FERTILITY AND STERILITY Copyright 1977 The American Fertility Society
Vol. 28, No.
0
10, October 1977 Printed in U.S.A.
SELF-CHECKING THE INTRAUTERINE DEVICE
GEOFFREY CHAMBERLAIN, M.D., F.R.C.S., M.R.C.O.G.* Queen Charlotte's Hospital for Women, London W.6, England
The self-examination habits of 155 women wearing an intrauterine device have been analyzed. One-third were persistently unable to find the tail. There was a loose relationship between the type of device, the length of the tail, and failure to detect. The more parous and those of higher social class were more adept at detection, as were those who examined themselves each month.
All doctors who fit an intrauterine device (IUD) place great emphasis on teaching the patient to check by self-examination that the appliance has not been expelled. Patients are told to examine themselves vaginally after each menstrual period and, if the tail of the IUD cannot be felt, to return to the doctor soon so that he can determine whether the device has been expelled. This advice is not followed by some patients, whereas others try but fail to find the tail of the IUD. This survey was conducted to assess the success of self-examination. The patients were seen in a hospital, a family planning clinic, or the private practice office of one observer. All patients within 1 year who had worn an IUD for a least 6 months were admitted to the study.
nation. All women were examined so that the length of the tail protruding from the external os of the cervix could be measured. Complete information was obtained from all 155 women assessed. RESULTS
Table 1 shows the results as analyzed by type of intrauterine device. The detection rate for the Copper 7 seemed to be lower than that for the Lippes Loop, but this finding may be inaccurate owing to the small numbers involved. However, it may be important that the Lippes Loop has two tails of thick nylon while the tail of the Copper 7 is a single, thinner thread. Table 2 shows the results as analyzed by the length of the tail at examination. There was no significant difference in the detection rates with increased length of the tail of the IUD. Since most of these devices were inserted by one gynecologist (G. C.) who probably used a reasonably consistent technique, the variations in tail length during 6 months' use may reflect subsequent movements of the IUD inside the uterus. Table 3 shows the results as analyzed by parity. There were few nulliparous patients in this series,
THE SURVEY
One hundred and seventy-four patients were evaluated during the year 1976. Seventeen patients had not tried to examine themselves, although thirteen of these did remember that they had been requested to do so. In two other cases the patients had been unable to find the tail, but at subsequent examination neither could the observer-in one case the IUD had been expelled and in the other it had ridden up into the uterus. The remaining 155 patients, all of whom had tried to find the tail of the IUD, were admitted to the study and analyzed by parity and social class, duration of IUD use, and frequency of self-exami-
TABLE 1. Results Expressed by Type of Intrauterine Device Type of IUD Copper 7 Lippes Dalkon AntiTotal Loop gon Shield Felt Not felt Detection rate (%)
Received April 29, 1977; accepted May 6, 1977. *Consultant Obstetrician.
Total
1121
67 46 59.3 113
28 10 83.8
2 1
1 0
98 57
38
3
1
155
TABLE 2. Results Expressed by Length of Tail at Examination Tail length 4 em
Total
29 12 70.7
2 1
98 57
41
3
155
Felt Not felt Detection rate (%)
13 4 76.6
15 60.0
39 30 57.8
Total
17
25
69
10
but a remarkable reversal was shown between primiparous women and the more multiparous women, with a detection rate improving greatly (from less than one-fourth to more than threefourths) between these two parities. In order to assess any social-class trends, the population was analyzed by social class according to the occupation of the husband; they were graded from professional through to unskilled occupations. There was a steady worsening of the reported detection rate as the socioeconomic grading descended. All patients were asked how often they had examined themselves over the previous 6 months. Approximately one-half reported that they had checked for the tail monthly, nearly all of these doing so after the menstrual period. Under onefourth examined themselves more frequently than this, and 29 of the 155 did so at longer than monthly intervals. The detection rate was about TABLE 3. Results Expressed by Parity Parity
3 Felt 2 Not felt Detection rate (%) 5
Total 3
0
Total
October 1977
COMMUNICATIONS-IN-BRIEF
1122
20 51 9 6 16 33 21.4 76.1 76.8 42
67
26
4
>4
7 0
8 0
98 57
7
8
155
the same in all who checked monthly or less but worse in those who had longer checking inter~als. DISCUSSION
The data were obtained from the complete patient population of one family planning doctor over a i-year period. Such small numbers do not justify a formal statistical evaluation, but the trends seem obvious. The intrauterine device is suitable for many women, but one-third of those who check regularly cannot find the tail and so have no certainty that the device is still there. This failure of self-examination may relate to the ty~e of IUD but apparently not the length of its tall. Other possible associations may be the parity of the patient, her social class, and the frequency of examination. Probably the motivation of the patient is the most important single factor in repeated selfexamination. Those who are made anxious by or "",:ho dislike vaginal manipulation are more likely eIther not to examine or to fail to find the tail for they do not penetrate deeply enough. Such women have always been recognized as being unsuited for vaginal diaphragm contraception since it is considered that they will place the device with difficulty. Maybe physicians should also consider such inhibitions in patients having an IUD, for sel~-examination of the tail is the only way in whIch the woman can be sure that she still has an effective contraceptive method.
This is a very simple clinical study. However, to my knowledge, no one has published information on this subject, and it is interesting to know which groups of women check their IUDs when so advised. Editor
Vol. 28, No.
0
10, October 1977 Printed in U.S.A.
SELF-CHECKING THE INTRAUTERINE DEVICE
GEOFFREY CHAMBERLAIN, M.D., F.R.C.S., M.R.C.O.G.* Queen Charlotte's Hospital for Women, London W.6, England
The self-examination habits of 155 women wearing an intrauterine device have been analyzed. One-third were persistently unable to find the tail. There was a loose relationship between the type of device, the length of the tail, and failure to detect. The more parous and those of higher social class were more adept at detection, as were those who examined themselves each month.
All doctors who fit an intrauterine device (IUD) place great emphasis on teaching the patient to check by self-examination that the appliance has not been expelled. Patients are told to examine themselves vaginally after each menstrual period and, if the tail of the IUD cannot be felt, to return to the doctor soon so that he can determine whether the device has been expelled. This advice is not followed by some patients, whereas others try but fail to find the tail of the IUD. This survey was conducted to assess the success of self-examination. The patients were seen in a hospital, a family planning clinic, or the private practice office of one observer. All patients within 1 year who had worn an IUD for a least 6 months were admitted to the study.
nation. All women were examined so that the length of the tail protruding from the external os of the cervix could be measured. Complete information was obtained from all 155 women assessed. RESULTS
Table 1 shows the results as analyzed by type of intrauterine device. The detection rate for the Copper 7 seemed to be lower than that for the Lippes Loop, but this finding may be inaccurate owing to the small numbers involved. However, it may be important that the Lippes Loop has two tails of thick nylon while the tail of the Copper 7 is a single, thinner thread. Table 2 shows the results as analyzed by the length of the tail at examination. There was no significant difference in the detection rates with increased length of the tail of the IUD. Since most of these devices were inserted by one gynecologist (G. C.) who probably used a reasonably consistent technique, the variations in tail length during 6 months' use may reflect subsequent movements of the IUD inside the uterus. Table 3 shows the results as analyzed by parity. There were few nulliparous patients in this series,
THE SURVEY
One hundred and seventy-four patients were evaluated during the year 1976. Seventeen patients had not tried to examine themselves, although thirteen of these did remember that they had been requested to do so. In two other cases the patients had been unable to find the tail, but at subsequent examination neither could the observer-in one case the IUD had been expelled and in the other it had ridden up into the uterus. The remaining 155 patients, all of whom had tried to find the tail of the IUD, were admitted to the study and analyzed by parity and social class, duration of IUD use, and frequency of self-exami-
TABLE 1. Results Expressed by Type of Intrauterine Device Type of IUD Copper 7 Lippes Dalkon AntiTotal Loop gon Shield Felt Not felt Detection rate (%)
Received April 29, 1977; accepted May 6, 1977. *Consultant Obstetrician.
Total
1121
67 46 59.3 113
28 10 83.8
2 1
1 0
98 57
38
3
1
155
TABLE 2. Results Expressed by Length of Tail at Examination Tail length 4 em
Total
29 12 70.7
2 1
98 57
41
3
155
Felt Not felt Detection rate (%)
13 4 76.6
15 60.0
39 30 57.8
Total
17
25
69
10
but a remarkable reversal was shown between primiparous women and the more multiparous women, with a detection rate improving greatly (from less than one-fourth to more than threefourths) between these two parities. In order to assess any social-class trends, the population was analyzed by social class according to the occupation of the husband; they were graded from professional through to unskilled occupations. There was a steady worsening of the reported detection rate as the socioeconomic grading descended. All patients were asked how often they had examined themselves over the previous 6 months. Approximately one-half reported that they had checked for the tail monthly, nearly all of these doing so after the menstrual period. Under onefourth examined themselves more frequently than this, and 29 of the 155 did so at longer than monthly intervals. The detection rate was about TABLE 3. Results Expressed by Parity Parity
3 Felt 2 Not felt Detection rate (%) 5
Total 3
0
Total
October 1977
COMMUNICATIONS-IN-BRIEF
1122
20 51 9 6 16 33 21.4 76.1 76.8 42
67
26
4
>4
7 0
8 0
98 57
7
8
155
the same in all who checked monthly or less but worse in those who had longer checking inter~als. DISCUSSION
The data were obtained from the complete patient population of one family planning doctor over a i-year period. Such small numbers do not justify a formal statistical evaluation, but the trends seem obvious. The intrauterine device is suitable for many women, but one-third of those who check regularly cannot find the tail and so have no certainty that the device is still there. This failure of self-examination may relate to the ty~e of IUD but apparently not the length of its tall. Other possible associations may be the parity of the patient, her social class, and the frequency of examination. Probably the motivation of the patient is the most important single factor in repeated selfexamination. Those who are made anxious by or "",:ho dislike vaginal manipulation are more likely eIther not to examine or to fail to find the tail for they do not penetrate deeply enough. Such women have always been recognized as being unsuited for vaginal diaphragm contraception since it is considered that they will place the device with difficulty. Maybe physicians should also consider such inhibitions in patients having an IUD, for sel~-examination of the tail is the only way in whIch the woman can be sure that she still has an effective contraceptive method.
This is a very simple clinical study. However, to my knowledge, no one has published information on this subject, and it is interesting to know which groups of women check their IUDs when so advised. Editor
