IUCD - A Forgotten Contraception Method
Frederick R. Jelovsek MD
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 IUCDs and reminds us that it is a very appropriate contraceptive for many women.
I have heard that IUCDs 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Because of the infection history of the Dalkon Shield, most IUCDs were withdrawn in the U.S. by their manufacturers even though their specific IUCD was not the cause of excessive infection.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 IUCDs.
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 IUCDs cause early abortions as their mechanism of providing contraception?
A popular idea about IUCDs 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.
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