IUD

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From:- SONAM M.GANDHI M.PHARMACY Industrial Pharmacy Intrauterine Device IUD

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Contents Introduction. Anatomy of Human Uterus. The I ntrauterine Devices. Historical Background Estimated extend Of Use Mechanism Of Action Morphological & Biochemical Endometrial Change By IUD Complications

Introduction:

Introduction The uterus function mainly as a reproductive organ harboring the developing embryo and fetus. Rich in blood supply, so potential organ for systemic drug administration. Intrauterine devices, being easily inserted into uterine cavity for long periods & having minimal complications, suggested as possible vehicle for this purpose. To use the uterine cavity for systemic drug delivery, the important parameter to be known are uterine anatomy, physiology & histology.

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Anatomy Of Uterus Uterus is hollow, pear shaped fibromuscular organ whose shape, weight & dimension vary considerably Depending upon both estrogenic stimulation & previous birth or parturition. The function of uterus is to house & nourish the embryo & fetus and birth by applying powerful contraction of its thick muscular walls In young nulliparous adult it measures 8cm long, 5cm width and 2.5cm thick, weigth around 30-40g Between birth and puberty the uterus descends gradually from lower abdomen to true pelvis.

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After puberty it located in the midline in true pelvis behind symphysis pubis & urinary bladder and in front of rectum. The uterus has 2 portions, an upper muscular corpus & lower fibrous cervix . Internal os is a slight constriction corresponding to narrowing of the cavity & part above it is corpus while below it is cervix. Fundas is nothing but portion of corpus that extends above insertions of fallopian tubes. In reproductive women, the corpus is considerably larger than the cervix, but before menarche, and after menopause, their size are similar.

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In coronal section it is triangular, its base being formed by the internal fundal surface between the openings of the uterine tubes; its apex is the internal os , leading to the cervical canal.

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Intrauterine Device Historical background The intrauterine device is highly effective in preventing the pregnancy. The first IUD used specifically for contraception was described by Richter in 1909. It was a ring made of silkworm gut Graefenberg in 1931 describe that core of silkworm gut encircled by alloy of copper, nickel & zinc highly effective in preventing pregnancy. Early devices had local success but general medical opinion prevented their large scale adoption.

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In 1960, the first of the so called “second generation” IUDs represented by “Margulies spiral” was introduced. This device was made of plastic without metal but with barium sulfate being added to the plastic to render its radio opaque ( dense material that prevent electromagnetic passage). In 1962, Lippes loop, which is still one the most widely used IUDs. This IUD was the first to have a nylon thread attached to the lowest part of the device; facilate easily removal form uterine cavity.

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Using a T carrier with addition of 200mm 2 copper wire reduced the pregnancy rate 18% in women year with plain T carrier to 1% women year. A number of copper bearing devices are now commercially including the copper-7 & copper-T in various other forms. Scommegna et al, developed the hormone releasing devices and showed that it is effective in preventing pregnancy as the copper-bearing IUD. The progestasert is a T shaped device, consisting of a permeable polymer membrane which releases progesterone at a predictable, controlled rate of 65 micro g per 24 hr over a period of a year.

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Similar devices containing large amounts of progestrone that is released at a lower rate, were expected to be effective for 3-5 yrs, but found to be effective life span for 1.5-2yrs A new hormone releasing device with shape based on that of the Nova-T IUD, releasing 20µg/day levonorgestrel from a reservoir in the form of polydimethylesiloxane collar ( silicon polymer) gives a low pregnancy rate i.e. 0.3% at 1 yr, with significant reduction in blood loss during menstrual. Reduction in pain during menstruation but an increase discontinuation rate on account of amenorrhea (up to 10%) ( absence of menstrual cycle in reproductive women ).

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Mechanism of Action I ntrauterine devices (IUDs) prevent fertilization primarily by interfering with the ability of sperm to survive and to ascend the fallopian tubes, where fertilization occurs. Having a foreign body in the uterus, such as an IUD, causes both anatomical and biochemical changes that appear to be toxic to sperm. Studies have generally found that sperm are not as viable among IUD users, compared to other women. When a foreign body (IUD) is in the uterus, the endometrium reacts by releasing white blood cells, enzymes and prostaglandins; and these reactions of the endometrium appear to prevent sperm from reaching the fallopian tubes.

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In addition, copper-bearing IUDs release copper ions into the fluids of the uterus and the fallopian tubes, enhancing the debilitating effect on sperm. Evidence for these mechanisms includes physical examination of women's eggs. When an ovum is fertilized, it begins to produce human chorionic gonadotropin ( hCG ) near the time of implantation. A 1987 study to monitor hCG production in 40 women using IUDs found only one probable fertilized egg among 107 cycles. "Whatever the IUD's specific mechanism of action, it appears that the IUD effectively interrupts the reproductive process before implantation," the study concluded.

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Half of the women using no contraception who had intercourse during the fertile period had ova that were consistent in appearance with fertilized eggs. In contrast, none of the ova taken from copper IUD users who had intercourse appeared to be fertilized. Also, no ova were found in the uterus of any of the copper IUD users. "IUDs exert effects that extend beyond the body of the uterus and interfere with steps of the reproductive process that take place before the eggs reach the uterine cavity,"

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The levonorgestrel IUD, called an intrauterine system, uses different mechanisms. Like other progestin methods, this device prevents pregnancy primarily by thickening cervical mucus, which inhibits the ability of sperm to enter the uterus.

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Morphological & Biochemical Morphological & biochemical endometrial changes caused by IUD are that whenever a foreign body is introduced into the uterine cavity. The biochemical & cellular changes reaction take place, characterized by specific changes in endometrial tissue. Increased vascular permeability, edema, and stromal infiltration of leukocytes, including neutrophils , mononuclear cells and macrophages have been seen. In the normal menstrual cycle, extensive leukocyte infiltration occur about 24-48hr prior to the onset of menstruation.

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It should be emphasized that the foreign body reaction seen with both medicated and non medicated IUDs occurs in the absence of bacterial infection & especially in the area adjacent to the device. The foreign body reaction should not be confused with the endometritis , which is a bacterial inflammatory condition. The high levels of intrauterine protein reported in IUD users might reflect the cellular degradation of these neutrophils & macrophages and thereby further contribute to anti fertility effect. The foreign body reaction caused by non medicated devices are enhanced by addition of copper to the IUD.

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Complication

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Insertion of the IUD may introduce bacteria into the uterus. The insertion process carries an increased risk of pelvic inflammatory disease in the first 20 days following insertion. It is very important that the provider use proper infection-prevention techniques during insertion. Some barrier contraceptives protect against STDs. Hormonal contraceptives reduce the risk of developing pelvic inflammatory disease (PID), a serious complication of certain STDs. IUDs, by contrast, do not protect against STDs or PID. During the placement appointment, the cervix is dilated in order to sound (measure) the uterus and insert the IUD. Cervix dilation can be uncomfortable and, for some women, painful.

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Taking NSAIDS before the procedure can reduce discomfort, as can the use of a local anaesthetic . Misoprostol 6 to 12 hrs before insertion can help with cervical dilatation. After IUD insertion, menstrual periods are often heavier, more painful, or both - especially for the first few months after they are inserted. On average, menstrual blood loss increases by 20–50% after insertion of a copper-T IUD; increased menstrual discomfort is the most common medical reason for IUD removal. The string(s) may be felt by some men during intercourse. If this is problematic, the provider may cut the strings even down to the cervix, so they cannot be felt. Shortening the strings does prevent the woman from checking for expulsion Non-hormonal (copper) IUDs are considered safe to use while breastfeeding.

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