Intrauterine contraception is the most cost-effective reversible method of contraception today.  The history of intrauterine contraception is remarkably short.  Many IUD designs and shapes are a direct result of clinicians efforts to improve the performance of IUDs and reduce the overall level of their side effects.  However only a few of these have ever been commercialised. The illustration shows a number of intrauterine devices dating from the beginning of the development of intrauterine contraception and including currently available IUDs. The two most successful copper IUDs currently on the market are the TCu380A IUD (Gravigard®) and Multiload® (ML) Cu375 IUD.   Dr Tatum, USA, conceived the plastic T-IUD and Dr Zipper, Chile, invented the use of copper to optimise the contraceptive effectiveness.  The Multiload® (ML) IUD, invented by the Dutch gynecologist Dr Willem van Os in 1974, is still used by many women.

M. Thiery.  Pioneers of the intrauterine device.  The European Journal of Contraception and Reproductive Health Care. 1997;2:15-23. (Click here for full text article)

Contraceptive efficacy
— the difference between “typical” and “perfect” use

Intrauterine contraception is the most cost-effective reversible method of contraception today.  Modern high-load copper IUDs are very effective (i.e., efficacy is now close to 100%, see table below) when compared with other birth control methods.

Table. Percentage of women experiencing an unintended pregnancy during the first year of typical use* and the first year of perfect use** of contraception and the percentage continuing use at the end of the first year (US).
*Failure rates during typical use show how effective the different methods are during actual use (including inconsistent or incorrect use)
**Failure rates during perfect use show how effective methods can be, where perfect use is defined as following the directions of use

The table above is adapted from Trussell J, Kowal D.  The essentials of contraception: efficacy, safety, and personal considerations and Trussell J, Contraceptive efficacy. In Hatcher RA, Trussell J, Stewart F, Cates W, Stewart GK, Kowal D, Guest F.  Contraceptive Technology: Seventeenth Revised Edition. New York NY: Ardent Media 1998

Reducing health risks with intrauterine contraceptives

The health risks related to oral contraceptives raises the question whether locally applied (intrauterine) contraceptives can offer a valuable alternative with respect to efficiency and safety.  Arguments against the use of IUDs (problems and complications with IUD insertion, the risk of pelvic inflammatory disease, ectopic pregnancy and infertility as well as side effects such as menorrhagia, pelvic cramps and IUD expulsion) generally appear to be based on a lack of awareness with respect to recent developments and other misunderstandings derived from bad experiences during the 1980s and earlier.

Dr. Malcolm Potts (quoted by H. Van Kets, Prof. Em. University Ghent, See ref. below) once developed a very original approach to the problem of health safety considering varous events in women’s life.  He calculated how long a woman would live if she had to die from only one isolated cause.  The risks of being hit by lightning or a falling airplane are so small that she could live several million years.  Using oral contraceptives as sole risk gives her 63,000 years to live but, using an IUD, she would reach the blessed age of 200,000 years.

J.V. Hamerlynck and M. Knuist.  Moderne intra-uteriene anticonceptie: het beter alternatief (Modern intrauterine contraception: the better option). Ned Tijdsch Geneeskd 2001;145:1621-1624. (Click here for full text article)  www.obgyn.nl

Wildemeersch D, Parewijck W, Van Kets H, Delbarge W, Vrijens M, Thiery M. Misconceptions about intrauterine devices. European. Proceedings of the 4th Congress of the European Society of Contraception; Barcelona, Spain, 1996, pp 145-153. Eds. C. Coll Capdevilla, L. Iglesias Cortit and G. Creatsas.

Risks associated with oral contraceptives

According to Folia Pharmacotherapeutica 2002;29:100-104  (an information brochure published by the Belgian Centre for Pharmacotherapeutic Information officially recognized by the FOD (Division of the Ministry of Health), the following conclusions as to the safety of oral contraceptives were formulated based on studies conducted in 2001 and 2002 (Click here for references):

• Breastcancer : In a recently conducted observational study in current or past users of oral contraceptives between 35 and 64 years of age, no increased risk was found when compared with non-users of oral contraceptives.  These results are reassuring.  However, the results have to be interpreted with respect to a meta-analysis of 54 observational studies published in 1996 which found a slight increased risk of breast cancer in oral contraceptive users, especially in those less than 35 years of age.

• Cervical cancer : There is increasing clinical evidence that women with a positive human papillomavirus (HPV) test have a higher risk for cervical cancer.

• Myocardial infarction : There is increasing clinical evidence that the risk of myocardial infarction is increased in women using oral contraceptives, especially in smokers.

• Venous thromboembolism : A meta-analysis shows evidence of the slightly increased risk of deep venous thrombosis in women using third-generation oral contraceptive in comparison to second-generation contraceptives.

Use and underuse of intrauterine devices

On a worldwide scale there are nearly 160 million IUD users, most of them (over 100 million) in China.  The popularity of intrauterine devices stems for their effectiveness, combined with their long duration of action.  Because of their long lifespan, IUDs require fewer visits to doctors, which means high cost-effectiveness.  IUDs are implanted and, therefore, cannot be “forgotten”, an asset much appreciated by many women. 

IUD use in developed countries, however, varies from as low as 1% in the Netherlands and the USA to about 30% in Scandinavia.

The limited IUD use, particularly in developed countries, can be ascribed to various causes:

• Pharmaceutical industry :  The pill market is of great economic importance.  This is the single drug that is taken by the greatest number of healthy women in the world.

• Medical profession : prescribing oral contraceptives is less time-and energy consuming than insertion an IUD.  Moreover not all practitioners have acquired the skills to perform a correct insertion which guarantees the best possible results.

• Women themselves are often very poorly informed, and fear that inserting an IUD in their uterus has to be painful and may bring an unknown infection and even cancer.

• The media have never been kind to IUDs and have often neglected their many advantages, but are still repeating the old stories of the ill-fated Dalkon Shield (which has been refuted in post-marketing studies conducted in the UK, See M. Cox J Fam Plann Reprod Health Care 2003;29:8).

Experts conclude that it is due time for the medical profession to realize that contraception does not equal oral contraception.  The correctly inserted IUD in correctly evaluated recipients has come of age, has eliminated a great deal of its previous disadvantages, has received a clean bill of health and offers an economically and medically justified choice.

H.E. Van Kets. Importance of intrauterine contraception.  In: Contraception Today.  Proceedings of the 4th Congress of the European Society of Contraception. Ed. C. Coll Capdevila, L. Iglesias Cortit and G. Creatsas.  The Parthenon Publishing Group, 1997: 112-116.

References:

1. Marchbancks PA et al. Oral contraceptives and the risk of breast cancer. New Engl J Med 2002;346:2025-2032.

2. Davidson NE and Helzlsouer KJ (editorial). Good news about oral contraceptives. New Engl J Med 2002;346:2078-2079.

3. Moreno V et al. Effect of oral contraceptives in risk of cervical cancer in women witrh human papilloma virus infection: the IARC multicenric case-control study. Lancet 2002;359:1085-1092.

4. Munoz N et al. Role of parity and human papillomavirus in cervical cancer. Lancet;359:1093-1101.

5. Skegg DCG (commentary): Oral contraceptives, parity and cervical cancer. Lancet 2002;359:1080-1081.

6. Tanis BA et al. Oral contraceptives and the risk of myocardial infarction. New Engl J Med 2001;345:1787-1793.

7. Chasan-Taber L and M Stampfer (editorial): Oral contraceptives and myocardial infarction – The search for the smoking gun. New Engl J Med 2001;345:1841-1842.

8. Kemmeren JM et al. Third generation oral contraceptives and the risk of venous thrombosis: meta-analysis. Brit Med J 2001;323:119-120.

9. Drife JO (editorial). The third generation pill controversy  (“continued”). The risks are still small compared with pregnancy. Brit Med J 2001;323:119-120.

10. Vasilakis-Scaramozza C and Jick H. Risk of venous thrombo-embolism with cyproterone or levonorgestrel contraceptives. Lancet 2001;358:1429-1429.