Insertion technique, not design, affects expulsion rates of postpartum intrauterine devices

What we have learned from recent IUD studies: a researcher's perspective

Many studies published on intrauterine devices (IUDs) during the last six years have consistently reported findings in favor of IUD use. Notable among these findings are: IUDs are not abortifacients; newly developed IUDs are highly effective and the efficacy is long-lasting; IUDs can be safely used by most lactating women, with lower removal rates attributable to bleeding and/or pain; and immediate postplacental IUD insertion reduces the risk of expulsion usually associated with postpartum insertion. Most importantly, in apparent contrast to results often reported in the late 1960s through the early 1980s, recent findings show that IUDs per se, especially the medicated ones, are not associated with an increased risk of pelvic inflammatory disease (PID), nor are they associated with an increased risk of ectopic pregnancy or subsequent infertility. There are still issues concerning IUD use that are controversial in spite of numerous studies. Should some of the contraindications currently listed for IUD use be modified according to the newer findings? Is the risk of uterine perforation increased when the IUD is inserted in lactating women? Do IUD tails increase the risk of PID? Does oral use of antibiotics at IUD insertion help prevent postinsertion PID? There are also issues that have not been sufficiently addressed and more information from empirical studies is needed. These include: the effect of the insertor's skill on IUD performance; IUD use in nulliparous as well as in older women; the relationship between IUD use and chlamydia infection; and long-term IUD use and safety, including actinomycosis, etc. Answers are also needed by administrators facing difficult programmatic decisions. For instance, should programs involving massive IUD removal be implemented as many IUD-wearing women are approaching or passing menopause? Similarly, are large programs to remove less-effective devices and replace them with newer and more effective IUDs advisable? This article reviews the state-of-the-art findings from recent IUD studies on the above issues.