**9. Management of problems in continuing users**

Patient satisfaction and acceptability are extremely important regardless of their contraceptive method. After a proper counseling regarding the risks and the benefits, women choose the appropriate most effective contraception option to prevent an undesired pregnancy. The *continuation* rates for copper IUD are reported to be as high as 84% at 12 months and 85% for hormonal IUD [85]. Overall, the satisfaction rates of women users of IUDs are the highest between all other contraceptive methods [86]. In terms of IUDs advantages, the most frequently reported reasons are the ease of use, efficacy, and reliability, but also reduction of the menstrual flows when using a hormonal IUD [40].

IUD must be removed and proper specific treatment should be initiated. IUD should be removed also in *intrauterine pregnancy* cases. If the woman wants to terminate the pregnancy, the removal procedure is done before the evacuation of the uterus. If the woman wants to continue the preg-

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During the insertion procedure, *perforation* may be suspected. In such situations, immediate removal of the IUD is recommended along continuous monitoring of the patient's vital signs. If perforation is suspected after 6 weeks of insertion or later, then the IUD should be removed

If the IUD is partially *expelled*, it must be removed and insertion of a new one should be decided with the patient after careful counseling. If the IUD is completely expelled, then other

*Male discomfort* during intercourse is a rare cause for switching to other contraception methods.

A series of medical conditions, due to high maternal mortality rates approaching 50%, represent an imperative indication for the most reliable methods of contraception in women. Essure was introduced in 2002 as a new sterilization method for women who do not desire to preserve fertility or for those who have significant medical contraindications. Essure is composed of two intra-tubal stents that must be inserted into the proximal section of the fallopian tube. This procedure is done hysteroscopically using only oral analgesia or sedation [91]. The contraceptive effect is installed in 3 months after insertion due to mechanical obstruction and inflammation causing fibrosis [92]. Thus, an additional form of contraception must be used in the meantime other than IUD. The main advantages of Essure are represented by the fact that Essure is non-incisional, permanent birth control device [93]. The insertion procedure is ideally performed in the proliferative phase when the tubal ostia can be easily visualized and cannulated. Tubal stenosis and tubal spasm can determine the failure of placement, but also poor visualization [94]. The procedure success rate varies from 85 to 98% [95]. When inserted, there is a risk of vaso-vagal attacks of 1.85% [96]. The Essure contraindications are the uncertainty regarding ending fertility, suspected pregnancy, active or recent PID, uterine anomalies, less than a 6-week interval after delivery or miscarriage, patient unwilling to use other contraceptive methods for the first 3 months, prior tubal ligation, and current immunosuppressive therapy [97]. After 3 months post-insertion, an imaging method to verify the position of the Essure is recommended. Several studies have been done in order to establish the best imaging method between hysterosalpingogram (HSG), X-ray, or hysterosalpingocontrast sonography. Still, all studies underline the importance of trained staff in assessing the appropriate Essure placement [93] (**Figure 6**). As complications, mild pain has been reported in most cases—80% of patients, while severe pain may be encountered in 17% [98]. Also, minor symptoms like cramping, nausea, and light bleeding or spotting can also occur in the first week [3]. Severe complications like tubal perforation and expulsion are rare. Essure is compatible with 1.5 T of magnetic resonance imaging (MRI), but special caution is indicated in 3 T MRI and with some techniques of endometrial ablation. In terms of efficacity, Essure has a 99.74% successful rate in permanent contraception after 5 years [97]. The minimal risk of

nancy, early removal of the IUD reduces the risk of preterm delivery or miscarriage.

by an experienced clinician and other contraception method should be considered.

contraceptive methods are advisable.

**11. New alternative to IUD**

*Pelvic pain* is the most frequent side effect of any IUDs. Approximately 27% of copper IUD users and 34% of hormonal IUD users have their IUD removed prior to 6 months because of continuing cramping [87]. The post-insertion pain can be managed with 400 mg of ibuprofen/325–650 mg of aspirin/325–1000 mg of paracetamol/200 mg of naproxen. The postinsertion recommendations forbid tampons, vaginal douching, and sex for 24 h [48].

Another reason for discontinuation is represented by irregular *bleeding patterns* especially for hormonal IUD users. With the copper IUDs, most women continue to have regular monthly periods and bleeding may get *heavier* [48]. In such cases, tranexamic acid can be required for a short-term relief, but unfortunately, it is not available in many countries. Another option may be nonsteroidal anti-inflammatory drugs, such as indomethacin, but not aspirin. Anemia may be a serious side effect of using copper IUD, so patients must receive iron tablets for the anemia prevention or indication to a specific diet rich in foods containing iron. *Amenorrhea* is a common side effect when using hormonal IUD. Even if irregular bleeding may bother the user, the menstrual flow is overall decreased [88]. In adolescents, a 7% rate of discontinuation has been reported within the first year, independent to the IUD type, due to abnormal bleeding [89].

Most cases of discontinuation can be prevented by an accurate medical informed discussion between the user and the health provider prior to IUD insertion. Both types of IUD should be taken into consideration and the best decision must consider the benefits, but also all adverse effects. The most important disadvantage of IUD use is the fact that it does not offer protection from sexually transmitted diseases and condom should be used for this purpose. In rare cases, the male partner can feel the IUD retrieval strings or stem during intercourse and this may bother him. Strings can be cut shorter or in some cases the IUD can be removed and a new one inserted. Lack of medical education seems to be the main cause for the reduced uptake and continuation rates for intrauterine contraception among female patients [90].
