Ask an American woman in her 20s or 30s to define an IUD, and she might tell you about a roadside bomb instead of one of the oldest forms of FDA-approved contraception.
In the late 1970s, this form of reversible contraception was used by nearly 10 percent of U.S. women on birth control. But today, IUDs are used by less than 2 percent of this U.S. market despite being wildly popular overseas, particularly in developing nations.
The intrauterine device is a small—roughly 1 inch—plastic “T” inserted into the uterus that hampers the interaction and implantation of the sperm and egg. It has to be placed by a trained gynecologist, midwife, or nurse practitioner, but once in, it’s a practically foolproof method of birth control—99 percent effective—that can last up to 10 years. * While daily or monthly forms of birth control can cost up to $60 a month, an IUD is a one-time cost between $300 and $500—though it’s often covered by insurance. There’s nothing to remember to take (unlike the pill), put in (unlike the NuvaRing), or take off (unlike the patch). And while efficacy studies suggest that the pill, patch, or ring are 99 percent effective in a clinical setting, real-life compliancy—like forgetting to take the pill at the same time every day—reduces its success rate. All that is a nonissue for the IUD: Once in, it requires no maintenance for the length of the device. Perhaps best of all, it can be hormone-free, which is better for the environment and ideal for women prone to some of the negative effects of hormonal birth control, like weight gain, mood swings, acne, or high blood pressure.
They seem like the perfect form of contraception: simple to use, long-lasting, reversible, hormone-free, economical. So why are American women so late to this party? Perhaps the better question is: Why did they leave the party to begin with?
That was my question when, after eight years and more than a dozen different incarnations of oral contraceptives, I decided to go back to the drawing board. I had never been good at taking the pill every day, and while my doctor suggested the patch and the ring, both were still under patent, making them more expensive than my monthly grocery bill. I needed something cheap, un-mess-up-able, and, ideally, hormone-free. So I did what any modern girl would do: I Googled. And thus began my research into the IUD and its mercurial history in the U.S. market.
“The major reason why women in the United States aren’t using IUDs and doctors aren’t recommending them is due to the erroneous belief that they’re highly dangerous,” says Dr. Katharine O’Connell, a gynecologist at Columbia University who specializes in contraception. Many in my mother’s generation remember the IUD’s heyday, when the contraceptive was linked to the horrors of pelvic infection, hysterectomy, and possible death. That negative rap stems from a particular device known as the Dalkon Shield. Heavily marketed in the early 1970s, it was the most popular model in the United States until a number of deaths from septic miscarriages caused the manufacturer to halt sales.
A study at the time linked the shield and other IUDs to pelvic inflammatory disease, and lawsuits were promptly filed. With the possibility of litigation of all IUDs on the table—and the terrible press at the time—the U.S. pharmaceutical industry abandoned the research and manufacture of IUDs in the mid-1980s, claiming the devices were no longer profitable. The result was a huge generational gap in knowledge about the IUD. Today, for women over 40, the thought of an IUD strikes terror into nether-regions; for those under 30, it’s a meaningless acronym, attached to a vaguely cautionary tale mentioned as an afterthought in high-school sex-ed class.
But while the United States panicked, other countries never took IUDs off the market, and they became only more popular. In France, they are used by 23 percent of women on birth control, and in China, 45 percent of married women use an IUD.
Eventually, stateside science caught up to the IUD witch hunt. In the early 1990s, a study inthe Journal of Clinical Epidemiologychallenged the validity of the research that had condemned the IUD. It’s now generally understood that the problems in the 1970s were due largely to the Dalkon Shield’s faulty design, which made users more susceptible to infection, as well as a lack of testing for sexually transmitted diseases before insertion, says O’Connell.
Now the IUD is being remarketed in the States, where there are two major IUDs: Mirena (FDA-approved since 2001) and ParaGard (one of the only IUDs that remained continuously available, though scarcely promoted, since the early 1980s). Mirena is made of a soft plastic and releases a steady amount of hormone directly in the uterus, comparable to taking a birth control pill or three a week. ParaGard is also made of plastic, but instead of releasing hormones, copper wire is wrapped around the device; the wire interferes with sperm transport and fertilization. Both IUDs also create a mild inflammation, which prevents sperm from fertilizing eggs and blocks fertilized eggs from implanting on the uterus.
Mirena’s advertising pitches the device to mothers, which might be why, despite being pretty well-informed about birth control, the IUD was still new to me when I discovered it this year. The same was true for my friend Daniela, who stuck with the pill—even though it made her “unbearably emotional”—until she graduated college and her pill bills, which had been partially subsidized by her student health care plan, rose from $7 to $50 monthly. On a trip to Brazil, she learned about the IUD from local friends, and had the ParaGard inserted on her return to the States.
Patients aren’t the only ones who don’t know much about IUDs. A recent study published in the medical journal Contraception surveyed premedical students in the United States and Canada. It found that 96 percent of education on contraception focused on oral contraceptive pills; 76 percent of those surveyed were taught about IUDs. Many medical schools limit their classes on contraception to one lecture, says O’Connell, leaving insertion and removal of an IUD to be taught during rotation, if it’s taught at all.
This lack of training can leave many doctors feeling uncomfortable recommending the once-controversial devices to their patients, which might explain why only 58 percent of family-planning clinics in the United States offer the IUD. Certain doctors who do know how to insert and remove an IUD still refuse to recommend it to childless patients because of the device’s checkered history. I experienced this with the first two doctors I visited. Though recent scholarship shows that the risk of an IUD creating infertility is almost nonexistent, some doctors prefer to insert them in patients already known to be fertile—so the IUD (and the doctor) can’t be blamed for any future infertility.
It took me four months, three doctors, and a $40 co-pay to get my IUD, and it was worth every minute, visit, and nickel. Despite how thrilled I am with my new birth control, I still have a hard time convincing women how great it is. Daniela has the same problem and thinks that many women in the United States are dissuaded from the IUD because of the high upfront cost and the invasiveness of the procedure. Though the insertion hurt and her periods were heavier and more crampy for a few months afterward, she describes it as a “very small price to pay for the peace of mind, money, and time” she saves with the IUD.
IUDs are still a contraception aberration in the United States, but if there’s one thing that creates change in America, it’s consumer demand. With Mirena advertising on television, the downturn in the economy forcing people to economize, and more women concerned about the long-term effects hormones have on their bodies, perhaps the IUD’s stigma will finally become a thing of the past.
Correction, Aug. 6, 2009: This article originally and incorrectly stated that an IUD has to be placed by a gynecologist. It can be placed by a trained gynecologist, midwife, or nurse practitioner. (Return to the corrected sentence.)
by Kate Klonick
