Modern IUDs are easily inserted, have a very high effectiveness rate (98-99%), and are well-tolerated by most of the women who use them. Their effectiveness continues for varying lengths of time, depending on the type of IUD. The "Copper T 380A," used frequently in the United States, can remain in place for 10 years before removal is recommended.
IUDs tend to make menstrual flows somewhat heavier, crampier and longer, a consideration in assessing the appropriateness of an IUD for any individual patient.
The Dalkon Shield
There were two reasons for these infections; a design flaw and a marketing flaw. The design flaw was located in the "tail" or string used to remove the IUD. After insertion, the string is left protruding through the cervix so it is visible on pelvic exam. This confirms that the IUD is correctly placed and facilitates removal at a later date. The Dalkon Shield string was made up of many tiny plastic filaments and encased in a plastic sheath. This design inadvertently caused the string to act as a wick, constantly drawing vaginal bacteria up through the cervix and into the uterine cavity where they could cause infection. The other IUDs had monofilament strings which did not have the same wicking capacity. The design, in retrospect, predisposed the Dalkon Shield to infections.
The marketing flaw was to promote IUD among young, single women without children. These women tended to have greater risk of exposure to sexually transmitted disease and multiple sexual partners. They tended to be more likely to seek medical attention late in the course of the illness. The consequences of permanent infertility among these young women was devastating.
While the design and marketing flaws of the Dalkon Shield are of primarily historical interest, the lessons learned at a terrible cost should not be forgotten in looking at more modern IUDs.
With the less common, serious infections, a high fever can be found, movement of the cervix causes excruciating discomfort and the adnexa are extremely tender. In addition to prompt removal of the IUD, IV antibiotics are recommended to treat this moderate to severe PID. In these cases, recovery is generally slow (days to weeks) and infertility is a distinct possibility.
A truly perforated IUD is usually removed from the abdominal cavity with laparoscopic or open surgery.
Missing IUD String
If the string is not inside the cervical canal, then further evaluation and treatment will be needed from an experienced and well-equipped gynecologic consultant. X-ray can confirm that the IUD remains somewhere within the pelvis. Ultrasound can demonstrate the presence of the IUD inside the uterine cavity. For an IUD which is clearly inside the uterine cavity but whose string has retracted into the cavity, a careful judgment must be made.
In some circumstances, the IUD is removed with an IUD hook, D&C or hysteroscopy, and a new once replaced. In other circumstances, it may be appropriate to leave the IUD where it is until the 10 years have expired before removing it.
If pregnancy occurs, it is important to remove the IUD immediately (that day). The normal spontaneous miscarriage rate is about 18-20%. For women who conceive despite an IUD, the miscarriage rate is about 25% when the IUD is removed immediately. If the IUD is left in place, the miscarriage rate increases to about 50%, and many of those are septic mid-trimester losses which are particularly unpleasant and which are associated with subsequent infertility in some cases.
If deployed, even the relatively inexperienced health care provider can remove the IUD because: 1) it is simple and easy to do, and 2) delaying removal for several days until a more experienced provider can see the patient risks retraction of the string up inside the uterus, making simple removal impossible. The IUD should first be removed and then the patient moved to a definitive care setting in anticipation of a possible miscarriage.
In many military settings, such an evaluation may not be possible and medical evacuation should be considered.
A bad candidate for an IUD is:
Most women considering an IUD don't fit perfectly into either category, so some judgment must be used. Contraindications to IUD use include:
Insertion of the IUD
Insertion usually causes mild uterine cramping which disappears in a few minutes. Pretreatment with a NSAID can block much of that discomfort.The use of prophylactic antibiotics is an unresolved controversy.
Removal of the IUD
After placing a vaginal speculum, visualize the cervix and the IUD string(s) protruding through the cervical os. Grasp the strings with any convenient instrument (hemostat, dressing forceps, ring forceps, etc.) and pull the IUD straight out with a steady, smooth, slow pull. The IUD, by virtue of its' pliability, will fold onto itself and slide out. Most patients will feel either no discomfort or minimal uterine cramping during removal. They generally comment that having the IUD removed was not as uncomfortable as having it inserted.
OB-GYN 101: Introductory
Obstetrics & Gynecology
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