Intrauterine Devices (lUDs)
Intrauterine devices are small and flexible, are made of plastic or plastic and copper, and are placed in the uterus through the cervical opening to prevent conception. An IUD must be put in and removed by a trained health professional. Once the device is in place, a woman is highly protected against pregnancy. Only two types of IUDs are approved by the FDA for use in the United States today: the Progestasert and the ParaGard T380A. The vertical stem of the T-shaped Progestasert contains a modest supply of progesterone that slowly diffuses over a 12-month period, after which this IUD must be removed and replaced. The ParaGard is also T-shaped but is partially copper covered. It is often called the "Copper T." It can be left in place for 10 years.
This form of birth control is extremely effective; it requires almost no attention; and the long-lasting ParaGard is very inexpensive over the long term. It does not interrupt lovemaking, and fertility returns immediately after it has been removed. Furthermore, when an IUD is in place in the uterus, neither partner can feel it. Outside the United States, modern IUDs are the most widely used reversible contraceptives.
The IUD does not protect against sexually transmitted diseases. A woman who has more than one sexual partner or whose partner may have other lovers is at high risk of acquiring STDs and, if she uses an IUD, is more likely to develop pelvic inflammatory disease. To be safe from STDs and PID, it is necessary to use a condom or to be in a long-term, mutually monogamous relationship in which neither partner has an STD.
The IUD was a more common form of contraception in the U.S. during the 1960s and later. Many types were available and one of the most popular was the Dalkon Shield. This all-plastic device had not been reviewed and tested before it was put on the market because, at that time, such devices did not require FDA approval.
The Dalkon Shield was designed with a "tail" composed of "twisted" strings that allowed bacteria to migrate upward into the reproductive organs. This badly designed IUD came on the market during the 1960s. It resulted in so many cases of pelvic inflammatory disease, infected pregnancies, miscarriages, and reproductive system damage—and lawsuits—that the Dalkon Shield was withdrawn from use.
Since then, federal regulations were put in place that require all medical devices, including IUDs, to be tested for safety. To reduce the risk of complications even further, IUD package information was made more explicit and providers became more careful about recommending IUDs.
It is now known that pelvic inflammatory disease can be related to an interaction between the device and the sexual behaviors of the woman and her partner. The device can make it more likely for a local infection to turn into PID. IUDs are not recommended for the woman who changes sexual partners, has had PID since her last pregnancy, or whose partner has other lovers. Some providers do not recommend the IUD to women who may be unusually susceptible to infections because their immune systems are compromised due to AIDS or leukemia.
The Progestasert became available in 1976 and the ParaGard in 1984. A 1989 review of both these IUDs by a diagnostic and therapeutic technology assessment panel found them to be safe and effec-
IN A NUTSHELL
The IUD is a small, T-shaped piece of plastic that is placed in a woman's uterus to prevent pregnancy. One type of IUD is wrapped in copper and can remain in the uterus for as long as 10 years. A second type gives off small amounts of the hormone progesterone for added effectiveness. It must be removed after 1 year.
Not all women can use an IUD. If you have had an infection like gonorrhea, chlamydia, or PID, you may not be able to use the IUD. The IUD is best for women who are in long-term, monogamous relationships.
The best time to have an IUD put into your uterus is when you are having your period, so you are sure you are not pregnant. It is also easier to insert it then. This is done during a pelvic examination by a doctor or nurse.
After the IUD is in place, a short string will hang down through the cervix into the back of your vagina. With your finger, you should check for the IUD string once a month. If the string is not there, if you can feel the plastic part of the IUD, or if the device comes out, you must call your clinic right away.
tive. When used by women in mutually faithful relationships, they are extremely reliable in preventing pregnancy and have relatively few complications.
Any IUD produces a reaction in the uterus that causes the production of white blood cells and substances called prostaglandins. Their presence in the uterus and the fallopian tubes interferes with the movement of sperm and eggs.
If the IUD contains copper, the effect on sperm and eggs is enhanced. Studies among women using copper IUDs have shown very few live sperm in the genital tract, compared to women not using a contraceptive. Copper IUDs exert their contraceptive effects primarily before fertilization—by killing sperm, by impeding the progress of surviving sperm so they fail to reach the fallopian tubes, or by diminishing any survivors' ability to fertilize eggs.
IUDs, particularly copper IUDs, also change egg movement through the fallopian tubes. A comparison of women who used a copper IUD with women who used no contraceptive showed that, after ovulation, none of the eggs from copper IUD users was fertilized, in contrast to more than half the eggs recovered from noncontraceptive users. The eggs were recovered from the fallopian tubes. No eggs were found in the uterus of any of the women using the copper IUD.
Two types of IUDs are available in the United States (Figure 11.1). The ParaGard is a copper-covered device that can be left in place for 10 years; the Progestasert is plastic, contains progesterone, and must be replaced after 1 year.
Approved for use in 1976, the Progestasert is a flexible, all plastic, T-shaped IUD with two monofilament (single, nontwisted) threads or strings attached to the base of the vertical stem. The threads hang down into the vagina. They are necessary to indicate that the IUD is in its correct position and are used to remove it. (These threads do not act as a ladder for bacteria.) The arm of the T measures about 1 1/4 inches, and the stem is just under 1 1/2 inches.
The Progestasert continuously emits a small amount of progesterone from its tiny, hollow stem. The hormone provides additional protection against conception. The reservoir releases just slightly more progesterone each day than a woman's body produces in one day during the latter part of a normal menstrual cycle. It acts directly on the lining of the uterus, making it inhospitable to a fertilized egg. Only a tiny amount of progesterone enters the bloodstream, virtually eliminating the side effects that can occur with other progestin methods of birth control. Women who cannot use other hormonal methods for health reasons can use this IUD safely. In addition, the Progestasert reduces menstrual bleeding, which can be a boon for women who have heavy
periods. After 12 months, the supply of the hormone is exhausted, and the Progestasert must be replaced.
The Progestasert is somewhat less effective than the ParaGard and has a slightly higher rate of ectopic pregnancy than the ParaGard or other contraceptives. Furthermore, its short duration of use also presents some disadvantages. Each time an IUD is inserted, there is always a risk that bacteria from the vagina may enter the uterus with it and cause an infection. And there is an expense associated with each insertion and removal.
Copper-covered IUDs have been in use in this country since 1974, ever since researchers found that the addition of copper to the device produced some distinct advantages. More than 20 million have been distributed in over 70 countries. The ParaGard Copper T 380A was approved by the FDA in 1984.
Copper IUDs are less likely to be expelled and do not cause as much menstrual bleeding as did earlier, all-plastic devices. The amount of copper they shed into the body produces no notable side effects. Women allergic to this metal, however, and women with the rare inherited disorder called Wilson's disease, in which excess copper accumulates in body tissues, are advised not to use the ParaGard. The ParaGard is more effective than the Pill and can remain in place for 10 years—a real asset.
The ParaGard is made of polyethylene, with fine copper wire wound around its stem and thin copper "sleeves" on its crosspiece. It is the same size as the Progestasert and also has a pair of monofilament threads extending from the bottom of the stem.
EFFECTIVENESS AND REVERSIBILITY
IUDs are extremely effective and reliable. Normal fertility returns when they are removed.
Both the Progestasert and the ParaGard have been tested in large clinical trials. The Progestasert has a failure rate of 2 percent or less over a 12-month period; the ParaGard's 12-month failure rate is less than 1 percent.
Fertility returns immediately after an IUD has been removed (or spontaneously expelled).
Women who feel they have completed their families and want long-term, highly effective contraception, but are not interested in sterilization, are excellent candidates for an IUD. Because pelvic inflammatory disease is a possible complication with this form of birth control, an IUD is only suitable for the woman who does not have an active or recurrent pelvic infection and is in a long-term,
WHO SHOULD NOT USE AN IUD
You are advised to choose another contraceptive if you have:
• An active or recurrent sexually transmitted disease or other pelvic infection, or a history of STDs or pelvic inflammatory disease. (A yeast infection does not rule out an IUD.)
• More than one sexual partner.
• A sexual partner who has intercourse with others.
• An ectopic pregnancy in the past.
• Undiagnosed, abnormal vaginal bleeding.
• A condition, such as AIDS or leukemia, that may make you more susceptible to infection.
• Wilson's disease or an allergy to copper.
mutually monogamous relationship—so she is not likely to be exposed to a sexually transmitted disease.
CAUTIONS, COMPLICATIONS, AND POSSIBLE SIDE EFFECTS
Like most birth control measures, IUDs occasionally can be associated with problems.
Discomfort or pain. If you have never had a child, you are more likely to experience cramps and pain severe enough to need to remove the IUD. Because of the association of IUDs with PID, other methods of contraception preserve fertility better in women who have never had a child and may want one in the future.
Pelvic inflammatory disease. Because an IUD is inserted into the uterus via the vagina and cervical canal, bacteria from those areas can be introduced into the usually sterile uterus, resulting in pelvic inflammatory disease. A vaginal infection should be treated before an IUD is put in. The IUD is not a good choice if you or your partner have a sexually transmitted disease unless you both have been treated successfully for it. IUDs may help STDs ascend into the upper reproductive tract, causing pelvic inflammatory disease.
Undiagnosed abnormal bleeding. The cause of any unusual bleeding should be found before an IUD is used.
Complications with the IUD can be serious, but they happen only rarely.
Pregnancy. Although pregnancy while using an IUD is uncommon, it may happen, usually because the IUD has unknowingly been expelled or has become embedded in the wall of the uterus. If the woman wishes to continue the pregnancy and the IUD has not been expelled, it should not be left in place—if it is, there is more than a 50 percent chance the pregnancy will end in a spontaneous abortion. There also is the possibility of infection. Although these risks are rare, they are real. If the IUD is removed early in the pregnancy, these risks are greatly reduced. If the IUD cannot easily be removed
Women who are not in long-term, mutually faithful relationships today are at risk of having one or more sexually transmitted diseases. If an STD reaches the upper reproductive tract, particularly the fallopian tubes, it can cause pelvic inflammatory disease. PID can damage the fallopian tubes, leading to future ectopic pregnancies and infertility, or to the need for a hysterectomy.
Because many cases of STDs and PID are "silent" and produce no noticeable symptoms, they often are not treated, and the PID can damage fallopian tubes. Severe PID, however, is likely to produce symptoms: chills and fever, abdominal or pelvic pain, an abdomen that is tender to the touch, painful intercourse, severe cramping, and unusual discharge or bleeding. If you develop these symptoms, contact your health care provider at once.
PELVIC INFLAMMATORY DISEASE (PID)
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