In vitro study of fracture forces associated with the Copper 7, Nova T and MLCu 250/375 intrauterine devices.

In the literature there is a paucity of reports of cases of intrauterine breakage of IUDs. In this study the forces required to break the Copper 7, Nova T and Multiload (MLCu) devices were measured. New and used devices were examined in vitro. The devices were broken in a water bath at body temperature. The mean rupture force of new and used Copper 7 devices was 30.4 newtons. The mean rupture forces for new Nova T and MLCu 250/375 IUDs was 6.8 and 15.7 newtons, respectively, and for used Nova T and MLCu 250/375 devices was 16.8 and 8.7 newtons, respectively. The decreased fracture forces associated with used as opposed to new MLCu devices may explain the reports of intrauterine breakage with this type of device.

Dilatation of the cervix with dinoprostone ('Prepidil gel') prior to insertion of an intrauterine device: report of two cases.

Routine insertion of an intrauterine device (IUD) is usually a simple procedure in parous and nulliparous subjects. There is normally very little cervical resistance, depending on the type of IUD used. We describe two cases in which cervical dilatation to allow passage of an IUD was facilitated by the intracervical insertion of 0.5 mg of PGE2 gel. The use of PGE2 gel in subjects where there appears to be marked cervical resistance at the level of the internal os probably allows safer introduction of the IUD using less force than after using analgesia to the cervix alone or a paracervical block. It is also faster and more convenient than using osmotic dilators. We recommend the use of 0.5 to 0.25 mg of PGE2 gel inserted into the cervix about half an hour to two hours prior to attempting insertion of the intrauterine device in women in whom there appears to be an abnormally high resistance at the level of the internal cervical os. The method appears to be simple and physiologically acceptable.

Interval insertion of an intrauterine contraceptive device following cesarean section.

Two previous studies of interval insertion of intrauterine contraceptive devices (IUCD) in women with previous cesarean delivery produced conflicting results. We studied the first and subsequent segment IUCD performance in 215 women with one or more cesarean deliveries. All the insertions were performed by doctors in the outpatient department of the hospital. The follow-up rate at 6 months was over 80%. There was a higher than expected expulsion rate of 19 per 100 insertions in the first 12 months, in both the first and subsequent segments. Other IUCD related problems were in keeping with expectations. The IUCD nonetheless remains a useful contraceptive option for these women.

PIP: 2 previous studies of interval insertion of intrauterine contraceptive devices (IUD) in women with previous cesarean delivery produced conflicting results. We studied the 1st and subsequent segment IUD performance in 215 women with 1 or more cesarean deliveries. All the insertions were performed by doctors in the outpatient department of the hospital. The follow-up rate at 6 months was over 80%. There was a higher than expected expulsion rate of 19/100 insertions in the first 12 months, in both the 1st and subsequent segments. Other IUD related problems were in keeping with expectations. The IUD nonetheless remains a useful contraceptive option for these women. (Author's).

Factors influencing the initial decision to use an intrauterine device.

This study analyses data from 104 women who elected to use an IUD for the first time. The reason they gave for requesting the IUD was evaluated against a number of personal and psychological characteristics. Parous women who had recently given birth were more likely to choose an IUD because of a fear of non-compliance with oral contraceptives and possible problems with other methods, eg, hormone injections. Nulliparous women, and women who had not recently given birth were much more likely to choose the IUD as their method of contraception because they felt it had health advantages and/or was more convenient than other methods. These reasons for choosing an IUD are not usually given a high priority by contraceptive methodology providers.

Intrauterine breakage of a Multiload Cu250 intrauterine device: report of a case.

A case of intrauterine breakage of a Multiload Cu250 IUD is reported. After a failed attempt to remove the IUD in which the IUD strings broke, the body of the IUD without the side arms was expelled spontaneously.

IUD insertion forces: effects of recent childbirth and lactation.

This investigation compared the force required to insert an IUD in women who were breastfeeding and who had recently delivered a child with that required in control women who were not breastfeeding and who had not recently delivered. Twenty-eight women who had recently delivered and who were breastfeeding were compared with twenty-eight controls. The women were matched for age and parity and for the type of IUD used. The mean IUD insertion force in the breastfeeding, recently-delivered women was 1.75 newtons (N) as compared to 2.80 N in the controls. The difference was statistically highly significant (paired t-test, p less than 0.01). Recent childbirth and lactation are associated with a reduction in IUD-related insertion pain, probably due to a reduction in the force required for insertion. This reduction in IUD insertion force is not necessarily related to lower uterine perforation rates in IUD insertion in this group. A number of physiological mechanisms may be responsible for this finding.

Attitudes to vasectomy among rural and urban African men.

PIP: The authors analyzed the responses of 79 rural workers (farm laborers) and 62 urban workers (gold miners) to a questionnaire on attitudes to vasectomy. There were no statistically significant differences in the personal characteristics of the 2 groups, with the exception of education level. The urban workers were significantly higher educated than those in the rural areas. Furthermore, the rural community wanted more than 2-3 children, were less aware of their church's attitude to contraception, and their wives were more likely to practice contraception. The urban community were more aware of what vasectomy and female sterilization entailed. Both the urban and rural men feared loss of manhood following the procedure and feared that their wives would become unfaithful to them and that they would lose dominance over their families. Both groups believed that a pregnant wife was more likely to remain faithful to them. Vasectomy is a safe, simple surgical sterilization procedure for men. Failure rates are low and complications are rare. Despite this, vasectomy is not widely used as a method of contraception in most countries. Although very widely used in the US, the United Kingdom, China, and India, it is not the case in most other countries. While its use may be growing in central and South America, this is not the situation in Sub-Saharan Africa, which includes South Africa. The Association of Voluntary Sterilization of South Africa is attempting to popularize sterilization as a means of contraception among both sexes and among all racial groups in South Africa. At the present, there are fewer than 10,000 vasectomies being performed in South Africa each year, in country where the population growth rate if about 2.5% and the total population is now over 35 million. The present study compares the attitudes of rural and urban unskilled and semiskilled working men to vasectomy in order to help discover areas of possible misgivings and misunderstandings. It is also attempting to help provide the type of literature and visual information which would encourage acceptance of this method or irreversible contraception.^ieng

Use and misuse of oral contraceptives by adolescents attending a free-standing clinic.

A total of 216 adolescents attending a free-standing clinic completed a questionnaire on oral contraceptive use. Over 80% knew the brand name of their pill and took it correctly from cycle to cycle. About a third had missed at least one pill in the previous three months. Those who took their pills irregularly were more likely to miss them. In the event of missing a pill only 25% would use additional contraceptive measures such as condoms. Over half thought that not menstruating was harmful. The pill-taking pattern in this group of adolescents does not appear to differ significantly from that in adults. Oral contraceptive packs containing 28 tablets (including placebos) appear to produce fewer cycle-to-cycle problems than packs containing 21 active tablets.

Insertion forces with intrauterine devices: implications for uterine perforation.

The force required to insert a Copper 7, Multiload Copper or Nova T IUD was measured in 197 successful and 25 unsuccessful insertion attempts. These forces were compared with the forces required to perforate freshly obtained uterine specimens with a metal uterine sound and Dalkon shield device, as well as with the clinically tested devices. The mean insertion forces for the Copper 7, Nova T and Multiload Copper devices were 1.502 N, 2.134 N and 4.041 N respectively, while the mean insertion pressures (N/mm2) were 0.203, 0.209 and 0.122 respectively. The mean in vitro fundal perforation forces with metal sounds was 20.7 N and with the Dalkon shield 31.6 N. The Copper 7, Multiload Copper and Nova T IUDs achieved mean in vitro forces of 5.75 N, 9.2 and 8.1 N respectively, without causing perforation. Primary uterine perforation at the time of insertion of these devices appears unlikely.

'Bowing' forces with IUD inserters in vitro: relevance to difficult IUD insertions.

The inserter tubes of the more modern copper bearing IUDs are flexible enough to give ('bow') when there is obstruction to the device. The MLCu 250, Copper 7 and Nova T inserters will bow considerably when forces of 1-3 N are exerted and the device obstructed up to 0.75 cm from its proximal end. This suggests that these devices are unlikely to cause cervical damage where their passage into the uterine cavity is impeded by cervical factors, provided the insertion attempt is discontinued when bowing of more than 2 cm off-centre is reached. However this does not apply to obstructions past the internal cervical os. In research circumstances great care should be used as it rapidly becomes possible to exert enough force to produce damage to the uterine muscle.

Do plain plastic and copper bearing intrauterine contraceptive devices have a central mechanism of action?

The notion that the intrauterine contraceptive device (IUCD) has a central, as well as a local action, is examined. Although the IUCD undoubtedly has a local action, certain IUCD related side effects, e.g. galactorrhoea, bloating and premenstrual syndrome and inadequate luteal function can be explained if the IUCD has some central action. The powerful postcoital anti-fertility effect of both copper-bearing and plain plastic IUCDs probably also depends to some extent on a central action. The central action of the IUCD is probably due to initiation of reflex hypothalamic activity following intrauterine reflex stimulation. The hypothalamic response to IUCD insertion consists of release of beta-endorphin accompanied by raised levels of prolactin, vasopressin and oxytocin.

PIP: The possibility that the IUD may have a central as well as a local action in humans was examined. For the IUD to have a central contraceptive action, it is necessary to produce evidence that IUD insertion and use interferes with the hypothalamo-pituitary ovarian axis. Biochemical studies have found that women using an IUD tended to have a shorter luteal phase of the menstrual cycle. The deficient luteal phase was presumed to be the result of inadequate luteal function as evidenced by reduced progesterone levels. In a study by Haukkamaa et al., the investigators found an increased incidence of anovular cycles as well as deficient corpus luteal function. All possible side effects of the IUD, including weight gain, bloating, cycle shortening, and postcoital contraceptive effect, can be explained by the central hypothalamic effect of the IUD, leading to increased beta-endorphin production.

Pain reduction during and after insertion of an intrauterine contraceptive device.

The intrauterine contraceptive device (IUD) is an established method of fertility regulation despite certain problems. The major problems relating to IUD use are unwanted pregnancy, excessive bleeding, genital infection, occasional uterine perforation, device translocation, and pelvic pain. All fertility regulation personnel are aware that a very large number of potential IUD acceptors are concerned about the possibility of pain before, during and after device insertion. Pain is recognized as one of the major reasons for termination of the use of the IUD. Despite this, and unlike other IUD problems, IUD-related pain has been very poorly studied. At a recent workshop on intrauterine contraception there was not one presentation on this topic. The reason for this is that IUD-related pain is difficult to study, requiring careful analysis of subjective rather than objective data. Nevertheless a thorough understanding of the mechanisms, causes, prevention and treatment of IUD-related pain is important for fertility regulators in both developed and developing countries.

A comparison of the actual and expected pain response following insertion of an intrauterine contraceptive device.

The expected, immediate, and three-minute pain response following IUCD insertion was evaluated in 84 nulliparous women undergoing a first IUCD insertion. Expected pain was significantly higher than immediate pain and both were significantly higher than three-minute pain. Immediate pain following IUCD insertion was positively related to expected pain but the relationship was not strong enough to be of clinical value. The pain was significantly related to the degree of cervical resistance and this relationship was made much more obvious by the use of the expected pain parameter which is a valuable additional clinical measurement in pain research. IUCD insertion pain consists of a short cervical (less than 3 minutes) and longer fundal component. Avoiding excessive uterine manipulation during device insertion results in lower immediate and later pain response scores for a given device when comparisons are made with other studies, where standard techniques were used.

PIP: This study was aimed at evaluating actual versus expected pain levels associated with an IUD insertion technique developed by the authors. This technique eliminates prior uterine sounding and use of local anesthesia or oral analgesia. It was tested in 84 nulliparous women ages 18-40 years who were undergoing their 1st IUD insertion. Expected pain before IUD insertion, immediate pain, and 3-minute pain following insertion were evaluated on a visual analog scale recorder. Expected pain was significantly higher than immediate pain, and both were significantly higher than 3-minute pain. Immediate postinsertion pain was independent of age, gravidity, or day of cycle but dependent on expected pain and cervical resistance; however, the relationship was not strong enough to be of clinical value. The relationship between cervical resistance and the difference in expected and immediate pain scores was highly significant (p0.001). The 3-minute pain score was significantly different from the immediate pain score but was not related to the expected pain score. Follow-up ratings were obtained from 44 study participants; the relationship between 3-minute pain score and follow-up symptoms was significant. These results confirm the clinical observation that IUD insertion without prior uterine sounding results in immediate and 3-minute pain levels that are lower than those expected by patients. IUD insertion pain appears to consist of a short cervical component and a longer (more than 3 minutes) fundal component. The cervical pain response can be abolished through use of local anesthesia whereas fundal pain should be treated with antiprostaglandin analgesics.

A comparison of the actual and expected response following removal of an IUD.

The expected pain before insertion and immediate and 3 minutes pain response following IUD insertion was evaluated in 38 nulliparous women undergoing a 1st IUD removal. Expected pain was significantly greater than immediate pain and both were significantly greater than 3 minute pain. Immediate pain after IUD removal was positively related to expected pain, but the relationship was not strong enough to be clinically useful. IUD removal was highly significantly related to cervical resistance, and this relationship was made very much greater by the use of expected pain as a clinical parameter. IUD removal pain is probably related to IUD retention forces, and this relationship should be investigated.

Delayed postcoital IUD insertion.

PIP: 71 women who presented on or after the 6th day following unprotected coitus were fitted with a copper-containing IUD. There were no postcoital contraceptive failures or later method failures in the 64 women who have been followed up. Medical removal due to bleeding, and requests for device removal, reached 46% within 6 months. Delayed postcoital IUD insertion appears to be a safe, effective procedure in skilled hands and may help avoid pregnancy termination.^ieng

Treatment of pain following IUD insertion with meptazinol--a new centrally acting analgesic.

PIP: 29 patients received meptazinol 100 mg and 30 received placebo in a randomized double-blind study of the efficacy of meptazinol for the relief of pain following insertion of a Copper 7 IUD. 55 nulliparas and 4 oligoparas aged 18-35 undergoing a 1st insertion of IUD were fitted with Cu 7 devices following standard procedures. Each patient received 50 tablets of either meptazinol 100 mg or placebo and 50 tablets of paracetamol to be used as rescue therapy if they felt the trial therapy was ineffective. Patients were asked to record presence or absence of abdominal cramps and other symptoms and to return for follow-up in 7 days. There were no significant weight or parity differences between the 2 groups. There was no significant difference in the IUD side-effects index in patients taking meptazinol or placebo and in those resorting to rescue therapy. Meptazinol scored better than placebo in an assessment of overall quality of treatment. The patients who used meptazinol as initial therapy did so on 66 separate occasions and resorted to secondary therapy on 19 occasions, while the patients who used placebos as initial therapy did so on 80 occasions and resorted to the secondary therapy on 33 occasions. The trends appear to have clinical significance but did not reach statistical significance. Adverse effects were minor and similar in both groups, indicating that meptazinol is a safe drug for the treatment of IUD pain.^ieng

The IUCD in nulliparous women: with special reference to the Multiload copper 250 'mini' and 'short' IUCDs.

The problems relating to the fitting of intrauterine contraceptive devices (IUCDs) in nulliparae are (i) when to fit, (ii) how to fit and (iii) what type of IUCD to fit. IUCDs are best fitted around the time of ovulation as the uterine cavity is most relaxed and accomodating towards the IUCD. The device should be placed to abut the uterine fundus to ensure that it does not encroach on the cervical isthmus. This may be a problem in this group as the endometrial cavity may sometimes be less than 3 cm. The functional endometrial cavity width in nulliparae is probably much smaller than was previously assumed. IUCDs with a horizontal width of about 18 mm and vertical length of less than 30 mm appear best suited to the nulliparous endometrial cavity. Two studies on the ML Cu250 short and ML Cu250 mini indicate that the ML Cu250 short is well suited to the nulliparous endometrial cavity and that the ML Cu250 mini will be useful in patients with extreme narrowing of the endometrial cavity. Both these devices are often acceptable to patients who are intolerant of other types of IUCD. Insertion of these devices may be accompanied by some pain which is usually of limited duration.