Endometrial morphological changes in IUD users: a review

Effect of a novel copper chloride gel on endometrial growth and function in healthy volunteers

RESEARCH QUESTION

Does the application of a micro-dose of copper chloride gel increase endometrial production of vascular endothelial growth factor (VEGF) without compromising endometrial function or producing embryo toxicity?

DESIGN

An estimate of optimal dose was made based on cell culture studies. Ten healthy participants received an initial uterine application of placebo gel, followed by copper chloride gel (37.5 μM, 75 μM, or 150 μM dose) in a later hormone replacement cycle. Endometrial biopsies (day 5.5 luteal) and pelvic ultrasound were carried out during each cycle to evaluate endometrial function and growth. Uterine fluid was assessed for residual copper levels on the day of biopsy, and copper chloride gel underwent mouse embryos assay assessment for potential embryo toxicity.

RESULTS

The copper gel significantly increased endometrial VEGF expression (quantitative polymerase chain reaction), and also increasing endometrial thickness by an average of 2.2 mm compared with matched control cycles. The copper gel did not adversely affect endometrial morphology or maturation (histological dating and molecular receptivity testing), and mouse embryos assay studies showed no evidence of embryo toxicity. Furthermore, uterine cavity flush samples mostly lacked copper, with only negligible amounts present in one sample.

CONCLUSION

Applying copper chloride gel to the uterine cavity upregulated endometrial VEGF and significantly increased endometrial thickness and volume. No adverse effects on the endometrium or embryos were observed. Copper chloride gels show promise for treating suboptimal endometrial thickness if the results of this study are confirmed by larger randomized controlled trials.

Development of an Intrauterine Device Releasing Both Indomethacin and Levonorgestrel During the First Months of Use: Pharmacokinetic Characterization in Healthy Women

BACKGROUND

Post-placement menstrual bleeding pattern changes with intrauterine contraceptives (IUCs), including levonorgestrel-releasing intrauterine systems (LNG-IUS), can be a reason for avoidance or early discontinuation. Prostaglandins play an important role in menstrual bleeding and pain. The key drivers of prostaglandin synthesis are cyclooxygenase (COX) enzymes, which are inhibited by non-steroidal anti-inflammatory drugs. In this study, we report the findings from pharmacokinetic (PK) analyses undertaken with an LNG-IUS (LNG-IUS 8) modified with an additional reservoir containing indomethacin (IND).

METHODS

The IND/LNG-IUS 8 is a proof-of-concept device studied in a phase II proof-of-concept/dose-finding study. IND/LNG-IUS 8 contains the same LNG content as the unmodified LNG-IUS 8 (13.5 mg) but was prepared with three different IND doses (low, 6.5 mg; middle, 12.5 mg; and high, 15.4 mg), resulting in different daily release rates. Overall, 174 healthy, premenopausal women were randomized to one of the four treatment arms (low-, middle-, high-dose IND/LNG-IUS 8 or LNG-IUS 8). Initial and residual IND and LNG content were collected and the amount of IND and LNG released in vivo over the period of use was calculated. A subset of 62 participants underwent dense blood sampling for PK analysis. Concentrations of IND and LNG in plasma were determined by validated liquid chromatography-tandem mass spectrometry methods and plotted over time. Descriptive statistics were calculated for plasma drug concentrations and PK parameters.

RESULTS

High-dose IND/LNG-IUS 8 initially released much higher levels of IND than expected based on in vitro release data, followed by a steep decline, with the reservoir emptied by 4.5 months. Middle- and low-dose IND/LNG-IUS 8 demonstrated steady sustained release of IND over time, emptying after 7.4 and 8.4 months, respectively. Peak plasma concentrations of IND for low- and middle-dose IND/LNG-IUS 8 remained below the 20% maximal inhibitory concentration (IC₂₀) values for COX enzymes. The average daily IND release rate in vivo was 49 µg/day for low-dose and 112 µg/day for middle-dose IND/LNG-IUS 8. The IND release rate profile and IND plasma concentrations in vitro both decreased steadily over time with low- and middle-dose IND/LNG-IUS 8. The LNG release rate profile was comparable for all IND/LNG-IUS 8 dose groups and LNG-IUS 8.

CONCLUSION

This PK study demonstrates that two different drugs can be released at different rates from an IUS designed with two drug reservoirs. Inclusion of IND does not impact the LNG PK profile. Low- and middle-dose IND/LNG-IUS 8 were associated with a systemic IND exposure that should preclude the occurrence of adverse events typically observed after oral IND dosing.

STUDY REGISTRATION

ClinicalTrials.gov identifier number: NCT03562624.

Effects of Levonorgestrel-Releasing Intrauterine Device Therapy on Ovarian Reserve in Menorrhagia

Objective This study aimed to investigate the effects of levonorgestrel-releasing intrauterine device (LNG-IUD) treatment on ovarian reserve in women of reproductive age diagnosed with menorrhagia. Methods This was a prospective controlled trial involving 50 women with menorrhagia and a control group comprising age-matched 50 healthy women. Women who satisfied the LNG group criteria underwent an endometrial pipelle biopsy and LNG-IUD insertion. Ovarian reserve tests were performed prior to and six months after LNG-IUD insertion in the LNG group cases. Results Follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), anti-Müllerian hormone (AMH), endometrial thickness (ET), total antral follicle count (AFC), and mean ovarian volume values before LNG-IUD insertion did not differ between the LNG and control groups. When the final measurements were compared, FSH, AMH, total AFC, and average ovarian volume increased (p=0.05, 0.046, 0.022, and 0.022, respectively), E2 and ET decreased (p=0.034 and 0.001, respectively) in the LNG group, while LH did not differ significantly between the groups (p=0.71). Conclusion We observed that LNG-IUD use effectively improves fertility capacity. In this study, LNG-IUD use in reproductive-age women diagnosed with menorrhagia decreased E2 levels, did not change LH levels, and increased FSH, AFC, and AMH levels.

Medical Applications of Porous Biomaterials: Features of Porosity and Tissue-Specific Implications for Biocompatibility

Porosity is an important material feature commonly employed in implants and tissue scaffolds. The presence of material voids permits the infiltration of cells, mechanical compliance, and outward diffusion of pharmaceutical agents. Various studies have confirmed that porosity indeed promotes favorable tissue responses, including minimal fibrous encapsulation during the foreign body reaction (FBR). However, increased biofilm formation and calcification is also described to arise due to biomaterial porosity. Additionally, the relevance of host responses like the FBR, infection, calcification, and thrombosis are dependent on tissue location and specific tissue microenvironment. In this review, the features of porous materials and the implications of porosity in the context of medical devices is discussed. Common methods to create porous materials are also discussed, as well as the parameters that are used to tune pore features. Responses toward porous biomaterials are also reviewed, including the various stages of the FBR, hemocompatibility, biofilm formation, and calcification. Finally, these host responses are considered in tissue specific locations including the subcutis, bone, cardiovascular system, brain, eye, and female reproductive tract. The effects of porosity across the various tissues of the body is highlighted and the need to consider the tissue context when engineering biomaterials is emphasized.

Effect of tissue microenvironment on fibrous capsule formation to biomaterial-coated implants

Within tissue exposed to the systemic immune system, lymphocytes and fibroblasts act against biomaterials via the development of a fibrous capsule, known as the foreign body reaction (FBR). Inspired by the natural tolerance that the uterine cavity has to foreign bodies, our study explores the role of microenvironment across classical (subcutaneous) and immune privileged (uterine) tissues in the development of the FBR. As a model biomaterial, we used electrospun fibers loaded with sclerosing agents to provoke scar tissue growth. Additionally, we integrated these materials onto an intrauterine device as a platform for intrauterine biomaterial studies. Polyester materials in vitro achieved drug release up to 10 days, greater pro-inflammatory and pro-healing cytokine expression, and the addition of gelatin enabled greater fibroblast attachment. We observed the materials that induced the greatest FBR in the mouse, had no effect when inserted at the utero-tubal junction of non-human primates. These results suggest that the FBR varies across different tissue microenvironments, and a dampened fibrotic response exists in the uterine cavity, possibly due to immune privilege. Further study of immune privileged tissue factors on biomaterials could broaden our understanding of the FBR and inform new methods for achieving biocompatibility in vivo.

Uterine synechiae after intrauterine device use: a case series

PURPOSE

The intrauterine device (IUD) is one of the most effective and safe contraceptive methods. Substantial literature suggests an overall return to normal fertility following IUD removal. However, there are no studies to date that evaluate endometrial function specifically in nulliparous women after levonorgestrel IUD use.

METHODS

We present three nulliparous women with a history of levonorgestrel IUD use who were evaluated for uterine dysfunction at the University of California, San Francisco Center for Reproductive Health. These patients had no other known risk factors or history of uterine manipulation, including prior uterine surgery, pelvic radiation, intrauterine infection, hypothalamic amenorrhea, or uterine anomaly.

RESULTS

Upon evaluation, these patients were found to have uterine synechiae concerning for Asherman syndrome. All three patients were eventually able to conceive through assisted reproductive technology or natural conception.

CONCLUSION

This case series is the first to suggest a possible effect of endometrial dysfunction on fertility resumption following levonorgestrel IUD removal in nulliparous patients. It is possible that a small subset of patients may be at risk for Asherman syndrome after IUD use. Larger prospective trials are needed to explore this possible association.

Risk factors for postpartum intrauterine device expulsion among women delivering at a tertiary Hospital in Uganda: a prospective cohort study

Background

Postpartum intrauterine device (PPIUD) use refers to intrauterine device (IUD) insertion after delivery but within 48 h of birth. In Uganda, the general use of modern methods of contraception is low with < 1% of the women adopting the IUD as a method of contraception. An important limiting factor to increased uptake of immediate postpartum IUD insertion may be its expulsion rates which vary widely. There is minimal documentation PPIUD expulsion rates and factors associated with PPIUD expulsion during puerperium in Uganda.

Objective

We aimed to determine the proportion of TCu380A (copper) intrauterine devices expelled by 6 weeks postpartum, and identify risk factors for expulsion among women delivering at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda.

Methods

We conducted a prospective cohort study from September 1, 2014 to January 31, 2015 at MRRH. We administered a structured questionnaire to all participants, to capture data on their baseline demographic, clinical and obstetric characteristics. We followed up women who accepted the PPIUD insertions at 6 weeks post insertion for any IUD expulsion. We fit multivariable log binomial regression models to identify risk factors for IUD expulsion.

Results

We enrolled 167 women who had PPIUDs inserted. Of the144 women who returned at 6 weeks for follow up, 13 (9%; 95%CI:4.9–15%) of them had the IUDs expelled. In the multivariable model, the significant risk factors for PPIUD expulsion were: IUD insertion more than 10 min post-delivery (aRR 8.1, 95%CI 1.26–51.98, p = 0.027) and bloody lochia flow of ≥15 days (aRR 8.5, 95%CI 1.47–48.47, p = 0.017).

Conclusion

The cumulative expulsion rate of postpartum IUDs among women delivering at MRRH was low and comparable to expulsion rates in interval insertions. Longer duration from delivery to IUD insertions and longer duration of bloody lochia flow were key risk factors for postpartum IUD expulsion. More emphasis should be put on prenatal counseling for postpartum family planning to allow for postplacental IUD insertions, which are associated with lower expulsion rates.

Effects of progestin-only contraceptives on the endometrium

INTRODUCTION

The contraceptive activity of synthetic progestins is mediated through three basic mechanisms: (a) An anti-gonadotrophic action leading to the inhibition of ovulation; (b) Changes in cervical mucus characteristics that inhibit sperm penetration and (c) desynchronization of the endometrial picture necessary for implantation.

AREAS COVERED

Mechanisms involved in the progestin-induced endometrium desynchronization are individually reviewed for each of the routes of administration and, whenever possible, by individual members of the various families of synthetic progestin derivatives.

EXPERT OPINION

For contraceptive purposes, progestins are today administered through several routes: orally, as injections, subdermally and via the vagina or the uterine cavity. Given this variety of modalities, their effects may differ, depending on the route of administration, concentration reached at the level of the endometrium and the duration of use. These are characterized by inactivation of the endometrium. Progestin-only contraception provides a safe and effective control of fertility regulation, although, they are associated with the problem of endometrial break through bleeding that may lead to discontinuation. Unfortunately, in spite of a major research effort over two decades, there is not, as yet, an established long-term intervention available to manage bleeding irregularities, making mandatory a deeper understanding of the mechanisms involved is required.

Is the Injectable Contraceptive Depo-Medroxyprogesterone Acetate (DMPA-IM) Associated with an Increased Risk for HIV Acquisition? The Jury Is Still Out

Intramuscular depo-medroxyprogesterone acetate (DMPA-IM) is the most widely used hormonal contraceptive in sub-Saharan Africa. Previous meta-analyses of observational studies found a significant 40%–50% increased risk associated with DMPA-IM use, relative to no contraception or infrequent condom use. This raised substantial concerns, although these studies had important limitations. Consequently, the open-label randomized Evidence for Contraceptive Options and HIV Outcomes trial was conducted, designed primarily to detect a 50% or greater difference in HIV risk between DMPA-IM, the levonorgestrel (LNG) implant, and the copper-intrauterine device. The ECHO study, published in July 2019, concluded that there is no substantial difference in HIV risk among the methods evaluated, and that all three methods are safe and highly effective. In response, the WHO relaxed the Medical Eligibility Criteria for DMPA-IM use among women at high HIV risk in August 2019. However, two of the three comparisons in the ECHO trial could rule out neither a 50% increase nor no change in HIV risk for one contraceptive compared with another. The study had limitations and the results contained considerable uncertainty. They also did not inform on associated HIV risk for any one of the individual methods due to the absence of a control group such as no contraception or only infrequent condom use. The HIV risks associated with LNG implant and copper-IUD relative to no contraception or infrequent condom use are unknown and these cannot be seen as controls, nor did the authors claim them to be. The results will be discussed in the context of their limitations, what they add to the body of work to date on contraception and HIV acquisition, and the implications of the findings and reports thereof for future research and contraceptive choice.

Differential Effects of the Hormonal and Copper Intrauterine Device on the Endometrial Transcriptome

The contraceptive effectiveness of intrauterine devices (IUDs) has been attributed in part to a foreign body reaction in the endometrium. We performed this study to better understand mechanisms of action of contraceptives of by studying their effects on endometrial and cervical transcriptomes. We collected endometrial and cervical biopsies from women using the levonorgestrel-releasing intrauterine system (LNG-IUS, n = 11), copper intrauterine device (cu-IUD, n = 13) or levonorgestrel-containing combined oral contraceptives (COC, n = 12), and from women not using contraceptives (control group, n = 11). Transcriptional profiling was performed with Affymetrix arrays, Principal Component Analysis and the bioconductor package limma. In endometrial samples from cu-IUD users, there were no genes with statistically significant differential expression compared to controls. In LNG-IUS users, 2509 genes were differentially expressed and mapped predominantly onto immune and inflammatory pathways. The cervical samples showed no statistically significant differential gene expression compared to controls. Hormonal and copper IUDs have significantly different effects on the endometrial transcriptome, with the LNG-IUS transcriptome showing pronounced inflammation and immune activation compared to controls whereas the cu-IUD transcriptome was indistinguishable from luteal phase endometrium. These findings argue against a foreign body reaction as a common mechanism of action of IUDs.

Contraception in chronic kidney disease: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology

Even though fertility is reduced, conception and delivery are possible in all stages of CKD. While successful planned pregnancies are increasing, an unwanted pregnancy may have long-lasting deleterious effects, hence the importance of birth control, an issue often disregarded in clinical practice. The evidence summarized in this position statement is mainly derived from the overall population, or other patient categories, in the lack of guidelines specifically addressed to CKD. Oestroprogestagents can be used in early, non-proteinuric CKD, excluding SLE and immunologic disorders, at high risk of thromboembolism and hypertension. Conversely, progestin only is generally safe and its main side effect is intramestrual spotting. Non-medicated intrauterine devices are a good alternative; their use needs to be carefully evaluated in patients at a high risk of pelvic infection, even though the degree of risk remains controversial. Barrier methods, relatively efficacious when correctly used, have few risks, and condoms are the only contraceptives that protect against sexually transmitted diseases. Surgical sterilization is rarely used also because of the risks surgery involves; it is not definitely contraindicated, and may be considered in selected cases. Emergency contraception with high-dose progestins or intrauterine devices is not contraindicated but should be avoided whenever possible, even if far preferable to abortion. Surgical abortion is invasive, but experience with medical abortion in CKD is still limited, especially in the late stages of the disease. In summary, personalized contraception is feasible, safe and should be offered to all CKD women of childbearing age who do not want to get pregnant.

Levonorgestrel IUD: is there a long-lasting effect on return to fertility?

Intrauterine devices (IUDs) are effective and safe long-acting reversible contraceptive methods for preventing unplanned pregnancies. While extensive studies were conducted to evaluate return to fertility after removal of IUDs, majority of them were focused on multiparous women using copper IUDs. Current trends indicate increased use of levonorgestrel (LNG) IUDs in nulliparous women for very long periods of time, with both nulliparity and long duration of LNG-IUD use being potentially associated with trends towards longer time to conception post removal. Understanding the effects that LNG-IUDs may have on endometrial morphology and gene expression has important implications to further understanding their mechanism of action. Studies examining endometrial gene expression show persistent changes in receptivity markers up to 1 year after removal of an inert IUD, and no similar studies have been performed after removal of LNG-IUDs. Given the current gap in the literature and trends in LNG-IUD use in nulliparous young women, studies are needed that specifically look at the interaction of nulliparity, long-term use of LNG-IUD, and return to normal fertility. Herein, we review the available literature on the mechanism of action of IUDs with a specific focus on the effect on endometrial gene expression profile changes associated with IUDs.

Long-acting reversible contraception: A route to reproductive justice or injustice

This article presents information on unintended pregnancies and the ongoing efforts of policy makers to promote long-acting reversible contraception (LARC) to reduce the numbers of such pregnancies. Also discussed is the tension between the encouragement of LARC to promote the public's interests in achieving that goal versus the need to assure that all women can decide about their bodies and reproductive needs. Our discussion includes information, primarily from the United States, on (a) risks associated with unintended pregnancies, (b) LARC devices approved in the United States (copper intrauterine devices (IUDs), hormone IUDs, and implants), (c) public and social benefits of increasing the use of LARC, (d) disadvantages and barriers to using LARC, (e) dangers of promoting LARC in unjust ways, and (f) the meaning of reproductive justice and its connection to social justice. By sharing the information with the audience of this journal, we hope that it will be integrated into clinical work and research on mental health and development. We also hope that experts in those fields will become discussants in the conversation regarding women's reproductive health and social justice that is taking place in the United States and elsewhere.

More Than Just 2 Layers: A Comprehensive Multimodality Imaging Review of Endometrial Abnormalities

Endometrial abnormalities develop in female patients of all ages. Symptoms related to endometrial pathologies are among the most common causes of gynecologist office visits, with the radiologists playing an important role in endometrial evaluation. In some instances, the radiologist may be the first physician to note endometrial pathology. In this article, we will provide a comprehensive review of radiologic modalities utilized in the evaluation of the endometrium, as well as the imaging appearance of various endometrial disease processes.

Hormonal Contraception and HIV-1 Acquisition: Biological Mechanisms

Access to effective affordable contraception is critical for individual and public health. A wide range of hormonal contraceptives (HCs), which differ in composition, concentration of the progestin component, frequency of dosage, and method of administration, is currently available globally. However, the options are rather limited in settings with restricted economic resources that frequently overlap with areas of high HIV-1 prevalence. The predominant contraceptive used in sub-Saharan Africa is the progestin-only three-monthly injectable depot medroxyprogesterone acetate. Determination of whether HCs affect HIV-1 acquisition has been hampered by behavioral differences potentially confounding clinical observational data. Meta-analysis of these studies shows a significant association between depot medroxyprogesterone acetate use and increased risk of HIV-1 acquisition, raising important concerns. No association was found for combined oral contraceptives containing levonorgestrel, nor for the two-monthly injectable contraceptive norethisterone enanthate, although data for norethisterone enanthate are limited. Susceptibility to HIV-1 and other sexually transmitted infections may, however, be dependent on the type of progestin present in the formulation. Several underlying biological mechanisms that may mediate the effect of HCs on HIV-1 and other sexually transmitted infection acquisition have been identified in clinical, animal, and ex vivo studies. A substantial gap exists in the translation of basic research into clinical practice and public health policy. To bridge this gap, we review the current knowledge of underlying mechanisms and biological effects of commonly used progestins. The review sheds light on issues critical for an informed choice of progestins for the identification of safe, effective, acceptable, and affordable contraceptive methods.

Morphologic Changes in the Endometrium Associated With the Use of the Mirena Coil: A Retrospective Study of 106 Cases

This study outlines the histologic changes seen in 106 endometrial specimens after use of the Mirena coil (levonorgestrel) and compares these changes with previous studies. The variables assessed include nature of the endometrial glands, metaplastic glandular changes, nuclear atypia, hobnail change, and endometrial hyperplasia. Stromal changes include pseudodecidualization, mucinous change, ulceration, and infiltration by granulocytes, neutrophils, and plasma cells, and stromal hyaline nodules, a feature not described previously. Additional changes include superficial micropapillary change, infarcted decidua, dystrophic calcification, hemosiderophages, polypoid indentations, cervical microglandular hyperplasia and endocervical pseudodecidualization. These variables are compared with a similar previous study. Significant differences in the incidence of glandular metaplasia, dystrophic calcification, plasma cell infiltrates, hemosiderophages, and presence of nuclear atypia are noted. With increased use of the Mirena coil, histopathologists need to be aware of the characteristic and constant endometrial changes due to progestogenic and mechanical effects, despite a wide variation in the duration of usage.

Morphological and Ultrastructural Changes in Human Endometrium Following Low-Dose Levonorgestrel Contraceptive Intrauterine Systems (LNG-IUS-12) 13.5 mg

OBJECTIVE

To study the effect of low-dose levonorgestrel contraceptive intrauterine systems (LNG-IUS-12) on endometrial morphology and ultrastructure.

METHODS

Twenty seven women who desired contraception were inserted LNG-IUS-12. Endometrial biopsies were collected during the late proliferative phase of the cycle before (control) and after the use of the LNG-IUS for 36 months. The changes of morphology and ultrastructure of endometrium tissue were observed by light microscope and transmission electron microscope.

RESULTS

After 36 months of use, the endometrial gland reduced in number and some were atrophic. A decidual change of stroma was present. Electronic microscopy demonstrated the presence of low columnar, karyopyknosis, and chromatin margination in the glandular epithelial cell. Some vacuolar degeneration in partial mitochondria and rough endoplasmic reticulum presented light extension. Changes could be concluded as cell inhibition of proliferation.

CONCLUSIONS

The low-dose levonorgestrel-releasing intrauterine systems has a suppressive effect on endometrium that is similar to LNG-IUS.

Intrauterine device use and the risk of pre-eclampsia: a case-control study

OBJECTIVE

To determine the association between intrauterine device (IUD) use, timing of removal prior to pregnancy, and the risk of pre-eclampsia.

DESIGN

A case-control study within the Clinical Practice Research Datalink, UK.

SETTING

Medical record database in the UK.

SAMPLE

Cases of pre-eclampsia (n = 2744) were identified among pregnancies resulting in singleton deliveries from 1993 to 2010. Four controls, or pregnancies unaffected by pre-eclampsia, were matched to each case on maternal age, general practice, and year of delivery.

METHODS

Data on IUD use were obtained from patient records. The odds ratios (ORs) for the association between IUD and pre-eclampsia were adjusted for covariates identified a priori, and analyses were stratified by BMI and number of prior deliveries.

MAIN OUTCOME MEASURES

Odds ratios (95% confidence intervals, 95% CIs) of pre-eclampsia in pregnancies among women with a history of IUD use, compared with women without a history of IUD use.

RESULTS

Prior IUD use was associated with a reduced risk of pre-eclampsia (OR 0.76; 95% CI 0.58-0.98). The timing of removal in relation to the start of pregnancy showed an inverse association, with shorter intervals associated with a larger decrease in risk of pre-eclampsia. IUD removal within a year prior to pregnancy had an OR of 0.68 (95% CI 0.46-1.00). Among women with a prior delivery, the association between IUD use and pre-eclampsia was null.

CONCLUSIONS

Intrauterine device use is associated with a small decreased risk of pre-eclampsia, specifically if removed within the year prior to conception.

TWEETABLE ABSTRACT

A case-control study of pregnancies in the UK suggests a reduced risk of pre-eclampsia for former IUD users.

Evaluation of pigtail macaques as a model for the effects of copper intrauterine devices on HIV infection

BACKGROUND

Long-acting, hormonal contraception may increase HIV risk. Copper intrauterine devices (IUDs) could serve as non-hormonal alternatives. We pilot a pigtail macaque model for evaluating HIV susceptibility factors during copper IUD use.

METHODS

Frameless and flexible GyneFix(®) copper IUDs were surgically implanted into three SHIVSF 162p3 -positive macaques via hysterotomy and monitored for up to 4 months. Four macaques served as non-IUD controls.

RESULTS

All animals retained the devices without complications. No consistent change in vaginal viral RNA or inflammatory cytokines was seen. Two animals had altered menstrual cycles and experienced marked thinning of vaginal epithelium after IUD insertion. Histological examination of uterine tissue at necropsy revealed endometrial ulceration and lymphocytic inflammation with glandular loss at sites of direct IUD contact.

CONCLUSIONS

Although the need for insertion surgery could limit its usefulness, this model will allow studies on copper IUDs and SHIV shedding, disease progression, and HIV susceptibility factors.

What influences young women to choose between the emergency contraceptive pill and an intrauterine device? A qualitative study

OBJECTIVE

To explore key factors influencing young women when choosing between two methods of emergency contraception (EC).

METHODS

We interviewed 26 young women who accessed community sexual and reproductive health services for emergency contraception after they had chosen an EC.

RESULTS

Most women had an unrealistically high expectation about efficacy of the emergency contraceptive pill (ECP) and lacked knowledge of the intrauterine device (IUD) as an alternative method of EC. Previous use, easy accessibility, ease of use, and advice from peers, influenced women to choose the ECP, whereas past experience of abortion, firm motivation to avoid pregnancy, presentation after 72 hours, and considering that an IUD may provide long-term contraception as well, inclined women to choose the IUD. When participants were shown the IUD, many found it to be smaller and less frightening than they had imagined.

CONCLUSIONS

Women need better information and education about the IUD as a highly effective method of EC. Health professionals must provide such information at every opportunity. Showing the IUD during counselling might help correct misconceptions and would improve acceptability. Wider availability of expertise concerning EC-IUDs is essential to assist more women in making informed decisions when choosing a method for EC.

Reduced expression and concomitant promoter hypermethylation of HOXA10 in endometrium from women wearing intrauterine devices

OBJECTIVE

To determine whether prolonged intrauterine device (IUD) usage is associated with decreased HOXA10 expression and increased methylation in the endometrium.

DESIGN

Observational study.

PATIENT(S)

Women wearing IUDs and not wearing IUDs.

INTERVENTION(S)

Immunohistochemistry of HOXA10 and methylation-specific PCR.

MAIN OUTCOME MEASURE(S)

Endometrial HOXA10 expression levels and methylation frequency.

RESULT(S)

The IUD usage was associated with decreased endometrial HOXA10 expression, concordant with higher frequency of HOXA10 promoter hypermethylation. The HOXA10 hypermethylation was associated with the duration of IUD usage, irrespective age, gravidity, parity, and IUD type.

CONCLUSION(S)

Prolonged IUD use may induce endometrial HOXA10 hypermethylation and reduced expression. These results suggest a possible novel mode of action for IUD, a possibility to rectify the aberrant methylation through pharmacologic means, and a possible noninvasive way for detection of aberrant methylation at HOXA10.

Expression of leukaemia inhibitory factor (LIF) during the window of implantation in copper T380A intrauterine device users

OBJECTIVE

The mechanism of action of intrauterine devices (IUDs) is not well understood. This investigation was intended to gain further insight into the role of leukaemia inhibitory factor (LIF) in intrauterine contraception. We evaluated the immunohistochemical distribution patterns of LIF in women wearing a copper T380A IUD.

METHODS

The immunohistochemical distribution patterns of LIF in women who had been using a copper T380A IUD for different periods of time, two months after removal of the IUD, and in normal fertile women were evaluated. Endometrial biopsies were obtained from four groups of patients according to the duration of T Cu380A IUD use (group I: <5 years, n = 15, and group II: > or = 5 years, n = 15), after IUD removal (group III, n = 15) and normal fertile women (controls, n = 15) during the window of implantation (WOI). Staining intensity of LIF was evaluated using semi-quantitative IRS-scores.

RESULTS

The lowest expression of LIF was observed in women using a copper T380A IUD, being statistically significant compared with the control group (p < 0.05). LIF immunostaining remained abnormal two months after IUD removal.

CONCLUSIONS

Copper IUDs can inhibit expression of LIF and they may cause inhibition of the implantation stage, which is crucial for pregnancy.

Decreased endometrial HOXA10 expression associated with use of the copper intrauterine device

OBJECTIVE

To characterize human endometrial HOXA10 expression in patients using a copper intrauterine device (IUD).

DESIGN

Case-control study.

SETTING

Academic medical center.

PATIENT(S)

Women using copper IUDs.

INTERVENTION(S)

Immunohistochemical analysis of endometrial HOXA10 expression in biopsy samples obtained from 24 women using a copper Paraguard T380A as well as in samples obtained from 10 normal cycling women who were not using an IUD or hormonal contraceptives.

MAIN OUTCOME MEASURE(S)

Endometrial HOXA10 expression.

RESULT(S)

Endometrial HOXA10 expression was markedly decreased in the biopsy samples obtained from women using the IUD contraceptive when compared with controls. The mean H score for endometrial stromal cell HOXA10 expression in samples obtained from women using the Paraguard IUD was 0.21 compared with 2.2 in the control endometrial biopsy samples. Endometrial glandular expression of HOXA10 was absent in all IUD users.

CONCLUSION(S)

Decreased endometrial HOXA10 expression was apparent in women who use a copper IUD. Expression of HOXA10 is essential for endometrial receptivity. A novel mechanism of copper IUD action involves suppression of genes required for endometrial receptivity. The dramatic decrease of endometrial HOXA10 in response to IUD use may contribute to contraceptive efficacy.

Assessment of menstrual blood loss in Brazilian users of the frameless copper-releasing IUD with copper surface area of 330 mm2 and the frameless levonorgestrel-releasing intrauterine system

OBJECTIVE

This study was conducted to evaluate the effect of two types of IUDs on the amount of menstrual blood loss (MBL): the frameless copper-releasing intrauterine device (IUD) with copper surface area of 330 mm2 (GyneFix; Contrel Research, Ghent, Belgium) and the frameless levonorgestrel (LNG)-releasing intrauterine system (IUS) releasing 14 microg per day (FibroPlant-LNG; Contrel Research). Heavy and abnormal MBL is the main reason for discontinuation of intrauterine devices.

METHODS

In 20 Brazilian women using GyneFix 330 and 32 using FibroPlant-LNG, respectively, MBL was measured by the quantitative alkaline hematin technique. In addition, ferritin levels were measured in GyneFix 330 and FibroPlant-LNG users.

RESULTS

MBL with GyneFix 330, measured over a 24-month period, increased but was less when compared with TCu380A. Ferritin levels with GyneFix 330 were not affected in contrast with TCu380A. In FibroPlant-LNG users, mean MBL decreased by about 90% and ferritin levels increased significantly.

CONCLUSIONS

The authors confirm earlier reports that, especially for women with low body iron stores and heavy menstrual bleeding, there is an order of preference for IUD use to minimize MBL. The choice should first be a progestin-releasing IUS, then a copper IUD, which has the least effect on menstrual bleeding, such as the frameless GyneFix IUD.

Evaluation of endometrial steroid receptors and cell mitotic activity in women using copper intrauterine device: Can Cu-T prevent endometrial cancer?

AIMS

To study changes in endometrial proliferative indices (i.e. cell mitosis and Ki67), endometrial steroid (estrogen and progesterone) receptors, and serum estradiol and progesterone level in women using copper intrauterine device (IUD) after 6 months of use.

METHODS

Fifteen healthy women were recruited having no contra indication to IUD or endometrial biopsy. Endometrial biopsies and serum samples were taken on 10/11th day of menstrual cycle at recruitment and after six months. The endometrial samples were subjected to: (i) steroid receptor estimation by immunohistochemistry; (ii) cell mitosis and Ki67 estimation by morphology and proliferative indices.

RESULTS

The mean glandular mitotic index was 1.69 +/- (0.39) at first visit and 0.35 +/- (0.15) at second visit after 6 months. Similarly, Ki-67 count in glands was 11.79 +/- (1.59) at first visit and 2.40 +/- (0.54) at second visit. In the stroma, Ki67 decreased from a mean of 0.85 to 0.01 in six months. This suggested statistically significant reduction in proliferation and mitotic activity in endometrial glands and the stroma of women who used Cu-T continuously for a long period. There was a significant reduction of estrogen receptor concentration in glands (from a mean of 51.67 down to 11.67) and the stroma (from a mean of 33.00 to 8.00) over this 6-month period. The observed fall in progesterone receptor counts was less compared to other parameters studied, being marginally significant in stroma (from a mean of 32.00 down to 14.33), but not significant enough in glands (from a mean of 45.00 down to 25.00). No changes were observed in serum hormone levels in these two visits.

CONCLUSION

Continuous use of copper intrauterine device causes significant reduction in endometrial mitotic activity as well as estrogen receptor concentration without affecting serum estradiol or progesterone levels. This finding infers that Cu-T may have a protective role against endometrial cancer.

Mechanisms of action of intrauterine devices: update and estimation of postfertilization effects

There are many potential mechanisms of action for the intrauterine device (IUD), which vary by type of IUD (inert, copper, or hormonal). This paper reviews the evidence for each potential mechanism of action. On the basis of available data for fertilization rates and clinical pregnancy rates, the relative contribution of mechanisms acting before or after fertilization were quantitatively estimated. These estimates indicate that, although prefertilization effects are more prominent for the copper IUD, both prefertilization and postfertilization mechanisms of action contribute significantly to the effectiveness of all types of intrauterine devices.

Cervical mucus granulocyte macrophage colony stimulating factor and interleukin-2 soluble receptor in women using copper intrauterine contraceptive devices

This study was undertaken to investigate the role of cytokines in intrauterine contraception. Cervical mucus samples were obtained from 20 women with proven fertility 7, 14, 30, and 120 days after insertion of copper-T380 intrauterine devices (IUDs) for the determination of interleukin-2 (IL-2) soluble receptor (IL-2SR) and granulocyte macrophage colony stimulating factor (GM-CSF) concentrations. Both levels of IL-2SR and GM-CSF were significantly elevated after insertion of copper-releasing IUDs. This elevation remained significant through 6 months post-insertion. The mean-fold rise of GM-CSF compared to pre-insertion mean values amounted to 12.4, 11.8, 2.1, and 1.5 at 7, 14, 30, and 120 days post-insertion, respectively. The corresponding values for IL-2SR were 10.4, 8.8, 2.6, and 2.5, respectively. These results demonstrate enhanced local cytokines production in IUD users indicating local inflammatory reaction in the endometrium. This inflammatory reaction together with the cytotoxic effects of these cytokines may produce an environment which adversely affect embryo pre-implantation. This may explain the antifertility effect of copper IUDs.

Intrauterine contraception in adolescent women. The GyneFix intrauterine implant

Pregnancy rates among adolescents have not decreased over the last 10 years, despite numerous efforts. To solve this important health problem, the major strategy recommended is to encourage contraceptive use among sexually active teenagers. An important means of obtaining this is by promoting methods that are not dependent on daily administration in order to avoid noncompliance. One such method (Norplant) has already shown to be much more effective than the combination pill in preventing pregnancy in adolescent women. The frameless intrauterine implant system (fixed, frameless, and completely flexible) has been studied since 1985 in women between 14 and 50 years of age. The results in young nulligravid women confirm its very high effectiveness (cumulative pregnancy rate at 36 months: 1.4%), its low expulsion rate (cumulative rate at 36 months: 0.9%) and its optimal tolerance (cumulative removal rate for medical reasons at 36 months: 2.4%), resulting in a high acceptance of the implant and a high continued use. The system (GyneFix) offers long-term protection (5 years), and its insertion, with or without anesthetic, is easily accomplished in the office. The GyneFix should therefore be recommended as an excellent alternative for birth control pills for young women with low risk for STDs, especially when compliance is a problem, without an increased risk for complications and without systemic side effects. Removal of the device is accomplished by traction on the tail. It can also be used for emergency contraception and for insertion immediately after termination of pregnancy.

Modern intra-uterine devices

Modern intrauterine devices (IUDs) provide effective, safe and long-term contraception and could be recommended to most women. The mechanism of action of an IUD is still not fully understood, but most recent research suggests that copper-IUDs as well as hormone-releasing intrauterine systems (IUSs) prevent conception. In women in mutually monogamous relationships the risk of PID is low and related to the insertion procedure. IUD/IUS use should be discouraged if there is a suspicion of increased risk of sexually transmitted disease. The risk of ectopic pregnancy is extremely low if modern, highly effective IUDs/IUSs are used. Copper-IUDs increase menstrual blood loss by around 50%, whereas hormone-releasing IUSs substantially reduce menstrual blood loss. Careful patient selection and counselling are the most important tools in order to provide acceptable and safe IUD use.

Women, contraception and STDs including HIV

It is estimated that eight million women are infected with the human immunodeficiency virus (HIV) worldwide. Heterosexual transmission is the predominant mode of HIV transmission on a global basis and is becoming increasingly important in the Western world. Women have long used contraceptives as a means of protection against an unwanted pregnancy, some of which may also protect against sexually transmitted disease (STD) including HIV. We review the relationship between contraceptive methods and STD acquisition and transmission; HIV acquisition and transmission; and the implications of contraceptive use, particularly regarding disease progression, in those women who are already infected with the virus. It is important for all women that protection against both unwanted pregnancy and HIV acquisition and transmission are considered together and not in isolation as nowhere is the argument for a broad based multi-disciplinary approach more cogent.

The frameless GyneFix intrauterine implant: a major improvement in efficacy, expulsion and tolerance

The CuFix (GyneFix), conceived in 1985, was developed to minimize three major problems frequently associated with discontinuation of IUD use: expulsion, bleeding and pain. Since the initial clinical investigations, over 10,000 woman years of experience and up to 8 years of follow-up in international multicenter, non-comparative and comparative clinical trials, including a large proportion of nulligravid/nulliparous women, have been collected. Based on new clinical information about the GyneFix from a long-term multicenter clinical trial, conducted in young nulligravid/nulliparous and parous women, the importance of this new contraceptive is discussed. The following conclusions were reached: The unique design characteristics of the GyneFix (frameless, flexible and fixed to the fundus of the uterus) have resulted in optimal tolerance and almost complete absence of expulsion. The result is enhanced effectiveness (comparable to OCs and male/female sterilization) and a high rate of continued use. The GyneFix reduces the IUD failure rate to a minimum and is, therefore, a welcome reversible alternative to OCs and female surgical contraception. Framelessness and flexibility explain the absence of side-effects and adverse events caused by dimensional incompatibility between the frame of conventional IUDs and the uterine cavity and may also explain the absence of PID and ectopic pregnancies in any of the clinical studies. The GyneFix is a promising new, highly effective and safe, contraceptive option for parous women and an equally effective and well-accepted method for nulliparous women.

Effect of intrauterine contraceptive devices on cytokine messenger ribonucleic acid expression in the human endometrium

OBJECTIVE

To compare cytokine messenger RNA (mRNA) expression in the endometrium exposed to an intrauterine contraceptive device (IUD) and in normal cycling endometrium.

DESIGN

Quantitative reverse-transcribed polymerase chain reaction was used to assess interleukin (IL) 1 beta, IL-6, tumor necrosis factor alpha (TNF-alpha), and colony-stimulating factor 1 (CSF-1) mRNA expression in endometrial tissue samples obtained by curettage or at hysterectomy from 11 women using a copper-releasing IUD, 10 women having a levonorgestrel-releasing IUD, and 13 fertile women during different phases of the menstrual cycle.

RESULTS

The mRNAs encoding the studied cytokines were detected in all endometrial samples. The mean IL-1 beta, IL-6, and TNF-alpha mRNA levels were higher in the late secretory menstrual phase compared with the proliferative early secretory phase of the menstrual cycle both in endometria exposed to the copper IUD and in the control samples. The IL-1 beta and TNF-alpha mRNA levels were significantly higher in endometria exposed to the copper IUD compared with the control endometria in the late secretory menstrual phase, whereas no difference was found in the expression of these cytokine mRNAs during the proliferative early secretory phase. In contrast, the mean IL-6 mRNA level was higher in the copper IUD-exposed endometria than in the control endometria in the proliferative early secretory but not in the late secretory menstrual phase. In the levonorgestrel IUD-exposed endometria, the mean levels of IL-1 beta, TNF-alpha, and CSF-1 mRNA were similar to those in normal endometrium in the late secretory menstrual phase. The mean IL-6 mRNA level in levonorgestrel IUD-exposed endometria was lower than that in late secretory menstrual phase of controls but, because of a great individual variation in the control samples, the difference did not reach significance. No significant cyclic change nor any difference in relative CSF-1 mRNA levels between the three study groups was detected.

CONCLUSIONS

These data provide the first evidence that the use of IUDs is associated with alterations in endometrial cytokine expression and that the alterations differ depending on the cytokine and the type of IUD. We speculate that cytokines are involved in intrauterine contraceptive effects of IUDs.

Endometrial morphometry in users of intrauterine contraceptive devices and women with ovulatory dysfunctional uterine bleeding: a comparison with normal endometrium

Copper-bearing intrauterine contraceptive devices (IUCD) are commonly associated with menorrhagia. They cause certain morphological changes in the endometrium. These have been extensively reported and the mechanisms of menorrhagia have been investigated in a number of studies. By contrast, ovulatory dysfunctional uterine bleeding has not been as widely studied and mechanisms of menorrhagia in these patients are still not well understood. In this study, we examined endometrial morphometry in a group of women using IUCD, a group of women with ovulatory dysfunctional bleeding, and a control group of women with entirely normal cycles. There was increased leukocytic infiltration of the endometrium in both groups of women with menorrhagia compared to control cases. In addition, IUCD use was associated with greater luteal phase glandular epithelial height, supporting the concept of a secretory function defect in glandular epithelium. Possible links are postulated between static morphometric observations and dynamic biochemical changes.

Intrauterine device use and risk of endometrial cancer

The relationship between intrauterine device (IUD) use and risk of endometrial cancer has been analysed in a case-control study conducted in Italy between 1983 and 1992, including 453 patients with histologically confirmed endometrial cancer and 1,451 controls admitted for acute, non-gynaecological, non-hormonal, non-neoplastic conditions to the same network of hospitals where cases had been identified. Two (0.4%) cases versus 36 (2.3%) controls reported ever using an IUD. The corresponding multivariate relative risk was 0.4 (95% CI 0.1-1.0). The results of this study and the few published available epidemiological data suggest a protective role of IUD use on endometrial carcinogenesis, but potential selective mechanisms for IUD utilisation (indication bias) should be carefully considered in the interpretation.

Contraceptive methods and the transmission of HIV: implications for family planning

Heterosexual transmission is the predominant mode of spread of the Human Immunodeficiency Virus (HIV) in most of the world. Whether the use of hormonal contraceptives, IUDs and spermicides is associated with an increased or decreased risk for HIV acquisition remains controversial. Several mechanisms whereby contraceptive methods may influence the transmission of HIV have been proposed. As contraceptive use increases among women of reproductive age, the group most vulnerable to HIV infection, any associations between contraceptive method and HIV risk become even more important. The available studies of these associations are predominantly cross-sectional and give conflicting results. We review the published evidence for associations between HIV and individual contraceptive methods. At this time no definitive conclusions regarding these associations can be drawn. Further research, especially prospective epidemiological studies and basic biological research on mechanisms of heterosexual transmission and the effect of contraceptives on these mechanisms, is urgently needed.

The pathology of intra-uterine contraceptive devices

The IUCD is a simple and effective way of producing contraception without the need for patient compliance. It is not rendered ineffective by other drugs, as may be steroid contraceptives, and its side-effects, for carefully selected patients, are considered by most practitioners to be acceptably low (Van Kets et al. 1989).

Intra-uterine contraception and the risk of endometrial cancer

Despite the increasing world-wide popularity of contraceptive intra-uterine devices (IUDs), their potential long-term effects on the risk of developing endometrial carcinoma have been poorly studied. This paper reports on the relationship between intra-uterine contraception and endometrial cancer by analyzing epidemiological data from a large, multicenter, population-based, case-control study of epithelial endometrial cancer. Cases were 437 women, 20 to 54 years of age, with histologically confirmed epithelial endometrial cancer ascertained through 6 population-based cancer registries in the United States. Controls were 3200 women selected at random from the populations of these areas. The age- and parity-adjusted odds ratio (OR) for the association between ever having used intra-uterine contraception and endometrial cancer was 0.51 (95% confidence interval (CI) 0.3-0.8). Although the protective effect increased with duration of use, a dose-response relationship among users was not statistically demonstrable. The association did not vary significantly with age at first or last IUD use or with time elapsed since first or last IUD use. Years of education significantly modified the effect of intra-uterine contraception. Thus, intra-uterine contraception appeared to be strongly protective for women with at least 13 years of education (OR = 0.29, 95% CI, 0.15-0.6). It is proposed that intra-uterine contraception exerts its protective effect through local structural and biochemical changes in the endometrium that may alter endometrial sensitivity and response to circulating estrogen and progesterone.

Cells adherent to IUDs produce tumor necrosis factor alpha

The nature of adherent cells obtained from the surface of intrauterine contraceptive devices (IUD) was investigated by immunofluorescence using antibodies directed against tumor necrosis factor alpha (TNF), leukocyte differentiation antigens, immunoglobulin isotypes and J chain. Macrophages/monocytes, lymphocytes and neutrophils were found in all fifty samples. Macrophages were characterized by CD14, CD15 and CD71 positivity, DAKO macrophage antibody and HLA-DR, CD11c and CD45 expression. B cells contained secretory IgA with J chain or IgG and some cells expressed surface IgM. Neither IgD nor IgE were found. T-antigens CD3, CD4 and CD5 were not detected, the CD8 was faintly expressed. The CD56 molecule identifying NK cells was found on small lymphocytes. Cytoplasmic C3 protein was detected in neutrophils. Tumor necrosis factor alpha (TNF) was visualized in 14.3 +/- 8.8% of nucleated IUD cells. This cytokine was localized in the cytoplasm of the macrophages and the lymphocytes.

Metal release from arch bars used in maxillofacial surgery. An in vitro study

Surgical arch bars (splints) are used in maxillofacial surgery as an aid to intermaxillary fixation procedures. Two different types of stainless steel arch bars, a solid bar and a silver-brazed bar, were studied with regard to metal release in vitro. Arch bars were ligated to jaw models and immersed in 0.9% saline solution. The electrolyte was analyzed for Ni, Cr, Fe, Cu, Zn, and Cd by atomic absorption spectrophotometry on days 3, 10, and 28. The amounts of metal released from the brazed arch bar were 140-600 times higher than those released from the solid arch bar. Clinical implications are suggested.

Effects on the endometrium, endo- and exocervix following the use of local progestogen-releasing delivery systems

Some conflicting reports have appeared in the literature as to the effect of progestogens on the endometrium and on the endo- and exocervix in animals and humans. Hyperplasia of the endometrial and endocervical epithelium has been reported in some non-human primates following the administration of progestogens. In other studies no evidence has been found for such changes. In women using combined oral contraceptives, it has been claimed that the progestogen component causes adenomatous hyperplasia of the endocervix and that this hyperplastic transformation could be a precursor to adenocarcinoma of the cervix. So far, there is, however, no evidence in the literature to confirm this hypothesis. In view of the development of new delivery systems with a constant release of small amounts of progestogens, previous reports in the literature on hyperplasia and potential malignant transformation of the endometrium and the endocervix have been a matter of concern. The aim of the present study is therefore to review results from studies in animals and humans in particular with reference to the effect of a local release of various progestogens on the endometrium and the endo- and exocervix.

Cells adherent to copper-bearing intrauterine contraceptive devices determined by monoclonal antibodies

The presence of nucleated cells adherent to copper-bearing IUDs removed from successful IUD users, as well as from those IUD users with accidental pregnancy, was determined by a panel of monoclonal antibodies. A significant decrease in the percentage of CD3+ cells-mature T lymphocytes was found in the cell population adherent to IUDs removed from pregnant compared to non-pregnant uteri (43 +/- 2.6 vs 34 +/- 1.5). Among these cells, the percentage of CD4+ cells was increased (from 22.9 +/- 1.9 to 30.4 +/- 2.0), and CD8+ was decreased (from 23 +/- 0.9 to 10.8 +/- 1.2). The percentage of HLA-DR+ cells was also decreased (from 24.3 +/- 1.7 to 16.7 +/- 1.8). B4+ cells (B lymphocytes) were present in a similar percentage on IUDs removed from pregnant as well as from non-pregnant uteri. Thus, the uterine cavity in the presence of an IUD, contains a consistent population of immunologically competent cells. The question still remains, whether the change in the number of nucleated cells present in the uterine cavity with an IUD could contribute to its antifertility effect.

The effect of the intrauterine contraceptive device on endometrial secretory function: a possible mode of action

The effect of the intrauterine contraceptive device (IUD) on the composition of endometrial secretion has been studied using the monoclonal antibody D9B1. The antibody binds to a polypeptide-associated oligosaccharide epitope that is secreted by endometrial epithelium in the secretory phase with a maximum around the time of implantation. In endometria affected by the IUD in situ, a significant reduction in epitope expression has been observed using immunohistochemistry. This defect can occur against a background of normal secretory differentiation and in the expectation of normal ovarian stimulus. The data provide new insight into the contraceptive mechanisms of action of the IUD.