The Intrauterine Device (IUD) is a highly effective form of birth control used by many women worldwide. Once an IUD is inserted by a health care provider it can offer 5 to 10 years of pregnancy prevention with no further action by the user (such as taking a pill every day or using a condom with every act of intercourse). As a result, the failure rates under typical use and perfect use are nearly identical and show that fewer than 1 percent of women using this method will become pregnant in the first year of use.
Nonetheless, this method has been relatively unpopular in the United States over the last few decades.
A new study, Renewed Interest in Intrauterine Contraception in the United States: Evidence and Explanation, however, suggests that the IUD is gaining popularity among American women of all ages. The study looks at data from the 2006–08 National Survey of Family Growth (NSFG) which found that approximately 2.1 million American women used the IUD, which is the highest level of use since the 1980s. This means that in 2006–08, 5.5 percent of women using contraception were using an IUD compared to 2.0 percent in 2002 and 1.3 percent in 1995 (when use was at its lowest).
The authors of the study suggest a number of reasons for this renewed interest in IUDs including product improvements, new guidelines, more trained providers, a better reputation, and increased access.
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Today, women have a choice of the CuT380A (also known as the Copper-T or Paraguard) and the LNG IUS (the levonorgestrel intrauterine system, sold under the name Mirena) which was approved by the FDA in 2000. The Copper-T last ten years while Mirena lasts five. New research has demonstrated that these modern devices are highly safe, that their efficacy comes close to that of surgical sterilization, but that they are instantly reversible if a woman decides she wants to get pregnant. All of which should make them a popular choice.
When I was first learning about various contraceptive methods, so that I could be a Peer Sexuality Educator at UMass, I was told that IUDs were intended for older women who had already had children. As such, we barely even mentioned them in the contraceptive education class that was mandatory for any woman who wanted to get birth control from the University’s health center.
This opinion was not unique to my program; it was likely based on the practice guidelines published by the American College of Obstetricians and Gynecologists (ACOG). These guidelines are used by providers to help determine whether a patient is a good candidate for a given contraceptive method. According to the authors of the study, the 1987 and 1992 bulletins were rather negative when it came to IUDs. In fact, they started with a statement about product liability and its impact on the IUD. Moreover, the guidelines suggested that IUDs were best suited for older, monogamous women who had already had children, had no history of pelvic inflammatory disease (PID) or ectopic pregnancy, and “ ‘are not candidates for the ‘slightly more effective’ oral contraceptive pill.’ ”
In contrast, the 2005 bulletin begins by saying:
“ ‘Intrauterine devices (IUDs) offer safe, effective, long-term contraception and should be considered for all women who seek a reliable, reversible contraception that is effective before coitus.’”
These new guidelines are echoed by the World Health Organization and the U.S. Centers for Disease Control and Prevention (CDC). Both organizations issued similar eligibility criteria which support the use of IUDs among wide populations, including women under 18 and those who have not had children.
The study notes that a greater number of providers are aware of the evidence supporting the safety and efficacy of IUDs, in part due to the new guidelines and, in part, due to concerted efforts by organizations such as the Association of Reproductive Health Professionals and the Society of Family Planning. The study also explains that a greater number of clinicians have been trained in the insertion and removal of IUDs.
Interestingly, the authors also point to an increase in family planning training programs in general and note that family planning fellowships for post-residency training have been established at many universities over the last several years.
A Better Reputation
When they hear the term IUD, many women, even those of us who are too young to really remember it, think instantly of the Dalkon Shield. Introduced in the early 1970s, this popular IUD caused increased risk of Pelvic Inflammatory Disease and left many of its users infertile. Though it was pulled from the market in 1974, the lawsuits around it continued for many years and damaged the reputation of all IUDs.
The study suggests that the method’s reputation is improving now that there are “no widespread medico-legal controversies or negative media attention.” It also suggests that direct-to-consumer marketing has increased demand and that as more women use the device positive word of mouth spreads.
Mirena has certainly had a widespread ad campaign that seems designed to remind women that IUDs are not just safe and effective but reversible. In each of the commercials I’ve seen, the women have a few kids running around and say they don’t want any more, that is until the commercial fast forwards a few years and we see that she’s changed her mind and now has another happy, healthy child.
Finally, the authors note that access to IUDs has increased through a number of factors. They point to the ARCH Foundation (Access and Resource in Contraceptive Health) which is a not-for-profit foundation that is funded by the manufacturer of the LNG IUS and provides financial assistance to low-income women who want to use that method. They also note that “many states have Medicaid family planning expansion programs (‘waivers’) that increase the income cutoff below which women can receive benefits, including access to all FDA-approved contraceptives.” And, finally, they explain that many states have passed contraceptive equity laws that require insurance plans to cover contraceptive methods. This is particularly important for IUDs, because while they are cost effective over time, they have an upfront cost that can be quite high (insertion of Mirena, for example, can cost over $800).
A woman’s decision about what birth control method to use is based on so many personal factors – how often she is having sex, whether she can safely take hormones, how good she is at remembering to take a pill, her relationship with her current sexual partner(s), her comfort with her own body, what her insurance will cover or what she can afford without it, when and whether she wants kids…the list goes on and on. Therefore, what is most important is that women have access to as many safe and effective options to prevent unintended pregnancies as possible. It is good to know that a new generation of IUDs has emerged and a new generation of women is using them.