Copper IUD
A copper intrauterine device , also known as an intrauterine coil, 'copper coil, or non-hormonal IUD', is a form of long-acting reversible contraception and one of the most effective forms of birth control available. It can also be used for emergency contraception within five days of unprotected sex. The device is placed in the uterus and lasts up to twelve years, depending on the amount of copper present in the device. It may be used for contraception regardless of age or previous pregnancy, and may be placed immediately after a vaginal delivery, cesarean delivery, or surgical abortion. Following its removal, fertility quickly returns.
Common side effects include heavy menstrual periods and increased menstrual cramps. Rarely, the device may come out or perforate the uterine wall.
The copper IUD was initially developed in Germany in the early 1900s, but came into widespread medical use in the 1970s. It is on the World Health Organization's List of Essential Medicines.
Medical uses
Copper IUDs are a form of long-acting reversible contraception and are one of the most effective forms of birth control available. The type of frame and amount of copper in the device can affect the effectiveness of different copper IUD models.The copper IUD is effective as contraception as soon as it is inserted, and loses efficacy when removed or if it becomes malpositioned. The effectiveness of the copper IUD is comparable to tubal sterilization for the first year. The failure rates for different models vary between 0.1 and 2.2% after one year of use. The T-shaped models with a surface area of 380 mm2 of copper have the lowest failure rates. The TCu380A has a one-year failure rate of 0.8% and a cumulative 12-year failure rate of 2.2%. Over 12 years of use, the models with less surface area of copper have higher failure rates. The TCu220A has a 12-year failure rate of 5.8%. The frameless GyneFix has a failure rate of less than 1% per year. A 2008 review of the available T-shaped copper IUDs recommended that the TCu380A and the TCu280S be used as the first choice for copper IUDs because those two models have the lowest failure rates and the longest lifespans. Worldwide, older IUD models with lower effectiveness rates are no longer produced.
Though only approved by regulatory agencies for a maximum of 12 years, some devices may be effective with continuous use for up to 20 years.
Because it does not contain hormones, the copper IUD does not disrupt the timing of an individual's menstrual cycle, nor does it prevent ovulation.
Emergency contraception
It was first discovered in 1976 that the copper IUD could be used as a form of emergency contraception. The copper IUD is the most effective form of emergency contraception, more effective than oral hormonal emergency contraception, including mifepristone, ulipristal acetate, and levonorgestrel. Efficacy is not affected by user weight. The pregnancy rate among those using the copper IUD for emergency contraception is 0.09%. It can be used for emergency contraception up to five days after unprotected sex, and does not decrease in effectiveness during the five days. An additional advantage of using the copper IUD for emergency contraception is that it can then be used as a form of birth control for 10–12 years after insertion.Removal and return to fertility
Removal of the copper IUD should be performed by a qualified medical practitioner. Fertility has been shown to return to previous levels quickly after removal of the device.Side effects and complications
Complications
The most common complications related to the copper IUD are expulsion, perforation, and infection. Infertility after discontinuation and difficulty breastfeeding during use are not associated with the copper IUD.Expulsion rates can range from 2.2% to 11.4% of users from the first year to the 10th year. The TCu380A may have lower rates of expulsion than other models, and the frameless copper IUD has a similar rate of expulsion to models with frames. Expulsion is more likely with immediate or early postpartum or post-abortal placement. In the postpartum period, expulsion is less likely when the device is placed less than tenminutes after the placenta is delivered, or when inserted after a cesarean delivery. Unusual vaginal discharge, cramping or pain, spotting between periods, postcoital spotting, pain during intercourse, or the absence or lengthening of the strings can be signs of a possible expulsion. As with intentional removal, the device is immediately ineffective after expulsion. If an IUD with copper is inserted after an expulsion has occurred, the risk of re-expulsion has been estimated in one study to be approximately one third of cases after one year. Magnetic resonance imaging may cause dislocation of a copper IUD, and it is therefore recommended to check the location of the IUD both before and after MRI.
File:Perforated IUD.jpg|thumb|Transvaginal ultrasonography showing a perforated copper IUD as a hyperechoic line at right, 3 centimeters away from the uterus at left. The IUD is surrounded by a hypoechoic foreign-body granuloma.
Perforation of the device through the uterine wall typically occurs at the time of placement, though it may occur spontaneously during the period of use. Estimates of the rate of perforation vary from 1.1 per 1000 to 1 per 3000 copper IUD insertions. Perforation may be slightly more common in people using the copper IUD while breastfeeding.
Due to its inflammatory mechanism of action, a copper IUD that has completely perforated typically requires surgical removal due to the formation of dense adhesions around the device. A device embedded in the uterine wall may be removed hysteroscopically or surgically.
The insertion of a copper IUD poses a transient risk of pelvic inflammatory disease for 21days, though this is almost always in the setting of undiagnosed gonorrhea or chlamydia infection at the time of insertion. This occurs in less than 1 in 100 insertions. Beyond this time frame there is no increased risk of PID associated with copper IUD use. Postpartum insertion of a copper IUD is not associated with increased risk of infection, provided that the delivery was not complicated by an infection such as chorioamnionitis.
During removal, the device may break, which can cause uterine wall perforation and potentially lead to more severe complications, including infertility. In rare cases, the IUD may be unintentionally expelled from the uterus, for example due to physical trauma such as a car accident.
Side effects
The most common side effects reported with use of the copper IUD are increased menstrual bleeding and menstrual cramps, both of which may remit after 3–6 months of use. Less frequently, intermenstrual bleeding may occur, especially in the first 3–6 months of use. The increase in menstrual blood volume varies in different studies but is reported to be as low as 20% and as high as 55%; however, there is no evidence for a concomitant change in ferritin, hemoglobin, or hematocrit.Menorrhagia and dysmenorrhea are typically treated with NSAID medications including naproxen, ibuprofen, and mefenamic acid.
Contraceptive failure
The absolute risk of ectopic pregnancy with copper IUD use is lower than with no contraception because it works primarily by prevention conception. The copper inhibits sperm migration and viability, which prevents fertilisation. However, when pregnancy does occur with a copper IUD in place, a higher percentage of those pregnancies are ectopic, from 3% to 6%, a two to sixfold increase. This corresponds to an absolute rate of ectopic pregnancy in copper IUD users of 0.2–0.4 per 1000 person-years, compared to 3 per 1000 person-years in the population using no contraception.If a pregnancy continues with the IUD in place, there is an increased risk of complications including preterm delivery, chorioamnionitis, and spontaneous abortion. If the IUD is removed, these risks are lower, especially the risks of bleeding and miscarriage; the rate of miscarriage approaches that of the general population depending on study population.
Overall failure rates with the copper IUD are low, and are mainly dependent on the surface area of copper in the device. After 12 years of continuous use, the TCu380A device has a cumulative pregnancy rate of 1.7%. The TCu 380A is more effective than the MLCu375, MLCu350, TCu220, and TCu200. The TCu 380S is more effective than the TCu 380A. The frameless device has similar failure rates to conventional devices.