H. Van der Pas

IMMEDIATE POSTPLACENTAL IUD INSERTION: THE EXPULSION PROBLEM

This paper reports an evaluation of immediate post-placental insertion of a non-copper (Lippes Loop D) and several copper-bearing IUD models (TCu200, TCu220C, MLCu375, MLCu250, Nova T-PP, DimélysR). Based on the analysis of a total of 2,646 insertions and 55,794 woman-months of experience, we conclude that placement of an IUD within ten minutes of delivery of the placenta is a valuable alternative to interval insertion, because this method is safe and effective. Effectiveness was significantly lower for the Lippes Loop D than for the T- and ML-IUD models tested, the latter showing roughly comparable pertinent event rates. Pertinent event rates for copper IUDs were influenced by the skill of the operator; age of the recipient only had a significant effect on effectiveness, whereas parity had no significant effect on pertinent event rates. The single and still unsolved problem associated with immediate postpartum insertion is the greater likelihood of expulsion compared with interval insertion, and this hazard is significantly much greater for the Loop than for the copper-bearing devices assessed. The evolution of the expulsion rates shows a constant time-relationship. This pattern makes it obvious why follow-up of recipients, at least during the first trimester following insertion, is mandatory if immediate post-placental IUD insertion is to be optimally effective.

IUD expulsion solved with implant technology

In an attempt to minimize the problem of IUD expulsion, implantation technology has been developed and tested. The trials have extended from 1985 until the present time for interval as well as for immediate postabortal and post-placental insertion and fixation of the CuFix IUD (Gyne-Fix). The present article reports on an ongoing study with GyneFix interval insertion, with an improved inserter, in 820 women, observed up to 3 years, of whom 213 (25.9%) are nulligravid/nulliparous. The cumulative expulsion rate is 0.6 per 100 women-years at 3 years and is not significantly higher in the nulligravid/nulliparous group. The cumulative pregnancy rate is 0.6 and the cumulative removal rate for medical reasons 3.2 at 3 years. The total experience in this multicenter study covers approximately 14,000 woman-months. It is concluded that the design characteristics of the GyneFix (fixed, frameless, and flexible) explain the low expulsion, high efficacy and high acceptability rates. The implantation technology is very effective and the improved inserter allows easy insertion and optimal anchoring.

Immediate postplacental insertion and fixation of the CuFix postpartum implant system

Since promising results were obtained with the CuFix interval implant system in international clinical trials conducted worldwide, a modification of the device adapting it for immediate postplacental insertion and fixation (IPPIF) seemed a logical approach to solve the expulsion problem of IUDs inserted at that particular time. Seventy-three insertions were performed at three university centers, during 1990 and 1991, both by skilled and unskilled investigators. The results of this multicenter study show the excellent retainability of the modified IUD supporting the validity of the anchoring principle. The insertion procedure is easy, requiring minimal training, and the insertion technique appeared to be safe.

Observations on the ML Cu 375

Grafenberg, in 1929, first introduced the idea of inserting a large foreign object in the cavum uteri as a contraceptive device. For medical as well as political reasons, this method was discredited. It was not until the end of the 1950s that a new trial to insert inert material into the uterine cavity was made by some young research-workers2.

First postpartum ovulation in women treated with a combination of ablactating steroids

This study was undertaken to pinpoint the first postpartum ovulation in non-nursing women who had received a combination of ablactating steroids (estradiol benzoate, estradiol phenylpropionate, testosterone phenylpropionate and testosterone isocaproate). Endometrial biopsies were taken from the 5th up to the 12th postpartum week. At six weeks, secretory patterns were found in 2 per cent of the treated women as against 15.2 of the control group. At the twelfth week these percentages amounted to 2 and 5, respectively. Our data indicate that the drug may influence the time of appearance of the first postpartum ovulation and, perhaps, the luteal function.

MLCu 250 im Vergleich zu anderen intrauterinen kontrazeptiven Mitteln

zwischen 500 000 und 1 000 000 I. E. Bei 36 Frauen kam es nach einmaliger Applikation der Proteinasen-Inhibitor-L6sung zum Blutungsstillstand innerhalb von 24 Std, bei 9 Frauen war eine 2. Gabe yon 500 000 I. E. Trasylol erforderlich. Lediglich bei 5 IUD-Tr/igerinnen sistierten die Blutungen nicht, es bestand weiterhin eine wenn auch geringe Schmierblutung. Die normale Periodenblutung trat bei den meisten Frauen zum erwarteten Zeitpunkt termingerecht ein, nur vereinzelt beobachteten wit eine Verschiebung des Menstruationsbeginns um 2 3 Tage. Nach der Beurteilung des Effektes der lokalen Proteinasen-Inhibition auf das Endometrium waren ftir uns 3 Kriterien mal3gebend: 1. Die Wirkung auf die Proliferation der Drtisenzellen, 2. die Wirkung auf die endometriale Entz/indungsreaktion und 3. die Wirkung auf die fremdk6rperbedingte Endometrium-Zellautolyse. Entztindliche Reaktion, Zellautolyse und Verlust der endometrialen Honigwabenstruktur der Zellverbiinde (Abb. 1) wurden nach Gabe von Proteinasen-Inhibitoren nicht mehr oder nur noeh gering ausgepr/igt gefunden (Abb. 2). Nach den durchgef/ihrten Untersuchungen erscheint uns das Konzept der lokalen, intracavit~ir verabreichten Proteinasen-Inhibitor-Therapie bei IUD-bedingten Blutungen sinnvoll und erfolgversprechend. Anhand von Endometriumzellausstrichen l~i/3t sich der Therapieerfolg belegen.The effectiveness of the MLCu 250 a new copper-containing intrauterine spiral was studied using Tietzes life table method. The rate of unwanted pregnancy was 1.1% in 462 nulliparae and 0.5% in 1511 multiparae. Spontaneous expulsion occurred in 1.7% of nulliparae and 1.3% of multiparae. The MLCu 250 was also inserted in 224 patients postpartum immediately after expulsion of the placenta. At x-ray checkup on the 6th postpartum day it was not visible in 0.53% of the patients; removal was necessary in 2 other patients. After 9 months observation of 172 patients (1127 woman-months) the following results are reported: 0.07% pregnancies; 2.3% expulsions; 1.9% removals due to bleeding or pain; 0.6% removal for medical reasons; 91.4% continuation. MLCu 250 is simple and safe to insert has low failure and expulsion rates and is well tolerated when inserted postpartum.