may cause contraception failure, organ injury, hemorrhage, and infection. The aim of the study was to evaluate the relationship between displacement and IUD positioning in the uterus, and uterine dimensions as measured using transvaginal ultrasonography.

MATERIALS AND METHODS

Three-hundred and eighty-four patients who had TCu380A devices inserted at a tertiary hospital were evaluated at insertion and at 1 month, 3 months, and 6 months after insertion. At the insertion visit, demographic characteristics, history of menorrhagia, dysmenorrhea, previous IUD displacement, and obstetric history were recorded. Transvaginal ultrasonographic measurement of the uterine cavity, uterine length, uterine width, cervix length, cervix width, transverse diameter of the uterine cavity, the distance between the tip of the IUD and the fundus, and endometrium were measured to evaluate IUD displacement.

RESULTS

Sixteen of 384 patients had displacement. There were significant differences in times between last pregnancy outcomes and IUD insertion and dysmenorrhea history (p = 0.004 and p = 0.028, respectively). Among TCu380A users, women with 7.5 mm IUD endometrium distances had a higher risk for displacement with a sensitivity of 81% and specificity of 37.5% (AUC: 0.607, 95% CI 0.51-0.70). Women with uterus width less than 41.5 mm were more likely to have displacement with a sensitivity of 53.8% and a specificity of 75% (AUC: 0.673, 95% CI 0.60-0.75).

CONCLUSION

IUD endometrium distance and uterus width are important parameters for displacement for TCu380A.

Ultrasound location of intrauterine devices placed at cesarean section over the first year postpartum

OBJECTIVES

The primary objective was to measure IUD-fundus and IUD-myometrium distances by ultrasound of IUDs placed during cesarean section over the first year of use. The secondary objective was to determine if these distances are associated with risk of expulsion or removal for side effects.

STUDY DESIGN

In this prospective observational study, we performed ultrasounds at six - ten weeks, three months and one year postpartum to measure the distance from the top of the device to the fundal serosa (IUD-fundus) and upper margin of the endometrial cavity (IUD-myometrium). We also assessed IUD expulsion or discontinuation for side effects at each visit.

RESULTS

We enrolled 93 women who had copper (n = 77) or levonorgestrel (n = 16) IUDs placed at time of cesarean section. Two patients had complete expulsion, six had partial expulsion and nine requested removal for symptoms. Overall, median IUD-fundus measurements were 2.13 cm (IQR 1.87-2.55) at 6-10 weeks, 1.87 cm (IQR 1.53-2.23) at 3-months and 2.02 cm (IQR 1.67-2.40) at 1-year. Among copper IUD users, distances at six weeks and three months were similar in women who did or did not have expulsion or removal at one year however small numbers limit our ability to assess this relationship.

CONCLUSION

We describe the location on ultrasound of IUDs placed at the time of Cesarean section over the first year. We found similar IUD locations at six weeks and three months for participants who did or did not experience expulsion or removal by one year.

IMPLICATIONS

Position of intrauterine devices placed during cesarean section was similar for those who did or did not have expulsion or removal for symptoms in the first year after placement. These data may help in the design of future studies to determine if ultrasound measurement of IUDs predicts IUD complications.

[Intrauterine contraception: CNGOF Contraception Guidelines]

OBJECTIVE

To provide national clinical guidelines focusing on intrauterine contraception.

METHODS

A systematic review of available literature was performed using Pubmed and Cochrane libraries. American, British and Canadian guidelines were considered as well.

RESULTS

Intrauterine contraception (IUC) displays a wide panel of indications, including adolescents, nulliparous, patients living with HIV before AIDS (Grade B) and women with history of ectopic pregnancy (Grade C). Cervical cancer screening should not be modified in women with IUC (Grade B). Bimanual examination and cervix inspection are mandatory before device insertion (Grade B). Patients should not systematically undergo screening for sexually transmitted infections (STI) before device insertion (Grade B). Screening for STI should be preferably done before insertion but it can be performed at the time of device insertion in asymptomatic women (Grade B). Routine antibiotic prophylaxis and premedication are not recommended before insertion (Grade A). A follow-up visit may be offered several weeks after insertion (Professional consensus). Routine pelvic ultrasound examination in not recommended after device insertion (Grade B). In patients with IUC, unscheduled bleeding, when persistent or associated with pelvic pain, requires further investigation to rule out complication (Professional agreement). Suspected uterine perforation warrants radiological workup to locate the device (Professional consensus). Laparoscopic approach should be preferred for elective removal of intrauterine device from abdominal cavity (Professional consensus). In case of accidental pregnancy with intrauterine device in situ, ectopic pregnancy should be excluded (Grade B). In case of viable and desired intrauterine pregnancy, intrauterine device removal is recommended if the strings are reachable (Grade C). Detection of Actinomyces-like organisms on pap smear in asymptomatic patients with intrauterine contraception does not require further intervention (Grade B). Immediate removal of intrauterine device is not recommended in case of STI or pelvic inflammatory disease (Grade B). Device removal should be considered in the absence of clinical improvement after 48 to 72 hours of appropriate treatment (Grade B).

CONCLUSION

Intrauterine contraception is a long-acting and reversible contraception method displaying great efficacy and high continuation rate. In contrast, complication rate is low. It should thus be offered to both nulliparous and multiparous women.

Three-dimensional versus two-dimensional ultrasound for assessing levonorgestrel intrauterine device location: A pilot study

PURPOSE

To compare the rates of success of two-dimensional (2D) and three-dimensional (3D) sonographic (US) examinations in locating and adequately visualizing levonorgestrel intrauterine devices (IUDs) and to explore factors associated with the unsuccessful viewing on 2D US.

METHODS

Transvaginal 2D and 3D US examinations were performed on all patients 1 month after insertion of levonorgestrel IUDs. The devices were considered adequately visualized on 2D US if both the vertical (shadow, upper and lower extremities) and the horizontal (two echogenic lines) shafts were identified. 3D volumes were also captured to assess the location of levonorgestrel IUDs on 3D US.

RESULTS

Thirty women were included. The rates of adequate device visualization were 40% on 2D US (95% confidence interval [CI], 24.6; 57.7) and 100% on 3D US (95% CI, 88.6; 100.0). The device was not adequately visualized in all six women who had a retroflexed uterus, but it was adequately visualized in 12 of the 24 women (50%) who had a nonretroflexed uterus (95% CI, -68.6; -6.8).

CONCLUSIONS

We found that 3D US is better than 2D US for locating and adequately visualizing levonorgestrel IUDs. Other well-designed studies with adequate power should be conducted to confirm this finding.

Association of the Position of the Copper T 380A as Determined by the Ultrasonography Following its Insertion in the Immediate Postpartum Period with the Subsequent Complications: An Observational Study

PURPOSE

Incorrectly placed copper T 380A leads to increased contraception failure. This study aimed to find an association between the ultrasonographic position of the copper T 380A in the immediate postpartum period and the adverse effects observed during the period of 6 months after its insertion.

METHODS

This descriptive study was carried out in the Department of Obstetrics & Gynaecology of a tertiary-care-center of India from September 2011 to February 2013. The women eligible for immediate postpartum copper T 380A insertion with previous regular menstrual cycles for at least 6 months before the current pregnancy, and those who were willing for follow-up visits and had easy accessibility to the hospital, were recruited. A clinical evaluation and ultrasonographic assessment of Intra-Uterine-Contraceptive-Device (IUCD) after insertion was carried out after enrolment. The complications (expulsions, vaginal discharge, menstrual irregularity, and lower abdominal pain) were subsequently assessed during a 6-month follow-up period. The primary objective was the ultrasonographic assessment of the placement of IUCD immediately after insertion. The incidence of complications and their association with the presence of malposition was also studied.

RESULTS

Hundred patients were evaluated during the study period. Forty-four (44 %) women were found to have malpositioned IUCDs on ultrasonographic evaluation done following insertion. The complications among the IUCD users included menstrual irregularity (27.17 %), pain in lower abdomen (20.65 %), vaginal discharge (7.6 %), and expulsions (9.7 %). The IUCD expulsions, menstrual irregularities, and pain were significantly more in patients with malpositions (p < 0.05).

CONCLUSIONS

Malpositioning of IUCD is common immediately following insertion and is significantly associated with more complications during the follow-up.

Pain and bleeding pattern related to levonorgestrel intrauterine system (LNG-IUS) insertion

OBJECTIVE

To investigate whether the pattern or pain or bleeding during levonorgestrel intrauterine system (LNG-IUS) insertion and in the first 6 weeks thereafter is altered by LNG-IUS malposition.

STUDY DESIGN

Prospective cohort of 413 women undergoing LNG-IUS insertion or replacement. A first questionnaire on pain perception was completed by the women immediately after insertion. In a second questionnaire the women were asked to record pain in the 3 days following insertion and both pain and bleeding from 4 to 6 weeks after insertion. Six weeks after insertion a 2D- and 3D-ultrasound examination was performed to evaluate the position of the LNG-IUS and of the uterus.

RESULTS

Parity was inversely related to pain at insertion, in the first 3 days and at 4-6 weeks. LNG-IUS insertion was less painful in the postpartum period. Women who had had a LNG-IUS as prior contraceptive method reported a higher percentage of amenorrhea at 4-6 weeks. The position of the LNG-IUS or of the uterus did not influence the pain scores or the bleeding pattern. The fact that the LNG-IUS arms appeared embedded in the uterine wall on coronal 3D-volume reconstruction did not influence pain or the bleeding pattern.

CONCLUSIONS

Because neither pain nor bleeding is a reliable predictor of LNG-IUS position, we suggest an ultrasound examination to confirm correct LNG-IUS placement in all patients at about 6 weeks after insertion.

Complications among adolescents using copper intrauterine contraceptive devices

OBJECTIVE

To evaluate the rate and pattern of complications associated with use of the Copper T 380A intrauterine device (IUD) among adolescents.

METHODS

A prospective comparative study of women eligible for IUD insertion who attended the family planning clinic of Sohag University Hospital, Egypt, between July 1, 2008 and December 31, 2010. The participants were categorized as adolescents or adults. The Copper T 380A IUD was inserted in all participants and follow-up visits were scheduled at 1, 3, and 6 months. Odds ratio and χ(2) square tests were used to compare the rates of complications at each visit.

RESULTS

Of 1512 patients eligible for IUD insertion, 852 met the inclusion criteria: 281 adolescents and 571 adults. The rates of pain, bleeding, displacement, expulsion, and removal of IUDs were significantly higher in adolescents (P<0.05). The rates of these complications were high in adolescents younger than 16 years; the rates then decreased with age and became comparable with the adult rates at 18 years of age.

CONCLUSIONS

IUD-associated complications were high in adolescents up to the age of 17 years. Our data suggest that adolescents younger than 18 years of age should be counseled carefully before IUD insertion, and examined more frequently to detect displacement or expulsion of the device.

Partial and complete expulsion of the Multiload 375 IUD and the levonorgestrel-releasing IUD after correct insertion

OBJECTIVE

The contraceptive efficacy of intrauterine devices (IUD) is thought to relate to the position of the IUD in the uterine cavity. Several trials examined the number of copper IUD expulsions, but none evaluated the partial and complete expulsion rate of the levonorgestrel-releasing device (LNG-IUD).

STUDY DESIGN

This retrospective cohort study compares the dislocation rate of the Multiload 375 IUD (ML 375) and the LNG-IUD in 214 women (107 subjects with each IUD). Transvaginal ultrasound was used to monitor the IUD position immediately after insertion, after 6 weeks, and later on at intervals of 6 months. The observation period included 3631 cycles.

RESULTS

We detected a significantly lower number of dislocations in LNG-IUD users. Previous expulsion was associated with a significantly higher risk for a re-expulsion in both IUD groups. Hypermenorrhea was not associated with an increased dislocation rate in LNG-IUD users.

CONCLUSION

Expulsions are less likely to occur with the LNG-IUD, which might contribute to its contraceptive efficacy.

FFPRHC Guidance (January 2004) The Copper Intrauterine Device as Long-term Contraception

This Guidance provides information for clinicians providing women with copper-bearing intrauterine devices as long-term contraception. A key to the grades of recommendations, based on levels of evidence, is given at the end of this document. Details of the methods used by the Clinical Effectiveness Unit (CEU) in developing this Guidance and evidence tables summarising the research basis of the recommendations are available on the Faculty website (www.ffprhc.org.uk). Abbreviations (in alphabetical order) used include: acquired immune deficiency syndrome (AIDS); actinomyces-like organisms (ALOs); automated external defibrillator (AED); blood pressure (BP); British National Formulary (BNF); confidence interval (CI); copper-bearing intrauterine contraceptive device (IUD); emergency contraception (EC); Faculty Aid to Continuing Professional Development Topic (FACT); levonorgestrel-releasing intrauterine system (IUS); human immunodeficiency virus (HIV); Medicines and Healthcare products Regulatory Agency (MHRA); non-steroidal antiinflammatory drugs (NSAIDs); odds ratio (OR); pelvic inflammatory disease (PID); relative risk (RR); Royal College of Obstetricians and Gynaecologists (RCOG); Scottish Intercollegiate Guidelines Network (SIGN); sexually transmitted infection (STI); termination of pregnancy (TOP); World Health Organization (WHO); WHO Medical Eligibility Criteria (WHOMEC); WHO Selected Practice Recommendations (WHOSPR).

T-shaped IUDs accommodate in their position during the first 3 months after insertion

The objective of this study was to observe the position dynamics of the T-shaped intrauterine device (IUD) in the uterine cavity, from insertion to 90 days of use. IUD position was evaluated in 214 women by vaginal ultrasound, measuring the IUD-endometrium, IUD-myometrium, and IUD-fundus distances. The 90th percentile of the IUD-endometrium distance was 5, 6, and 8 mm at time of insertion, 30 and 90 days of use; 7, 9, and 10 mm for IUD-myometrium distance; and 23, 24, and 27 mm for IUD-fundus distance, respectively. Seventeen IUDs were classified as misplaced at insertion by using the 90th percentile of the IUD-myometrium distance as standard. Of these, only 6 remained misplaced after 90 days of use. On the other hand, 21 IUDs were beyond the 90th percentile at the 90-day observation, only 6 of which were considered misplaced at insertion. We conclude that the T-shaped IUD accommodates its position in the uterine cavity during the first 3 months following insertion, and that ultrasound evaluation of its position is not a good predictor of future evaluation.

T-shaped IUD move vertically with endometrial growth and involution during the menstrual cycle

Ultrasound has been used to detect and evaluate intrauterine device (IUD) position for some years. Different definitions of the IUD in the uterine cavity have been discussed trying to relate them to bleeding and pain complaints. Most of these definitions do not take into account the uterine wall or endometrial thickness. This is a secondary analysis of a previous cross-sectional study, in which 481 IUD users had their T-shaped IUD evaluated by transvaginal sonography. The correlation between the endometrium thickness and the IUD-myometral distance was studied, defined by the linear measurement between the upper end of the IUD and the myometrium/endometrium interface. These two measurements were highly correlated over the entire sample range (r = 0.29) and an even stronger correlation existed (r = 0.66) when only cases below the 90 percentile of the IUD-endometrial distance distribution were considered. These results suggest that the IUD position in the uterine cavity is influenced by the growth and thinning of the endometrium, and that this information should be considered when evaluating the IUD position by sonography.