**2. History of IUDs**

Intrauterine contraception with various devices seems to have a long history, from the ancient Arabs who placed round smooth stones in the camels' uteri to prevent conception during long journeys. In the late nineteenth century, intracervical devices have been used to prevent pregnancy or to induce abortion [3]. Still, the first medical communication on medical IUD was published in Germany, at the beginning of the twentieth century by Richter [4], who reported the results of intrauterine insertion of a metallic ring with catgut tied around it. In the 1920s, Ernest Graefenberg attached a silver wire to the ring for Roentgen visualization, but silver rings were rapidly abandoned as they led to gingival argyrosis. An alloy of copper, nickel, and zinc was used instead [5]. In 1959, the first paper was published who condemned the IUDs as dangerous because of the ineffectiveness, risk of infection, and carcinogenic potential [5]. The modern IUDs evolved from 1960 with a T-shaped product that configured better to the natural shape of the uterus [6]. By the mid-1960s, IUDs became a widely used method with fewer potential cardiovascular risks when compared to oral contraceptives [7]. In 1970, nearly 10% of women were using the Dalkon Shield IUD as a contraceptive method. Since then, the use of IUDs dropped because of the severe septic cases reported, along with the increased risk of pelvic inflammatory disease (PID) and infertility [8]. IUDs were even withdrawn from the US market between 1986 and 1988.

Other types of copper IUDs include the *Multiload* series of devices that consists of *ML250* for a 3 years' use and the *ML375* with more copper to enhance a longer use, up to 5 years. The device has additional plastic fins on the lateral, and curved arms to avoid spontaneous expul-

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The *GyneFix* device has been introduced in 1997 as a frameless copper-bearing device designed especially for nulliparous women. However, it associates an increased risk of expulsion in the first 3 months. Both *GyneFix* and *T380A* are reported to have high efficiency in women con-

Besides pure copper devices, there is also a gold IUD called *Eurogine Gold T*, *Goldlily,* or *GoldringMedusa*, with a gold core that prevents the copper from fragmenting or corroding

Silver was also being added on a copper device, to reduce fragmentation, and to prolong the lifespan of the device. The production of the initial *NovaT200* was ceased, because of poorer

To reduce side effects of IUDs such as bleeding, pain, and expulsion, *Flexi-T300* was introduced, with a smaller and more flexible frame and thinner side arms that are bent back on themselves. *Flexi-T300* is also preferred for emergency contraception, as it is cheap and easily

Since 1976, medicated or *hormonal IUDs* were developed. *Mirena* was produced in 2001 as a hormonal IUD releasing 52 mg of levonorgestrel during a 5 years' period of approved use [7]. Mirena releases approximately 20 μg of levonorgestrel daily in the first few weeks with a decrease to 18 μg/day by the end of 1 year and 10 μg/day after 5 years [16]. Other hormonal IUDs, as *Skyla* or *Jaydess,* have a shorter period of use (3 years) because of the lower levonorgestrel content (13.5 mg), that is released 14 μg daily after the first few weeks and with a rapid decrease to 10 μg/day by 2 months and 5 μg/day by the end of 3 years [17]. Besides contraception, the hormonal IUDs reduce the blood flow with amenorrhea in about 20% of cases within 1 year [18]. *FibroPlant* is a frameless levonorgestrel-releasing IUD with a nonresorbable thread through the center and with similar effects on uterine-bleeding patterns as

Other IUDs include the *copper indomethacin* type, available in China, with a silicone elastomer beads containing 25 mg of indomethacin that does not interfere with the copper release and

In Austria and Israel, a *copper intrauterine ball* is available, which once inserted takes the shape of a sphere. The rationale of the ball shape is to reduce the irritating effect of classic copper IUD. It is also easy to insert with no uterine perforation reported and highly accepted by

New IUDs, such as flexible VeraCept—that utilize a low-dose copper configuration of 175 mm<sup>2</sup> surface area on a shape memory Nitinol frame—need clinical trials for validation of efficacy

sion [12].

[15].

traception [14].

inserted and removed [12].

reduces the menstrual cramping [12].

and tolerability [20] (**Figures 1** and **2**).

Mirena [12].

patients [19].

performance and *NovaT 380* was developed [12].

Since the introduction of the levonorgestrel 52 mg IUD in 2001, this intervention achieved a new, therapeutic, dimension—because of significant benefits in treating heavy menstrual bleeding and dysmenorrhea [7].

Today, IUDs are an important component of family planning, as they are used by one in 10 women in the USA and 9–24% of all contraceptives in European countries [9]. The highest rates of IUD use are recorded in Asia: 40% of women in China, 50% in Korea, and 56% in Uzbekistan [10], while the lowest rates are recorded in Africa. The trend of contraceptive method is declining as the use of injectable products is increasing [11]. From the beginning, the gynecologists were preferred for a safe insertion of the IUD, instead of general practitioners [3].
