Population Reports Series B Number 3 May 1979 Reprinted January i980 INTRAUTERINE DEVICES Population Information Program, The Johns Hopkins University, Hampton House, 624 North Broadway, Baltimore, Maryland 21205 , USA IUDs- Update on Safety, Effectiveness, and Research Summary. After nearly two decades of use, the IU D remains " a does the latest permutation of device. With this recognition, generally safe, effective and useful form of birth control " (337). attention is now focusing on specific techniques of insertion, With fewer than si x pregnancies per 100 woman-years of use training of personnel, and conscientious follow-up. The result and fewer than ten deaths per one million woman-years of use, has been improved performance over the years with the first according to a comprehensive new review by the United States generation of IUDs, especially the Lippes Loop, which for the Food and Drug Administration, the IUD has an important place la st decade has been the standard device against which others in modern famil y planning programs. were measured . The number of women using IUDs is growing slowly but stead­ To ensure best results, proper insertion is crucial. The IUD ily. Most extensive use is in the People's Republic of China, must be inserted gently and high into the uterine fundus. New where visitors have been told that half or more of all those measuring devices ma y well facilitate selection and precise using contraception have accepted IUDs. In Korea and placement of the right size of device. For postpartum use, a Taiwan, where successful programs have been underway since longer inserter or even hand insertion may be most effective. the mid-1960s, the IU D is also the principal method. In about a The withdrawal technique of insertion, in which the inserter is dozen other developing countries more than 5 percent of all placed in position, the IUD released, and the inserter then married women of reproductive age use IUDs. In Europe IUD withdrawn from the uterus, results in fewer perforations than use ranges from less than 5 percent in Italy to as high as 20 the original technique of pushing the device out of the inserter. percent in Scandinavian countries. In the USA about 6 percent Many clinicians find the T- and 7-shaped devices easier to of married women of reproductive age have IUDs. Worldwide, insert than the more complex configurations with a larger sur­ approximately 50 to 60 million devices ma y be in use, 40 face area. million or more in China and 15 million in the rest of the world. In the past IUD insertion was often limited to the time during Nevertheless, despite extensive experience and continuing re­ and immediatel y after menstruation or more than eight weeks search in both developed and developing countries, some of after delivery. Now, even though many centers still follow the original problems of IUD use remain unresolved and some these traditional patterns, data show that IUDs can be safely of the promising new solutions remain unproven. The basic inserted at any time (including immediately after abortion) problems of IUD use are : provided the woman is reasonably sure she is not pregnant. • increased menstrual bleeding or spotting Unless there are specific medical contraindications, IUDs can • expulsion soon after insertion be inserted at the convenience of the woman. • increased frequency of pelvic infection • unwanted pregnancies that are more likely to be ectopic or to result in septic mid trimester abortion than pregnan­ CONTENTS cies in nonusers The promising new approaches that could minimize or elimi­ History ... ..... .. ... .. .. .... .... .... ... ..B-51 nate some of these problems include: Di5tribution and U age .. .... ... ..... .. B-52 • medicated devices that are effective up to 10 years Safety and Effect ivene . .. .. .. ... .. ... 0 .B-56 • medicated devices with compounds to reduce bleeding Inse rtion and Removal . .. 0 •• 0 • 0 •• • • 0 • 0 0 • •• 0 0 0 .B-59 • devices designed to reduce expulsion after early postpar­ ExpulSion ... .. 0 • •• •• 0 0 •••• 0 0 • ••• 0 0 •• 0 • 0 0 0 ••• B-62 tum and postabortion insertion Perforati on and Embedding .. 0 ••• ••• • • • 0 • 0 ••• • oB-63 • improved fit of IUD size and configuration to the uterus Bleedmg and Pa in 0· •• • 0 0 0 • ••• 0 0 ••••• • •• 0 •• • • • B-64 • better insertion techniques and instrumentation Infection ...... ... .. 0 0 • • • • 0 0 0 • • •• 0 0 ••• • •• • •• B- 67 Pregnancy . 0 0 0 0 • ••• 0 ••••• ••• •• 0 • • • •• 0 • 0 •• •• oB-69 Experience with the IUD throughout the world has dem­ Guidelines for Use of IUDs .. 00 0 • •• 0 .0 00 •• • ••B-74 onstrated that within certain limits clinical and individual fac­ Evaluation and Research 0 • • • 0.00 ••• 0 0 • •• • • 0 •• • B-77 tors may have more impact on continuing IUD use than the IUD Ph otograph and Information . ..... 00 0 ••• • B-86 design of the device itself. The ski II of the health personnel, Bibliography . .. ....... 0 0 • ••• 0 0 0 •• • 0 • 0 0 ••• • • B-94 whether physician, midwife, or other au xiliary, and the care and follow-up provided may produce more satisfied users than Volume VII , Number 3 In adc tion to commercially available devic , other med i­ cated JDs are being used on an experimental basis. ThE" -e This issue of Population Reports was prepared by Phyllis includ the Population Council's copper devin 's with 220 or T. Piotrow, Ph.D. , Ward Rinehart, and John C. Schmidt of 380 s mm of copper surface area. They ntain copper the Population Information Program on the basis of pub­ sleeve on the transverse bars of the T, wh re the opr:er lished and unpublished materials, correspondence, and reach( the uterine fundus more effectively and lasts longer, as interviews. Comments and additional material are wel­ well a on the vertical arm. Other experimentill device ~ con­ come. tainint antifibrinolytic substances for release int the uterus to The assistance of the following reviewers is appreciated: reduC( bleeding directly are now being tested by the Interr a­ L.P. Chow, Elizabeth B. Connell, Gordon Duncan, David tional erti lity Research Program. The World H · alth Organi7a­ Edelman, Henry Elkins, Henry Gabelnick, A.T. Gregoire, tion's pecial Programme of Research in Human Reprod clion Paul A. Harper, James R. Heiby, John F. Kantner, Theo­ is test Ig a T device designed to release 2 J.I. a day of the dore M. King, Leonard E. Laufe, Daniel R. Mishell, Jr., proge ~ in levonorgestrel for a minimum of fi years with a Dorothy Nortman, Howard Ory, Bruce Pharriss, Allan substa tially reduced menstrual blood loss. Bec.lUse an mia is Rosenfield, Marschal Rothe, Patrick J. Rowe, James D. a seri, us problem for women in developing countrie" any Shelton, Irving Sivin, Robert Snowden, J. Joseph Speidel, modif :ation that could reduce bleeding without causing other Bruce Stadel, William Sweeney, Howard Tatum, Carl probl( ns would be extremely useful. Taylor, Robert Wheeler, Jack Lippes, Dean L. Moyer, One \ riation that is being tested to reduce ex ulsions of e­ and Malcolm Potts. vices Iserted immediately after delivery or ab rtion is to a fl x Population Reports (USPS 063-150) is published short ( '1 romic sutures to the upper horizontal bar of the devi-ce. bimonthly (January, M arch, May, July, September, Th e c romic suture material, which is biodegr dable and d is­ November) at624 North Broadway, Baltimore, Maryland solves Within a few weeks, helps to anchor th device. si n e 21205, USA, by the Population Information Program of the d omic projections make the device larg r at the timE of the Johns Hopkins University and is supported by the inserti n and then temporarily embed in the uterus as fhe United States Agency for International Development. uterus returns to normal size. Second class postage paid at Baltimore, Maryland, and Even 5 solutions are being proposed for bleeding and ex~ 'u l­ additional offices. Postmaster to send address changes to sion r: blems, however, new data suggest that t e risk or infec­ Population Reports, Population Information Program, tion", lich helped to discredit IUDs earlier in the century nlay The Johns Hopkins University, 624 North Broadway, Bal­ still b! significant. Higher rates of both diagnos d infection ~ nd timore, Maryland 21205, USA. asyml omatic inflammation have been found , mong IUD us­ Population Reports is designed to provide an accurate ers, e pecially among young, sexually active women in the and authoritative overview of important developments in devel, ped countries, where pelvic inflammatory disease (PID) the population field. It does not represent official state­ is oft( 1 a sexually transmitted disease. It is p ssible that PID ments of policy by the Johns Hopkins University or the US may I ad to infertility among older women. Moreover, w hen Agency for International Development. pregn ncy occurs with an IUD in situ the ri sk of an ectopic pregn ncy or a septic midterm abortion is igher than in Phyllis T. Piotrow, Ph.D., Director; Helen K. Kolbe, M.S., nonu: ~rs. Roughly estimated, one in 30 pregnancies In IU D Co-Director; Ward Rinehart, Editor. users 3 ectopic compared with one in 250 in large popi la­ tions. leiter protection against uterine than ect opic pre 'na ICY for II D users may explain this difference. Whether ot er mech nisms are also at work is not clear. Th danger of ec­ Good clinical management includes counseling the IUD user, topic oregnancy, especially in developing co u'ntries w~ e re explaining potential problems clearly, and providing sym­ emer .ency surgical care is scarce, and t similarity of pathetic management both'of immediate postinserlion compli­ symp )ms to IUD-related bleeding and pain require health cations and of long-term side effects.