A study of the copper T intrauterine contraceptive device (TCu 200) in nulliparous women

Systematic review of copper intrauterine contraception continuation in young nulliparous women based on intrauterine device type

OBJECTIVES

No copper intrauterine device (IUD) type is known to better suit young nulliparous women who tend to experience higher rates of IUD discontinuation compared with their older parous counterparts. A systematic review to determine which IUDs have higher continuation rates in young nulliparous women was undertaken.

DESIGN

Systematic review and meta-analyses of available evidence based on IUD type.

DATA SOURCES

AMED, BNI, CINAHL, DARE, EMBASE, EMCARE, HMIC, MEDLINE, PsycINFO, PubMed, TRIP, and the Cochrane Library electronic databases were searched from inception to 11 May 2022; as well as the Bandolier, Medicines and Healthcare products Regulatory Agency, Faculty of Sexual and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists, Department of Health, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines, WHO and Google Scholar websites.

ELIGIBILITY CRITERIA

All studies on IUDs currently available in the UK or comparable (same design and size) to those available in the UK, involving nulliparous women of any age including those aged under 30.

DATA EXTRACTION AND SYNTHESIS

Independently extracted data were assessed as low risk of bias using the Mixed Methods Appraisal Tool. Random effects meta-analyses of proportions were performed where data, including subgroups, were amenable to quantitative synthesis. Heterogeneity was reported using tau2 and I2 statistics, and sensitivity analyses were also performed.

RESULTS

Nineteen studies involving 13 045 nulliparous women were included but the heterogeneity of participant ages, parity and IUD types made quantitative synthesis of outcome data in totality inappropriate. The highest continuation rate obtained was 91.02% (95% CI 88.01% to 93.64%) for the smaller TCu 380A at 12 months post insertion.

CONCLUSIONS

Evidence for IUD use in young nulliparous women based on IUD type remains limited. Smaller sized IUD types appear better suited to this group of IUD users, however, more research is needed.

PROSPERO REGISTRATION NUMBER

CRD42019120969.

Length of the endometrial cavity as measured by uterine sounding and ultrasonography in women of different parities

BACKGROUND

In view of current controversies regarding the need for new, shorter intrauterine devices (IUDs) that would reduce expulsion rates in nulligravida, endometrial cavity length was measured in women of different parities using uterine sounding and ultrasonography.

STUDY DESIGN

A cross-sectional descriptive study was performed including 570 women of 17-52 years of age, 260 of whom were nulligravida and 310 parous.

RESULTS

The difference in mean length between measurements taken by uterine sounding and ultrasonography was 0.28 cm. Mean endometrial cavity length was 3.84+/-0.03 cm (mean+/-S.E.M.) in nulligravida and 4.25+/-0.03 cm in parous women according to uterine sounding (p<.001) and 3.70+/-0.03 cm and 3.84+/-0.03 cm, respectively, according to ultrasonography (p=.006).

CONCLUSIONS

By either technique, mean length of the endometrial cavity was >3.6 cm, the length of the most common IUDs, the TCu380A and the levonorgestrel-releasing intrauterine system. Therefore, the issue appears controversial for developing new, shorter IUDs, since current models fit most women, including nulligravida, albeit one third of the women of our sample showed endometrial length shorter than 3.2 cm.

Five years private practice experience of nulliparous women using copper IUD's

This is a study of 296 nulliparous women who used Copper IUD's as their method of contraception. At the time of first insertion the women had an average age of 21.6 years. The gross cumulative pregnancy rate rose to 11.8 over 5 years. The gross cumulative expulsion rate rose to 13.6 over 5 years and the removal rate for bleeding and pain to 20.4. The net rates were lower over 5 years (pregnancy 8.6, expulsion 11.2 and bleeding and pain 17.3). 29 women expelled their IUD's, of whom 20 underwent reinsertion. 43 women requested removal of their IUD's because of bleeding and pain, of whom 6 requested a reinsertion at a later date. Taking reinsertions into account, the continuation rate over 5 years was 55.2. Inability to insert the IUD was encountered in 28 women (8.6%). In 20 of the women cervical stenosis precluded the insertion of the IUD without local anesthetic, and in the other 8, the pain and/or syncope encountered during sounding the uterus precluded the continuation of the procedure. Insertion problems were encountered in 31 women (10.5%). Syncope occurred in 4 women and one of the women developed a 'grand mal' seizure. Clinically significant pelvic infection occurred within 30 days of insertion in 5 women (approximately 1% of insertions), and one woman developed pelvic infection from gonorrhoea.

IUD compared with oral contraception in nulliparae

172 nulliparae attending a Swedish family planning clinic were studied. Doctors and midwives with various experiences gave the contraceptive method. Continuation rate at 12 months was 58 per cent for IUD and 86 per cent for OC. The expulsion rate in the IUD group was 11 per cent and in 30 per cent of IUD users the device was removed because of adverse effects. 10 per cent of the IUD group and 5 per cent of the OC group discontinued their method without introducing another one, thereby risking an unwanted pregnancy.

Comparison of three different models of the copper T intrauterine contraceptive device

A random sequential comparative study of three models of the Copper T intrauterine contraceptive device (IUD) was undertaken in 1,792 women. For 7 months, the TCu 300 and TCu 220C were randomly inserted, and then the TCu 380A and 220C were randomly inserted for the next 12 months. The log-risk method of life-table analysis of event rates was performed at the end of each of the first 3 years of use of each device. The TCu 380A had the lowest pregnancy rate during each year of use, although the difference was not significant. At the end of each of the first 2 years, the TCu 300 was removed significantly less than the TCu 220C and TCu 380A for bleeding and pain. At the end of three years, the rates of removal for bleeding and pain for the TCu 380A and TCu 300 were similar and lower than that for the TCu 220C, but the overall difference was not significant. There were no differences among the devices for any other relevant use-related reasons. The TCu 380A was removed for other medical reasons significantly more frequently than the other devices at the end of 2 and 3 years. Adjusting for parity did not alter the results. The findings of this study suggest that the copper sleeves along the horizontal arms together with copper wire on the vertical arm in the TCu 380A model provide greater protection against intrauterine pregnancy, whereas the copper sleeves along the vertical arm as in the TCu 220C caused increased removals for bleeding and pain. The TCu 380A should be studied in a larger number of patients for a longer period of time to determine its clinical effectiveness. It may become the IUD of choice for all women irrespective of parity.

Is development of pelvic inflammatory disease in women using intra-uterine device equal regardless of parity? A one year follow-up study

Seven hundred and fifty women using IUD(TCu 200) were observed for one year after insertion. Sixteen (2.1%) of the women were hospitalized for salpingitis (PID), and the diagnosis was always confirmed by laparascopy. Of these 16 women, 8 belonged to the nulliparous group and 8 to the parous group. In the high-risk age-group (16--25 years), the incidence of salpingitis was 47/1000 women-year in the nulliparous group, and 42/1000 women-year in the parous group. Thus, the rate of development of salpingitis is equal regardless of parity.

Copper intrauterine contraceptive devices in adolescent nulliparae

Copper intrauterine contraceptive devices (IUCDs) were used in 243 young nulligravidae attending a gynaecological clinic for schoolgirls in Uppsala between March 1973 and June 1975; 226 of these girls (93%) were seen again during December 1975 making a total of 3138 months of observation. At the time of follow up, 126 patients (55.8%) still had the IUCD in situ; 20% had expelled the IUCD and in another 24.2% the IUCD had been removed because of bleeding and/or pain or because of suspected pelvic inflammatory disease (7 patients). Twelve of the girls conceived during the period of observation making the Pearl index 4.6; nine of the conceptions occurred within nine months of the insertion of the IUCD. Unlike others we do not advocate the use of the IUCD for young nulligravidae.

Contraception in adolescence--a review of the literature

During the last 10 years an increasing number of pregnancies have been noted in adolescents. The children of these pregnancies are often at risk. The problem was discussed in a meeting on Pregnancy and Abortion in Adolescence in 1974, held at WHO headquarters, Geneva. An annotated bibliography was prepared for that meeting, from which this review originated. The literature covered a wide range of subjects, but an attempt has been made in this review to discuss the problem in six main sections: social aspects; sexual attitudes and behaviour; sex education and information; contraceptive services for adolescents; medical and clinical aspects and legislation. Quite a number of teenagers are sexually active even in their early teens but often keep to one partner. Their use of contraception is poor, partly because of a lack of education and information. Young people are demanding better information and services, which would probably best be provided through special teenage clinics. So far, there have been very few investigative studies dealing exclusively with adolescent use of different contraceptive methods. Methods of contraception available at present are often unsuitable for use by adolescents, and further research on the problem is needed.

The Copper T 220C: a new long-acting copper intrauterine contraceptive device

The Copper T(TCu) intrauterine contraceptive device (IUD) has been found to be an effective method of contraception but has the disadvantage of needing periodic replacement due to loss of copper through dissolution and fragmentation of the copper wire. Modification of the Copper T to overcome this disadvantage involved substitution of copper sleeves for wire on the vertical arm and the addition of copper sleeves to the horizonal arms to give an effective surface area of 220 sq. mm. of copper and an estimated life span of 20 years. A randomized comparative study was undertaken in 999 women to determine if the new model performed as well as the wire-wound Copper T 300. Net cumulative first-event rates at one year were as follows: TCu 220C-pregnancy 0.9, expulsion 3.7, removal for pain or bleeding 14.4; TCu 300-pregnancy 1.1, expulsion 3.1, removal for pain or bleeding 9.3. None of the differences in event rates were significant. If long-term follow-up confirms these findings, this new long-lasting copper intrauterine device could become the IUD of choice for all women.

A fluid-filled intrauterine device: initial clinical trials

Initial clinical trials of a saline-filled IUD were conducted with 697 women (397 nulliparas and 307 multiparas) experiencing 6,672 woman-months of use. The cumulative rates for multiparas were: pregnancy 1.5, expulsion 10.5, medical removal 10.9, continuation 68. For nulliparous women the rates were: pregnancy 4.3, expulsion 19.4, medical removal 14.3, continuation 58. Efforts are being made to modify the geometry and content of this IUD to decrease the expulsion rate and removals for bleeding.