Characterization of calcified deposits on contraceptive intrauterine devices

Feasibility evaluation of a Cu-38 Zn alloy for intrauterine devices: In vitro and in vivo studies

The existing adverse effects of copper in copper-containing intrauterine devices (Cu-IUDs) have raised concerns regarding their use. These adverse effects include burst release of cupric ions (Cu²⁺) at the initial stage and an increasingly rough surface of the Cu-IUDs. In this study, we investigated the use of two copper alloys, Cu-38 Zn and H62 as the new upgrading or alternative material for IUDs. Their corrosive properties were studied in simulated uterine fluid (SUF) by using electrochemical methods, with pure Cu as a control. We studied the in vitro long-term corrosion behaviors in SUF, cytotoxicity to uterine cells (human endometrial epithelial cells and human endometrial stromal cells), in vivo biocompatibility and contraceptive efficacy of pure Cu, H62, and Cu-38 Zn. In the first month, the burst release rate of Cu²⁺ in the Cu-38 Zn group was significantly lower than those in the pure Cu and H62 groups. The in vitro cytocompatibility Cu-38 Zn was better than that of pure Cu and H62. Moreover, Cu-38 Zn showed improved tissue biocompatibility in vivo experiments. Therefore, the contraceptive efficacy of the Cu-38 Zn is still maintained as high as the pure Cu while the adverse effects are significantly eased, suggesting that Cu-38 Zn can be a suitable potential candidate material for IUDs. STATEMENT OF SIGNIFICANCE: The existing adverse effects associated with the intrinsic properties of copper materials for copper-containing intrauterine devices (Cu-IUD) are of concern in their employment. Such as, burst release of cupric ions (Cu²⁺) at the initial stage and an increasingly rough surface of the Cu-IUD. In this work, Cu alloyed with a high amount of bioactive Zn was used for a Cu-IUD. The Cu-38 Zn alloy exhibited reduced burst release of Cu²⁺ within the first month compared with the pure Cu and H62. Furthermore, the Cu-38 Zn alloy displayed significantly improved biocompatibility and a much smoother surface. Therefore, high antifertility efficacy of the Cu-38 Zn alloy was well maintained, while the adverse effects are significantly eased, suggesting that the Cu-38 Zn alloy is promising for a Cu-IUD.

In vitro and in vivo studies to evaluate the feasibility of Zn-0.1Li and Zn-0.8Mg application in the uterine cavity microenvironment compared to pure zinc

Significant advances have been achieved in the research evaluating Zn and its alloys as degradable metallic biomaterials mainly for application in bone and blood vessels. In the present study, the degradation behaviors of Zn-0.1Li and Zn-0.8Mg alloys in simulated uterine fluid (SUF) were systematically investigated for 300 days. In vitro viability assays were conducted in different uterine cells (HUSMCs, HEECs, and HESCs), and histological examination after the in vivo implantation into the uterine cavity was performed using pure Zn as control. The immersion test results indicated that both Zn-0.1Li and Zn-0.8Mg alloys exhibited better corrosion resistance than pure Zn, with Zn₃(PO₄)₂⋅4H₂O and CaZn₂(PO₄)₂⋅2H₂O being the main corrosion products detected in the SUF in addition to ZnO. The cell cytotoxicity assays revealed that Zn-0.1Li and Zn-0.8Mg exhibited better cytocompatibility than Zn. Moreover, the in vivo experiments demonstrated that the Zn-0.1Li and Zn-0.8Mg alloys induced less inflammation in the uterine tissue than pure Zn, with CaCO₃ and Zn(HPO₄)⋅3H₂O being the major biocorrosion products in addition to ZnO. According to these results, zinc alloys appear to be suitable potential candidate materials for future intrauterine biomedical devices.

The effect of intrauterine device presence and other factors in medical treatment success of tuboovarian abscess

BACKGROUND

To identify the epidemiologic and clinical risk factors associated with failed response to medical treatment in tuboovarian abscess (TOA) patients and whether there is a relationship between the presence of intrauterine device (IUD), duration of use and medical treatment success or not.

METHODS

For this study, the medical records of patients diagnosed with TOA and hospitalized in an 8-year period were analyzed retrospectively. The presence of TOA and IUD was confirmed ultrasonographically in all patients. Parenteral antibiotic treatment was initiated as the first step. Patients who did not improve with this medical treatment underwent surgery. Patients who recovered with medical treatment were defined as the successful group, while those who underwent surgery after medical treatment failure were recorded as the failed group.

RESULTS

There were 37 patients in successful group and 87 patients in failed group. The mean age, parity, white blood count, TOA size, duration of IUD use, rate of multigravida and multiparity were higher in the failed group. Logistic regression analysis revealed that presence of multiparity, TOA size and the duration of IUD use were significant independent factors in predicting medical treatment success of TOA. The best cut-off value for TOA size was 4.5 cm and for duration of IUD use was 5.5 years in the Receiver Operating Characteristic curve analysis.

CONCLUSION

The presence of long-term IUD use, increased TOA size, and multiparity were found to be risk factors related to the failure of medical treatment in TOA cases.

In vitro and in vivo studies on magnesium alloys to evaluate the feasibility of their use in obstetrics and gynecology

Magnesium and its alloys were widely investigated in many body fluid microenvironments including bone, blood, bile, saliva, and urine; however, no study has been conducted in the intrauterine microenvironment. In this study, the degradation behaviors of HP-Mg, Mg-1Ca, and Mg-2Zn alloys in simulated uterine fluid (SUF) were systematically investigated, and then the biological response of four kinds of uterine cells to these materials was observed. For this purpose, the gluteal muscle of rat was used as the implantation position to study the in vivo biocompatibility as a mimic of the intrauterine device (IUD) fixation part. The 120-day immersion test indicated that the Mg-1Ca alloy had a faster degradation rate than the Mg-2Zn alloy and HP-Mg and dissolved entirely in the SUF. Indirect cytotoxicity assay showed that the extracts of HP-Mg, Mg-1Ca, and Mg-2Zn alloys have positive effects on human uterine smooth muscle cells (HUSMC), human endometrial epithelial cells (HEEC), and human endometrial stromal cells (HESC), especially for the Mg-1Ca alloy group. Furthermore, the in vivo experiment showed that HP-Mg, Mg-1Ca, and Mg-2Zn alloy implants cause a light inflammatory response in the initial 3 days, but they were surrounded mainly by connective tissue, and lymphocytes were rarely observed at 4 weeks. Based on the above facts, we believed that it is feasible for using biomedical Mg alloys in obstetrics and gynecology and proposed three kinds of medical device candidates for future R&D. Statement of Significance Magnesium alloys were widely investigated in various body microenvironments including bone, blood, bile, saliva, and urine; however, no study has been conducted in the intrauterine environment. In this work, the degradation behaviors of Mg alloys in simulated uterine fluid were systematically investigated, and then the biological response of four kinds of uterine cells to these materials was observed. For this purpose, the tibialis anterior of a rat model was used as the implantation position to study the in vivo biocompatibility. The comprehensive in vitro and in vivo testing results indicated that biomedical Mg alloys are feasible for use in obstetrics and gynecology. Further, three kinds of medical device candidates were proposed.

[Intrauterine device and pelvic inflammatory disease: Myth or reality?]

INTRODUCTION

Intrauterine device (IUD) is a reliable contraceptive method that is long term reversible, and well tolerated. Numerous studies prove its efficiency and report rare complications that are attributed to it. However, its use is limited due to fear that it can cause a pelvic inflammatory disease (PID). This is based on historical data on infections related to the "Dalkon Shield", which was removed from the market in 1974.

METHOD

The analyzed articles were extracted from PUBMED database between 2000 and 2016. In total, 22 studies were retained. A meta-analysis was not possible due to the methodological diversity among the selected articles contributing to this narrative review of the literature.

RESULTS

After analysis, the following factors influence the risk of PID linked to IUDs: an advanced age and sexually transmitted infections.

CONCLUSION

The risk of PID linked to IUDs is lower than 1%. This is explained by new models of IUD, better screening tests, more frequent follow-up of the patients and the improvement of care PID patients. In the light of our results, the threat of pelvic inflammatory disease should not hinder the use of IUDs.

Intracavitary deposits on Essure® hysteroscopic sterilization devices: A case report

Objective

To study the composition of intracavitary deposits on Essure® hysteroscopic sterilization devices.

Design

Case report.

Setting

Reproductive Medicine and Gynecology department of a University Hospital.

Patient(s)

A 39 years old patient presenting with a request for surgical removal of Essure® sterilization devices. Diagnostic hysteroscopy showed a crystal like white deposit attached to one of the devices.

Intervention

Diagnostic hysteroscopy and surgical removal of Essure® devices was performed. The deposits were collected and infrared spectroscopy analysis was performed.

Main Outcome Measure

Chemical composition of the deposits attached to the device.

Result(s)

Infrared spectroscopy of the material showed patterns conclusive with calcite (calcium carbonate, CaCO₃).

Conclusion

Until now, it is not clear if there is a relationship between reported complaints and formation of calcite deposits on Essure®.

Capsule

Infrared spectroscopy of deposits on Essure® devices showed a pattern conclusive with calcite. The relationship between reported complaints and the formation of calcite deposits on Essure® remains unclear.

•

A white, strongly attached deposit was observed on Essure sterilization devices.

•

Infrared spectroscopy of this deposit showed a pattern conclusive with calcite.

•

A relationship between reported complaints and the deposits remains unclear.

•

Future research should focus on the genesis of the deposits, to determine its clinical relevance.

Microbiological profile and biofilm formation on removed intrauterine contraceptive devices from a sample of Egyptian women

AIM

The aim of this study was to investigate the presence of biofilm formation around intrauterine contraceptive devices (IUCD) and to correlate the microbiological profile of the IUCD-associated genital infections to the microbiological profile of specimens retrieved from vaginal discharge.

MATERIAL AND METHODS

Samples of the vaginal discharge in the posterior fornix were collected from 50 women attending the Family Planning Clinic in Ain Shams University Hospital using two high vaginal swabs. Swabs were immediately sent for Gram staining as well as microbiological culture. The IUCD was then removed. A 0.5-cm piece of the removed IUCD was cut and sent for culture. Growing colonies were tested for their abilities to form a biofilm (colorimetric method). Another 0.5-cm piece of the removed IUCD was examined by electron microscopy (EM) for detection of biofilm formation.

RESULTS

Among the included 50 women, 24 (48%) women showed biofilm formation (via colorimetric methods). EM scanning was able to detect biofilm formation in the prepared pieces of the removed IUCD of 48 (96%) women. There was no significant agreement between the isolated microorganisms on the removed IUCD and the vaginal swab (proportion of agreement was 14 [11.4%]; κ = -0.089, P = 0.892).

CONCLUSION

Scanning EM is a useful tool in detection of biofilm formation on removed IUCD.

Alterations in the endometrium of rats, rabbits, and Macaca mulatta that received an implantation of copper/low-density polyethylene nanocomposite

A copper/low-density polyethylene nanocomposite (nano-Cu/LDPE), a potential intrauterine device component material, has been developed from our research. A logical extension of our previous work, this study was conducted to investigate the expression of plasminogen activator inhibitor 1 (PAI-1), substance P (SP), and substance P receptor (SP-R) in the endometrium of Sprague Dawley rats, New Zealand White rabbits, and Macaca mulatta implanted with nano-Cu/LDPE composite. The influence of the nano-Cu/LDPE composite on the morphology of the endometrium was also investigated. Animals were randomly divided into five groups: the sham-operated control group (SO group), bulk copper group (Cu group), LDPE group, and nano-Cu/LDPE groups I and II. An expression of PAI-1, SP, and SP-R in the endometrial tissues was examined by immunohistochemistry at day 30, 60, 90, and 180 postimplantation. The significant difference for PAI-1, SP, and SP-R between the nano-Cu/LDPE groups and the SO group (P<0.05) was identified when the observation period was terminated, and the changes of nano-Cu/LDPE on these parameters were less remarkable than those of the Cu group (P<0.05). The damage to the endometrial morphology caused by the nano-Cu/LDPE composite was much less than that caused by bulk copper. The nano-Cu/LDPE composite might be a potential substitute for conventional materials for intrauterine devices in the future because of its decreased adverse effects on the endometrial microenvironment.

Effective inhibition of the early copper ion burst release with ultra-fine grained copper and single crystal copper for intrauterine device application

To solve the main problems of existing coarse grained copper (CG Cu) intrauterine devices (IUD)-namely burst release and a low transfer efficiency of the cupric ions during usage-ultra-fine grained copper (UFG Cu) and single crystal copper (SC Cu) have been investigated as potential substitutes. Their corrosion properties with CG Cu as a control have been studied in simulated uterine fluid (SUF) under different conditions using electrochemical measurement methods. Long-term immersion of UFG Cu, SC Cu and CG Cu samples in SUF at 37 °C have been studied for 300 days. A lower copper ion burst release and a higher efficiency release of cupric ions were observed for UFG Cu and SC Cu compared with CG Cu in the first month of immersion and 2 months later. The respective corrosion mechanisms for UFG Cu, SC Cu and CG Cu in SUF are proposed. In vitro biocompatibility tests show a better cellular response to UFG Cu and SC Cu than CG Cu. In terms of instantaneous corrosion behavior, long-term corrosion performance and in vitro biocompatibility, the three pure copper materials follow the order: UFG Cu>SC Cu>CG Cu, which indicates that UFG Cu could be the most suitable candidate material for intrauterine devices.

Zn(2+) release behavior and surface characteristics of Zn/LDPE nanocomposites and ZnO/LDPE nanocomposites in simulated uterine solution

To decrease the side effects of the existing copper-bearing intrauterine devices, the zinc/low-density polyethylene (Zn/LDPE) nanocomposite and zinc-oxide/low-density polyethylene (ZnO/LDPE) nanocomposite have been developed in our research for intrauterine devices (IUDs). In this study, the influences of preparation methods of nanocomposites and particle sizes of zinc and zinc oxide on Zn(2+) release from composites incubated in simulated uterine solution were investigated. All release profiles are biphasic: an initial rapid release phase is followed by a near zero-order release period. Zn(2+) release rates of nanocomposites prepared by compressing moulding are higher than those of the nanocomposites prepared by hot-melt extrusing. Compared with Zn(2+) release from the microcomposites, the release profiles of the nanocomposites exhibit a sharp decrease in Zn(2+) release rate in the first 18 days, an early onset of the zero-order release period and a high release rate of Zn(2+) at the later stage. The microstructure of the Zn/LDPE sample and the ZnO/LDPE sample after being incubated for 200 days was characterized by SEM, XRD and EDX techniques. The results show that the dissolution depth of ZnO/LDPE nanocomposite is about 60 mum. Lots of pores were formed on the surface of the Zn/LDPE sample and ZnO/LDPE sample, indicating that these pores can provide channels for the dissolution of nanoparticles in the matrix. The undesirable deposits that are composed of ZnO are only detected on the surface of Zn/LDPE nanocomposite, which may increase the risk of side effects associated with IUDs. It can be expected that ZnO/LDPE nanocomposite is more suitable for IUDs than Zn/LDPE nanocomposite.

Effect of implanted Cu/low-density polyethylene nanocomposite on the morphology of endometrium in the mouse

OBJECTIVE

To investigate the damage of endometrium caused by the implanted Cu/low-density polyethylene (LDPE) nanocomposite and the contraceptive effect of this novel copper-containing intrauterine device material.

DESIGN

Experimental animal study.

SETTING

TongJi Medical College of Huazhong University of Science and Technology.

PATIENT(S)

Sixty healthy female mice.

INTERVENTION(S)

Twenty mice received no implants, 20 mice received the Cu/LDPE nanocomposite, and 20 mice received bulk copper.

MAIN OUTCOME MEASURE(S)

Morphologic features of the endometrium, contraceptive effect, and surface condition of the implanted implants.

RESULT(S)

The contraceptive effect of both the Cu/LDPE nanocomposite and bulk copper is 100%, the damage of the endometrium caused by the Cu/LDPE nanocomposite is much less than that caused by bulk copper, and the surface of the implanted Cu/LDPE nanocomposite is much smoother and much softer than that of the implanted bulk copper.

CONCLUSION(S)

The contraceptive effect of the Cu/LDPE nanocomposite is comparable with that of bulk copper, and the damage of the endometrium caused by the Cu/LDPE nanocomposite is much less than that caused by bulk copper. The endometrium injury is related to the surface condition of the implanted intrauterine device material.

In utero incrustation of intrauterine systems--consequent complications and monitoring

As a result of physical aging of intrauterine therapeutic systems, in utero incrustments form on the rate-controlling membrane of the IUSs.

The Impact of Age and Intrauterine Contraception on the Clinical Course of Pelvic Inflammatory Disease

BACKGROUND

The aim of the study was to investigate the clinical course of pelvic inflammatory disease (PID) and factors that could predict failed conservative treatment of PID. Additionally, the study aimed to examine the role of age and intrauterine device (IUD) use on the severity of PID.

METHOD

Fifty-one women admitted to hospital with the diagnosis of acute PID were recruited. Of those, 17 patients were subsequently operated because of failed conservative treatment. All women underwent careful examination and completed a questionnaire at admission. Their clinical course was followed and the clinician responsible for the patient completed forms at admission and at discharge. Two groups were established retrospectively, those who were treated conservatively and those who underwent surgery. The outcome results were analyzed with regard to IUD use, duration of IUD use (>or=5 or <5 years), and with regard to age below or above 35 years. All data were analyzed using the statistical package SAS. A p value <0.05 was considered significant.

RESULTS

Women who subsequently underwent surgical treatment were significantly older and significantly more frequently, current IUD users. There was no significant difference with regard to other socio-demographic characteristics. Women who subsequently underwent surgery had significantly more frequent complaints of severe abdominal pain, elevated body temperature, symptoms of peritoneal irritation, and appearance of adnexal mass. No differences were found between groups with regard to anaerobic microbiological findings, nor with regard to the finding of Actinomyces. IUD use and age >or=35 were found to be highly significant risk factors for surgery in patients with PID.

CONCLUSION

Age over 35 years and IUD use, independently of each other, were factors strongly associated with an increased risk of surgery for PID as a result of failed conservative treatment.

‘Older’ age is a risk factor for pelvic inflammatory disease in intrauterine device users

BACKGROUND

To asses the role of a copper intrauterine device (IUD) per se in the development of pelvic inflammatory disease (PID) and complicated PID in women considered at low risk of PID.

METHODS

Cases were 51 women admitted to hospital with a diagnosis of acute PID, and controls were 50 healthy women attending an outpatient clinic for routine gynecological check-up. The women were 25-45 years old. Data were analyzed and compared between groups using the statistical program package sas.

RESULTS

IUD use was not associated with an increased risk of PID in general, but in women > or =35 years, IUD use was associated with a risk of PID [odds ratio (OR) = 4.2, confidence interval (CI) 1.1-16.3]. When adjusting for smoking, educational level, employment, and microbial findings in women with PID, IUD use was associated with complicated PID in women > or =35 years (OR = 33.9, CI 1.2-959.6), but not in younger women. When adjusting age and IUD use duration for each other in IUD users, age > or =35 years was a significant risk factor for PID (OR = 4.9, CI 1.3-19.2), but not long (> or =5 years) duration. In IUD users with PID, age > or =35 years was a risk factor for a PID to be complicated in both the unadjusted and adjusted analysis (OR = 12.7, CI 1.6-102.3; OR = 12.1, CI 1.4-104.7), whereas long duration of IUD use was not. When adjusting for significant endocervical microbial findings, long duration of IUD use and age, only age > or =35 years, remained significantly associated with both PID and complicated PID (OR = 5, CI 1.1-21.9; OR = 36, CI - 1.9-670).

CONCLUSIONS

IUD use was not associated with PID in low-risk younger women, but in women > or =35 years, IUD use was associated with an increased risk of PID. The study also demonstrates an association between IUD use and complicated PID in women > or =35 years.

Comparison of surface morphology and composition of intrauterine devices in relation to patient complaints

The morphology and the related composition of T-type intrauterine devices (IUDs) made of gold-plated copper were studied in relation to patient complaints. The removed IUDs were examined without pretreatment by scanning electron microscopy and energy dispersive x-ray spectroscopy. Besides the previously found incrustation formation, lamination cracks were observed on the surface of gold-plated copper IUDs causing various side effects (abdominal pain, inflammatory complication). A possible explanation for lamination cracks could be the difference in the heat expansion of the copper and its gold-plated surface and the great difference between the strong acidic galvanizing pH during production and the in utero pH. Stability tests in combination with morphology screening of such IUDs could be required during their development phase to avoid such side effects.