Table II-9-3. Mechanism of Action of Intrauterine System (IUS)
• ↓ sperm transport
• ↑ tubal motility
• ↓ implantation
• Sperm and blastocyst destroyed
• Cervical mucus altered (LNG)
Definition of abbreviations: LNG, levonorgestrel.
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Chapter 9 l Fertility Control
Absolute Contraindications include a confirmed or suspected pregnancy; known or suspectedpelvic malignancy; undiagnosed vaginal bleeding; and known or suspected salpingitis. Relative Contraindications include abnormal uterine size or shape; medical condition (e.g., corticoste-roid therapy, valvular heart disease, or any instance of immune suppression increasing the risk of infection); nulligravidity; abnormal Pap smears; and history of ectopic pregnancy.
Side Effects. Menstrual bleeding and menstrual pain may be increased with the copper IUS, butnot with the progesterone IUSs.
Potential Complications. The popularity of the IUS has varied greatly during the past2 decades. Despite its excellence as a method of contraception, it has yet to recover from the negative publicity generated by the Dalkon Shield in the late 1970s. The LNG-containing IUS is effective for 5 years, the copper T-380A is effective for 10 years, making it potentially the least expensive contraceptive available.
• Chlamydia. This patient’s recent chlamydia infection is a significant risk factor for IUSuse. Most of the increased risk of infection actually attributable to IUS use is within 20 days after infection; consequently, any vaginal infection should be treated and resolved before insertion of the IUS to prevent introduction of organisms into the upper genital tract. Medical conditions that increase the risk of infection, such as HIV infection and immunosuppressive therapy, are also relative contraindications to IUS use. This patient’s periodic need for steroid treatment for Crohn disease is a risk factor.
• Leiomyomas. Uterine fibroids could also be a relative contraindication because theyalter the shape of the endometrial cavity or cause heavy bleeding. The subserosal fun-dal fibroids should not interfere with IUS placement.
• Expulsion is higher in young, low parity women.
• Ectopic pregnancy. The IUS does not increase ectopic pregnancies. However, withpregnancy from failed IUS, the likelihood of it being ectopic is higher because primar-ily, intrauterine pregnancies are prevented.
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• Septic abortion occurs in 50% of patients with concurrent pregnancy.
• Uterine perforation, although rare, occurs more likely at time of insertion.
• PID may occur within the first 2 months after placement if pathogenic organisms arepresent in the reproductive tract.
IUS Options
• “Mirena.” A levonorgestrel-impregnated (LNG) IUS that releases the hormone gradu-ally over 5 years. Bleeding and cramping may be decreased. Failure rate is <1%.
• Skyla. A smaller (LNG) IUS similar to Mirena but effective for only 3 years. Failure rateis <1%.
• Copper T-380A IUS. Marketed under the trade name “Paraguard,” this copper-bandedIUS releases copper gradually over 10 years. Bleeding and cramping may be increased. Failure rate is <1%.
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