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The Intrauterine Device: An Effective Contraceptive Method

The Intrauterine Device (IUD) is a highly effective and safe form of contraception that is greatly underused in the United States. Only three percent of married women who are of reproductive age use this form of contraception. First used in the early 1900s, IUDS were popular through the 1970s. In 1986, however, the U.S. Food and Drug Administration (FDA) discontinued the sale of a specific type of IUD (the Dalkon Shield) in the United States, due to a series of pelvic infections in women who used them. Other IUD manufacturers, concerned with the possibility of lawsuits, stopped producing their products. Two years later, IUDs were reintroduced into the market, but unfortunately, even to this day, there is a negative perception of the IUD by both the general public and many physicians. I urge all of you who are

Are IUDs All the Same?
The IUD is a small plastic device used for long-term contraception that is placed through the cervix and into the uterine cavity. In the United States, there are two common types available: the copper IUD (Para-Gard) and the hormonal IUD's (Mirena and Progestasert). Both are highly effective and each has different advantages. For example, the copper IUD has a lower failure rate and can remain in place for up to 10 years before removal. The hormonal IUDs release small amounts of progesterone-like hormones into the uterine cavity. Progesterone is a hormone that can stabilize the endometrium (inner lining of the uterus) and minimize menstrual bleeding. Hormonal IUDs are associated with less menstrual bleeding than copper IUDs and even less bleeding than in women with no IUD in place.

How IUDs Work
The ways in which IUDs work are not entirely clear. We know that these devices induce an inflammatory reaction in the endometrium, which impairs sperm function and survival as well as fertilization. It is important to realize that, contrary to popular belief, IUDs do not appear to cause embryos to detach from the uterine wall and therefore, do not cause abortions. Hormonal IUDs have the added ability to thicken the cervical mucus, thus hindering movement of sperm through the female reproductive tract.

Are IUDs effective?
IUDs are extremely effective. Depending on the type of IUD used, pregnancy occurs in only one to three percent of women each year. Although both types of IUDs are effective, the copper IUD has a lower failure rate than the hormonal IUD's.

Disadvantages/Risks of IUD Use
The copper IUD can cause increased menstrual flow, cramping, and pelvic discomfort, and about 15 percent of women discontinue IUD use in the first 12 months after insertion due to these complaints. As stated earlier, the hormonal IUD's can lessen menstrual flow and may actually be used to treat women with heavy periods. Hormonal IUD users may experience spotting between periods. Like all procedures, even minor ones, the insertion of an IUD does have risks, such as perforation of the uterus (a one-in-a-thousand chance) and infection. Although several studies have failed to actually quantify the risk of infection (as so many infections are very mild and not clinically apparent), it is clear that the infection risk is quite low. The intrauterine device may be partially or completely expelled in approximately 10 percent of women as well. If you do become pregnant while the IUD is in place, there is an increased risk of miscarriage, premature labor, and ectopic pregnancy (pregnancies that occur outside the uterine cavity, such as in the fallopian tubes or abdominal cavity). This risk is particularly high in women who become pregnant using hormonal IUD's. Fortunately, pregnancies are so rare in IUD users that this is not of concern to most IUD users.

Who are the Best Candidates for IUDS?
If you are in a mutually monogamous relationship, at a low risk of contracting sexually transmitted diseases, and have completed childbearing, an IUD is an excellent choice. This is especially true if you wish to avoid permanent sterilization procedures such as tubal ligation (having your "tubes tied"). Some physicians recommend IUDs to women who meet the above criteria and who have had at least one child. Although medical opinions differ on this matter, I do not recommend IUD use in any woman who has not completed childbearing. Many infections are mild and escape the attention of the patient and the physician. However, even mild infections can damage the fallopian tubes and may cause scarring and even infertility.

New data suggest that IUD's may be just as safe in women who have not yet had children - in this study, the rate of infertility due to fallopian tube blockage was no higher among women who had used IUD's than in those who never used them.

Women Who Should not Use IUDs
If you experience irregular vaginal bleeding, it is imperative that your physician determine the cause of the bleeding before he inserts an IUD. Also, if you believe you may be pregnant, a pregnancy test should be performed before IUD placement. Because pelvic infection rates increase in the first few months after IUD insertion (probably related to the insertion itself), anyone with a current infection or who is at a high risk for infections (for example, women with multiple sexual partners, women whose partners exhibit high-risk sexual behavior, and/or women with medical conditions that suppress the immune system) should avoid using IUDs. I also advise my patients who have never conceived, or have a history of ectopic pregnancy, to avoid using IUDs. Other women who should avoid IUD use are those who have a misshapen uterus, those with congenital malformations (structural abnormalities since birth), or those with benign uterine tumors (e.g., fibroids). In such cases, expulsion of the IUD is more common. Any woman who has had an abnormal Pap smear should avoid IUD use until the problem is resolved. Furthermore, women with cancers of the uterus or cervix should not have an IUD inserted.

Acquiring an IUD
The first thing you should do is to make an appointment with your doctor to discuss whether you are an appropriate candidate for an intrauterine device. You will then undergo a pelvic examination to rule out any uterine structural abnormalities that would preclude the use of IUDs (an IUD may be more easily expelled from a misshapen uterus). A Pap smear and cervical bacterial cultures will be performed to rule out cancerous or precancerous cervical abnormalities, as well as any active infections.

Pregnancy With an IUD in Place
If you miss your period, you must contact your physician immediately. If you desire an abortion, and the pregnancy is in the uterus (i.e., not ectopic), the IUD can be removed at the same time. If pregnancy is desired, removal of the IUD in the first trimester is generally safe and will not lead to an increased chance of complications seen later in the pregnancy, including early labor, infection, or birth defects. Do not wait to contact your doctor, as delays can lead to life-threatening consequences such as rupture of an ectopic pregnancy, serious pelvic infections, and early labor.

IUD Insertion
While IUDs can be inserted at any time during the menstrual cycle, even during the period itself, I recommend that insertion be performed shortly after your period ends. As blood is a good nutrition source for any bacteria introduced, it is best to have no blood in the uterine cavity at the time that the IUD is inserted. Your doctor may advise you to take ibuprofen or Naprosyn (pain killers and anti-inflammatory agents) prior to insertion to minimize cramping. Some doctors also prescribe a short course of antibiotics prior to IUD placement, although the use of antibiotics in this setting has never been shown to be necessary.

Before insertion, your cervix will be cleaned with an antiseptic solution and your uterus will be measured to ensure proper placement of the IUD. After insertion, your doctor will ask you to place a finger into your vagina to feel the string, which is attached to the end of the IUD. This string allows you to confirm the continued presence of the IUD within the uterine cavity. Furthermore, it facilitates later removal of the IUD. If you ever do not feel the string, contact your doctor immediately, as the IUD may have been expelled out of the vagina (no longer providing contraception) or may have migrated through the uterus into the abdominal cavity where it can lead to infections and scar tissue. Keep in mind that during the first month after the IUD is placed, a second form of contraception should be used, such as condoms and spermicide. Four to six weeks after insertion, you should have an examination by your physician and if all is well, follow up annually thereafter.

Pregnancy After IUD Removal
Good news for the vast majority of women: The chances of future conception are not diminished by prior use of an IUD. If you did experience a pelvic infection following the insertion of an IUD, however, the risk of infertility is increased. Keep in mind that many factors affect fertility potential, such as age, sperm function, ovulation, and the condition of the fallopian tubes. Therefore, there is no guarantee that removal of an IUD will result in a pregnancy, but your chances of getting pregnant are not decreased, either.

Conclusion
The intrauterine device is an excellent, effective, and generally safe contraceptive method that should be more popular than it is. In my consultations with patients seeking long-term contraception, I do include a discussion of IUDs. As with anything else in medicine, you as a patient and medical consumer must understand the advantages, disadvantages, and risks of all of your contraceptive options. For the appropriately selected woman, the IUD is a great choice.