Many women of reproductive age are at risk for unintended pregnancy. When you couple that with the lack of a perfectly ideal, reversible contraceptive, dilemmas are created for women who have certain risk factors or concerns about possible complications. The IUCD, intrauterine contraceptive device, is only used by about 1% of the population in the U.S. because of women's concerns about possible increased infections of the genital tract. Internationally, the IUCD is one of the most common forms of contraception. In most instances it has been shown that infection rates are not increased with long term use and there are definite benefits to using a contraceptive that does not have unwanted hormonal effects. Thus the IUCD has been given a bad but undeserved reputation and it is really worth looking at as a method of contraception for many women.
A recent clinical opinion paper, Dardano, KL, Burkman RT: The intrauterine contraceptive device: An often-forgotten and maligned method of contraception.Am J Obstet Gynecol 1999;181:1-5,outlines the pros and cons of IUCD's and reminds us that it is a very appropriate contraceptive for many women.
I have heard that IUCD's cause infection. Is that true?
In the 1970's, one specific IUCD, the Dalkon Shield, was shown to have a design flaw of a braided string which allowed vaginal bacteria to be harbored in the crevices of the string and sometimes cause an infection that went into the upper genital tract. Later studies in the 1980s showed that the risk of infection was limited to two situations:
- Right at the time of insertion of the IUCD into the uterus
- In women who have multiple sexual partners who themselves may carry sexually transmitted bacteria
Subsequent research has shown that if antibiotics are given at the time of IUCD insertion, there is no increased infection rate if, additionally, a woman is not exposed to multiple different sex partners.
Because of the infection history of the Dalkon Shield, most IUCD's were withdrawn in the U.S. by their manufacturers even though their specific IUCD was not the cause of excessive infection. Only two types remain in much use in the U.S,: the copper T IUD (Paragard®) and the progesterone-releasing IUCD (Mirena®). The copper T IUD is approved for 10 years of use and the progesterone-releasing IUCD is approved for five years. Several studies using the copper IUD demonstrate an infection rate approximately 1 per 1000 insertions. This rate is felt to be acceptable in view of the fact of the high pregnancy protection rate and low long term cost for IUCD's
How effective is the IUCD in preventing pregnancy?
The total cumulative pregnancy rate of the copper T IUD by 7 years of use is 1.6 pregnancies per 100 women or 0.16 pregnancies per 100 women years. The progesterone-releasing IUD has a similar pregnancy rate at about .1-.2/100 women years. The IUCD (copper T) also reduces ectopic pregnancies by ten fold to 0.05 annually per 100 women. The only downside on the pregnancy rates is that there is about an 8% incidence of expulsion of the IUCD right after it is first inserted. Thus the low pregnancy rates are based only on the IUDs that stay in place. Also, over 7 years, 30% of the IUDs are removed because of increased cramps or bleeding problems.
Do IUCD's cause early abortions as their mechanism of providing contraception?
A popular idea about IUCD's that has limited their acceptance by many women is that the way in which they prevent pregnancies is by acting as an abortifacient. That is, they prevent fertilized eggs from implanting in the endometrial lining. More recent studies, however, suggest that the copper IUD prevents fertilization of the egg. It somehow blocks the sperm from getting to the faloppian tube and those that do are damaged and thought not capable of fertilization. Also supporting the concept of not being an abortifacient is that super sensitive pregnancy tests show that women without any contraception have much higher rates of slightly positive HCG levels and do not end up being clinically pregnant. Women with IUDs have very low rates of low level positive pregnancy tests. No one could ever say for certainty that IUDs do not cause early abortion but the best evidence suggests that is not the primary mechanism by which they work.
Which women are the best candidates to use an IUCD as a contraceptive?
Women who are not at increased risk of genital tract infection are the best candidates for IUD insertion. This usually means women in a monogamous relationship who have not previously had pelvic inflammatory disease or any chronic diseases such as leukemia, acquired immunodeficiency syndrome or any other immune compromising disease.
Women with certain medical problems that contraindicate other forms of contraception are actually ideal candidates for IUDs. A history of venous thromboembolism (blood clots), severe blood lipid problems, liver disease, estrogen dependent tumors, poorly controlled hypertension, and even smokers over age 35 would be well advised to strongly consider the IUCD as a form of contraception. This is also true for women without infectious risk factors who want a non hormonal method that does not require constant decisions and preventative actions with each episode of intercourse.
The Mirena® levonorgestrol releasing IUCD has also been shown to be effective for women with heavy menses. The progestin decreases the amount of menstrual flow in about 70% of women. In fact about 30% will almost completely stop menses. It is an alternative to hysterectomy for women with menorrhagia (heavy menstrual flow).
What are the contraindications to using an IUCD?
The only absolute contraindications to having an IUCD inserted would include current or recent pelvic infection, unexplained abnormal uterine bleeding and possible current pregnancy. Diabetes, valvular heart disease and even bleeding disorders are not contraindications. Relative contraindications would include heavy menstrual bleeding, moderate to severe menstrual cramps or unexplained pelvic pain. Even not having had a previous pregnancy is not a contraindication although a woman who has not had children and has moderate or worse menstrual cramps would be better off to consider another form of contraception first.
The letters IUCD stand for Intrauterine Contraceptive Device. This means it is placed inside a woman’s uterus (womb). It is also known as the IUD, loop or coil, but these terms are now inaccurate and are no longer widely used. IUCD's are made of plastic with a coating of thin copper wire. Different IUCD's suit different women; the doctor will choose the best one after learning the woman’s medical history and examining her.
Who is it suitable for?
Many women like the IUCD because it does not interrupt intercourse. It works as soon as it is in place. The method is most suitable for women who have had children and for older women who may be advised to stop the pill.
IUCD users may be more likely to get an infection in the womb and fallopian tubes. This is sometimes called salpingitis or PID (pelvic inflammatory disease). Infection is most common in young IUCD users who may have new sexual partners, or whose partner has more than one sexual partner. For this reason it is not a first choice method for young women.
How does it work?
The IUCD is thought to work in several different ways, and through a combination of factors. Its main action is to stop sperm reaching the egg to fertilise it. It may also delay the egg coming down the fallopian tube, as well as preventing the egg settling in the womb.
When and how is it fitted?
- The IUCD must be fitted and removed by a specially trained doctor. It is fitted during your period to make sure you are not pregnant. It also may be easier to fit during a period as the cervix is a little softer at this time. IUCD's are fitted at special sessions in the clinic. Please phone for an appointment.
- If you have just had a baby, an IUCD is usually fitted about 6-8 weeks after the birth. You will need to use another contraceptive method until then.
- The fitting of the IUCD can cause some discomfort. Some discomfort may be felt for a few hours afterwards, which may feel like period pain. You may get some bleeding afterwards.
How will I know if it’s still in place?
You can check to see if your IUCD is still in place by putting your finger in the vagina so that you can feel the threads coming through the cervix. The best time to do this is regularly in the first month and then after each period.
If you cannot feel the threads, or if you feel a hard end rather like a matchstick, you should see your doctor straightaway. If your partner says he can feel the threads and it is uncomfortable during intercourse you should have them checked. They may need trimming, or the IUCD may be coming out. You can use tampons as usual.
Check-ups
It is important that you have a checkup regularly with the doctor – within 6-12 weeks of fitting and then at least once a year. IUCD's are usually replaced every 5 or more years depending on which type is fitted. It’s important to know what sort you have. Then you’ll know when to have it changed.
When else should I see my doctor?
You should talk to your doctor if you have any problems, worries or points that you wish to discuss. Make sure to seek an appointment if:
- You think the device has come out.
- You have pain with intercourse or abdominal pain.
- You have unusual vaginal discharge and fever.
- Your period is more than l4 days Late.
Are there any problems?
It is important that you are aware of possible problems with your IUCD.
- IUCD's may cause heavier or longer periods in some women, especially in the first few months. May be slight bleeding between the first few periods. This should settle down.
- The womb can push the IUCD out (expulsion). This is most likely soon after insertion and you may not know it has happened, so the use of an additional method of contraception until your check-up is advised.
- If you get pregnant with an IUCD in place, there is a possibility of this being an ectopic pregnancy. This is when a fertilized egg settles outside the womb, usually in a fallopian tube, and starts to grow. This is rare but serious. Consult your doctor straight away if you have any sudden lower abdominal pain, as well as a light or delayed period.
- The warning signs of pelvic infection are pain during or after intercourse, pain in your lower abdomen or unusual vaginal discharge, especially if you have a fever. Infection can be easily treated, but if left it can be serious. See your doctor.
- The IUCD is usually removed, if possible, if you become pregnant while using it. This reduces the risk of miscarriage though that may still happen.
- Rarely when the IUCD is fitted it might perforate the womb tissue or cervix. The IUCD may then have to be removed surgically.
Removal of your IUCD
- If you want to become pregnant, ask your Doctor to remove the IUCD (you must never try to remove it yourself).
- If you do not want to become pregnant, but want your IUCD removed, it is best done during a period and you should immediately start using another method of contraception.
A final word
This leaflet can only outline basic information about the IUCD based on evidence available and current medical opinion at the time of publication. You may come across conflicting advice on certain points concerned with the use of an IUCD. If in doubt, seek your doctor’s advice in your individual case.
The above articles were adapted from the following web sites:
http://www.wdxcyber.com/ncontr07.htm
http://www.ifpa.ie/contraception/iucd.html
