FHI - Intrauterine Devices

Modern intrauterine devices (IUDs) are safe and extremely effective.
- Efficacy rates for IUDs are comparable to female sterilization. The Copper-T 380A IUD (TCu-380A), the most effective copper-containing IUD, has a cumulative pregnancy rate of 0.3 percent and 0.6 percent at three years and nine years, respectively. The U.S. Food and Drug Administration (USFDA) labels IUDs as effective for 10 years; long-term studies have shown that the TCu-380A is effective for up to 12 years. A recent study demonstrated that copper IUDs can even retain their effectiveness up to 20 years. Benefits of the IUD include that fertility returns immediately after removal and no regular action is required by the user.
  - Grimes DA, López LM, Manion C, Schulz KF. Cochrane systematic reviews of IUD trials: lessons learned. Contraception 2007;75(6 Suppl):S55-9. (abstract)
  - Kulier R, Helmerhorst FM, O'Brien P, et al. Copper containing, framed intra-uterine devices for contraception. Cochrane Database Syst Rev 2006;3:CD005347. (abstract)
  - New Attention to the IUD. Population Reports, Series B number 7, February 2006. (full text [PDF, 131 KB])
  - Sivin I. Utility and drawbacks of continuous use of a copper T IUD for 20 years. Contraception 2007;75(6 S):S70-5. (abstract)
  - Skjeldestad FE. The impact of intrauterine devices on subsequent fertility. Current Opinion in Obstetrics and Gynecology 2008:20(3):275-80. (abstract)
  - Thonneau PF, Almont T. Contraceptive efficacy of intrauterine devices. Am J Obstet Gynecol 2008;198(3):248-53. (abstract)
  - Trussell J. Contraceptive efficacy. Hatcher RA, Trussell J, Nelson AL, et al. In: Contraceptive Technology. 19th rev. ed. New York: Ardent Media, 2007. (abstract)
  - United States Food and Drug Administration. Intrauterine contraceptive devices; professional and patient labeling. Regulation No. 884.5360. Rockville, MD: FDA, 2005.
  - United Nations Development Programme, United Nations Population Fund, World Health Organization, et al. Long-term reversible contraception: Twelve years of experience with the TCu380A and TCu220C. Contraception 1997;56:341-352. (abstract)
- The IUD does not increase the risk of infertility. The presence of STIs at the time of IUD insertion is the main risk factor for pelvic inflammatory disease (PID) and possible subsequent infertility. The IUD itself is thought to contribute very little to this risk. Even in settings with high STI prevalence (10 percent), the PID risk that is attributable to IUD insertion is estimated to be less than 0.15 percent. Any risk of PID after IUD insertion decreases over time. Twenty days after an IUD has been inserted, the IUD user is no more likely to develop PID than a nonuser. Initiating use of the IUD is usually not recommended for women with an increased individual risk of STIs, although a recent study has shown that providers can identify appropriate IUD candidates in areas of high STI prevalence by asking a set of targeted questions.
  - Aradhya KW. Providing intrauterine devices to women at risk of sexually transmitted infections. Mera 2007;29:iii-iv. (full text)
  - Farley TM, Rosenberg MJ, Rowe PJ, et al. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet 1992;339(8796):785-8. (abstract)
  - Grimes D. Intrauterine device and upper-genital-tract infection. Lancet 2000;356(9234):1013-19. (abstract)
  - Hubacher D, Lara-Ricalde R, Taylor D, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345(8):561-67. (abstract)
  - Morrison CS, Murphy L, Kwok C, et al. Identifying appropriate IUD candidates in areas with high prevalence of sexually transmitted infections. Contraception 2007;75(3):185-92. (abstract)
  - Shelton JD. Risk of clinical pelvic inflammatory disease attributable to an intrauterine device. Lancet 2001;357(9254):443. (abstract)
  - Sivin I, Webb A, Stedman Y. The IUD and recovery of fertility. Fam Plann Perspect 2001;33(5):234. (full text)
  - Skjeldestad FE. The impact of intrauterine devices on subsequent fertility. Curr Opin Obstet Gynecol 2008;20(3):275-280. (abstract)
  - Stanback J, Shelton JD. Pelvic inflammatory disease attributable to the IUD: modeling risk in West Africa. Contraception 2008;77(4):227-9. (abstract)
  - World Health Organization. Medical eligibility criteria for contraceptive use. Geneva: WHO, 2004. (full text)
- Intrauterine devices can be safely provided to nulliparous women and young women (under age 20). Use of an IUD does not increase risk of tubal infertility among nulliparous women. Regardless of whether a woman has had a child, the IUD is among the safest methods of contraception, especially if a woman is free of STIs when the IUD is inserted.
  - American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 392, December 2007. Intrauterine device and adolescents. Obstet Gynecol 2007;110(6):1493-5. (abstract)
  - Brockmeyer A, Kishen M, Webb A. Experience of IUD/IUS insertions and clinical performance in nulliparous women-a pilot study. Eur J Contracept Reprod Health Care 2008;13(3):248-54. (abstract)
  - Gold MA, Johnson LM. Intrauterine devices and adolescents. Curr Opin Obstet Gynecol 2008;20(5):464-9. (abstract)
  - Haydon A, Olawo A. A new look at IUDs. Health Work Matter 2005;1(2):3.
  - Hubacher D. Copper intrauterine device use by nulliparous women: Review of side effects. Contraception 2007;75:S8-S11. (abstract)
  - Hubacher D, Lara-Ricalde R, Taylor D, et al. Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women. N Engl J Med 2001;345(8):561-67. (abstract)
  - World Health Organization. Medical eligibility criteria for contraceptive use. Geneva: WHO, 2004. (full text)
- Recent research shows that IUDs are safe and effective for use by women infected with HIV. Women with AIDS who are on ART and seem to be doing clinically well on these drugs may initiate use of IUDs. Women who have developed AIDS and are not on ART or do improve while on ART generally should not initiate IUD use unless another method is not available or acceptable. However, if an HIV-positive woman chooses to have an IUD inserted and later develops AIDS, the IUD need not be removed.
  - Morrison CS, Sekadde-Kigondu C, Sinei SK, et al. Is the intrauterine device appropriate contraception for HIV-1 infected women? Br J Obstet Gynaecol 2001;108(8):784-90. (abstract)
  - Sinei S, Morrison C, Sekadde-Kigondu C, et al. Complications of use of IUDs among HIV-1 infected women. Lancet 1998;351(9111):1238-41. (abstract)
  - Stringer EM, Kaseba C, Levy J, et al. A randomized trial of the intrauterine contraceptive device vs. hormonal contraception in women who are infected with the human immunodeficiency virus. Am J Ob Gyn August 2007;197(2):144:e2-e8. (full text [PDF, 1.91 MB])
  - Browne H, Manipalviratn S, Armstrong A. Using an intrauterine device in immunocompromised women. Obstet Gynecol 2008;112:667-9. (abstract)
  - World Health Organization. Medical eligibility criteria for contraceptive use. Geneva: WHO, 2004. (full text)
- Use of an IUD does not increase the risk of HIV infection. Women using an IUD are not at any higher risk of HIV infection than women using other nonbarrier methods. Also, there is no evidence of increased cervical shedding among HIV-positive women using an IUD; thus, a sero-negative male partner does not have a higher risk of HIV acquisition from sexual contact.
  - Cates W Jr. Review of non-hormonal contraception (condoms, intrauterine devices, nonoxynol-9 and combos) on HIV acquisition. J Acquir Immune Defic Syndr 2005;38(Suppl 1):S8-10. (full text)
  - Richardson B, Morrison C, Sekadde-Kigondu C, et al. Effect of intrauterine device use on cervical shedding of HIV-1 DNA. AIDS 1999;13(15):2091-97. (full text)
- Family Health International has devised a simple checklist that service providers can use to determine whether clients are medically eligible to use an IUD.
  - Wesson J, Gmach R, Gazi R, et al. Provider views on the acceptability of an IUD checklist screening tool. Contraception 2006;74(5):382-8. (full text)
An IUD can be inserted during the postpartum or postabortion period; in the first 12 days of the menstrual cycle; or at any other time in the menstrual cycle, as long as a provider is reasonably sure that the client is not pregnant. An IUD can be inserted any time within 48 hours after birth (the provider must have special training); after 48 hours, it is recommended that insertion be delayed for four weeks after delivery.
- Expulsion rates are higher among nulliparous women using copper IUDs than among parous women and with immediate postpartum insertions than with interval insertions.
  - Eroglu K, Akkuzu G, Vural G, et al. Comparison of efficacy and complications of IUD insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up. Contraception 2006;74(5):376-81. (abstract)
  - Grimes D, Schulz K, van Vliet H, et al. Immediate post-partum insertion of intrauterine devices. Cochrane Database of Systematic Reviews 2003;(1):[12] p. (abstract)
  - Hubacher D. Copper intrauterine device use by nulliparous women: review of side effects. Contraception 2007;75:S8-S11. (abstract)
  - Letti Muller AL, Lópes Ramos JG, Martins-Costa SH, et al. Transvaginal ultrasonographic assessment of the expulsion rate of intrauterine devices inserted in the immediate postpartum period: A pilot study. Contraception 2005;72(3):192-95. (full text)
- Providing antibiotics before IUD insertion does not necessarily reduce the risk of PID. However, in populations with a high prevalence of STIs, prophylactic administration of antibiotics may reduce the incidence of PID.
  - Grimes D, Schulz K. Antibiotic prophylaxis for intrauterine contraceptive device insertion. In The Cochrane Library, Issue 2. Oxford, UK: Update Software, 2003. (abstract)
  - Grimes D, Schulz K. Prophylactic antibiotics for intrauterine device insertion: a meta-analysis of the randomized controlled trials. Contraception 1999;60(2):57-63. (abstract)
  - Walsh T, Grimes D, Frezieres R, et al. Randomized controlled trial of prophylactic antibiotics before insertion of intrauterine devices. Lancet 1998;351(9108):1005-8. (abstract)
- Even among first-time users, pain from IUD insertion is generally low; prophylactic ibuprofen does not appear to affect level of pain. For users who experience IUD-induced side effects such as increased menstrual blood loss and pain, non-steroidal anti-inflammatory drugs can make IUD use more comfortable.
  - Grimes DA, Hubacher D, López LM, et al. Non-steroidal anti-inflammatory drugs for heavy bleeding or pain associated with intrauterine-device use. Cochrane Database Syst Rev 2006;CD006034. (abstract)
  - Hubacher D, Reyes V, Lillo S, et al. Pain from copper intrauterine device insertion: randomized trial of prophylactic ibuprofen. Am J Obstet Gynecol 2006;195(5):1272-7. (abstract)
  - Hubacher D, Reyes R, Lillo S, et al. Preventing copper IUD removals due to side-effects among first-time users: randomized trial to study the effect of prophylactic ibuprofen. Human Reproduction 2006;21(6):1467-72. (full text)
Expanding access to postabortion IUD services can help prevent repeat abortions.
Misinformation about the IUD persists in a number of sources, including medical textbooks and Internet Web sites, and many providers hold misconceptions about the IUD. Changing providers' knowledge and practices will require that several strategies be employed over the long term.
The IUD is the most cost-efficient form of reversible contraception when program costs (including materials and staff time) and the length of time each method will protect a woman from pregnancy are taken into account. For clients, IUDs can have a higher start-up cost than other contraceptive methods; however, the method entails substantially lower costs over time.
- Unless a client experiences any complications, only a single follow-up visit three to six weeks after insertion is needed. Additional follow-up visits can be eliminated without a significant decrease in quality of care and with substantial cost savings.
  - Hubacher D, Cárdenas C, Hernández D, et al. The costs and benefits of IUD follow-up visits in the Mexican social security institute. Int Fam Plann Perspect 1999;25(10):21-26. (full text [PDF, 430 KB])
  - Hubacher D, Fortney J. Follow-up visits after IUD insertion. Are more better? J Reprod Med 1999;44(9):801-6. (abstract)
  - Janowitz B, Hubacher D, Petrick T, et al. Should the recommended number of IUD revisits be reduced? Stud Fam Plann 1994;25(6):362-67. (abstract)
  - Neuteboom K, de Kroon C, Dersjant-Roorda M, et al. Follow-up visits after IUD-insertion: sense or nonsense? A technology assessment study to analyze the effectiveness of follow-up visits after IUD insertion. Contraception 2003;68(2):101-4. (abstract)
  - Wesson J, Gmach R, Gazi R, et al. Provider views on the acceptability of an IUD checklist screening tool. Contraception 2006;74(5):382-8. (full text)
While the TCu-380A is the most effective copper-containing IUD, the LNG-IUS (commercially known as the Mirena) is the most effective hormonal IUD. The LNG-IUS, which has a lifespan of five years after insertion, can lead to decreased menstrual bleeding or amenorrhea and can be used to effectively treat menorrhagia. No generic version of the LNG-IUS is currently on the market, so it is typically more expensive than the TCu-380A.

Additional Resources

Topical page: Intrauterine Devices

Brief: Improving Provision of the IUD (PDF, 167 KB)

Case Study: Reintroducing the Intrauterine Device in the Mandiana District of Guinea (PDF, 143 KB)