The IUD Makes a Comeback

Before she began her freshman year at Stanford University, Jenny, 18, realized she might start having sex during college. She wanted to be prepared, so her doctor put her on birth-control pills. She quickly learned that she was allergic to the synthetic forms of estrogen and progesterone found in hormone-based contraceptives.

"I went on this birth-control odyssey," Jenny says with a laugh (she asked to use a nickname to save her religious family from embarrassment). "I couldn't use the pill, the ring, or the patch."

After some investigation, Jenny decided on one of the only nonhormonal methods on the market, a copper intrauterine device (IUD), a method that would have been unavailable to her even a few years ago. For years, the IUD was FDA-approved only for women who had gone through childbirth: in 2005 the FDA broadened the approval to include all women.

Since the shift in FDA approval, women who are young, single, and childless like Jenny are turning to the device, which boasts the lowest failure rate of any reversible contraceptive on the market: 1 percent. (By comparison, the pill fails 3 percent of the time and condoms fail 12 percent when used imperfectly.) As a result, since 2005, IUD use has gone up by 161 percent with numbers continuing to increase, according to consumer health-care data from SDI Health. The company also found that IUD insertions went up 23 percent between January 2008 and January 2009. (During that same yearlong period, total contraceptive prescriptions fell by 2.6 percent.)

A new generation of sexually active women is now able to select IUDs as their birth-control method of choice, thanks in part to better access to information, the recent FDA decision, and a decreasing a stigma against the device, which earned a bad reputation after a product recall in the 1970s.

Before 1974, the IUD was as popular in the United States as the pill, with each taking 10 percent of the market. (Inserted by a doctor through the cervix and into the uterus, the IUD affects the way sperm move, preventing them from fertilizing the egg.) However, the Dalkon Shield, the most frequently used IUD, created serious health problems for many of the women who used it. The shield's design provided a way for bacteria from sexually transmitted diseases to climb into the uterus and fallopian tubes, clogging them with scar tissue. The shield was discontinued in 1974 and finally recalled in 1980, after a string of deaths from septic pregnancies and cases of infertility attributed to scarring from pelvic inflammatory disease.

The bad press was enough to scare American women off the IUD, and for years thereafter usage levels hovered at around 2 percent of American women who used contraception. (Other models of the IUD available abroad represented the most popular form of reversible contraception worldwide.)

The copper IUD, Paraguard, made a return to the American market in 1984 (copper is toxic to sperm). A second type of IUD, called Mirena, entered the market in 2001. This IUD uses a localized dose of progestin, releasing hormones into the uterus in smaller doses but to similar effect as the birth-control pill. However, citing possible risks of permanent infertility, the FDA approved these devices only for women who had already borne children.

But data from several studies suggests that infertility is unrelated to current IUDs, notably a 2001 New England Journal of Medicine study and a 2006 study published in the journal Contraception. A 2007 study done by Virginia Commonwealth University surveyed women with clinically defined "high-risk" sexual behavior (one third had documented histories of sexually transmitted disease), and found that modern IUDs do not increase the rate of pelvic inflammatory disease or infertility among women who have multiple partners or contract STDs. Some of the study's data suggested that the Mirena actually protects against STDs by causing an overproduction of cervical mucus, which can act as a barrier to pathogens.

Due in part to these studies, medical schools are educating a new generation of doctors to insert the IUD, something their counterparts over the past 30 years did not necessarily learn how to do.

Dr. Catherine Matthews, the VCU study's chief investigator, says the relaxing of the FDA approval is excellent news, since younger women tend to be less monogamous and more at risk for sexually transmitted disease than older women. They also have the most difficulty using birth control.

"The demographic group that is most likely to benefit from contraceptive use is exactly the demographic that is least reliable," says Matthews. "Take for example the 17-year-old teenager. There is the greatest negative impact if she gets pregnant. [Old] FDA standards and World Health Organization literature would say she is not a candidate for an IUD, but she is in fact the ideal candidate. "

But while women and public-health experts are often eager to embrace the IUD, some health providers are not.

"Everybody's very gangbusters about IUDs, but let's be careful. I think it's great, too, but fertility is really important," says Dr. Hilda Hutcherson, an ob-gyn at Columbia-Presbyterian Hospital in New York who has 28 years of experience. "If you contract an STD with a foreign body in your uterus, there's a greater chance that you'll get a significant infection and infertility, second to that. Call me old-fashioned, but that's what I think." This is counter to what the research says. But it's indicative of the attitudes of many doctors, who, after all, want to do what they think is right for their patients.

Salena Braun, 23, and a recent graduate of Bard College, recalled a similar attitude when she tried to get an IUD inserted two years ago. Her family doctor in Alabama was unaware that IUDs were FDA-approved for women who had never been pregnant, and the gynecologist to whom she'd been referred was against the idea.

"She said it would make me infertile. I kept saying, 'No, that's just not true,' but she wouldn't listen to me," Braun recalls, adding that she eventually got a copper IUD at a Planned Parenthood center near school.

With some doctors potentially unaware of the new research, women have turned to the Internet to praise the contraceptive and discuss their own experiences. More than 25 Facebook groups and Web communities—including IUD Divas, a Livejournal community with 3,390 members and almost 2,000 registered fans—are providing word-of-mouth education on the IUD, as well as listings of local doctors who perform insertions and descriptions of side effects, discomfort levels, and post-IUD sex.

Ralonda McIntosh Akins, 32, runs Facebook group called I [Heart] My IUD. She says that having an IUD implanted as a young woman would have significantly changed her medical history, something she hopes to share with the next generation.

"I grew up in a neighborhood where a lot of people I went to high school with had kids [too young], so I try to talk to girls who are younger than me and let them know what their choices are," she says. "And truthfully, I've had abortions, prior to having my son. Had I known that maybe the IUD was an option, I could have avoided that."

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