sera Greetings from Dr.
(Prof. Dr. Srimanta Kumar Pal) : drsrimantapal@gmail.com.09333315050.
Intrauterine Devices: Intrauterine
contraceptives:
(Contraceptive Coil)
INDEX
Basics of IUDs – P, Type of IUD – P, Information on string of IUD – P,
Brand names & Life span – P, Mode of Action – P, How soon become effective
– P, Contraceptive efficacy – P, Users satisfaction & Continuation Rate –
P, Advantages as contraceptive – P, Side effect and their management – P,
Disadvantages as contraceptive – P, Candidacy for IUDs – P, Who criteria &
Checklist – P, IUD & Timing of insertion – P, Insertion Procedure – P,
Follow up – P, When to remove (Indications for removal) – P, Procedure of
removal – P, Switching to some other method – P, Return of fertility – P,
Complications, Health Risks & warring – P, Skill of HCP – P, Pill or IUD
which one to choose – P, LNG IUS or copper bearing IUD – P, Conclusion – P,
Further Reading – P, Webs – P.
1. The basics of IUDs: The
Preface :-
An IUD (also
called IUC) is a small ‘T-shaped’ flexible plastic device that is inserted
inside the womb (uterus) through birth canal to avert pregnancy. It is the world’s most widely used reversible birth control
method for women. The letters ‘IUD’ stands for “Intrauterine Device” and IUC is
for intrauterine contraceptives.
Both abbreviations are for the same device. The ‘contraceptive coil’ or
‘loops’ are just other names for the same contraceptive. Earlier it was used to
be called as IUCD i.e. intrauterine contraceptive device. Globally the present
abbreviation is IUD and only in some countries it is called IUC.
IUD is an
easy, convenient, highly effective form of contraception that Copper IUDs does
not interfere with sexual spontaneity. Once
introduced the IUD is immediately effective.
2. It is a regular contraceptive: But does it effect
as EC as well?? It can also be used as emergency contraceptive
i.e. As after sex conceptive if the IUD is fitted within seven days of
unprotected sex. The sooner the device is fitted after unprotected sex more
will be the contraceptive efficacy. This is unfortunately
little discussed. Health Care Providers (HCP) are to be held responsible
for poor use as Emergency Contraception. People will
have unprotected sex for the centuries to come but unbiased information
should come from doctors and other HCPs as well.
3. Types of IUDs:--
Not all IUDs
are alike. There are several types, and they come in different sizes and
varying shapes. Like other drugs and devices there is long history of its evolution and hundreds of IUD
have been tried in last two centuries. Readers will be surprised to know
that the idea of putting some device inside the womb to prevent conception
initiated with contraception camels. Camels frequently undergo long journey in
the desert. To avoid pregnancy during this long voyage some pebbles (stone like
material) used to be inserted in the womb of camel. Thus the camels did not
fall sick in the voyage.
4.
Classifcation of IUds :Basically
there are two types of IUDs. One is copper
impregnated IUDs which when fitted inside the womb release copper ions and
other one is progesterone hormone
containing IUDs which releases in sick the womb. It is the released copper
or progesterone which effect contraception though plastic frame itself has some
contraceptive effect. Copper bearing IUDs have proven the test of time and most
popular form of IUD. In fact, there is a museum which exhibits over 300 IUD
designed over two centuries collected from different countries.
Copper containing IUDs are the most inexpensive long-term reversible method of
contraception. It can be removed at any time and fertility resumes within
couple of months. The IUD requires no daily attention and this is the distinct
advantage over contraceptive pills, or condom. The only responsibility of the
acceptor is to confirm the placement of IUD after each menstrual period by
feeling the thread of IUD which hangs in the upper part of birth canal. The
thread is tied to the lowermost part of the device.
Like other
contraceptives it has its own limitations
and disadvantages. For instance, IUDs must be inserted and removed by a
health care professional. It should never
be removed by the client even if the thread is easily palpable.
Occasionally the device causes menstrual irregularities and cramps in the lower
part of belly (uterine cramps). Rarely there can be spontaneous expulsion of
the device through birth canal particularly during excessive straining at
defecation.
Principal Types of IUDs:
Classification of
Medicated IUDs: All
modern IUD contain some active substances either in the form of metal (e.g.
copper) contain synthetic progesterone hormones. So modern IUDs are called medicated IUDs. Unmedicated i.e. only
plastic devices are less effective. Though these were once popular in the
decade sixties and seventies are no longer used nowadays.
Further Classification
of Medicated IUDs:
Medicated
IUDs are of two types
a) Copper bearing IUDs and b) Hormone releasing IUDs. First group and most
widely used is copper bearing IUDs
has a band of copper (either in the form of wire or sleeve) worn around the
plastic device. This type of copper bearing device can be kept inside the womb
for 3-14 years depending upon the copper content. The most popular copper
containing IUD is T-cu-380A which
when fitted is effective for fourteen years. In U.K. & U.S.A. it is sold
under the brand name of ‘PARAGARD’.
The second group is hormone containing
IUDs which contains a special hormonal reservoirs from which small amount
of female hormone called ‘progesterone’
is released daily inside the womb and effect contraception.
This second
group of IUDs again is of two types depending upon the type of progesterone
used. If ‘pure progesterone’ is used then it has to be replaced annually. Such
device is available in the market under the trade name Progestasert but for varying reasons it is no longer used and it
was never been available in Indian market.
The other
type of hormone containing IUD is impregnated with ‘levonorgestrel’ type of progesterone. This relatively newer type of
hormonal IUD is gaining popularity at a very fast rate because it has the
ability to ameliorate variety of gynecological diseases in addition to
contraceptive effect. Fortunately it has become available in India since 2002
(under the brand name Mirena IUS Fig.-2). Scientists often call it ‘LNG-IUS’ or
LNG-20. The word LNG- stands for ‘levonongestrel intrauterine system’. In
this book the word ‘LNG-IUS’ will be used to mean this type of hormone
releasing IUD. The contraceptive efficacy of this IUS lasts for five years.
Many other
IUDs which were used in the twentieth century are no longer used. These are safe coils, Lippes loop,
Dalcon Shield, Cu-7. The modern copper IUDs however are safe, effective
and inexpensive method of achieving reversible contraception in properly selected women.
Most copper
medicated IUDs have an abbreviation depending on the design of the frame and
exposed surface area of copper wire. For instance the most commonly used copper
containing device is abbreviated as T-Cu-380A which means the shape of the device
is ‘T’, and the exposed copper wire winded around the device is 380 sq.mm. In fact this copper wire is winded
both in vertical limb as well as on the collar i.e. transverse bar of the
plastic device.
5. Remarks on the string
of IUD:
As mentioned
earlier the only commitment of the client after the IUD is fitted is to cheek
the presence in the upper part of vagina at monthly intervals. Thus it is
worthy to know few relevant points pertaining to the string attached to IUD.
Both copper
medicated and hormone containing IUDs have one or two ‘filaments’ or ‘strings’ –
that is threaded through a hole in the bottom of the vertical arm of the device
which is shaped as T (sig. Fig.-3). The strings are tied in the device with a
knot and strings hang through the lower opening of the cervix into the upper
birth canal. The string is monofilament i.e. a single strand of strong plastic.
Contrary to popular belief, this thread which hangs in the birth canal does not
absorb fluid from birth canal neither transmits bacteria up into the womb. The partner
does not feel the thread during lovemaking process neither the male organ is
hurt by the thread.
The string
has two purposes. It is primarily meant for easy removal of the device with the
help of an instrument called ‘artery forceps’. The string also gives an
opportunity to the woman clinician to know if the IUD is still in the correct
position i.e. inside the womb. As said earlier, the women or her husband should
periodically check (once a month is sufficient) its presence by touching the
string. It is best palpated in squatting position or else woman can put one foot
on a low tool and then insert her index and middle fingers in the birth canal.
It should be searched more in backwards than upward direction. Usually, the
thread is readily palpable. If not, then one can put her fingers up in the
birth canals. When she will be able to feel cervix which feel like tip of nose
with a small hole i.e. depression at centre. Some amount of mucus is easily
felt at this part and it is in this portion the string should be searched.
If the string
seems to shorten or lengthen, the IUD it may mean that have moved up inside
then womb or has come down. This mandates an ultrasonography (imaging the womb)
to verify correct location of IUD in relation to longitudinal axis of womb
(uterus).
If the string
can’t be located at all it may mean that IUD has expelled spontaneously
possibly without the knowledge of the acceptor. On very rare occasion device
may have perforated the womb and travelled to tummy (abdomen). In summary the
purpose of putting a sting in IUD is as follows –
a)
It
satisfies the client that the IUD has not fallen off the body.
b)
It
helps in easy removal of IUD.
c)
If
there is there is lengthening or shortening of thread then it implies that IUD
has either come down from womb or has coiled up in the womb.
6. What are the Brand
Names:
A) Copper bearing IUDS:
1)
‘Multiload cu 250 (ML-Cu-250) and
Multiload Cu-375 (ML-Cu-375): The intrauterine life
span of such IUDs is 3 and 5 years respectively. The cost such IUD in Indian
market.
i)
Multiload
IUDs - Multiload IUDs have curved flexible arms with spurs. These spurs seek
anchorage to fundus, thus reducing expulsion rate. Copper wire on the stem is
worn around vertical limb of T and two popular designs are with 250 mm2
and 375 mm2 surface area of copper. Multiload 250 has lesser side
effects. While Multiload 375 is as effective as Tcu-380A.
ii)
T Cu 380A – Tcu-380A has solid copper sleeves on transverse arm and coil of copper wire
around the stem. This is a highly effective copper device with efficacy as high
as 99%. By adding silver to this (TCu-380 Ag), efficacy has further improved
with a failure rate as low as 0.7%. This is available abroad under the brand
name of Paragard or T-safe-Cu 380A. The name paragard was
used as its use was initially restricted to porous women only. This device was
approved by FDA (Food and Drug Authority of US) in the year 1984. In India it
is sold in open market under the brand name of “NUGUARD 380A” & T-Cu-380A
is the other name distributed by Govt. of India free of cost through all Govt.
hospitals.
Globally two types of
Copper IUDs e.g. T-Cu-380A and ML-Cu-375 are the most commonly used
copper medicated IUDs which is there are about dozens of other copper bearing
IUDs still popular in different parts of the globe. These are Cu-7, T-Cu 200,
T-Cu 220C, T-Cu 220B, Cu Nova T, and T-Cu 200C. These are not popular in India
and neither they are readily available in all the provinces of India.
B) Hormone bearing IUDs:
1)
IUDs impregnated with progesterone
hormone: ‘Progestasert’ is the brand name and these
have life span 1 year only – As stated earlier the devices are rarely used
now-a-days. This is not available in India.
2)
Device containing levonorgestrel
hormone: This device is available under the
brand names of ‘LevoNova’ or more commonly ‘Mirena’ (intrauterine dwelling time
5 years). Instead of IUD scientists often call it as IUS (Intrauterine System).
This device is manufactured by Bayer Healthcare Pharmaceticals, Wayne, and New
Gersey. It is marketed in India by German Remedies and the approximate cost in
India is Rs. 6000/-.
6. The Newer IUDs :-There
are some newer IUDs which has become available recently:
In the last
two decades some newer IUDs has come in the market. They are ‘T-safe-Cu-380A’, ‘Gynae-fix’, ‘NOVA T’,
‘Flexi-T-380’, ‘Fibro plant IUS’. These are used with varying degree of
satisfaction. Sadly, such modern IUDs
are not available in our country.
Why newer devices?
For
last several decades modifications of size, shape and chemical content are
being aimed at to reduce the expulsion rate of side effects while maintaining
the exceptionally high effectiveness and safety profiles of IUDs. Reproductive
scientists are working on different frame designs too. In the process frames of
different sizes and shapes with various active substances incorporated in the
frame for pregnancy prevention has been made available. Some are still in newer
clinical trial phase. Hopefully, IUDs will bring many more options for
fertility regulation. The uterine cavity has a hollow space. However, in
reality, this space, which varies in size and shape peculiar to each woman, can
better be described as a potential cavity that widens at the tubal openings.
The area adjacent to the tubal openings is often described as being overly
sensitive for irritation, and hence, leads to increased uterine contractions
when IUDs are fitted. So scientists are trying hard to design such IUDs
which will minimize repeated trauma in these parts of uterus i.e. the most
sensitive parts.
As
on in 2004, Chinese women had 21 types of IUCs to choose from. Examples of
research on in IUC include smaller less bulky devices intended to geometrically
adapt to smaller nulliparous uteri, frameless copper IUDs fixed to the
endometrium with a thread, devices with movable joints in the cross bars to
help them expand and contract with uterine contractions and adapt to different
uterine sizes and contours (geometric adaptation). Some newer devices have
cervical components and cervical anchoring systems. Still smaller devices
appropriate for the smaller atrophic perimenopausal uterus are also under
clinical trial. For detailed information on newer devices reader is requested
to refer appendix.
7.
IUD
acceptability: IUD use by Indian women:
There were
three National Family Health Survey in India. The study period was 92, 93, 98,
99 and 05, 06. The contraceptive use amongst married women aged 13-49 years and
% as per NFHS I, II & III. In these survey it was revealed that %, % and %
of women used IUD.
8. IUD use in other
Countries:
Almost 156
million married women of reproductive age worldwide use IUD. Amongst all
married women who use any family planning method as many as 20% rely on IUD.
Copper IUD is
very popular In China and 92 million of Chinese women are wearing copper IUDs.
Globally sixty percent all IUD users live in China. In China 83% of married
women use some form of contraceptive. This is commonly expressed as CPR i.e. Couple Protection Rate. Thirty six
percent of them use IUD!!!
IUD is also
popular form of contraceptive in Egypt, Mongolia, Vietnam, North Korea &
Latin America particularly Mexico. Similarly this contraceptive device is also
popular in Eastern Europe, Finland and Norway. Ten to thirty percent of women contraceptors of those countries
use IUC.
USA doctors
prefer to use IUC for themselves! In USA though the prevalence amongst general
population is only 2% but the use amongst female physicians and female
gynecologists were 5% and 9% respectively. Female fellows of the American
College of Obstetricians and Gynecologists answered that would choose IUC as
their first choice contraceptive method when childbearing was completed and as
their second choice after oral contraceptives, if desiring to space their
children. US women who have the most knowledge to make their contraceptive
decisions i.e. obstetrician/gynecologists choose IUC more frequently than their
patients.
9. Mode of Action as
Contraceptive:
The
way an IUD works as contraceptive is not fully understood. The most recent
studies however indicate that the very presence of an IUD impedes the movement of sperm inside the womb thereby
preventing fertilization of eggs. This action applies both to inert i.e. non-mdeicated
IUDs (not available nowadays) and modern medicated IUDs. Additionally, copper
released from copper containing IUDs disrupts sperm-oocyte interaction. We know
that union between sperm and ova which occur in egg transport tube are depended
on about dozen of enzymes. Released copper ions impair the efficacy of such
enzymes involved in the fertilization process. Thus copper IUDs acts prior to
fertilization and thus it is not an abortificient per se. Copper ions which
diffuse from the copper bearing IUDs also damage the spermatozoal enzymes
system and other enzymes present in the womb necessary for blastocyst (future
embryo) implantation. In contrast to oral pills neither copper bearing IUDs nor
the hormone containing IUDs alter ovary and function and suppress release of
eggs.
In
summary, the main effect of copper IUDs is prevention
of fertilization and even if fertilization occurs there is ‘implantation blocking effect’ which acts
as a back-up contraceptive mechanism.
10.
Effectiveness
or Reliability of IUD as contraceptive:
Modern IUDs
are very effective in preventing
pregnancy. The first year failure rate for the copper IUDs is about 1.5 to 0.8
%, which is slightly higher than that of tubal sterilization (0.5% in the first
year). The efficacy of this device can be compared favorably with ‘combined’
pills (first year failure rate 0.1%) and progesterone only pill (first year
failure rate of 2%). Fortunately, the failure rate for copper IUDs appear to be
highest in the first year and declines thereafter. Similarly pregnancy rate in
first-year perfect users are 0.8 to 0.6 and 0.1 per 100 women, in LNG-IUS users
and Copper T380A users respectively.
11.
Life
span of IUD: Intrauterine Dwelling Time: How long an IUD is going to offer
contraceptive protection after it is fitted in womb?
International
agencies differ on this issue so also the Drug Controller Authorities of
different countries. It will be prudent for the HCP to strictly follow
guidelines approved by the country in which he/she practices. For instance
Govt. of India recommend 10 year intrauterine efficacy of T-Cu 380A device (the
most popular IUD) though WHO has declared that the particular IUD is effective
for 14 years without any loss of contraceptive efficacy. The life span of other
two commonly used copper IUD e.g. Multiload Cu 375 and ML Cu 250 are five year
and three years respectively. These two IUDs are freely available in Indian
market.
12.
Continuation
Rates & Clients Satisfaction:
Women spend most of their
reproductive years on average 30 years trying to avoid pregnancy. Thus the
impact of continuation rates on contraceptive success cannot be underestimated.
IUC demonstrates high contraceptive effectiveness and it has high biologic
efficacy. It requires almost no compliance. In fact it takes a volitional act
to discontinue protection rather than to use protection. IUD has the highest
continuation rate of any reversible method.
The copper
IUD continuation rate is 78%, and the LNG IUS continuation rate is 81% at the
end of first Year of use. In contrast, oral contraceptive continuation rates at
1 year range from 50% to 68%. Although the efficacy of Depo-Provera is
considered top-tier, the overall continuation rate at 1 year is only 56% and is
as low as 22% in some populations.
Although
continuation rates with the two IUDs are similar, reasons for discontinuation
differ. More women discontinue the copper device because of bleeding and cramping complaints,
whereas more women discontinue the LNG-IUS device because of amenorrhea (stoppage of menstruation)
and hormone related side effects.
Overall, continuation rates are similar.
13.
Why
woman will opt for IUD? Advantages of IUDs as contraceptive:
1)
Immediately
effective and very little to remember subsequently.
2)
Can
be used during breastfeeding. Does not alter the quantity of breast milk.
3)
A
single decision leads to effective long term prevention of pregnancy. IUD is a
long acting contraceptive, therefore often called as ‘forgettable contraceptives’.
4)
T-Cu
380A is distributed at no cost by Govt. of India and available even in remote
rural areas e.g. PHCS, BPHCS (Block Primary Health Centers).
5)
Less
follow up to clinic. The contraceptive induced side effects after six months
are minimal (worry free contraceptives).
6)
Requires
no attention except for monthly checks for the string (to be done by
self/husband).
7)
Does
not interrupt sex. Efficacy of this method is very high, so increased sexual
enjoyment because there is no need to worry about pregnancy or contraceptive
failure.
8)
Fertility
resumes immediately upon removal.
9)
There
are no hormonal side effects with copper bearing IUDs. In fact there are no
systemic side effects like oral pills, hormonal injections, implants or transversal
patches.
10)
There
is no interaction with any drugs.
11)
There
are certain ailments or diseases where oestrogen hormone use is
contraindicated. Such women should avoid combined oral contraceptives which
contains oestrogen hormone. Fortunately most of them can use copper IUDs which do not contain any hormones whatsoever.
14. Contraindications of IUDs : The clinical
conditions when oestrogen hormone should be avoided are:
List
of such clinical situations where IUD can be safely used are 1) Heavy smokers
and or obesity 2) Diabetes mellitus of all severity. 3) Benign breast diseases
4) Migraine (IUD can be used in all types of migraine). 5) Controlled high
blood pressure if BP is up to 160/100 or even beyond 6) Thrombophilia i.e.
blood coagulation problem e.g. women with past history of deep vein thrombosis
may be fitted with IUD. 7) Past history of stroke 8) Gall bladder diseases 9)
Varicose veins 10) Ischemic heart disease 11) Hyperlipidaemia (excessive bad
cholesterol in blood) 12) uncomplicated valvular diseases of heart in absence
of pulmonary hypertension and atrial fibrillation (to be fitted with the consent of
cardiologist) 13) Depressive disorders 14) Women suffering from tuberculosis
provided tuberculosis is outside the genital organs (e.g. non pelvic
tuberculosis) 15) Diseases of the mouth of womb i.e. cervix. These are often
called CIN (cervical intraepithelial neoplasia) & ectropion of cervix.
Copper
bearing IUDs however can be safely used in above quoted conditions provided if
she does not have concomitant diseases of womb e.g. tumors, or descent of
genital organs or infections. These diseases of womb may make the client
unsuitable for IUD use. Thus HCP coming across such women with above quoted
‘systemic or general diseases seeking contraception may be motivated for using
copper IUD as first choice contraceptive and women should be counseled and made
aware of relative safety of IUD. Such counseling should preferably be done both
during antenatal visits and also during postpartum visits.
15.
Covert
use of IUD:
Husband
and some family members often do not approve contraceptive used, particularly
in rural India. This is a complex social issue involving gender inequality and women
control of their own health and fertility no pane.
This
is often nowadays called ‘altitudinal
factor’ for any social problem and not limited to contraceptive non use
only. Fortunately, this contraceptive device can be used without the knowledge
of the husband and family members. In some societies social norms many make it
difficult for a woman to discuss sexual matters with her husband or adoption of
methods that control her fertility. This not only true for rural Indian women
but for slum dwellers too. This particular long-term contraceptive may be used
without the permission of husband. Covertly quarterly shots (total four doses
of injection per year) can also be taken without disclosing to her husband
provided the wife is motivated.
In summary there are three special situations
where copper IUD surpasses all other contraceptives. Firstly, it can be used in
a variety of medical diseases where hormonal contraceptives are contraindicated
and may be harmful to client. Secondly, once fitted it will offer contraceptive
protection for 12-14 years with virtually no follow up. Thirdly IUD is used
covertly without the knowledge of husband and family members. It can also be
used soon after birth (puerperal insertion of IUD) or it can be fitted after
six weeks of childbirth without affecting breast-milk production.
16.
Candidacy
for IUDs i.e. selection of acceptors: Who are the ideal women for IUD? The most ideal women for
IUDs should have following characteristics:
1)
Have
had children but do not wish to have more by another 3-4 years time. It is not a good contraceptive where short
term contraception is planned.
2)
Have
no history or clinical evidence of pelvic infection e.g. pelvic pain, white
discharge or dyspareunia etc.
3)
Have
no history of sexually transmitted infections (S.T.I.).
4)
Have
only one sexual partner.
5)
No
uterine tumor or distortion of womb.
6)
No
dysmenorrhoea or menstrual irregularity.
IUD can be
used in women who had ectopic pregnancy earlier. The absolute risk of ectopic
pregnancy is extremely low due to high effectiveness of IUDs. However when a
woman becomes pregnant during IUD use, the relative chance of ectopic pregnancy
as compared to uterine pregnancy is considerably increased.
17.
Poor
candidates for IUDs: Contraindication of IUD as a contraceptive:
a)
Recurrent or current pelvic infection (PID). This is the most important
contraindication for IUD use. But IUD can be used if there is one pregnancy
after an attack of PID and there is no risk of acquiring S.T.I.
b)
Behavior
of the acceptor or her husband is so that there is a fair chance for acquiring sexually transmitted disease.
It any of the spouse has multiple sex partners then ideally sexual copper
bearing IUD should not be fitted. Hormone containing IUDs may however will be a
better option.
c)
Those
who are already suffering from menstrual
cramps and/or heavy periods. Hormone containing IUC (Mirena) may be
beneficial in such women. Such IUD will serve the dual purpose of contraception
and disease transmission.
d)
Similarly
those who are suffering from abnormal
bleeding or anemia are also not good candidates for IUD.
e)
Part
history of ectopic pregnancy: It is better to avoid IUD for that group of women
though opinion differs. Now only a few gynecologists believe that IUD should
not be fitted in such women.
f)
Uterine Fibroids hormone containing IUDs may however
be used. According to WHO if myoma does not distort the uterine cavity then
copper IUD may be used if no other suitable contraceptive is available?
g)
A
very large/small uterus and other anatomical abnormalities of womb.
h)
Obvious
cervical or uterine cancer.
18.
The
assessment of suitability of IUD is done in stepwise manner. e.g. -
1)
Replies
by the client in response to some question.
2)
Clinical
examination by the HCP.
3)
Laboratory
lists to desires exclude STI.
19.
Checklist
(question) for screening clients who to initiate Use of the copper IUDs:
Intrauterine devices (IUDs) are generally safe and effective for use by
many women, including those who have not given birth, who want to space births,
and those who are at risk of HIV infection or living with HIV infection. But
some women are unsuitable for IUD due to the presence of certain female
diseases, such as current cervical infections (infections of the mouth of the
womb), PID or other diseases of womb (uterus). For these reasons, women who
desire to use an IUD must be screened for associated gynecological
conditions to determine whether if they are appropriate candidates for the IUD.
It no such screening is done prior to IUD insertion then post insertion
complications will increase considerably which must be avoided by all means.
The
checklist consists of a series of questions planned to identify any medical
condition or behavior that would either prevent safe IUD use or require further
screening in the form of investigation. As well as provide further guidance and
directions based on client responses. A health care provider should analyze her
response to all questions before inserting an IUD and thus assess eligibility
of IUD use.-Further information will follow.
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