Update on Intrauterine Contraceptive Device usage in Myanmar 2022

The late Prof Daw Khin Nyunt published the article, “Use of IUD in Myanmar” in Myanmar Journal of Current Medical Practice Volume 1(1) in 1996. ⁽¹⁾ I would like to present an update on this article 26 years after her publication. During this period, there are many changes in the fields of reproductive health indicators and contraception, although the main aim of contraception to reducing maternal death from unsafe/induced abortion and family planning remains the same.

Intrauterine contraceptive Device (IUD) is highly effective and long-acting. The licensed duration of use of IUD ranges from 3 to 10 years. IUD is significantly more cost-effective than shorter-acting methods due to very low failure rates and requirement for very minimal action by the user apart from undergoing the initial insertion procedure. The failure rates are similar to various forms of sterilization. There are many benefits of IUDs, including efficacy, ease of use, reversible nature, and patient satisfaction, especially with time commitment for long-term use and cost.

Reproductive Health Indicators

During the 26 years, the rate of maternal mortality in rich and poor countries still shows greater disparity than any other public health indicator.

Maternal mortality is now expressed as Maternal Mortality ratio per 100,000 live births. The estimate maternal mortality ratio for Myanmar is 250/100,000 Livebirth and the estimate for South East Asia Region is 163/ 100,000 Livebirth in 2017.⁽²⁾ The main causes of maternal death in Myanmar are shown in Table (1).

Table 1. Causes of Maternal Death in Myanmar 2017⁽³⁾

Death due to abortion (13%) and sepsis (5.9%) ranked third and fourth commonest causes of maternal death in Myanmar. These causes are due to induced abortion for unwanted pregnancies. Since abortion is illegal in this country, contraception and family planning are the only way to reduce maternal death due to induced abortion and sepsis.⁽³⁾

Total fertility rate is 2.51% in Myanmar. Contraceptive prevalence rate which is the percentage of married women ages 15- 49 who are practicing or whose sexual partners are practicing any form of contraception at any given point of time is reported as 52.2% in 2016 according to World Bank estimates in 2022. Unmet need for contraception which is defined as percentage of currently married women who want to space or limit births but are not currently using contraception is 16% in 2016 (World Bank estimates 2022).⁽²⁾

There are many areas to improve the use of contraception and reduce the unmet need of contraception in Myanmar. Improving accessibility to contraceptive services, training of skills, counseling and health education are essential.

Family Planning 2022

Recently, International Conference of Family Planning (ICFP) 2022 was held in Pattaya, Thailand from 14^th to 17^th November 2022. World Health Organization (WHO) released important updates to its landmark Family Planning Handbook fourth edition with the support for its production and dissemination provided through the Johns Hopkins Bloomberg School of Public Health and the United States Agency for International Development (USAID).

It provides health workers and policy makers with the most current information on contraceptive options. It is a vital resource, helping health workers to support contraceptive users around the world in making informed choices. It also expands guidance for women and young people at high risk of HIV, the latest WHO guidance on cervical cancer and pre-cancer prevention, screening and treatment, management of sexually transmitted infections, and family planning in postabortion care, which can all be provided through family planning services.⁽⁴⁾

Experience from recent outbreaks and disasters shows that family planning services can be severely compromised during emergencies. To help avoid such outcomes in the future, the manual details practical measures that support continuity of family planning services during epidemics. These include wider access to self-administered contraceptives, the use of digital technologies by the providers and direct distribution of contraceptives through pharmacies, providing multi-month supplies when physical mobility is reduced.

Self-administered contraceptives include condoms, contraceptive pills, some diaphragms, spermicides and most recently, the option of self-injection of DMPA (a progestin-only contraceptive) since this can now be safely administered just under the skin rather than into the muscle. Many women prefer injectable contraceptives since they are private and non-intrusive, requiring action only ever 2-3 months, with the option of self-injection likely to further increase uptake.⁽⁴⁾

UNFPA also launches new family planning strategy, “Expanding Choices – Ensuring Rights in a Diverse and Changing World” at ICFP 2022. This new Strategy reframes UNFPA’s approach towards meeting family planning needs. which broadens the role to capture the full range of fertility and contraceptive policies and services needed to end unmet need for family planning by 2030.⁽⁵⁾

Rapid population growth, conflict, migration, urbanization, environmental degradation and declining fertility are megatrends and emerging issues that are reshaping entire communities and societies. As the world changes all around us, achieving universal access to family planning takes on new urgency.

This strategy will shift UNFPA’s work in key ways to drive progress towards 2030, by building decisive leadership, integrating family planning through innovation, use of evidence-based high-impact practices and responding to emerging needs, fostering a shift from reliance of countries on external financing to sustainable financing including investing in domestic resources.

UNFPA supports many aspects of voluntary family planning, including procuring contraceptives, training health professionals to accurately and sensitively counsel individuals about their family planning options, and promoting comprehensive sexuality education in schools. UNFPA never promotes abortion as a form of family planning.⁽⁵⁾

Overcoming barriers to family planning

Common reasons why women do not use reliable, modern contraceptives include logistical problems, such as difficulty travelling to health facilities or stock outs at health clinics, and social barriers, such as opposition by partners or families. Lack of knowledge also plays a role, with many women not understanding that they are able to become pregnant, not knowing what contraceptive methods are available, or having incorrect information about modern methods.

Poorer women and those in rural areas often have less access to family planning information and services. Certain groups – including adolescents, unmarried people, the urban poor, rural populations, sex workers and people living with HIV – also face additional barriers to family planning. This can lead to higher rates of unintended pregnancy, increased risk of HIV and other STIs, limited choice of contraceptive methods, and higher levels of unmet need for family planning. Particular attention must be paid to promoting their reproductive rights, access to family planning, and other sexual and reproductive health services.

UNFPA works at every level to improve access to family planning and empower individual choices. UNFPA works with governments, NGOs, community-service organizations, faith-based organizations, youth groups and the private sector to strengthen community-based and youth-friendly reproductive health services, and to provide these services during humanitarian crises.

UNFPA works with partners and governments to ensure access to a reliable supply of contraceptives, condoms, and medicines and equipment for family planning, STI prevention and maternal health services. UNFPA also works to integrate family planning services into primary health care, so that women and girls are able to access information and contraceptives no matter what health facility they visit. To meet this goal, and achieve the Sustainable Development Goals, UNFPA is focusing on four key areas: Investment in adolescents and youth, supply chains so that contraceptives reach those who need them, ensuring that family planning services and supplies have sustained funding support, improving the quality of care in family planning service.

With its current strategic plan, UNFPA aims to achieve three world-changing transformative results: ending maternal deaths, ending unmet need for family planning, and ending gender-based violence and harmful practices. Providing family planning information and services is a critical part of these efforts.⁽⁵⁾

Contraceptive Method used

There are modern and traditional methods of contraception. Modern methods include natural methods (Safe period, Lactational amenorrhoea, Coital methods), Non hormonal methods (barrier methods: Male and female condoms) and Copper IUDs, Hormonal methods (pills, Injectables, LNG –releasing IUDs, Ullipristal). In Myanmar, modern method of contraception is used by 51% of currently married women ages 15-49, 3% out of the 51% used IUD. The injectables are most commonly used (28%), followed by pills (14%), female sterilization (5%).⁽⁶⁾

Fig 1. Contraceptive Use⁽³⁾

Types of IUD

Essentially in the 1990s, there are three types of IUD.

Fig 2. Types of IUDs available in the 1990s

The inert IUDs (Lippes Loop,Dalkon shield, Grafenberg ring, Saf-t coil) are no longer used now. Only two types, Copper-bearing intrauterine device (Cu-IUDs) and Levonorgestrel-releasing intrauterine system (LNG-IUS) are used nowadays.

Copper-bearing intrauterine device (Cu-IUD)

Cu-IUDs have copper on their central stems and may also be banded with copper sleeves on the arms. The surface area from which copper is released varies between devices. In general, banded Cu-IUDs which have the higher surface areas of copper are the most effective and long-lasting so are recommended as the first-choice copper devices. There are two new additional Cu IUD in the 2000s.⁽⁶⁾

Postpartum copper T380A is a new Cu IUD for immediate postpartum insertion. It has a T shaped plastic frame which contain approximately 176 mg copper wire on its vertical arm and a copper sleeve contain approximately 66.5mg copper on each horizontal arm. Total surface area of copper on the device is 380 mm³.⁽⁶⁾

Copper Y 380 IUD has a Y shaped plastic frame which contain 311mg copper wire on its vertical arm and total surface area of copper on device is 380 mm³.⁽⁶⁾

Levonorgestrel-releasing intrauterine system (LNG-IUS)

Several LNG-IUS devices are now available with three dosages of LNG. The 13.5 mg LNG-IUS (releasing 6 μg LNG/day) is licensed for 3 years and the 19.5 mg and 52 mg LNG-IUS (releasing 20 μg LNG/day) for 5 years. Medicated IUD releasing low concentration of progestins and Norgestral of the 1990s are no longer used now.⁽⁸⁾

Fig7. LNG releasing IUDs, Mirena

Indications and Choice of IUD

Based on the fact that there are two different types of IUDs, including levonorgestrel and copper-containing, there are different indications for each of these although all IUDs are indicated for the use of contraception.

For the levonorgestrel-containing IUD, there are three different strengths of levonorgestrel available, 13.5 mg, 9.5 mg, and 52 mg. They are all equally effective at providing reliable contraception. However, the higher dose IUD, 52 mg device, is also approved for the treatment of menorrhagia and endometrium protection during hormone replacement therapy.⁽⁸⁾

The copper IUD is approved for contraceptive use for up to 10 years. However, there is a documented off-label indication to use this as emergency contraception within 5 days of unprotected intercourse. It will prevent implantation of embryo. The failure rate after placement for emergency contraception is approximately 0.1%.(9) IUDs may be placed immediately post-partum within 10 minutes of delivery of the placenta, delayed post-partum within 4-6 weeks of delivery, and post-abortion, so long as it was not a septic abortion.⁽⁷⁾

Additionally, there are also indications for the removal of the IUD. The primary indication for removal is the patient’s preference for any reason, including, but not limited to, desire for pregnancy, irregular bleeding pattern, heavy vaginal bleeding, and discomfort or pain, which may represent the displacement of the device. Bleeding changes, especially heavier bleeding, were more likely to occur in the copper-containing IUDs rather than the levonorgestrel-IUD, prompting the patient’s desire for removal.(6) Another indication for removal is an intrauterine pregnancy. However, the device should only be removed if the strings are visible or easily found within the cervical os with no devices entering the uterine cavity. Leaving the IUD in place increases the risk of spontaneous abortion by 40% to 50%. However, there is no risk of teratogenesis with leaving the IUD in place. In such cases, removing the IUD decreases the risk of spontaneous abortion to 20%.⁽⁶⁾

For the levonorgestrel-containing IUD, additional indications for removal include the diagnosis of a cervical or uterine malignancy or jaundice. The last indication for removal is if the device has been in for longer than the approved efficacy period. For some, e.g., perimenopausal women, the approved duration is 10 years. These approved durations are constantly changing, and it is best practice to refer to the individual product’s package insert for the most up-to-date prescribing information.⁽⁸⁾

Contraindications

Given that there are two classes of IUDs available, there are specific contraindications for each type of IUD. However, there are also universal contraindications that are specific to both types.

Universal contraindications for the use of IUD includes; pregnancy or suspected pregnancy, sexually transmitted infection at the time of insertion, including cervicitis, vaginitis, or any other lower genital tract infection, congenital uterine abnormality that distorts the shape of the uterine cavity making insertion difficult, acute pelvic inflammatory disease, history of pelvic inflammatory disease, unless a subsequent successful intrauterine pregnancy has occurred, history of septic abortion or history of postpartum endometritis within the last 3 months, confirmed or suspicion of uterine or cervical malignancy/neoplasia, abnormal uterine bleeding of unknown origin, any condition that increases the risk of pelvic infection, history of previously inserted IUD that has not been removed, hypersensitivity to any component of the device.⁽⁶⁾

For the levonorgestrel IUD, additional contraindications include; confirmed or suspicion of breast malignancy or other progestin-sensitive cancer, liver tumors, benign or malignant, acute liver disease.⁽⁸⁾

For the copper IUD, additional contraindications include: Wilson disease, sensitivity to copper.⁽⁶⁾

Mechanism of action

The two types of IUD have different methods of action to prevent pregnancy. The copper IUD works by preventing sperm motility and viability within the uterine cavity by causing a localized cytotoxic inflammatory response.⁽⁶⁾ Because of this mechanism, copper IUDs are also an extremely effective form of emergency contraception if placed within 5 days of unprotected intercourse.(9) The levonorgestrel-containing IUDs work by the progesterone acting on the endometrium to suppress growth and implantation. The endometrium becomes insensitive to estradiol produced by the ovary. Additionally, the levonorgestrel thickens the consistency of the cervical mucus, which prevents pregnancy by inhibiting the motility of the sperm.⁽⁸⁾ Because of the efficacy, reliability, and reversible nature of these devices, these are often an excellent choice for women to prevent pregnancy.

Technique of insertion

All IUDs currently available, apart from Copper Y, are T-shaped, with the top of the T resting across the top of the endometrial cavity. IUDs are between 28 mm to 32 mm wide and 30 mm to 36 mm long. Uterine width traditionally has been assumed to be adequate in all patients; however, recent ultrasound studies have indicated that cavity width in nulliparous women may be narrower than device width.⁽¹¹⁾ Therefore, it is important to consider the available IUD options available. The smallest IUDs measure 28 mm wide and 30 mm long and are best suited for nulliparous and young women. IUD need not be avoided in nullipara and the concept of IUD causing infection which can later result in infertility is no longer accepted nowadays. Levonorgestrel containing IUD can also be used safely. Additionally, there is strong guidance that long acting reversible contraception (LARC) should be first-line in preventing teenage pregnancy and that IUDs are safe to use in this age group.⁽¹²⁾

When performing IUD insertion and removal, the primary anatomical landmarks that need to be identified are the cervix and uterus. The uterus will be identified by the bimanual exam to assess for size, shape, position, and to identify any anatomical abnormalities. The cervix will be identified during the speculum examination. The aim is to place the device as high as possible in the endometrial cavity at the fundus without perforating the myometrium.

The use of medications, naproxen or tramadol prior to the insertion can be beneficial. Additionally, the use of misoprostol to help with cervical dilation and insertion if a patient has a history of previous difficult insertions, may also be beneficial. Topical anaesthetics in both cream and gel forms show some benefit for pain control with tenaculum placement; however, no benefit with uterine sounding or IUD placement. The use of paracervical blocks has also been studied both for IUD insertion and for other cervical procedures. There is conflicting evidence over the use of these blocks for routine IUD insertion. These blocks are placed at the 4 and 8 o’clock positions in nulliparous patients.⁽¹¹⁾

Procedure

After deciding that an IUD placement is the best choice for the patient, the following procedure is followed: confirm a negative pregnancy test or make sure that patient is not pregnant, exclude sexually transmitted diseases and pelvic infection ,obtain informed consent, have the patient move into a dorsal lithotomy position, with gloved hands and in aseptic condition, perform a bimanual exam to determine whether the uterus is anteverted or retroverted, cleanse cervix and vaginal fornices with a cleansing solution, typically povidone-iodine. If the patient has iodine or shellfish allergy, use chlorhexidine gluconate, insert speculum and identify the cervix, if desired, consider paracervical block placement or application of the anesthetic gel, switch to sterile gloves at this time, and using a sterile single-tooth tenaculum, grasp the anterior lip of the cervix and apply gentle traction to straighten the cervical canal and uterine cavity. If the uterus is retroverted, it may be beneficial to grasp the posterior lip of the cervix.⁽¹¹⁾

If a patient is found to be positive for an infection after insertion of the IUD, the patient should be treated with antibiotics, and the IUD should remain in place. There is a small risk, approximately 0.1%, of progression to pelvic inflammatory disease if patients have an infection at the time of insertion. However, the device should not be removed if a patient is noted to have purulent cervical discharge or physical exam consistent with an active infection, the IUD insertion should be postponed, and the patient should be treated.

By using sterile uterine sound, determine the depth of the uterine cavity, typically between 6 cm to 9 cm. If less than 6 cm, IUD should not be placed. If there is difficulty in placing the uterine sound, try cervical dilators. If cervical dilators are needed, it is recommended to use a paracervical block.

Once uterine depth is determined, follow package instructions for the specific IUD being inserted. Once IUD is inserted and strings are visible, cut strings to a length of 3 cm to 4 cm with sharp scissors; note this length in the chart. Remove the tenaculum and make sure there is no bleeding from the site of the tenaculum, and remove the speculum.

Have the patient follow up in 4-6 weeks for a string check to ensure proper placement.

After the IUD has been in for the approved amount of time, it is time to remove the IUD. If the patient desires further contraception, it is permissible to remove and insert an IUD at the same time. For IUD removal, the steps are as follows: obtain informed consent, have the patient move into a dorsal lithotomy position, with gloved hands, insert the speculum, and identify the cervix and IUD strings. If IUD strings are not immediately identified, twirl cytobrushin os to help identify strings, grasp IUD strings with ring forceps, place gentle traction on the IUD strings and remove the device from the uterine cavity, ensure that the IUD is intact and no portions are missing.⁽¹¹⁾

Complications or Risk of IUD

When counseling patients about the risks associated with the insertion of IUDs, it is important to realize that there are specific factors that contribute to a poor or unexpected outcome. Less experienced health care professionals placing the IUD and women who had never had a vaginal delivery were more likely to have a difficult insertion or inability to insert IUD. Issues with cervical dilatation and bradycardia/vasovagal symptoms were more common in nulliparous women, likely because of cervical manipulation. Additionally, older women also had increased issues with appropriate cervical dilatation. In all of these cases, the ability and experience of the inserting provider to handle the complication at hand were protective. Therefore, as part of the consent process, it would make good sense to counsel patients about their specific risks, given their individual history.

There are very few complications associated with the procedure of IUD insertion. The most common complication is displacement or accidental removal of the IUD after insertion, usually occurring within the first three months of insertion. There is also an increased risk of expulsion if placed after vaginal delivery or after an abortion. However, there is a benefit to placing IUDs in patients immediately postpartum, in that patients did not always follow up for a postpartum visit and IUD placement, putting them at risk of unwanted pregnancy.⁽¹¹⁾

The most concerning complication for a patient is unintended pregnancy. While becoming pregnant with an IUD is exceedingly rare, this can happen in a small percentage of patients. The percentage of patients to become pregnant with the copper IUD is approximately 0.6%, and for the 20mg levonorgestrel IUD, the rate is approximately 0.2%.⁽¹¹⁾

Additionally, in a small percentage of patients, there is also a risk of possible uterine perforation when inserting the IUD. There is conflicting data on the rate of this as sometimes the initial perforation is not identified at the time of insertion. It is reported that the levonorgestrel IUD has a slightly higher risk of perforation compared to the copper IUD. However, it should be noted that in this study, they used the larger levonorgestrel device.

With both insertion and removal of IUDs, there is a risk of vasovagal symptoms with associated bradycardia that may occur when engaging with the cervix. These patients should be managed symptomatically. These symptoms are more likely to occur in nulliparous women or women who perceive greater pain at the time of insertion or removal.⁽¹²⁾

Conclusion

Family planning saves lives by preventing unwanted pregnancies, reduce the number of unsafe abortions and lower the incidence of maternal and fetal death related to complications of pregnancy and childbirth. It also promotes self-esteem, empowerment, gender equality, women education, economic benefits as well as health and wellbeing. Contraception can be provided safely and affordably so that no matter where they live, couples and individuals are able to choose from safe and effective family planning methods. LARCs including IUD are suitable for women of all ages. They are also cost effective and user friendly. There are many developments in family planning services and devices over the decades.

References

1. KhinNyunt, 1996, “Use of IUD in Myanmar”, Myanmar Journal of Current Medical Practice MJCMP, 1 (1): p 47-52.
2. WHO,UNICEF, UNFPA, World Bank Group and United Nations Population Division 2017, “Trends in Maternal Mortality (2000-2017) Estimates”, p 57-109.
3. UNOPS-3MDG, Ministry of Health and Sports ,Ministry of Immigration and Population.2016, “Myanmar Demographic and Health Survey (2015-2016), Nay Pyi Taw ,Myanmar” p 235-237.
4. WHO, Updates recommendations to guide family planning decisions, Family Planning Handbook, 2022, WHO, Pattaya, Thailand.
5. UNFPA Strategy for Family Planning, Expanding choices-Ensuring rights in a diverse and changing world, 2022-2030, UNFPA.
6. Bahamondes L, Fernandes A, Monteiro I, Bahamondes MV, 2020. “Long-acting reversible contraceptive (LARCs) methods” Best Pract Res ClinObstetGynaecol. 66: p 28-40.
7. Chen BA, Reeves MF, Hayes JL, Hohmann HL, Perriera LK, Creinin MD, 2010. “Postplacental or delayed insertion of the levonorgestrel intrauterine device after vaginal delivery: a randomized controlled trial”. Obstet Gynecol. 116 (5): 1079-87.
8. Grandi G, Farulla A, Sileo FG, Facchinetti F, 2018. “Levonorgestrel-releasing intra-uterine systems as female contraceptives” Expert OpinPharmacother. 19 (7): p 677-686.
9. Goldstuck ND, Cheung TS. 2019. “The efficacy of intrauterine devices for emergency contraception and beyond: a systematic review update.” Int J WomensHealth. 11: p 471-479.
10. Grimes DA, Lopez LM, Schulz KF, Stanwood NL. 2010. “Immediate postabortal insertion of intrauterine devices” Cochrane Database Syst Rev. (6): CD001777.
11. Committee on Practice Bulletins-Gynecology, Long-Acting Reversible Contraception Work Group. Practice Bulletin No. 186: 2017, “Long-Acting Reversible Contraception: Implants and Intrauterine Devices” ObstetGynecol. 130 (5): p 251- p269.
12. ACOG Committee Opinion No. 735: 2018, “Adolescents and Long-Acting Reversible Contraception: Implants and Intrauterine Devices”. Obstet Gynecol. 131(5): p130 – p139.

Author Information

Yin Yin Soe
Professor (retired) Department of Obstetrics and Gynaecology,
University of Medicine 1, Yangon