Scanning and transmission electron microscopy of material adherent to intrauterine contraceptive devices

Intracavitary deposits on Essure® hysteroscopic sterilization devices: A case report

Objective

To study the composition of intracavitary deposits on Essure® hysteroscopic sterilization devices.

Design

Case report.

Setting

Reproductive Medicine and Gynecology department of a University Hospital.

Patient(s)

A 39 years old patient presenting with a request for surgical removal of Essure® sterilization devices. Diagnostic hysteroscopy showed a crystal like white deposit attached to one of the devices.

Intervention

Diagnostic hysteroscopy and surgical removal of Essure® devices was performed. The deposits were collected and infrared spectroscopy analysis was performed.

Main Outcome Measure

Chemical composition of the deposits attached to the device.

Result(s)

Infrared spectroscopy of the material showed patterns conclusive with calcite (calcium carbonate, CaCO₃).

Conclusion

Until now, it is not clear if there is a relationship between reported complaints and formation of calcite deposits on Essure®.

Capsule

Infrared spectroscopy of deposits on Essure® devices showed a pattern conclusive with calcite. The relationship between reported complaints and the formation of calcite deposits on Essure® remains unclear.

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A white, strongly attached deposit was observed on Essure sterilization devices.

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Infrared spectroscopy of this deposit showed a pattern conclusive with calcite.

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A relationship between reported complaints and the deposits remains unclear.

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Future research should focus on the genesis of the deposits, to determine its clinical relevance.

The effects of transcervical monofilament insertion on the microbial status of the uterus in guinea-pigs

The monofilament marker tail attached to intra-uterine contraceptive devices (IUCDs) has been implicated in the development of pelvic infection because it acts as a substrate for bacterial adhesion, and facilitates the transmission of vaginal bacteria into the uterus. A guinea-pig model was used to investigate the role of transcervical monofilaments in the transmission of vaginal bacteria into the uterus. By 21 days the degree of uterine contamination was significantly lower than after 24 h (P < 0.05), but was still significantly greater than control values (P < 0.01). Coating the monofilaments with poly (2-hydroxyethyl-methacrylate) (polyHEMA) had no effect on uterine bacterial counts at 24 h. After 21 days, however, contamination within the uteri fitted with polyHEMA-coated monofilaments had significantly increased from levels observed at 24 h (P < 0.01). These counts were also significantly greater than those recorded for the uncoated and control groups at the same time interval. In animals fitted with monofilaments, in which chlorhexidine had been incorporated into the polyHEMA coating, the level of uterine contamination after 24 h was significantly lower than that observed with uncoated threads at the same time interval (P < 0.02). After 21 days there was no significant difference between uterine bacterial counts from the chlorhexidine group and control animals. It is concluded that the use of such drug-loaded monofilaments offers the potential to minimize infections associated with the transcervical insertion of IUCDs.

Endometrial morphological changes in IUD users: a review

The introduction of an intrauterine device into the uterine cavity induces a foreign body reaction in the surrounding endometrium which is characterized by the infiltration of polymorphonuclear leucocytes and macrophages into the endometrial stroma and subsequently through the surface epithelium. Leucocyte migration is greater with copper IUDs than with inert IUDs. Ulceration of the surface epithelium, haemorrhage of erythrocytes and microthrombosis of stomach capillaries occur in the functional endometrium in contact with inert and copper IUDs. In endometrium adjacent to, but not in contact with, the IUD gaps appear in the endothelial lining of small blood vessels without a haemostatic response. The most striking response in endometrium exposed to progesterone-releasing IUDs is the occurrence of dilated, thin-walled vesicles, associated with a thinning of the surface epithelium and a decidual reaction in the stroma. A uniform suppression of the endometrium in progesterone IUD users is always found after six months of treatment, whereas the insertion of IUDs releasing 20-30 micrograms levonorgestrel induce a profound uniform suppression of the functional endometrium throughout the uterus after only four weeks.

Review: Microbial colonization of prosthetic devices

The threat of bacterial colonization and biofilm formation poses the most important limitation on the use and development of prosthetic devices in human medicine. Data from the literature suggest that microbial adherence effected by the glycocalyx is a fundamental factor in sepsis involving biomaterials and that it may explain the resistance of such infections to host defense mechanisms and to antibiotherapy. A full appreciation of the existence and the consequences of the biofilm mode of bacterial growth is required so that we can both prevent and eliminate these protected microbial reservoirs.

Antigenic and cytochemical characterization of cells adhering to intrauterine contraceptive devices

Eighteen copper intrauterine devices (IUDs), removed after 25 months of use, were examined to evaluate cells adhering to them (IAC). By means of monoclonal antibodies, the antigenic phenotype of IAC was studied, along with some IAC cytochemical properties. Sixty percent of IAC were identified as granulocytes based on morphological, cytochemical, and antigenic characteristics. A small proportion of IAC were shaped like large foreign-body macrophages, with multiple picnotic nuclei, and diffused alpha naphthyl acetate esterase (ANAE) activity. Some IAC identified as macrophages from a morphological view point also showed dipeptidyl-diaminopeptidase IV (DAPIV) reactivity, previously described only in T-helper lymphocytes. Most IAC identified as macrophages reacted with the monoclonal antibodies OKM1 and HLA-DR, and showed ANAE activity in the form of small multiple granules. The hypothesis that IUD-adhering macrophages with an ANAE+, DAPIV+, OKM1+, and HLA-DR+ phenotype could play a role in the inactivation of spermatozoa can be proposed.

Microbial colonization of tailed and tailless intrauterine contraceptive devices: influence of the mode of insertion in the rabbit

An experimental rabbit model was developed to study the microbial colonization of intrauterine contraceptive devices. Tailed and tailless devices were surgically inserted into into the uterus by two different routes: surgically, directly into the uterine horn, thus avoiding contact with the vaginal and cervical microfloras, or via the vagina and cervix. After 1 to 8 weeks the devices were recovered and prepared for scanning electron microscopy. The surfaces of surgically inserted devices remained uncolonized all through the experiment whereas in those inserted via the cervix microorganisms colonized the core surface as early as 2 weeks after insertion. Our data suggest that in our experimental conditions the mode of insertion appears to be the major factor influencing the microbial colonization of intrauterine contraceptive devices and that the presence of a tail does not seem to play a significant role.

The Ljubljana IUDs: further observations on surface morphology

Twelve IUDs that had been worn from 8 years 10 months to 24 years were examined by SEM. Photomicrographs of selected samples are shown, and a discussion of the nature of the surface encrustations is provided. The authors are of the opinion that surface encrustations are generic to different types of IUDs and that their clinical significance is presently unknown.

Scanning electron microscopy, x-ray diffraction, and electron microprobe analysis of calcific deposits on intrauterine contraceptive devices

Deposits found intrauterine contraceptive devices (IUDs) were studied by scanning electron microscopy, x-ray diffraction, and energy dispersive x-ray microanalysis. All seven devices, including five plastic and two copper IUDs, were coated with a crust containing cellular, acellular, and fibrillar material. The cellular material was composed of erythrocytes, leukocytes, cells of epithelial origin, sperm, and bacteria. Some of the bacteria were filamentous, with acute-angle branching. The fibrillar material appeared to be fibrin. Most of the acellular material was amorphous; calcite was identified by x-ray diffraction, and x-ray microanalysis showed only calcium. Some of the acellular material, particularly that on the IUD side of the crust, was organized in spherulitic crystals and was identified as calcium phosphate by x-ray microanalysis. The crust was joined to the IUD surface by a layer of fibrillar and amorphous material. It is suggested that the initial event in the formation of calcific deposits on IUD surfaces is the deposition of an amorphous and fibrillar layer. Various types of cells present in the endometrial environment adhere to this layer and then calcify. Thus, the deposition of calcific material on the IUDs is a calcification phenomenon, not unlike the formation of plaque on teeth. Hum Pathol 16:732-738, 1985.

Group B-beta haemolytic streptococcal colonization in women using intrauterine contraceptive devices

Two-hundred-and-eighteen gynaecological patients were screened for group B-beta haemolytic streptococci (GBS) colonization of the vagina, cervix, urethra and rectum. The overall colonization rate was 17%. There is no relation between the rate of colonization and the patient's age or parity. The colonization rate among the intrauterine contraceptive device (IUCD) users (31%) is significantly higher than the non-users (14.5%). The IUCD does not cause GBS vaginal colonization. Nevertheless, its presence helps the microorganisms' vertical spread through the cervical canal. The short duration of IUCD use among the Saudi patients may have provided a protective mechanisms against the development of PID. All the four sites were colonized in the IUCD users and only in 8.1% of the non-users. The urethra was the most common site involved in both groups (83.8%). A higher incidence of GBS colonization was found among patients presenting with excessive vaginal discharge as the main complaint. The presence of excessive vaginal discharge is a significant factor towards the spread of the microorganism to the cervix and urethra. Therefore, an IUCD user with excessive vaginal discharge has a higher chance of getting cervical and urethral colonization.

Surface changes in intrauterine contraceptive devices after variable use

Four used intrauterine contraceptive devices and two new control devices were studied by scanning electron microscopy. All intrauterine contraceptive devices were found to have surface deposits that differed not only from site to site on a given device but between devices. A finding of this study not previously described in the literature was the observation of a euhedral crystal rosette of an apatite mineral group [Ca5(PO4)3(F,Cl,OH)] on the Lippes Loop that had been in situ for 15 years.

The effects of intrauterine contraceptive devices on the ultrastructure of the endometrium in relation to bleeding complications

The effects of inert (Lippes Loop D and Dalkon Shields) and medicated (copper 7, copper T, and Progestasert) intrauterine contraceptive devices (IUDs) on the ultrastructure of the endometrium were studied in intact human uteri. The most striking morphologic changes induced by the inert and copper-bearing devices were erosion of the surface epithelium and extensive microthrombosis in stromal capillaries of the endometrium in contact with the device. These abnormalities were associated with extravascular thrombi, erythrocytes, and fibrin deposition in the adjacent stroma. Capillary microthrombosis and leukocyte infiltration into the uterine cavity were most extensive around the active part of the copper-bearing devices. With the Progestasert erosion of surface epithelium was rarely seen, but the intact epithelial lining had fewer ciliated cells with flattened and shortened cilia. Large dilated venules were a common finding below the surface epithelium adjacent to the active part of the Progestasert; capillary microthrombosis was found only below the inert arms of the Progestasert. The vascular response of the endometrium to IUDs appears, therefore, to be directly related to the type and proximity of the device. The morphologic changes induced in both surface epithelium and the microvasculature of the endometrium are the likely explanation of the uterine bleeding problems associated with IUDs but are probably intrinsic to the mode of action of the IUD in interfering with implantation.

A scanning and transmission electron microscopic study of the surfaces of intrauterine contraceptive devices

We studied 10 intrauterine contraceptive devices by scanning and transmission electron microscopy. All the devices had material adherent to them. The amount of this material varied considerably. Many different morphologic types of bacteria were observed adherent to the devices, often buried in a thick biofilm. Occasionally a microcolony containing only a single bacterial morphotype was observed. Electron microprobe analysis revealed the presence of calcium in the biofilm formed by bacterial colonization. Very few types of bacteria were recovered by our cultural technique, suggesting that material must be scraped from the surface of the device, homogenized, and then cultured by means of selective media. An understanding of the mechanisms of adherence of bacteria to these devices could lead to the development of a device which will resist bacterial colonization.

An ultrastructural study of menstrual blood in normal menstruation and dysfunctional uterine bleeding

Menstrual fluid was obtained from the uterine cavity and vagina in 20 women within the first 48 h of menstruation. Ten of the women had normal menstrual cycles and blood loss and ten were patients with dysfunctional uterine bleeding. The menstrual samples were examined by electron microscopy for the presence of fibrin and platelets and nearly all were found to contain both fibrin and aggregating platelets. By a simple quantitative system no differences in fibrin and platelet content were found between samples collected from the uterine cavity or the vagina. Likewise no difference was found in the morphology of fibrin and platelets between women with normal menstrual loss and patients with dysfunctional uterine bleeding.