An estimated 128 million women worldwide use intrauterine devices (IUDs), more than any other contraceptive method except female sterilization. The most popular IUD in most countries is the Copper T 380A.
The Copper T 380A is safe and highly effective for at least 12 years (approved for 10 years of use in the United States). With an annual pregnancy rate of 0.4 per 100 women,1 the Copper T 380A has a very low failure rate, comparable to the effectiveness of male or female surgical sterilization. Thus, this reversible, long-term form of contraception offers a reliable alternative to sterilization.
IUDs are popular in several Asian and Latin American countries, and many Arab countries. However, IUDs remains underutilized in many other areas, due largely to a lack of accurate information, unfounded fears about safety, or lack of supplies and provider training.
IUD Use by Country
Leading in Number of Users
Leading Use (percentage of women of reproductive age)
Most women can use IUDs. Certain conditions or circumstances influence whether IUD use is appropriate, including the following:2
Women who breastfeed, use antibiotics, have irregular menstrual patterns without heavy bleeding, or smoke can use IUDs without restriction.
Advantages to using the IUD generally outweigh the risks for women who have not given birth and are under age 20, have undergone a second trimester abortion, have severe dysmenorrhea or irregular menstrual patterns with heavy bleeding, have sickle cell disease or have iron deficiency anemia.
A woman who currently has a sexually transmitted disease (STD), or has had an STD or pelvic inflammatory disease in the last three months, should not receive an IUD. An IUD should not be used if a woman has purulent cervicitis, but may be used if she has vaginitis. Harmful bacterial already present in a woman can be introduced into the upper reproductive tract during the insertion process, increasing the risk of pelvic inflammatory disease.
If a woman has cervical cancer and is awaiting treatment, she should not initiate IUD use. (Using an IUD may result in lowered risk for endometrial and cervical cancer.3)
Women with unexplained vaginal bleeding or those who have a uterine cavity disorder should not use an IUD.
Although pregnancies are rare, the IUD should be removed immediately if pregnancy occurs during use.
IUDs may be inserted at any time during the menstrual cycle, as long as the provider is reasonably sure the woman is not pregnant. Even in remote areas, providers can use a simple checklist procedure to determine whether a woman is pregnant, without laboratory tests or waiting until her next menstrual cycle.
Trained clinicians other than physicians can insert IUDs safely. A study in Nigeria, Turkey and Mexico concluded that these clinicians can insert IUDs safely in many settings if they receive appropriate, competency-based training.4
Good insertion technique requires aseptic conditions, and slow and gentle insertion. In rare cases (about one per 1,000 insertions), the insertion process results in perforation of the uterus.5 A sharp pain during insertion could indicate perforation. If this occurs, the provider should terminate the procedure and remove the device.
Providers should tell women that they might experience pain and cramping during the insertion, as well as light bleeding and continued mild cramping for a few days after insertion. Women should be informed that these side effects do not indicate a serious medical problem.
Women should be aware that the IUD could be expelled spontaneously. Risk factors for expulsion are young age, abnormal amount of menstrual flow, and painful menstruation.
Expulsion occurs most frequently during menstruation. A woman should check the string after each menstrual period to be sure the IUD is in place. She should also check if she has cramping in the lower abdomen, spotting between periods, pain after intercourse, or her partner has discomfort during intercourse. If the woman cannot feel the string, if it feels shorter or longer than normal, or if she feels the IUD itself protruding from the cervix, she should seek medical attention.
Pain and bleeding are the leading reasons for removal. An FHI study involving 10,000 women using the Copper T found 5 percent had the device removed because of pain or bleeding.6
While significantly better than earlier IUDs that are no longer widely used, copper-bearing IUDs cause an increase in menstrual bleeding. This usually is not a medical problem. Typically, bleeding declines after several cycles. The LNg intrauterine system, which releases levonorgestrel, reduces the amount of bleeding.
Prolonged and excessive bleeding is rare. Because prolonged and excessive bleeding increases the risk of anemia, women who experience these side effects should use iron tablets. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, may reduce pain and bleeding.
IUDs can be used postpartum. Because IUDs do not affect lactation, they are safe for breastfeeding women.
The main concern with postpartum insertion is expulsion. The risk of expulsion for postpartum insertions is lower if done immediately after birth. The lowest risk of expulsion is for insertions done within 10 minutes of delivery of the placenta, and is reasonably low up to 48 hours postpartum. If insertion cannot be done within 48 hours, guidelines recommend waiting until four weeks postpartum, when the uterus has returned to its pre-pregnancy condition.
IUDs can be safely inserted immediately after a spontaneous or induced abortion except when the uterus is infected or at risk of infection, or when there is hemorrhage or severe injury to the genital tract. However, providers need special training for IUD insertion if the abortion occurs after 16 weeks of pregnancy. If such providers are not available, the insertion should be delayed six weeks for the uterine cavity to return to its typical shape.
A postpartum program in the Dominican Republic involving more than 1,400 women found that coordination among the prenatal, family planning, and labor and delivery services contributed to a good safety and effectiveness record. Prenatal counseling included clinical and STD risk screening.7
To minimize the risk of pelvic inflammatory disease (PID), providers should:
Remove and replace IUDs only when necessary and avoid new insertions by using the longest-acting IUD that is appropriate.
Counsel women receiving IUDs about PID symptoms and urge them to seek medical help if they notice symptoms.
Encourage clients to return for a follow-up visit, typically about one month after insertion, to determine if they are having any problems.
As for all clients, encourage condom use if women with IUDs have sex with potentially infected men.
Also, aseptic techniques are recommended during IUD insertion to prevent the introduction of bacteria or other pathogens into the uterus. For example, instruments that will be reused must be disinfected.
-- William R. Finger and Kim Best
References
United Nations Development Programme, United Nations Population Fund, World Health Organization, World Bank, Special Programme of Research, Development and Research Training in Human Reproduction. Long-term reversible contraception: twelve years of experience with the TCu 380A and TCu 220C. Contraception 1997;56(6):341-52.
World Health Organization. Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Geneva: World Health Organization, 1996.
Endometrial and cervical cancer risk may be lower with IUD use. Contraception Rpt 1998; 9(5):9-10.
Farr G, Rivera R, Amatya R. Non-physician insertion of IUDs: clinical outcomes among TCu 380A insertions in three developing-country clinics. Adv Cont 1998;14(1):45-57.
Sivin I, Greenslade F, Schmidt F, et al. The Copper T 380 Intrauterine Device: A Summary of Scientific Data (New York: The Population Council, 1992)19.
Rivera R, Farr G, Chi I-c. The Copper IUD, Safe and Effective: The International Experience of Family Health International. (Research Triangle Park, NC: Family Health International, 1992)4.
Cordero CF, Barone MA, Calderón V. A postpartum IUD program in the Dominican Republic. Int J Gynecol Obstet 1996;55(2):181-82.
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