Series B, Number 7
Intrauterine Devices

CONTENTS

Home (Key Points)

The IUD: An Important Method with Potential
Table 1. Overview of IUDs
Figure 1. Most IUD Users Are in China
Web Table 1. Current Use of Contraceptive Methods Reported by Married Women 15-49, 1976-2005
Table 2. Estimated Worldwide Use of IUDs Among Married Women Ages 15–49, 2005

Providing High-Quality IUD Services

Spotlight: Kenya Commits To Renewing Interest in the IUD

Feature: Good Counseling Increases Client Satisfaction

Very Low Overall Risk of Infection with IUDs
Figure 2. Risk of Pelvic Inflammatory Disease (PID) Greatest in First Few Weeks After IUD Insertion

Box: Evidence Shows Many Women with HIV Can Use IUDs

Minimizing the Risk of Infection

Clinical Characteristics of IUDs
Web Box 1. Managing Problems with IUD Use

Bibliography

Credits

Go to the IUD Toolkit at http://www.iudtoolkit.org for full-text resources, including tools and best practices, on IUDs.

• Checklist: Program Plan for Providing High-Quality IUD Services
• Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, from Family Health International
• Counseling Aid for Communicating IUD Effectiveness

• IUD Use, STIs, and HIV-Related Conditions: 2004 WHO Medical Eligibility Criteria
• Do IUDs Increase the Risk of PID in Women with STIs?

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The IUD: An Important Method with Potential

• Outdated Safety Concerns and Current Programmatic Challenges Have Held Back Use
• Current Supply of IUDs

The intrauterine device (IUD), a flexible frame that fits inside a woman's uterus, provides very effective, safe, and long-term—yet quickly reversible—protection from pregnancy. IUDs can be one of the most cost-effective contraceptive methods because modern IUDs can be used for many years-up to 10 years and possibly more for the copper-bearing TCu-380A IUD, and up to 5 years for the copper-bearing Multiload-375 or the hormonal levonorgestrel-releasing IUD (LNG-IUD) (See Table 1). Many women find the IUD to be very convenient because it requires little action once it is in place.

Because it is a long-term, reversible method, the IUD could meet the needs of many women—both those who want to end childbearing altogether and those who want to postpone childbearing for some years. More than 100 million sexually active women in developing countries have an unmet need for family planning (191). That is, they do not want more children or they want to postpone their next pregnancy by at least two years, and yet they are not using contraception. Many of these women might find a long-term contraceptive method convenient.

Table 1. Overview of IUDs
Characteristics of the copper-bearing TCu-380A IUD and the hormonal levonorgestrel-releasing IUD (LNG-IUD)
TCu-380A				LNG-IUD
EFFECTIVENESS • Very effective – 3 to 8 women per 1,000 become pregnant in the first year of use (214, 216, 249)				• Even more effective – 1 to 3 women per 1,000 become pregnant in the first year of use (125, 214)
DURATION OF USE • Up to 10 years and may be extended to 12 years (49, 249)	• Up to 5 years and may be effective for longer (29, 267)
POSSIBLE SIDE EFFECTS • Increases menstrual bleeding (244)	• Decreases menstrual bleeding with continued use and may cause lack of bleeding altogether (7, 38, 69, 127, 161, 235) • Some other hormonal side effects, such as bloating, acne, and breast tenderness
THERAPEUTIC USES • None	• Increases blood iron levels over time (6, 188, 218, 219); helps avoid anemia (56) • Treating prolonged or excessive menstrual bleeding (6, 33, 98, 237) • As the progestin component of hormone replacement therapy, in place of oral progestins, to avoid bleeding caused by oral progestins (175, 234, 260)
PROGRAM CONSIDERATIONS • Cost effective because one IUD can be used for a long time • Requires specially trained providers	• More costly than the TCu-380A but still cost effective • Requires training providers in new insertion technique

In addition, many women become pregnant unintentionally due to contraceptive failure, often a result of users' incorrect or inconsistent use of contraceptives. Because IUDs are highly effective, their wider use would reduce the overall number of unintended pregnancies more than would wider use of most other methods. For example, in 19 countries with Demographic and Health Surveys, a median of 15% of unintended pregnancies resulted from contraceptive failure (31). Among IUD users, however, contraceptive failure is rare. In these 19 countries, 2% of IUD users who did not stop using the IUD for other reasons became pregnant by the end of the first year of use (due to method failure), compared with 7% of pill users, 10% of condom users, and 20% of periodic abstinence or withdrawal users. The IUD is very effective—more than many other methods—both because its contraceptive effect makes it less likely to fail than other reversible methods and because it requires little action from the user (31, 245).

Despite these advantages, IUDs are widely used only in a few large countries, such as China, Egypt, and Vietnam, and little used in most countries (see Figure 1). Due to these few large countries, however, almost 153 million married women of reproductive age worldwide, or 13% of all such women, use IUDs (see Table 2). Among married users of family planning, about one in every five relies on the IUD—a rate second only to that of female sterilization (169, 248).

As family planning programs become aware of the potential of the IUD, more and more countries are taking action to create or renew interest in the method, among both clients and providers, by addressing barriers to greater IUD use (see below). These countries include Bangladesh, Ethiopia, Ghana, Guatemala, Honduras, Kenya, Mali, Nepal, Nigeria, Tanzania, and Uganda (66, 71, 99, 186, 187, 220). In these countries levels of IUD use among married women ranged from 0% to 10% in the latest surveys, conducted between 1999 and 2003. (See Web Table for country data on use of contraceptive methods by married women.)

Outdated Safety Concerns and Current Programmatic Challenges Have Held Back Use

Misperceptions about the safety of the IUD help explain low rates of use in many countries. Concerns first arose in the 1970s, when one particular all-plastic IUD, the Dalkon Shield, was linked to septic (infected) miscarriages and pelvic inflammatory disease (PID) (infection ascending from the cervix into the uterus, fallopian tubes, and ovaries, which can lead to infertility) (213, 239). Unlike other IUDs, which have a single string of solid plastic, the strings of the Dalkon Shield were made of many fibers wound together and enclosed in a plastic sheath. Some researchers think that these multifilament strings helped bacteria to move from the vagina into the uterus, causing PID (213, 239, 240). The Dalkon Shield was available in the U.S. from January 1971 to June 1974 (236). Sales outside the U.S. stopped in April 1975 (298). After the Dalkon Shield controversy, most manufacturers took their IUDs off the market. Even now only 2% of married women in North America use IUDs (see Table 2).

Table 2. Estimated Worldwide Use of IUDs Among Married Womena Ages 15-49, 2005
	% Using
Region & Country	Any Method	IUDs	% of Contraceptors Using IUDs
DEVELOPING AREAS	57	14	24
Sub-Saharan Africa	19	1	3
Near East & North Africa	52	14	29
Asia	63	16	26
China	84	36	43
Other Asian	50	4	9
Latin America & Caribbean	69	8	12
Pacific (Oceania)	28	1	2
All developing areas except China	48	5	11
DEVELOPED AREAS	69	13	19
Europe	73	9	13
Eastern Europe/ Central Asia	63	26	42
North America	75	2	3
Other developed b	59	3	5
WORLD	59	13	23
World, except China	52	7	13
a Most countries in Asia and the Near East and North Africa do not survey unmarried women about their contraceptive practices. To facilitate cross-national comparisons, data reported are only for married women of reproductive age. b Includes Australia, Israel, Japan, and New Zealand. Methodology and data sources: Data for the number of married women ages 15-49 for each country were obtained from population projections for 2005 by the World Bank (261). Percentages are weighted by population size and use the most recent data from the Demographic and Health Surveys and Reproductive Health Surveys and, for countries without these surveys, data from the United Nations, 2004 (248), the U.S. Census Bureau's International Database (253), and other nationally representative surveys.

Early research linking other types of IUDs to PID and infertility further damaged the reputation of IUDs. Most research since 1980, however, finds that serious complications such as PID are rare with modern IUDs (see 'Very Low Overall Risk of Infection with IUDs'). Early studies suffered from several biases that led them to overstate the risks. For example, most early studies compared IUD users with users of contraceptive methods that protect against PID, such as oral contraceptive pills and barrier methods (244). Still, a recent meta-analysis of 36 observational studies published between 1974 and 1990 concluded that users of IUDs other than the Dalkon Shield were about twice as likely as women not using contraception to develop PID (288). Analysis of data from 13 World Health Organization (WHO) clinical trials found the greater risk of PID among IUD users is concentrated in the first 20 days after insertion, suggesting that the risk is associated with the presence of a sexually transmitted infection (STI) at the time of insertion (see 'Very Low Overall Risk of Infection with IUDs').

Studies in El Salvador, Ghana, Guatemala, Kenya, Morocco, and elsewhere reveal that programmatic challenges also have hindered IUD use (20, 26, 64, 84, 101, 108, 231). These challenges include the need for more infrastructure, supplies, and equipment to provide IUD services than for many other reversible methods and a shortage of trained and motivated professionals who are confident of their skills to insert and remove IUDs. A further problem has been inappropriate policies or providers' practices that hinder clients' access to IUDs, such as the misconception that IUDs cannot be used by women who have never had children.

Current Supply of IUDs

The U.S. Agency for International Development (USAID) supplies the TCu-380A to developing-country programs. The two other major donors of contraceptives, the United Nations Population Fund (UNFPA) and the International Planned Parenthood Federation (IPPF), provide both the TCu-380A and the Multiload-375. In 2000 USAID provided about 1.6 million IUDs to family planning programs, and in 2004, nearly 2 million (179). The large majority of the IUDs were provided to one country—Egypt.

The hormonal LNG-IUD, marketed under the brand names Mirena® and, in some European countries, Levonova®, is currently registered in 104 countries worldwide (195). It has been sold in Europe since 1990. The U.S. Food and Drug Administration (FDA) approved it in December 2000 (28, 168). FDA approval would allow USAID to supply the LNG-IUD to developing countries. Its high cost and the need to train providers in a new insertion technique have discouraged USAID from distributing it, however (199, 201). Patent rights for the Mirena LNG-IUD expired in December 2003 (174). This could open up the market for less expensive, generic versions of the LNG-IUD.