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Your patient says she wants a highly effective, safe, long-term form of birth control. If the ensuing discussion does not include the intrauterine device (IUD), then perhaps it is time to rethink your contraceptive counseling. New research now points to the safety of the IUD and should encourage both providers and patients to take a fresh look at the method.1
According to Philip Darney, MD, MSc, professor at the University of California at San Francisco, and chief of the department of OB/GYN at San Francisco General Hospital Medical Center, the case control study of 1,895 women helps refute the myths that IUDs cause pelvic infection, increase ectopic pregnancy and infertility, and are inappropriate for young or never-pregnant women. Darney authored an accompanying commentary to the published study.2
Concerns regarding pelvic infection and tubal infertility prevent many U.S. clinicians and women from using IUDs, observes Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/Jackson-ville. Because of ongoing concerns regarding the safety of IUDs among clinicians and women, fewer than 1% of U.S. women choose these devices for their birth control method.3 In contrast, 10%-20% of Northern European women use IUDs, states Kaunitz.3
"With the publication of this and other recent reassuring data regarding the safety of IUDs, it is time to re-educate ourselves and our patients regarding this convenient, safe, effective, inexpensive, and underutilized birth control method," says Kaunitz.
Previous IUD studies — many of which examined IUDs no longer in use — suggested that the devices might cause tubal infertility. The recently published case control study, conducted in Mexico where IUDs are widely accepted, assessed prior contraceptive use in women with primary infertility who had undergone hysterosalpingography in 358 cases with documented tubal occlusion and 953 infertile controls who did not have occlusion. In a second analysis, cases were compared with 584 primigravid pregnant controls. Each woman also was tested for antibodies to chlamydia.
Compared with women who had not used hormonal, intrauterine, or barrier contraception, use of a copper IUD was not associated with an increased risk of tubal infertility in the analysis involving infertile controls or primigravid controls, says Kaunitz. Neither duration of IUD use nor the removal of an IUD due to such problems as bleeding or cramping was associated with tubal infertility. The presence of antibodies to chlamydia, however, was associated with infertility, he notes.
The key points from the study are as follows, says lead author David Hubacher, PhD, epidemiologist with Research Triangle Park, NC-based Family Health International:
Myths persist that pelvic and upper genital tract infections are common with intrauterine contraception, according to a recent publication issued by the Washington, DC-based Association of Reproductive Health Professionals.3 These concerns are based, in part, on observational research that found an increased risk of salpingitis or tubal infertility among IUD users.
A 2000 literature review concluded that many previous studies were unreliable because of inappropriate use of comparison groups (such as women using contraceptives that lower the risk of PID), systematic overdiagnosis of salpingitis among IUD users, and inability to control for confounding factors.4
Analysis of data from Geneva-based World Health Organization (WHO) clinical trials indicate that the incidence of PID is very low with appropriate patient selection.5 A 2001 review concludes that fully symptomatic PID attributable to IUD use is quite uncommon, even with high STD prevalence.6
According to A Pocket Guide to Managing Contraception, the recommended patient profile for IUD candidacy includes parous women in stable, mutually monogamous relationships (at low risk for sexually transmitted diseases) with no history of PID.7 However, nulliparous women at low risk for sexually transmitted diseases also might be candidates. Women with a history of PID might be candidates if they are in stable mutually monogamous relationships and have had a pregnancy since the PID episode.7
Women with HIV infection face challenges when selecting appropriate birth control options. Both a WHO expert group and the London-based International Planned Parenthood Federation have made general recommendations against use of the IUD by HIV-positive women based on concerns about pelvic infection and female-to-male HIV transmission.8,9 New research, however, suggests that the IUD may be an appropriate contraceptive method for HIV-1-infected women with ongoing access to medical services.10
Researchers designed a prospective cohort study, examining 649 women (156 HIV-1-infected, 493 noninfected) in Nairobi, Kenya, who requested an IUD for contraceptive use. Information was gathered on complications related to IUD use; including PID; removals due to infection, pain, or bleeding; expulsions; and pregnancies at one, four, and 24 months after insertion.
Low rates of IUD-related complications were reported over the 24-month period by the HIV-positive women, researchers note. The infected women were not at increased risk of overall or infection-related complications when compared with noninfected women, although there was some evidence that they may have a somewhat increased risk of infection-related complications with IUD use longer than five months.
Cervical infection one month after insertion of an IUD was associated with both overall and infection-related complications after adjusting for HIV-infection status; conversely, HIV status was not associated with either endpoint after adjusting for cervical infection. This finding suggests that clinical focus best may be placed on avoiding IUD insertion in women with cervical infections rather than in women with HIV infection, researchers note.
1. Hubacher D, Lara-Ricalde R, Taylor DJ, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001; 345:561-567.
2. Darney PD. Time to pardon the IUD? N Engl J Med 2001; 345:608-610.
3. Grimes DA, Parker Jones K, eds. New Developments in Contraception Featuring the Levonorgestrel Intrauterine System (LNG IUS). Washington, DC: Association of Reproductive Health Professionals; 2001.
4. Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet 2000; 356:1,013-1,019.
5. Skegg DCG. Safety and efficacy of fertility-regulating methods: A decade of research. Bull World Health Organ 1999; 77:713.
6. Shelton JD. Risk of clinical pelvic inflammatory disease attributable to an intrauterine device. Lancet 2001; 357:443.
7. Hatcher RA, Nelson AL, Zieman M, et al. A Pocket Guide to Managing Contraception. Tiger, GA: Bridging the Gap Foundation; 2001.
8. WHO Scientific Working Group on Improving Access to Quality Care in Family Planning. Medical Eligibility Criteria for Initiating and Continuing Use of Contraceptive Methods. Geneva: World Health Organization; 1996.
9. IPPF International Medical Advisory Panel. IMAP statement on HIV infection and AIDS. IPPF Med Bull 1998; 32:1-4.
10. Morrison CS, Sekadde-Kigondu C, Sinei SK, et al. Is the intrauterine device appropriate contraception for HIV-1-infected women? Br J Ob Gynecol 2001; 108:784-790.