V s\u00fa\u010dasnosti sa pou\u017e\u00edvaj\u00fa dva typy vn\u00fatromaternicov\u00fdch teliesok (IUD – Intrauterine Devices):<\/p>\n
(1) IUD uvo\u013e\u0148uj\u00face levonorgestrel (LNG)<\/p>\n
(2) IUD uvo\u013e\u0148uj\u00face me\u010f<\/p>\n
Obidva typy vyu\u017e\u00edvaj\u00fa plastov\u00e9 polyetyl\u00e9nov\u00e9 r\u00e1my v tvare T. K dispoz\u00edcii s\u00fa aj \u010fal\u0161ie inertn\u00e9 a kovov\u00e9 IUD, ktor\u00e9 sa v\u0161ak pou\u017e\u00edvaj\u00fa menej.[i]<\/a> Vzh\u013eadom na skuto\u010dnos\u0165, \u017ee pojedn\u00e1vame o\u00a0hormon\u00e1lnej antikoncepcii, budeme sa venova\u0165 len teliesku (inzertu), ktor\u00e9 uvo\u013e\u0148uje horm\u00f3n levonorgestrel (LNG).<\/p>\n LNG-IUD patr\u00ed k tzv. dlhodobo p\u00f4sobiacej reverzibilnej antikoncepcii (long-acting reversible contraception, LARC). V\u00e4\u010d\u0161ina gynekologick\u00fdch spolo\u010dnost\u00ed intenz\u00edvne a\u00a0nekriticky podporuje pou\u017e\u00edvanie LMG-IUD najm\u00e4 smerom k\u00a0dospievaj\u00facim diev\u010dat\u00e1m. Pod\u013ea Americk\u00e9ho kol\u00e9gia p\u00f4rodn\u00edkov a gynekol\u00f3gov<\/em> (ACOG) je dlhodobo p\u00f4sobiaca reverzibiln\u00e1 antikoncepcia (LNG-IUD, implant\u00e1ty) bezpe\u010dn\u00e1 a\u00a0prijate\u013en\u00e1 antikoncep\u010dn\u00e1 met\u00f3da nielen pre dospel\u00e9 \u017eeny, ktor\u00e9 rodili, ale aj\u00a0pre adolescentky a \u017eeny, ktor\u00e9 e\u0161te nerodili.[ii]<\/a> [iii]<\/a><\/p>\n Mechanizmus \u00fa\u010dinku<\/strong><\/p>\n Problematika mechanizmu \u00fa\u010dinku LNG-IUD je intenz\u00edvne diskutovan\u00e1, ke\u010f\u017ee LNG-IUD sp\u00f4sobuje v\u00fdznamn\u00e9 zmeny na sliznici maternice br\u00e1niace uhniezdeniu embrya.[i]<\/a> LNG-IUD m\u00f4\u017ee zabr\u00e1ni\u0165 tehotenstvu jednak \u00fa\u010dinkami abort\u00edvnymi (postfertiliza\u010dn\u00fdmi, t. j. \u00fa\u010dinky zabra\u0148uj\u00face tehotenstvu po oplodnen\u00ed vaj\u00ed\u010dka) ako s\u00fa zmeny na sliznici maternice alebo ovplyvnenie pohyblivosti vaje\u010dn\u00edkov a\u00a0tie\u017e \u00fa\u010dinkami antikoncep\u010dn\u00fdmi (prefertiliza\u010dn\u00fdmi, t. j. zabra\u0148uj\u00facimi oplodneniu vaj\u00ed\u010dka) ako s\u00fa blok\u00e1da ovul\u00e1cie, zahustenie hlienu kr\u010dka maternice a zn\u00ed\u017eenie pohyblivosti spermi\u00ed.[ii]<\/a> [iii]<\/a><\/p>\n Ukazuje sa, \u017ee LNG-IUD m\u00e1 len minim\u00e1lny vplyv na funkciu vaje\u010dn\u00edkov, ke\u010f\u017ee v\u00e4\u010d\u0161ina \u017eien pou\u017e\u00edvaj\u00facich LNG-IUD m\u00e1 ovula\u010dn\u00e9 cykly.[iv]<\/a> V\u00a0\u0161t\u00fadii, ktor\u00fa vykonali Apter a kol. <\/em>(2014), vysok\u00e1 miera ovul\u00e1cia (90% \u017eien v\u00a0prvom roku u\u017e\u00edvania, 93% v\u00a0druhom roku a\u00a098% v\u00a0tre\u0165om roku u\u017e\u00edvania) sa pozorovala u v\u00e4\u010d\u0161iny \u017eien pri v\u0161etk\u00fdch typoch LNG-IUD (LNG-IUD 13.5mg, LNG-IUD 19.5mg a\u00a0LNG-IUD 52mg).[v]<\/a> Podobne aj vplyv LNG-IUD na hustotu hlienu kr\u010dka maternice a\u00a0pohyblivos\u0165 spermi\u00ed sa zd\u00e1 by\u0165 minim\u00e1lny. V\u00a0\u0161t\u00fadii, ktor\u00fa vykonali Barbosa a\u00a0kol. <\/em>(1995), u\u00a0\u017eien pou\u017e\u00edvaj\u00facich LNG-IUD a\u017e 69 % ovula\u010dn\u00fdch cyklov malo hlien kr\u010dka maternice priazniv\u00fd pre transport spermi\u00ed.[vi]<\/a> Aj ke\u010f uveden\u00e9 antikoncep\u010dn\u00e9 mechanizmy m\u00f4\u017eu p\u00f4sobi\u0165 vo v\u00e4\u010d\u0161ine men\u0161trua\u010dn\u00fdch cyklov, nie s\u00fa dostato\u010dn\u00e9 na dosiahnutie vysokej \u00fa\u010dinnosti LNG-IUD.[vii]<\/a><\/p>\n Hlavn\u00fdm mechanizmom \u00fa\u010dinku LNG-IUD je potla\u010denie fyziologick\u00fdch funkci\u00ed sliznice maternice[viii]<\/a> [ix]<\/a>, a\u00a0teda zabr\u00e1nenie uhniezdeniu embrya, ak d\u00f4jde k\u00a0oplodneniu vaj\u00ed\u010dka. Tento \u00fa\u010dinok LNG-IUD sa prejavuje najm\u00e4 sten\u010den\u00edm sliznice maternice, naru\u0161en\u00edm g\u00e9novej expresie, rozsiahlou decidualiz\u00e1ciou (decidualiz\u00e1cia ozna\u010duje morfologick\u00fa a biochemick\u00fa zmenu \u013eudsk\u00fdch endometri\u00e1lnych strom\u00e1lnych buniek na decidu\u00e1lne bunky, ktor\u00e9 reguluj\u00fa uhniezdenie embrya a n\u00e1sledn\u00fa tvorbu placenty[x]<\/a>), zn\u00ed\u017eenou expresiou estrog\u00e9nov\u00e9ho, progester\u00f3nov\u00e9ho a androg\u00e9nov\u00e9ho receptora, zv\u00fd\u0161en\u00fdm prienikom leukocytov, zv\u00fd\u0161enou tvorbou cytok\u00ednov a\u00a0prostagland\u00ednov, zmenenou novotvorbou ciev, zv\u00fd\u0161enou tvorbou matrixov\u00fdch metaloprotein\u00e1z (proteolytick\u00e9 l\u00e1tky potrebn\u00e9 na prestavbu sliznice maternice po\u010das men\u0161tru\u00e1cie a\u00a0implant\u00e1cie), zv\u00fd\u0161enou tvorbou tkanivov\u00e9ho faktora a IGFBP-1 (insulin-like growth factor binding protein 1) a\u00a0zv\u00fd\u0161enou aktivitou enz\u00fdmu 17hHSD-2 (17\u03b2-hydroxysteroid dehydrogen\u00e1za typu 2), \u010do vedie k\u00a0zv\u00fd\u0161enej premene estradiolu na slab\u0161\u00ed estr\u00f3n, a teda k\u00a0prostrediu s\u00a0nedostatkom estrog\u00e9nov.[xi]<\/a> V\u00a0\u0161t\u00fadii, ktor\u00fa vykonali Smith-McCune a\u00a0kol.<\/em> (2020), pou\u017e\u00edvate\u013eky LNG-IUD mali v\u00a0sliznici maternice v\u00a0porovnan\u00ed s\u00a0fyziologickou sliznicou maternice odli\u0161ne exprimovan\u00fdch a\u017e 2 509 g\u00e9nov reguluj\u00facich predov\u0161etk\u00fdm imunitn\u00e9 a z\u00e1palov\u00e9 dr\u00e1hy.[xii]<\/a> Li a\u00a0kol.<\/em> (2019) zistili, \u017ee levonorgestrel zni\u017euje frekvenciu cili\u00e1rneho rytmu vo vajcovodoch prostredn\u00edctvom zn\u00ed\u017eenej regul\u00e1cie expresie \u201eTransient Receptor Potential Vanilloid (TRPV) 4\u201d kan\u00e1lov, \u010do vedie k\u00a0zadr\u017eaniu embry\u00ed vo vajcovodoch a n\u00e1sledn\u00e9mu mimomaternicov\u00e9mu tehotenstvu.[xiii]<\/a> V\u0161etky vy\u0161\u0161ie uveden\u00e9 zmeny na sliznici maternice vo ve\u013ekej miere zabra\u0148uj\u00fa uhniezdeniu embrya a\u00a0sp\u00f4sobuj\u00fa jeho odumretie. \u017deny, ktor\u00e9 zva\u017euj\u00fa pou\u017e\u00edvanie LNG-IUD by mali by\u0165 informovan\u00e9 o\u00a0tomto mechanizme \u00fa\u010dinku, ktor\u00fd m\u00f4\u017ee sp\u00f4sobi\u0165 odumretie embrya.<\/p>\n <\/p>\n <\/p>\n Odborn\u00e9 pramene<\/strong><\/em><\/p>\n [i]<\/a> Agulles Sim\u00f3 P. Efecto Abortivo de los Anticonceptivos Hormonales: Una Revisi\u00f3n [Abortifacient effect of hormonal contraceptives: a review]. Cuadernos de Bioe\u0301tica : Revista Oficial de la Asociacio\u0301n Espan\u0303ola de Bioe\u0301tica y E\u0301tica Me\u0301dica. 2015 Jan-Apr;26(86):69-109.<\/p>\n [ii]<\/a> Dinehart E, Lathi RB, Aghajanova L. Levonorgestrel IUD: is there a long-lasting effect on return to fertility?. Journal of Assisted Reproduction and Genetics. 2020;37(1):45-52.<\/p>\n [iii]<\/a> Costescu DJ. Levonorgestrel-releasing intrauterine systems for long-acting contraception: current perspectives, safety, and patient counseling.\u00a0 International Journal of Women’s Health.2016;8:589-598.<\/p>\n [iv]<\/a> Xiao B, Zeng T, Wu S, et al. Effect of levonorgestrel-releasing intrauterine device on hormonal profile and menstrual pattern after long-term use. Contraception. 1995 Jun;51(6):359-65.<\/p>\n [v]<\/a> Apter D, Gemzell-Danielsson K, Hauck B, et al. Pharmacokinetics of two low-dose levonorgestrel-releasing intrauterine systems and effects on ovulation rate and cervical function: pooled analyses of phase II and III studies. Fertility and Sterility. 2014. Jun;101(6):1656-62.e1-4.<\/p>\n [vi]<\/a> Barbosa I, Olsson SE, Odlind V, et al. Ovarian function after seven years‘ use of a levonorgestrel IUD. Advances in contraception : the official journal of the Society for the Advancement of Contraception. 1995 Jun;11(2):85-95.<\/p>\n [vii]<\/a> Stanford JB, Mikolajczyk RT. Mechanisms of action of intrauterine devices: update and estimation of postfertilization effects. American Journal of Obstetrics and Gynecology. 2002 Dec;187(6):1699-708.<\/p>\n [viii]<\/a> Attia AM, Ibrahim MM, Abou-Setta AM. Role of the levonorgestrel intrauterine system in effective contraception. Patient Preference and Adherence. 2013 Aug 9;7:777-85.<\/p>\n [ix]<\/a> Xiao B, Zeng T, Wu S, Sun H, Xiao N. Effect of levonorgestrel-releasing intrauterine device on hormonal profile and menstrual pattern after long-term use. Contraception. 1995 Jun;51(6):359-65.<\/p>\n [x]<\/a> Tochigi H, Kajihara T, Mizuno Y, et al. Loss of miR-542-3p enhances IGFBP-1 expression in decidualizing human endometrial stromal cells. Scientific Reports. 2017;7:40001.<\/p>\n [xi]<\/a> Guttinger A, Critchley HO. Endometrial effects of intrauterine levonorgestrel. Contraception. 2007 Jun;75(6 Suppl):S93-8.<\/p>\n [xii]<\/a> Smith-McCune K, Thomas R, Averbach S, et al. Differential Effects of the Hormonal and Copper Intrauterine Device on the Endometrial Transcriptome. Scientific Reports. 2020;10(1):6888.<\/p>\n [xiii]<\/a> Li C, Wu YT, Zhu Q, et al. TRPV4 is involved in levonorgestrel-induced reduction in oviduct ciliary beating. The Journal of Pathology. 2019;248(1):77\u201387.<\/p>\n [i]<\/a> Nelson AL, Massoudi N. New developments in intrauterine device use: focus on the US. Open Access Journal of Contraception. 2016;7:127-141.<\/p>\n