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IUD Toolkit

Up-to-date evidence and best practices related to the Intrauterine Device

Brought to you by USAID's Maximizing Access & Quality Initiative

Method Characteristics

Effectiveness

The Copper-T 380A IUD (TCu-380A) is a highly effective form of long-term, reversible contraception, with an associated pregnancy (failure) rate of 0.8 percent in the first year of use (Trussell, 2007). In a long-term international comparative trial sponsored by the World Health Organization (WHO), the average annual failure rate was 0.4 percent or less, and after 12 years of use the cumulative failure rate for women using the TCu-380A IUD was 2.2 percent, which is comparable to that of female sterilization (United Nations Development Programme et al., 1997).

Return to Fertility

After removal of the LNG-IUS, there is no delay in a woman’s return to fertility (Andersson et al., 1992; WHO, 2007; Skjeldestad, 2008).

Lifespan after Insertion of TCu-380A IUD

Long-term studies have shown that the TCu-380A is effective for at least 12 years after insertion (United Nations Development Programme et al., 1997), and some have shown effectiveness for as long as 20 years (Sivin, 2007). However, the US Food and Drug Administration (FDA) labels the TCu-380A as effective for 10 years (United States Food and Drug Administration, 2005). The IUD Toolkit guidance is that it is “effective for at least 12 years,” although some of the documents within the Toolkit may cite the effectiveness of the TCu-380A as 10 years.

Mechanism of Action

Research shows that copper IUDs prevent pregnancy mainly by preventing fertilization. Several studies have shown that IUDs reduce the number of viable sperm that reach the fallopian tubes, where fertilization is supposed to take place. This may be because the sterile foreign body reaction in the uterine cavity causes both cellular and biochemical changes that are toxic to sperm (WHO, 1987). Also, it is hypothesized that copper ions, found throughout the fluids in the uterus and fallopian tubes of IUD users, alter the sensitive environment necessary for fertilization (Alvarez et al., 1988; Croxatto et al., 1994; Ortiz et al., 2007).

Side Effects

Pain/cramping/menstrual irregularities

During insertion, some women may experience discomfort or cramping (Grimes, 2004). Cramps may continue for several days beyond insertion. Cramping, pain, and menstrual irregularities associated with IUD insertion or menstruation usually subside within a few months. Heavy or prolonged bleeding may be treated with nonsteroidal anti-inflammatory drugs such as ibuprofen (World Health Organization, 2004b; Grimes et al., 2006). Thoughtful counseling about side effects and treatment options is critical since menstrual irregularities are the most common medical reason for IUD removal.

Bleeding/anemia

No significant changes in hemoglobin levels, or likelihood of anemia have been noted with copper IUDs (although menstrual blood loss is increased by about 50%.) (Andrade et al., 1987; Milsom et al., 1995; Task Force for Epidemiological Research on Reproductive Health, 1998). Accordingly, copper IUDs can generally be used by women with anemia (World Health Organization, 2004a).

Non-Contraceptive Health Benefits

Non-hormonal IUDs, such as the Copper-T 380A IUD, may protect against endometrial cancer and cervical cancer (Hubacher et al., 2002; Beining et al., 2008; Curtis et al., 2007).

Perforation

Perforation of the uterus during insertion has been shown to be quite rare, with fewer than 1.5 perforations per 1,000 IUD insertions occurring in large clinical trials (Treiman et al., 1995; United Nations Development Programme et al., 1997). The skill and experience of the provider is the most important factor that minimizes the risk of perforation (Harrison-Woolrych et al., 2003).

Expulsion

Expulsion of the IUD is uncommon. The skill and experience of the provider is the most important factor that minimizes the risk of expulsion (Chi, 1993). Cumulative expulsion rates of 2.4, 3.4, and 4.4 percent at one, two, and three years of use, respectively, have been reported among copper IUD users (UNDP et al., 1995). In the first year of use, expulsion rates vary from 2 percent to 8 percent (Treiman et al., 1995). Based on clinical experience, women are usually aware when they have expelled their IUD. Such expulsion is not dangerous for the user; however, the woman is no longer protected against pregnancy.
Although expulsion rates tend to be slightly higher for nulliparous women (compared to parous women) (Hubacher, 2007) and for postpartum insertions (compared with interval insertions) (Grimes et al., 2001), WHO guidance allows IUD use for women with either of these conditions. Women can have an IUD inserted within 48 hours after childbirth (category 1). Nulliparous women can generally have an IUD inserted (category 2).

Ectopic Pregnancy

Because they are so effective in preventing pregnancy, IUDs protect well against ectopic pregnancy. Women who use second-generation copper IUDs have a 91 percent lower chance of ectopic pregnancy than do women using no contraception, according to an analysis of 42 randomized trials published between 1970 and 1990 (Sivin, 1991).
In the unlikely event of pregnancy in an IUD user, that pregnancy is more likely to be ectopic than is a pregnancy in a non-user. Still, the pregnancy in an IUD user is far more likely to be normal than ectopic: only an estimated 1 in every 13 to 16 pregnancies, or 6 percent to 8 percent, is ectopic (Furlong, 2002).

STI-Related Health Risks

Pelvic inflammatory disease (PID)

Rates of clinical PID are very low among IUD users--lower than previously thought and much lower than providers may realize.
A multinational study by the World Health Organization (WHO) of 23,000 IUD insertions with 51,000 years of follow-up found an overall rate of PID of 1.6 cases per 1000 women per year, that is, 998.4 per 1000 women per year did not get PID (Farley et al., 1992).
The risk of an IUD user developing PID appears to be increased only in the first 3-4 weeks after insertion; beyond this time the risk is similar to non-IUD users. The rate of PID during these first few weeks post-insertion is 7 PID cases per 1,000 women per year. After 3-4 weeks post-insertion, an IUD user appears to be no more likely to develop PID than a non-user (Farley et al., 1992).
When PID in an IUD user does occur, the PID is caused by (recognized or unrecognized) sexually transmitted infections (STIs) with the organisms Chlamydia trachomatis or gonococcus (agent that causes gonorrhea), not by the IUD itself (Grimes, 2000).
In settings with a high prevalence (10 percent) of Chlamydia trachomatis or gonococcus among the population, the risk of PID attributable to the IUD is likely to be very small, estimated at 3 cases of PID per 1,000 insertions (Shelton, 2001). With simple screening by history alone (based on a few key questions to identify an individual's STI risks), the estimated attributable risk could be reduced in half, to 0.15 percent, or 1 case in 667 insertions (Shelton, 2001).
A more recent model, using STI prevalence data from five West African countries, estimated the risk of PID attributable to the IUD in that region is only 0.75 PID cases per 1,000 insertions (Stanback et al., 2008). The estimated prevalence of STIs in these five countries was 5 percent. A study in Zambia showed that the rate of PID among IUD users with HIV was very low. During two years of follow-up, 1 of the 296 women (0.3 percent) using a copper-bearing IUD developed PID 29 days after the IUD was inserted (Stringer et al., 2007).
Even among women who have confirmed STIs at the time of IUD insertion, the chances of developing PID are low. A recent analysis of published studies compared the risk of PID in two groups: those with STIs at the time of insertion and those without STIs. The absolute risk of PID was low for both groups (0 percent to 5 percent for those with STIs and 0 percent to 2 percent for those without) (Mohllajee et al., 2006).

Infertility

Sexually transmitted infections with Chlamydia and gonococcus can cause PID which in turn can lead to infertility by damaging the fallopian tubes and causing occlusion. However, a single episode of PID is associated with only about a 1 in 8 (13 percent) occurrence of occlusion of the fallopian tubes. More frequent episodes of PID are associated with higher chances of infertility (Westrom, 1975).
In a study examining the relationships between infertility, IUD use, and sexually transmitted bacteria, the risk of infertility due to tubal damage was not associated with previous IUD use, but rather to past exposure to Chlamydia trachomatis (Hubacher et al., 2001). A review of randomized controlled trials of performance of different IUDs and case series among women removing their IUDs found high pregnancy rates after IUD removal similar to rates among the general population (Skjeldestad, 2008).

HIV/AIDS

Use of the IUD is not known to increase the risks of female acquisition of HIV or to speed progression toward AIDS among HIV-infected IUD users.
IUD use by HIV-infected women does not increase genital shedding of the virus; therefore risk of HIV acquisition by an uninfected male partner should not be elevated either. (Richardson et al., 1999).
Complications of IUD use are low among HIV-infected users, and are comparable to the complication rates among IUD users who are not HIV-infected, with 0.2 percent to 2 percent infectious complications and 7 percent to 10 percent overall complications (Morrison et al., 1999; Sinei et al., 1998).
The first randomized trial comparing use of copper-bearing IUDs with use of hormonal contraceptives among women with HIV found that IUDs were safe and effective for use in HIV-positive women (Stringer et al., 2007).