The IUD Comeback Continues Apace

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Analysis Contraception

The IUD Comeback Continues Apace

Martha Kempner

Intrauterine devices were popular until the '70s, when one model caused infertility and even death in some women. Though the new generation of IUDs are safe and effective, it has been a slow climb back to their previous rates of acceptance.

New data, released last week as part of the National Survey of Family Growth, finds that 6.4 percent of women ages 15-to-44 are currently relying on intrauterine devices (IUDs) as a method of contraception. While this lags behind those who are using the pill (16 percent) and even sterilization (15.5 percent), it shows a renewed interest and increased trust in a highly effective birth control method that had fallen out of favor. This is good news for public health advocates—many of whom believe that long-acting methods like the IUD are the key to preventing unintended pregnancy in this country.

Today’s IUDs are small t-shaped plastic devices that are inserted into the uterus by a health-care provider. A string hangs down through the cervix to allow for removal. IUDs prevent pregnancy primarily by interfering with the path of the sperm toward the egg. Two of the IUDs on the market—Mirena and Skyla—also release hormones similar to those in some birth control pills, which thickens the cervical mucus (creating a barrier to sperm) and may also prevent ovulation. The other, called ParaGard, releases copper, which is thought to create a substance that is toxic to sperm. ParaGard lasts for ten years, Mirena for five, and Skyla for three, but any of them can be removed if a women wishes to become pregnant.

IUDs, which were first invented in the early 1900s, were at one point a very popular method of contraception. In the 1970s, there were 17 models of IUDs on the market manufactured by 15 different companies.

Unfortunately, one model, the Dalkon Shield, had severe design flaws. It has been described as looking like the shell of a horseshoe crab, but instead of having one large spike at the top, it had five short ones coming off of each side. These spikes were meant to keep the IUD in place, but they turned out to be very irritating to the lining of the uterus and could become embedded in the endometrium. The string on the device also differed from that on other IUDs and allowed bacteria to travel up it, into the uterus. Many users got pelvic inflammatory disease (PID), which in turn caused them to become infertile. In addition, the Dalkon Shield had a higher failure rate than other IUDs, and some users became pregnant. Those who did were at risk of septic miscarriage, a miscarriage followed by a severe infection. Eighteen women who used the Dalkon Shield died from this.

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In 1974, the company A.H. Robbins took the Dalkon Shield off the market, but stories of complications and negative press continued, and more than 400,000 lawsuits were filed. Ultimately, A.H. Robbins went bankrupt and a $3 billion fund was set up to compensate women who’d had issues with the IUD.

Though only the Dalkon Shield was implicated in these medical issues, there was an impact on usage of all IUDs. “The Dalkon Shield single-handedly turned an entire generation of American women against all IUDs,” Jenny Higgins, a researcher at the University of Wisconsin who focuses on contraceptive usage, told Rewire. “The same isn’t true in other countries, like France, where IUD use remained high. It’s understandable that women in this country lost faith in IUDs, but it’s too bad that they also lost out on a method that is not only highly effective but that many women really like.”

By 1986, there was only one IUD on the market, and few women were using it.

The new generation of the IUD was born a few years later with the introduction of ParaGard in 1988 and Mirena in 2000. Originally, these methods were approved only for use in women who had already had children, but as research showed their safety and efficacy, they were approved for use in all women. (The newest model, called Skyla, which was released in 2013, was designed for and is being marketed toward younger women who have not yet had children.)

Still, few women were using them until recently. A National Survey of Family Growth analysis found a steady downward trend in the percentage of women who had ever used an IUD, from 18 percent in 1982, to 10 percent in 1995, to 5.8 percent in 2002.

In the last few years, however, there has been a push by public health advocates and providers who would like to see more women, especially adolescents and young women, using this method. In 2011, the American Congress of Obstetricians and Gynecologists revised its official practice guidelines to suggest that young women could be offered IUDs. In 2012, it made this language stronger by saying that sexually active young women should be encouraged to use long-acting methods such as IUDs or contraceptive implants. The American Academy of Pediatrics announced in October of this year that it agrees that IUDs and implants should be considered a first-line contraceptive method for sexually active young women.

A number of interventions have found that increased IUD use does reduce the rates of unintended pregnancies. For instance, the CHOICE Project at Washington University in St. Louis, Missouri, which has provided contraception to over 9,200 women, found that after one year those who chose the pill, ring, or patch were 20 times more likely to have had an unintended pregnancy than those who chose the IUD or contraceptive implant.

What sets the IUD and implant apart from other methods is that user error is essentially taken out of the equation—a pill user can skip a dose, and a condom user can leave the protection at home, but once an IUD is put in place it works for between three and ten years without any further effort on the part of the user. This means that the efficacy rates in real life are just as good as the efficacy rates in a laboratory setting. In fact, IUDs have a failure rate of just 0.8 percent, which means that out of 100 couples who rely on this method each year, fewer than one will experience an unintended pregnancy.

The publicity IUDs have gotten as an effective birth control method may finally be enough to get rid of the stigma that’s been attached to IUDs since the Dalkon Shield. And indeed use is going up. The latest National Survey of Family Growth data suggests that 6.4 percent of women are currently using an IUD, compared to 5.6 percent between 2006 and 2010. Even more striking: In 1995, just 0.8 percent of women were using an IUD.

“It’s exciting to see this change because we are likely to see fewer unintended pregnancies among people who switch to IUDs,” said the University of Wisconsin’s Higgins. She pointed out, however, that the IUD is still used by far fewer women than hormonal birth control methods. She added that women who use IUDs have higher satisfaction and continuation rates than those who use other methods. “One of the reasons they’re so acceptable is the forgettable nature. You never have to think about this device that protects you from pregnancy,” she said. “The IUD may not be the best method for every woman, but it is great that it is once again being seen as part of our method mix.”