The use of intrauterine devices, or IUDs, as a form of birth control was revolutionized when modern IUDs made from shapable plastic were introduced in the United States in 1962 and then made available to women two years later.
The intrauterine device (IUD) is a small loop, coil, or ring made of plastic, copper, or stainless steel that is inserted into the uterus by a physician. Although often thought of as a form of birth control first introduced in the 1900’s, primitive forms of the IUD have been in existence for some time. For many centuries in the Middle East, camel drivers prevented camels from becoming pregnant by inserting pebbles into the uteri of female camels. During the Middle Ages, uterine plugs made of tightly bound paper tied with string were used by Persian women.
The problem with these early forms of IUDs was that they were often inserted into the female reproductive tract under unsanitary conditions, which often led to infections. In the 1920’s, physicians in Germany developed a metal ring that could be inserted into the human uterus, but because of many cases of inflammation and infection, this form of birth control was soon abandoned.
With advances in plastic technology during the 1940’s, there was renewed interest in the IUD as a form of birth control in Israel, Japan, and the United States. IUDs could now be formed in a variety of shapes including coils, loops, spirals, and bows. A new form of IUD introduced in the United States in the early 1960’s was the so-called Lippes loop, developed by Jack Lippes. The plastic loop and its inserter, first introduced by Lippes at a medical conference in 1962 and first marketed in 1964, could be straightened and fitted into a tube for insertion and then positioned in such a way that it would resume its original shape in the uterus. Two threads attached to the loop extended through the cervix into the upper part of the vagina to allow the woman to check the placement of the loop. If pregnancy was desired, the loop could be removed by a physician simply by pulling on these threads.
Studies found that there was much less chance of expulsion of the Lippes loop and other plastic IUDs, which increased their contraceptive effectiveness. In addition, the chance of serious infection occurring with the use of these IUDs was reduced with the development of antibiotic drugs.
The exact way in which the Lippes loop and other IUDs prevent pregnancy is not known, although several hypotheses have been suggested. An IUD does not kill sperm or block the entrance to the uterus. Instead, it prevents either fertilization of the egg or implantation of the embryo in the uterus. Experiments done with monkeys indicate that the presence of the IUD may cause minute vibrations of the oviduct, speeding passage of the egg to the uterus before the uterus is ready to receive it. As a result, pregnancy is prevented. Other studies suggest that irritation of the lining of the uterus caused by the presence of the IUD prevents the implantation of the blastocyst or causes an implanted blastocyst or embryo to be sloughed off as part of menses. It may be possible also that the IUD immobilizes sperm as they pass through the uterine cavity.
The type of IUD a doctor selects depends upon the condition of the uterus, the presence of problems with menstruation or infection, and whether the woman has been pregnant. The IUD is an excellent form of birth control for women who have had at least one child, are involved in a monogamous relationship, and who do not wish to be sterilized. IUDs are not appropriate for women under twenty-five years of age or for those who have not had children, since there is a higher rate of IUD expulsion in these women. Women with heavy menses or severe menstrual cramps are also not good candidates.
The insertion of the IUD is a rather simple procedure for the physician. The patient is usually asked to sign an informed consent indicating that she understands the nature and limitations of the IUD. After explaining the procedure to the patient and describing the IUD, the physician performs a pelvic exam to rule out the possibility of pregnancy or an active pelvic infection. The cervix (opening to the uterus) is washed with an antiseptic solution, and a local anesthetic may be applied at this time. A sterile IUD is then straightened and fitted into a sterile tube, and the tube containing the IUD is passed through the vagina and cervix into the uterus. When the IUD is gently pushed out of its inserter tube, it resumes its original shape as it presses against the lining of the uterus. A small portion of the tail (threads attached to the IUD) is allowed to extend through the cervical canal to allow the woman wearing the IUD to check its placement from time to time.
Most physicians prefer to insert an IUD during the woman’s menstrual period. At this time, the cervix is somewhat dilated, making it easer to insert the tube containing the IUD. The flow of blood from the uterus washes away bacterial contaminants and reduces the possibility of infection following the initial introduction of the IUD into the body. Also, the physician can be reasonably sure that the patient is not pregnant.
As with any contraceptive device, the IUD has several limitations and disadvantages. Approximately 10 to 15 percent of women will have their IUDs removed because of bleeding, spotting, or pain. Bleeding is related to the size of the IUD in relation to the size of the uterus. A tight-fitting IUD pressing against the walls of the uterus will cause more bleeding than one that does not exert as much pressure. If the tip of an IUD presses against the cervical canal, bleeding will result; thus, it is very important that the IUD be placed in the uterus in such a way that it does not protrude into the cervix.
Since the consequence of an unnoticed expulsion is often an unwanted pregnancy, it is important that a woman wearing an IUD frequently check the placement of the threads attached to the IUD and also examine her sanitary napkin or tampon during menses for an expelled IUD. If the IUD is expelled, another IUD of a different size or shape or both may be inserted, usually with no further complications. Although rare, perforations of the uterus by the IUD are also possible. In most cases, however, these perforations occur during the time of insertion.
The most serious complication related to the use of the IUD is a higher chance of developing pelvic inflammatory disease (PID). Most hospitalizations and deaths resulting from the use of the IUD result directly from PID. Chances of developing this infection are greatest during the first four months following insertion.
The IUD is a highly effective form of birth control (98 percent effective) and is second only to oral contraceptives in preventing unwanted pregnancies. The IUD has many advantages in that its insertion requires only one procedure and it does not interfere with the spontaneity of intercourse. The IUD provides long-term protection against pregnancy and does not have undesirable systemic effects. The IUD does not alter the hormone levels in the body. When a woman wearing an IUD wishes to become pregnant, the device can be removed by a physician. The cost of the IUD is much lower than any other form of birth control when used over time.
The Lippes loop was the most widely used form of inert IUD during the 1960’s and 1970’s and was the standard against which other IUDs were usually compared. (Inert IUDs do not contain medication.) Many of the other inert plastic IUDs manufactured during the 1960’s and 1970’s were removed from the market because they did not prove to be superior to the Lippes loop, which had a high success rate in preventing pregnancy in 94 percent of the women who used it.
Further advances in the field included an IUD developed by Jaime A. Zipper, professor of physiology, obstetrics, and gynecology at the University of Santiago in Chile, and Howard Tatum, professor of gynecology and obstetrics of the Emory University School of Medicine in Atlanta, Georgia. Studies by Zipper indicate that iron, zinc, and copper are toxic to the enzymes in the cells of the uterine lining that are necessary for the proper implantation of the embryo; copper also prevents fertilization of the egg. Zipper and Tatum added copper wire to the stem of a T-shaped IUD, which had been developed by Tatum. It resulted in a significant improvement in the contraceptive effect of the IUD. This new IUD was placed on the market by G. D. Searle in 1973.
Despite these tremendous advances in the development of the IUD, a number of events occurred during the 1970’s and early 1980’s that resulted in a decreased number of women using the IUD as a form of birth control. One of the earlier forms of plastic IUDs known as the Dalcon shield
In the months that followed, an increasing number of reports of infections related to the use of the IUD as well as papers citing complications, difficult removals, and perforations of the uterus caused by the IUD were published. These reports received widespread media attention, and soon all IUDs became tainted by the reputation of one faulty product. A large number of lawsuits by plaintiffs claiming that they had not been warned of potential serious pelvic infections eventually resulted in the withdrawal of most IUDs from the market. The Lippes loop was discontinued in September, 1985, by Ortho Pharmaceutical because of lack of use and increased litigation costs.
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Corson, Stephen L., Richard J. Derman, and Louise B. Tyrer, eds. Fertility Control. 2d ed. London, Ont.: Goldin, 1994. The editors have synthesized the works of many contributing authors in this reference book designed for students, resident physicians, and clinicians. Topics such as the history of birth control, various forms of contraception, and ethical issues of birth control are discussed in a clear, concise manner. Illustrated, with an extensive list of references. -
Duffy, Benedict J., Jr., and M. Jean Wallace. Biological and Medical Aspects of Contraception. Notre Dame, Ind.: University of Notre Dame Press, 1969. Addresses contraception as a global scientific problem. Provides information on the biology of reproduction and the medical aspects of contraception, with emphasis on the importance of education in dealing with fertility regulation globally. Includes illustrations and glossary. -
Guillebaud, John. The Pill and Other Hormonal Contraception: The Facts. 6th ed. New York: Oxford University Press, 2005. Explains the basic facts about the birth control pill and other forms of contraception. Written for those with little or no scientific knowledge of contraception. -
Hafez, E. S. E., ed. “Clinical Aspects of Inert and Medicated Intrauterine Devices.” In Human Reproduction: Conception and Contraception. 2d ed. Hagerstown, Md.: Harper & Row, 1980. Provides a detailed clinical discussion of all aspects of the IUD, including descriptions of various types of IUDs and their selection, insertion, advantages, disadvantages, and pregnancy in women wearing the IUD. Contains illustrations, tables, graphs, and an extensive list of references. -
Hardin, Garrett. Birth Control. New York: Pegasus, 1970. A detailed explanation of the various forms of birth control, including the effectiveness, safety, advantages, and disadvantages of each type. As a biologist, Hardin presents a straightforward explanation of the anatomy and physiology of the reproductive system and the functioning of birth control methods as well as the moral and psychological issues concerned with birth control. This book is well written and includes illustrations and suggested readings. -
Hatcher, Robert A., et al. Contraceptive Technology. 18th ed. New York: Ardent Media, 2004. This textbook provides family planning information on the safety and effectiveness of various forms of contraception. Provides updated information on such topics as infertility, pregnancy, sexually transmitted diseases, and family health. Excellent reference. Includes illustrations, diagrams, reference tables, and bibliography. -
Lieberman, E. James, and Ellen Peck. Sex and Birth Control: A Guide for the Young. Rev. ed. New York: Thomas Y. Crowell, 1981. Presents facts and ideas clearly and often incorporates examples of real-life situations and quotations from teenagers expressing concerns about birth control. Enjoyable reading. Includes illustrations and bibliography.
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