44 Usha Verma and Neil Verma
discontinued due to multiple reported side effects and procedural difficulty in
removing the implant.
Levonorgestrel Intrauterine Device
Mechanism of Action of the LNG Releasing IUD
The LNG releasing IUD (LNG-IUD) has been available since 1990 in
Europe and is available in the United States since 2000. It is marketed under
the name Mirena® (Bayer Schering Pharma, Berlin, Germany). Another two
LNG-IUD introduced later in the market are Skyla and Liletta. The LNG-IUD
Mirena provides highly effective contraception for up to five years, while
Skyla is approved for 3 years.
The mechanisms of action for LNG-IUD are similar to that of LNG
implants or LNG-containing mini-pills. It achieves these effects with much
lower peak serum levels than other progestin-containing contraceptives (0.1–
0.4 ng/ml vs 1.7–15.2 ng/ml with combined and progestin-only oral
contraceptives, respectively, and 5.4 ng/ml for combined vaginal
preparations)[54]. The LNG-IUD is a T-shaped device containing 52 mg of
LNG. Initially, 20 μg of LNG is released every 24 hours, decreasing to 11 μg
every 24 hours by the end of five years, with an average release rate of 14 μg
per day over the life of the IUD. LNG causes thickening of the cervical mucus
and also suppresses endometrial proliferation (preventing decidualization of
the stroma). The thickening of the cervical mucus creates an unfavorable
environment for the survival of the sperm, inhibiting motility and capacitation
and thus it prevents fertilization [54].
The LNG-IUD also produces endometrial thinning with fragile superficial
vessels which, in the unlikely event of fertilization, may prevent implantation.
The low serum levels of absorbed progestin are below the threshold for
inhibition of ovulation, therefore with the LNG-IUD ovulation is not inhibited
[54].
Contraception
LNG-IUD is a highly effective, long-acting, and reversible contraceptive
agent. Due to various contraceptive mechanisms of action, the efficacy rate of
the LNG-IUD is high, with only 0.1% of women experiencing an unintended
pregnancy within the first year of typical use. In four clinical studies which
represented more than 10,000 woman-years of use, the average Pearl Index (a
statistical estimation of the number of unintended pregnancies in 100 woman-