from the uterus, a termination of the pregnancy should be considered. When the IUD is withdrawn and the pregnancy carried full term, no negative effects occur. If you suspect you may be pregnant, get in touch with your health care provider immediately.
Ectopic Pregnancy. If you become pregnant while using a Progestasert IUD, the pregnancy is more likely to be ectopic (a tubal pregnancy) than it would be for a woman using another method or the ParaGard. The risk is about the same as it is for a sexually active woman not using birth control.
If you have an ectopic pregnancy, you may develop these symptoms:
• Sudden, severe, or persistent abdominal pain or cramping, often on one side.
• Unusual vaginal bleeding or spotting, along with abdominal pain, especially if this occurs after an unusually light period, or a late or missed period.
• A spell of faintness or dizziness (an indication of internal bleeding), together with any of the preceding symptoms.
You should contact your health care provider at once, because an ectopic pregnancy may rupture at any time. If you cannot reach your doctor, seek help at the nearest hospital emergency room.
Expulsion. Most expulsions take place during the first three months after the IUD has been inserted. The uterus has a natural tendency to expel foreign objects, and the IUD can be pushed out through the cervical opening. It may be expelled by uterine contractions during the first few days of menstruation, when the cervical os is more open. An estimated 2 to 8 percent of IUD users spontaneously expel their IUDs during the first year.
If you find your IUD on a sanitary napkin or in the toilet, obviously it has been expelled. If it has been only partially expelled, you or your partner may feel it in your cervix or vagina. Other signs are pain during intercourse, finding that the IUD threads feel longer, spotting after intercourse or between periods, unusual vaginal discharge, cramps, or pain. If the IUD is expelled without being no ticed, the first sign would be missing threads. Pregnancy can occur when the IUD is out of place, so another signal would be signs of pregnancy such as a missed period or morning sickness or tender breasts. It is a good idea to check the threads at least once a month, particularly right after your period.
Perforation. A rare but potentially serious complication of using an IUD is perforation of the uterus (or cervix) by the device. Part of the IUD may penetrate the wall of the uterus or the entire IUD may work its way into the surrounding abdominal cavity. If the IUD traps a loop of the intestine, it could cause a medical emergency. IUDs that perforate the uterus should be removed as soon as the perforation is detected. Removal is usually done via laparoscopy (discussed later in this chapter), but occasionally it can require major surgery. Perforation happens most often at the time the IUD is put in, and it is more likely to occur if the correct technique is not used or if the person doing the insertion it is not thoroughly experienced in the procedure. Perforation is less likely if the health care provider measures the depth and position of the uterus beforehand.
Perforation takes place in approximately one out of every 2,500 insertions. It generally produces no symptoms. The only indication may be the fact you cannot find the threads during your monthly thread-check. Perforations sometimes are discovered only when a woman develops signs of pregnancy. Ultrasound or x-ray can be used to check the position of the IUD.
Embedding. This is a rare and usually less serious complication, in which the lining of the uterus begins to grow around the IUD. An embedded IUD is harder to remove and might break during the removal process. In some cases, a dilatation and curettage (D&C) or other procedure might be necessary to take out the IUD. Threads that seem shorter can be a sign that the IUD is becoming embedded, and this should be brought to the attention of your health care provider right away. Your IUD can be removed and replaced, or you can try another form of birth control.
Both the ParaGard and the Progestasert have fine polyethylene threads that reach into the vagina so you can feel them with a finger. It is a good idea to check their location before you leave the doctor's office or clinic so you know where they are. Not being able to find them later may mean that the IUD has been expelled or has moved. If this happens, use your backup birth control until the IUD can be checked by your practitioner. You are not protected against pregnancy if your IUD moves out of place.
There are several ways to locate the IUD. Your practitioner can probe the uterus with an instrument or use ultrasound or x-ray to see it. Both the Progestasert and the ParaGard have an opaque material built into them that makes them visible by x-ray. If the IUD is not in the right place, it should be removed. On rare occasions, removal may require surgery.
Infection. Although pelvic infections are not common in healthy women who are not exposed to STDs, there is still some risk. The risk is highest in the months right after an insertion. Since prompt treatment is important, be attentive to possible signs of infection and do not delay seeking treatment if you have: chills and fever, abdominal or pelvic pain, a tender abdomen, severe cramping, painful sex, or any unusual vaginal bleeding or discharge. Even if you are not sure it is a symptom, check with your health care provider.
Bleeding. The most common adverse effects you might experience while using the ParaGard IUD are spotting between periods, or longer and sometimes heavier periods. These problems often diminish over the first few months. Sometimes, however, bleeding problems are so severe the IUD must be removed. Between 5 and 15 percent of women have their IUD removed during the first year because of excessive bleeding or spotting.
Heavier-than-normal periods may cause iron deficiency anemia and the need for iron supplements. If you normally have painful or heavy periods, you may want to choose the Progestasert or avoid the IUD altogether. The Progestasert can lighten periods and reduce cramps because of the effect of its progesterone on the lining of the uterus.
Cramping and Pain. The most common reaction of the uterus to the presence of the IUD is cramps, very much like strong menstrual cramps, as the uterus tries to expel the device. The cramps can last for a day or two after the insertion and may recur during the first few menstrual periods. Acetaminophen, ibuprofen, and other over-the-counter or prescription painkillers generally can ease this discomfort.
GETTING AN IUD
Have all your questions answered before you have an IUD inserted and be sure it is put in by an experienced professional.
Since careful IUD insertion is the key to safety, you want a health care provider who has been properly trained and has had a lot of experience inserting IUDs. Check carefully to find someone who has such qualifications, because IUDs were not widely used in the U.S. from the late 1970s to the late 1980s, when ParaGard came on the market. Many health care providers may not be familiar with IUD insertion and may not feel comfortable suggesting it. IUDs are inserted by physicians, nurse practitioners, physician assistants, and other health care providers working in private medical offices or family planning centers, state and community health department clinics, or in the gyne-cology department of your hospital. It may be necessary to call a number of such places to find someone experienced in inserting an IUD and providing counseling about it. If sources in your community do not offer this contraceptive, they may be able to refer you to a clinic or health care provider in another community who does.
Before you receive an IUD, you will be asked to read and initial a detailed patient information booklet that outlines the pros and cons of the type of IUD you have chosen. To reduce possible compli cations, especially from STDs, detailed counseling on IUDs has become an important part of this method. Health care professionals now realize that the success of any method is enhanced when the method is appropriate and counseling has been given about its benefits and possible side effects.
A practitioner will take an extensive medical and sexual history from you. You should not ask for this method if you are likely to have more than one sexual partner, if your partner may have other lovers, or if you have had PID. You will also be given a physical exam, including a Pap smear. Tests for pregnancy and for STDs, particularly chlamydia and gonorrhea, may be a routine part of this exam. After the results are available, you will be given an appointment for the insertion.
You can have an IUD inserted almost any time, as long as you have not had unprotected intercourse since your last period. Your practitioner may prefer to insert it during your menstrual period, to be certain you are not pregnant. Furthermore, the IUD is easier to insert then, because your cervix is dilated and lubricated by blood, and you are less likely to be bothered by the spotting that insertion usually causes. On the other hand, there is a slightly greater risk of infection and a slightly greater chance of the IUD being expelled when the procedure is done during menstruation. Inserting the IUD at midcycle—at the time of ovulation—can be just as easy as during your period because the cervix is dilated also at that time.
Most practitioners recommend insertion no sooner than six weeks after the delivery of a baby, to avoid the risk of the IUD being expelled as the uterus slowly returns to normal size. It is also possible to have an IUD inserted immediately after childbirth, right after the placenta has passed, although this seldom is done in the United States. An IUD will not interfere with the production or quality of breast milk. The device also can be inserted immediately or within three weeks after an uncomplicated, first trimester abortion, whether spontaneous or induced.
The Insertion Procedure
Before the IUD is inserted you may be given acetaminophen or ibuprofen, to help ease the cramps that can occur when the IUD is inserted.
During insertion, the vagina is held open with a speculum, the same instrument used for examinations of the cervix. The cervix and vagina are cleansed with antiseptic solution. The cervix is held steady with a grasping instrument, the tenaculum, which may cause discomfort or pain when it is first applied. If you are worried about this, ask your provider to apply a bit of local anesthetic to the cervix. The practitioner then guides a skinny, flexible, measuring rod, called the "sound," through the cervical opening to the top of the uterus, to measure its depth and determine which way and how much the uterus may be slanted. The uterus may cramp while the sound is inserted and withdrawn.
The IUD is prepacked into a slim, plastic tube ready for use. The tube slides into the uterus as close to the top as possible. Then the tube is slowly withdrawn, allowing the arms of the T to unfold within the broadest part of the uterus. The inserter is slipped out of the uterus, leaving the IUD in the uterus and the threads in the vagina, where they are clipped to the right length—long enough so you can feel them but not so long they get in the way of a tampon. They are so fine they're impossible to feel during sex. It is a good idea for you to check the location of the threads before you leave the examining room so you know where they are and what they feel like.
Before you leave, you may want to make an appointment for a followup visit a month or so later, so your provider can check to see if your IUD has stayed in the right position.
The reaction of women to the insertion process varies, ranging from none to slight discomfort to a great deal of pain. Most women find the process no more painful than strong menstrual cramps. If you are particularly sensitive to pain, the cervix can be desensitized with a lidocaine injection. Some bleeding may occur after the insertion.
You will not feel the IUD. Neither you nor your partner will be aware of the IUD, because it is in your uterus and not in your vagina. This is a major benefit of this method. You can have intercourse as soon after the insertion as you wish. If you do become aware of the IUD, it may have been partially expelled from the uterus and you need to call your health care provider right away—and use another contraceptive. If your partner can feel the threads, they can be shortened by your practitioner.
Check the strings. The first few months after you have received your IUD is the peak time for it to be expelled. While you are still on the examining table, ask your practitioner to teach you how to check for the threads. If you are familiar with their length, you will notice if that length changes. During the first weeks, check the threads once or twice a week, especially right after your period. If at any time they seem longer or you cannot feel them at all, or if you can feel the IUD itself in your cervix or vagina, call your practitioner immediately. And, if you have sex, use your backup birth control. Aerobics, jogging, or other vigorous physical activities will not dislodge an IUD. The contractions of your uterus during menstruation are the likeliest cause of your IUD being expelled, and the chance of this happening will decrease as time passes.
Be aware of the possibility of infection. Do not forget that if you develop the symptoms of infection mentioned earlier, you should contact your health care provider immediately.
Watch for your menstrual periods. If the IUD has been expelled or has perforated your uterus, it will not provide protection against pregnancy. If your menstrual period does not arrive at all, or if it is late and then is very light, contact your practitioner to check on the possibility of pregnancy.
Heavier periods are common. With the ParaGard, you are likely to have more bleeding, cramps that are more severe, an increase in mucus discharge, and spotting between periods. These disturbances are not unusual with an IUD and they begin to subside after a few months as your uterus gets used to the IUD. If you are anemic, however, those heavier periods could exacerbate the anemia. Discuss this with your health care provider before deciding on this method. If you choose the ParaGard and your periods remain heavy for more than several months, you may wish to switch to a Progestasert.
If you change partners. If you change sex partners or your partner stops being monogamous, start using a barrier method of contraception such as the female condom, diaphragm, cervical cap, or male condom. If your new relationship becomes lasting and mutually monogamous, and you both test free of STDs and HIV infection, you may be able to give up condoms and rely on your IUD for pregnancy protection. Discuss this change with your health care provider, and remember that an STD or HIV may not produce any symptoms.
Tampons and douching. You can wear a tampon without concern while you have an IUD. The IUD is in your uterus, out of reach of any tampon or anything else you put in your vagina. Although douching liquids usually stay in the vagina, douching is not a recommended practice today. It may wash bacteria or sperm up into the uterus.
Additional contraception. The IUD is effective as soon as it is in place. As with any birth control method, however, it is always wise to keep another type of contraceptive on hand in case of emergencies. If the IUD string changes in length or you have another reason to suspect that it is no longer in the right place, start using your backup method right away and call your health care provider.
Have your IUD checked by your health care provider at least once a year.
If you miss a period or have other signs of pregnancy such as tender breasts, call your practitioner right away. If you are pregnant, your IUD should be removed immediately.
You will notice how frequently we stress that you contact your health care provider as soon as you have any negative reaction to your IUD. There is a reason for this. A review of the problems associated with IUDs during the 1970s reveals that early treatment would have prevented many serious complications. Many women who experienced discomfort believed it was typical of the IUD and did not tell their physicians. As a result, many infections and other complications were not treated and the consequences for some were serious.
The removal process is much simpler than the insertion. The best time to have an IUD removed is during a menstrual period or during the midcycle days, when the cervix is dilated. In an uncomplicated removal, the practitioner pulls steadily on the threads and slowly draws the IUD from the uterus.
In the uncommon instances when this technique does not work, the cervix may need to be dilated to ease the removal. An anesthetic can be injected into the cervix to reduce pain. If you have worn your IUD for several years, it may be embedded securely in the uterus, or your cervical canal may have narrowed, making the device more difficult and more painful to remove. If the string has worked its way up into the cervix, a long, narrow forceps can be used to get it. A forceps or other slender instrument (IUD hook) can be used to find and withdraw either the threads or the IUD.
NOTE: Do not try to remove the IUD yourself or even attempt to tug on the string—if you pull at the wrong angle, you can cut or otherwise injure your cervix.
The average cost of having an IUD inserted ranges from $300 to $700 or more, a cost that should include the device itself, counseling, a physical exam, the necessary tests, and the insertion. Followup visits may be extra. The cost of IUD removal is usually the same as a routine office visit—between $40 and $100. Some Planned Parenthood and other nonprofit family planning clinics make contraceptives like the IUD available on a sliding scale based on their client's income. Some clinics accept Medicaid payments for both insertion and removal.
Since prices for contraceptive services can vary widely even in the same city or state, it is worthwhile to shop around by telephone to find both a good price and an experienced practitioner.
Although the cost of an IUD insertion may seem high, with the ParaGard this one-time expense provides 10 years of contraception. For example, over 10 years a $500 IUD insertion averages out to a yearly cost of $50, much less than the typical annual expense of the Pill, condoms, or spermicide products. Consequently, the copper IUD is one of the least expensive methods of birth control for those who use it for many years.
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