Research has shed new light on how IUDs prevent pregnancy. Studies suggest that IUDs prevent sperm from fertilizing ova (437, 501, 544). Current evidence does not support the common belief that the IUD usually works by preventing implantation (501).

Researchers in Chile recovered ova from 56 women using various IUDs and 115 women not using contraception. The researchers were significantly less likely to recover ova from the fallopian tubes of the IUD users, especially those using copper IUDs, than from the other women. Fourteen of the IUD users and 20 of the nonusers had recently had sexual intercourse around the time of ovulation. None of the ova recovered from these IUD users showed clear signs of fertilization and normal embryonic development. In contrast, half of the ova recovered from the nonusers did (478). These results provide the clearest evidence to date that IUDs work chiefly by preventing fertilization.

Studies using assays for human chorionic gonadotropin (hCG), a hormone secreted by cells surrounding the fertilized ovum, also suggest that IUDs generally prevent fertilization (317, 416, 427). These assays can detect fertilization within 7 to 10 days, well before implantation of a fertilized ovum is complete (106, 198, 437). Two studies of women using mainly copper IUDs have found hCG assays indicating fertilization in less than one percent of menstrual cycles (317, 427).

Copper IUDs affect ova and sperm in various ways. They stimulate a pronounced inflammatory reaction, or foreign-body response, in the uterus. The concentration of various types of white blood cells, prostaglandins, and enzymes in uterine and tubal fluids increases markedly (174, 243, 264, 312, 322, 437), especially with copper IUDs (235). These changes may interfere with transport of sperm in the genital tract and may damage sperm and ova so that fertilization is impossible (260, 437). In most studies fewer sperm are found in the fallopian tubes, where fertilization is thought to take place, in IUD users than in nonusers (12, 193, 312, 386). Various types of white blood cells probably consume many sperm in the uterus (312). Other sperm maybe damaged so that they cannot move into the fallopian tubes (260). Thus, while the precise mechanism of action of copper IUDs is still not certain, most likely the primary action is altering the function or survival of sperm and ova before they can meet (501). In contrast, the LNG-20 IUD, although it also prevents sperm and ova from joining, has a primarily hormonal mode of action, probably working chiefly by thickening cervical mucus so that sperm cannot pass through it (610).

Clinical trials show that all of the widely used copper IUDs are effective for at least five years and many are effective longer (21, 225, 226, 307, 380, 383, 405, 451, 453, 491, 547, 549, 566). The only IUD currently approved for more than five years, however, is the TCu-380A, which in 1993 was approved by the United States Food and Drug Administration for 10 years of use (620). Regulatory approvals are generally based on effectiveness demonstrated in clinical trials but must await the sponsor's application and often lag behind the latest research findings.

Long-term randomized clinical trials of copper IUDs report low cumulative pregnancy rates for the second-generation copper IUD—after 10 years, 2.1 per 100 women with the TCu-380A and 5.7 with the TCu-220C, and after five years, 3.4 to 10.0 in three trials with the Nova T (226, 307, 566, 573, 625) (see Table 1).In WHO comparative trials the TCu-380A was significantly more effective than the TCu-220C (625), and the TCu-220C was significantly more effective than the Nova T (307). In a WHO 3-year comparative trial the pregnancy rate for the MLCu-375 was low, at 2.9 pregnancies per 100 women, but this IUD was significantly less effective than the TCu-380A, at a rate of 1.6 (648) (see Table 1). By comparison, nonrandomized trials of the TCu-200, a first-generation copper IUD with less copper, reported generally higher 5-year pregnancy rates—from 7 to 12 per 100 women (331, 451, 453). Annual pregnancy rates do not increase over time for long-term IUD users, and they may decrease. For example, in WHO clinical trials annual pregnancy rates for the TCu-220C fell from 1.3 during the first two years to 0.5 during the third through fifth years to 0.4 during the sixth through eighth years. Over the same period annual pregnancy rates for the TCu-380A fell from 0.3 to 0.1 (545). Over 10 years of use pregnancy rates averaged less than 0.5 per 100 women per year for the TCu-380A and less than 1.0 for the TCu-220C from the second year of use (625). This study has continued through 12 years of use, and data covering the last two years will be published in 1996.

The fall in annual pregnancy rates after the first two years of IUD use does not appear to reflect a cumulative effect of the IUD. Rather, it occurs largely because the women using IUDs for long periods tend to be older and thus less fertile than short-term users (437). Also, women whose IUDs are improperly inserted, are expelled without their noticing, or perforate the uterus are most likely to become pregnant early in the study. Declining annual pregnancy rates over long periods are seen also in women using inert devices such as the Lippes Loop (385).

As researchers study women using second-generation copper IUDs for increasing lengths of time, the approved lifespans of some copper IUDs may be further extended. Less frequent replacement reduces the risks of pelvic inflammatory disease, perforation, and other complications that mainly occur at or soon after insertion. Also, less frequent insertions cost less and are more convenient.

To develop a consensus in light of current scientific understanding, a group of experts recently answered important questions concerning procedures for providing various family planning methods including IUDs. The group was convened by the USAID Collaborating Agencies, private and nonprofit organizations working with support from the US Agency for International Development (USAID).

The group, named the Technical Guidance Working Group, intends its answers as guidance for programs developing or revising their own procedural and service guidelines. In issuing its report, the group sought to address two problems—(1) inconsistencies or conflicts in existing procedural guidelines can cause confusion; and (2) guidelines that are out of date in light of scientific evidence often restrict access to contraceptive methods unnecessarily (634).

Assessing the value of specific clinic procedures, the Working Group concluded that counseling, including discussion of increased bleeding, reasons to return, STD risk behavior, and condom use for STD protection; pelvic examination; and verbal STD screening are essential procedures. In contrast, a blood pressure test, breast examination, lab tests for STDs in women without symptoms, and cervical cancer screening may be appropriate for good preventive health care when indicated but are not required or not related to safe use of IUDs. Routine, mandatory lab tests such as cholesterol, glucose, and liver-function tests are irrelevant (634).

Questions and answers from the Working Group include the following:

1. Q: When can an IUD be inserted in a woman who is having menstrual cycles?

   A: Any time during the menstrual cycle, at the woman's convenience, when the provider can be reasonably sure that the woman is not pregnant (426). It is not necessary to limit insertion to the time of a woman's menstrual bleeding since there are other ways to be reasonably sure that she is not pregnant—for example, she may not have had sex since her last menstrual period or she may have been using another effective contraceptive method.

Q: When can an IUD be inserted postpartum?

A: An IUD can be inserted immediately after delivery of the placenta or at the time of cesarian section and any time up to 48 hours after delivery. IUD insertion is not advisable between 48 hours and four weeks postpartum. As early as four weeks postpartum copper IUDs can be inserted because their withdrawal insertion technique minimizes risk of uterine perforation; other types of IUDs can be inserted as early as six weeks postpartum (233, 498, 535). Breastfeeding women can safely use IUDs (508).

2. Q: Can an IUD be inserted immediately postabortion?

   A: Yes, provided the uterus is not infected. Also, an IUD can be inserted at any time during the first seven days after abortion or any other time that the provider can be reasonably sure that the woman is not pregnant. IUD insertion should be delayed in cases of: (1) evidence or reason to presume that the uterus is infected (septic); (2) serious injury to the genital tract; (3) hemorrhage leading to severe anemia (progestin-releasing IUDs can be used in cases of severe anemia because they decrease menstrual bleeding) (605).

3. Q: What is an appropriate follow-up schedule after IUD insertion?

   A: One follow-up visit should be planned for three to six weeks after IUD insertion, after the woman's next menstrual period (507). At this visit the provider should check that the IUD is still in place and that no signs of infection have developed. Further routine visits are not required (601). Women should be encouraged, however, to return at any time that they have problems, questions, or concerns (see sidebar, The GATHER Approach to Counseling About IUDs).

4. Q: Is there a need for a routine separate visit for an examination before IUD insertion?

   A: No. If at all possible, counseling, screening, and insertion all should be done at one visit, for the convenience of the client.

5. Q: Is there a minimum or maximum age for starting IUD use?

   A: There is no minimum or maximum age for IUD use. All women who use IUDs, and especially young women, should be at low risk of sexually transmitted diseases (STDs). Before choosing the IUD, a woman should understand that IUD use may involve a heightened risk of infection that could lead to infertility.

6. Q: Can women who have had no children use IUDs?

   A: Yes, but IUD expulsion, bleeding, and pain may be more likely than for women who have had children (618). A young woman who has not had children may need special help thinking through a decision on IUD use. A young woman, especially if not married, is less likely than an older, married woman to have a mutually faithful sexual relationship. Thus she faces a risk of STDs and of subsequent infertility that might be increased by IUD use. Still, understanding the possible risks, each woman should be permitted to make her own decision.

7. Q: After removing an IUD, how soon can another IUD be inserted?
        Is there a need for a rest period after using an IUD for a time?

   A: If a woman wants to continue IUD use, she can have another IUD inserted immediately after an expired IUD is removed or an IUD is expelled, so long as she does not have any uterine infection. There is no benefit in a rest period or waiting time. In fact, immediately replacing an IUD poses less risk of infection than separate removal and insertion procedures (507).

8. Q: What are valid reasons for IUD removal?

   A: 1. The woman requests removal, whatever her reason.
        2. The woman develops a complication.
        3. The effective life of the IUD has expired.

9. Q: Can an IUD be inserted without any lab tests?

   A: Yes, provided the woman is not at risk for STDs, has no clinical signs or symptoms of infection including purulent discharge, cervicitis, and pelvic inflammatory disease (PID), and is not likely to be pregnant.

10. Q: Should an IUD be removed if a woman's sexual partner complains about the IUD string?

    A: Not necessarily. The couple may need reassurance and an explanation of what the string is. If this is not satisfactory, the end of the string can be tucked behind the cervix. If this too is not satisfactory, the string can be cut flush with the cervix. (This should be noted in the woman's record.) Such short strings will mean that the woman will not be able to check the strings and a provider will need narrow forceps to grasp the strings when removing the IUD. The woman should be given the choice of what she wants done, including whether the IUD should be removed.

11. Q: If the cervix is red due to ectropion, can an IUD be inserted without further investigation?

    A: Yes, an IUD can be inserted. Ectropion is the presence of cells from inside the cervical canal appearing on the outside of the cervix, causing a reddening. This is not a sign of infection. It occurs normally and routinely during adolescence and pregnancy.

12. Q: Are heavier menstrual periods or bleeding between menstrual periods a medical reason to remove the IUD?

    A: Not necessarily. If the client wishes, or if bleeding or pain is severe, the IUD should be removed. Abnormal conditions that might cause heavy bleeding should be investigated. For most women, copper and all-plastic IUDs increase the amount of menstrual blood loss, particularly in the first few months of use. Women should be counseled to expect this. Bleeding and pain usually decrease over time. For mild to moderate bleeding and pain in the first month after insertion, a woman who wants to keep her IUD can take a short course of nonsteroidal anti-inflammatory drugs such as ibuprofen, which decrease uterine bleeding and cramping (but not aspirin, which promotes bleeding). The LNG-20 IUD reduces menstrual blood loss (see Chapter 2.5, Bleeding and Pain).

13. Q: Can specifically trained nurses and midwives insert IUDs?

    A: Yes. Nurses and midwives have learned to perform interval, postpartum, and postabortion IUD insertions successfully (see The role of nurses, midwives, and paramedics in Chapter 7.3).

14. Q: How much time should elapse between STD treatment and IUD insertion?

    A: After an STD infection has been treated and resolved, an IUD can be inserted provided the woman will not face a risk of STDs in the future. After treatment of PID, waiting three months before IUD insertion will allow healthy tissue to form.

15. Q: Should IUDs be provided if infection prevention measures cannot be followed?

    A: No. Infection prevention measures must always be followed (see sidebar, Infection Prevention for IUD Insertion and Removal). Basic infection prevention requirements for IUD insertion or removal are:

    • Aseptic technique including appropriate handwashing by the provider and careful preparation of the cervix,
    • Sterile or high-level disinfected IUDs and equipment,
    • Correct decontamination of instruments, and
    • Safe disposal of contaminated disposable items (635).

1. Q: Can the IUD travel from the woman's uterus to distant parts of her body, such as her heart or her brain?

   A: No. The IUD normally stays within the uterus. Very rarely, the IUD may come through the wall of the uterus and rest in the abdomen. This is probably due to a mistake during insertion and not to slow migration through the wall of the uterus. It never travels farther than the abdomen.

2. Q: Will the IUD prevent a woman from having babies after it is removed?

   A: No. A woman can become pregnant after her IUD is removed. But the IUD does not protect her from sexually transmitted diseases (STDs). A woman should understand that the IUD may somewhat increase her chances of getting pelvic inflammatory disease (PID) if she contracts an STD. PID could make her infertile. Therefore, it is important for a woman who uses an IUD to have sex only with one, uninfected man and for him to have sex only with her. Then she is protected from STDs.

3. Q: Should antibiotics be given routinely before IUD insertion to prevent infection?

   A: No. No benefit has been demonstrated in routine use of antibiotics at the time of IUD insertion. When the IUD is inserted correctly, using proper infection-prevention techniques (see sidebar, Infection Prevention for IUD Insertion and Removal), there is little risk of infection for healthy women. Antibiotics should be given before insertion, however, to women at high risk for endocarditis (inflammation of the membrane lining the heart). Women at high risk for endocarditis include those with symptoms of valvular heart disease, history of endocarditis, artificial heart valves, or cardiopulmonary shunt (abnormal passage of blood within the heart).

4. Q: Can a woman with diabetes use an IUD?

   A: Yes. IUDs are safe for women with diabetes. Women with diabetes are at greater risk of many infections, however. They should see a nurse or doctor if they notice possible signs of sexually transmitted disease or other infection, particularly right after IUD insertion.

5. Q: When does a copper IUD need to be replaced? A: The latest models of copper-bearing IUDs are effective for many years. The TCu-380A has been approved by the US Food and Drug Administration for 10 years of use. It probably can prevent pregnancy even longer. (Inert IUDs do not need to be removed until menopause.)

Careful infection-prevention practices are essential during IUD insertion and removal. IUDs should not be inserted or removed if infection-prevention procedures cannot be followed (634).

For insertion, infection-prevention practices involve four steps:

(1) Washing hands and then putting on gloves. Washing hands may be the single most important infection-prevention measure (614). Either new disposable gloves or gloves that have been high-level disinfected (HLD) by boiling or steaming for 20 minutes (655, 656) should be used for each new client. Gloves need not be sterile.

(2) Cleaning the cervix and vagina. After the speculum is inserted, an effective antiseptic solution should be liberally applied first to the cervix (especially the os) two or three times and then to the vagina. A water-based antiseptic should be used, such as an iodophor or chlorhexidine gluconate. Alcohol should not be used because it burns and it dries out and irritates mucous membranes, making them more susceptible to infection. When using an iodophor, such as povidone iodine (e.g., Betadine®), the provider should wait one or two minutes for these antiseptics to become effective before proceeding (614).

(3) Using the no touch insertion technique. For the TCu-380A and other IUDs that come with inserters in sterile packaging, the IUD is loaded into the inserter while both are still in the package (591). During sounding and insertion, the provider avoids touching the vaginal wall or speculum blades, which would contaminate the HDL (or sterile) uterine sound or loaded IUD. The provider passes the HDL sound and the sterile IUD, loaded in the inserter tube, each only once through the cervical canal (614). This no touch technique is easy to learn and use.

(4) After the insertion procedure, washing hands again and then processing instruments for the next use (283, 635). Similar steps—handwashing before and after, applying disinfectant to the cervix, and proper processing of instruments—also apply to IUD removal.

Processing Instruments for Reuse

(a) (b) (c)

Decontamination requires soaking soiled instruments and gloves in 0.5% chlorine (bleach) solution for 10 minutes and then rinsing several times with clean water. The bleach kills viruses including hepatitis B virus and human immunodeficiency virus (HIV), bacteria, fungi, and parasites. Surfaces contaminated with body fluids, such as table tops, should be wiped with bleach solution. Cleaning requires scrubbing instruments with a soft brush in water and detergent to remove all debris, and then rinsing well and drying (281, 283, 435). High-level disinfection can be accomplished by boiling for 20 minutes in a container with a lid (longer at high altitudes). Alternatively, instruments and gloves can be soaked for 30 minutes in activated 2% glutaraldehyde or 8% formaldehyde and then washed thoroughly in sterile or boiled water to remove the disinfectant, which can irritate the skin (281, 435). High-level disinfectants must be carefully prepared according to the manufacturer's instructions. Fresh solution should be prepared daily or more often, as needed (190, 436).

High-level disinfection, if properly carried out, destroys most microorganisms including hepatitis B, herpes simplex type 2, human papilloma virus, and HIV, which causes AIDS (96, 435). Low-level disinfectants such as benzalkonium chloride (for example, Zephiran®) and antiseptic solutions (such as Savlon®, which is a mixture of cetrimide and chlorhexidene), as well as alcohols and iodine solutions, do not quickly kill viruses and some other microorganisms and should not be used (96, 283, 635). Sterilization—that is, destroying all microorganisms, including bacterial endospores—is desirable but not necessary with instruments used for IUD insertion and removal since the instruments touch only mucous membranes and do not come in contact with the blood stream (96, 191, 436).

HLD or sterile instruments and loaded IUD inserters should be carefully handled so that they are not contaminated. Providers should touch them only with HLD or sterile gloves or instruments, and there is no need to touch the loaded IUD at all. HLD or sterile instruments can be stored dry for about a week in a HLD container with a tight-fitting lid (635).

For more information and guidance about infection-prevention practices for IUD insertion and removal, see McIntosh, N., Kinzie, B., and Blouse, A., eds. IUD guidelines for family planning service providers: A problem-solving reference manual. Baltimore, Johns Hopkins Program for International Education in Reproductive Health (JHPIEGO), 1993 (614); Tietjen, L., Cronin, W., and McIntosh, N. Infection prevention for family planning service programs. Baltimore, JHPIEGO, 1992 (635).

An IUD should not be inserted in a woman with certain lower genital tract—infections particularly acute mucopurulent cervicitis (inflammation of the cervix with pus and mucus discharge), gonorrhea, and chlamydial infection (419, 458, 565). Also, an IUD should not be inserted in a woman likely to have pelvic inflammatory disease (126, 398, 419, 437, 565). All potential IUD users should be screened for the clinical signs and symptoms of these infections. Since gonorrhea and chlamydial infection are often asymptomatic in women, family planning providers also should ask a woman if her sexual partner has symptoms, although men also may show no symptoms. The common clinical signs and symptoms of genital infections include:

Signs and Symptoms in Women

• Discharge (from the cervix or urethra) containing pus and mucus, sometimes with a cervix that bleeds easily;
• Difficult or painful (burning) urination; and
• Ulcers, sores, or swellings in the groin.

• Lower abdominal or pelvic pain*,
• Pain on manipulation of the cervix during pelvic exam*,
• Tenderness in the area of the fallopian tube or ovary on both sides of the body+,
• Oral temperature of 38.3C (100F) or higher,
• Abnormal cervical or vaginal discharge,
• Bleeding between menstrual periods.

Signs and Symptoms in Men

• Discharge from the penis containing pus and/or mucus,
• Painful (burning) urination,
• Ulcers, sores, or swellings in the groin.

This information can be copied and given to IUD users.

Very effective, convenient, long-lasting, reversible.

Little to do once the IUD is in place.

You may have cramps for the first few days, vaginal discharge or spotting for a few weeks, and somewhat heavier menstrual periods.

You can check the IUD strings to be sure the IUD is still in place. Always wash your hands first. Then, with your finger, you should be able to feel the IUD string in the vagina. Check once a week for the first month. Then check after each menstrual period. If the string feels longer, shorter, or missing, or if you feel something hard, come to the clinic. The IUD may be out of place.

The IUD is safe for most women, but some should not use the IUD.

Women who have a sexually transmitted disease (STD) or who think they might get an STD should not use IUDs. People can get STDs if they have more than one sexual partner or their sexual partner has other partners.

If you already have an IUD and now might get a sexually transmitted disease, you should use condoms along with your IUD. Also, think about switching to a different family planning method. The IUD does not prevent sexually transmitted diseases including AIDS.

Please come back...

...If you have very heavy bleeding or bad pain in the belly, especially with fever, or if you might get or have an STD, if you might be pregnant, or if the IUD might be out of place.

...Any time you have any questions, problems, or concerns. Your family planning provider is always happy to help.

...Any time you want the IUD taken out, for any reason.

You can keep your IUD for at least 10 years.

Source: Hatcher et al. 1996 (597)

There are six steps to family planning counseling (see Population Reports, Counseling Guide, J-36, December 1987). The provider can remember the steps using the English word "GATHER."

G—Greet clients. The provider greets clients politely and gives them full attention.

A—Ask clients about themselves. The provider asks clients about their family planning needs and obtains information that will help the provider advise and inform each client individually.

T—Tell clients about family planning methods. The provider lists the available family planning methods and clearly describes those that interest the client—how they work, advantages and disadvantages, and possible side effects. Even clients who immediately express a preference for the IUD or some other method should know of other available methods for future reference and so they can inform friends and family members.

H—Help clients choose a method. Some women may have already decided that they want an IUD. Others may want advice and guidance from the provider. In either case the provider helps the woman decide on a safe method that suits her needs and plans. If the method is not appropriate, the provider explains why and helps the client select another method. If there are reasons that another method would be preferable, the provider and client compare the risks and benefits of the IUD and of other contraceptive methods and consider the risks of an unintended pregnancy. The final decision to use an IUD—or any other method—must be an informed choice made by the client. If possible, involving the husband in counseling is a good idea. In an African study husbands' wishes accounted for many IUD removals after postpartum insertion (592).

E—Explain how to use the IUD. Once a woman decides to use an IUD, the provider explains:

• When, where, and how it will be inserted,
• The common side effects,
• The slight chance of more serious complications, expulsion, or unintended pregnancy,
• Reasons to return to the clinic or see another provider;
• When a copper or hormone-releasing IUD should be replaced.

It is helpful to give clients printed material to take home, particularly a card with the name and picture of the IUD, noting the date of insertion and time for removal (398). (Printed ~materials can help providers, too. During counseling and screening, flip charts, wall charts, cue cards, and checklists help providers maintain accuracy and remember what to cover, and they help clients understand.)

The client should be told if and how she will be notified when it is time for the IUD to be replaced. The family planning program should keep records for each IUD user showing the type of IUD and when it was inserted. These records should be used to answer questions from women who have forgotten when to have their IUDs replaced and to follow up users when the time for replacement approaches.

R—Return for follow-up. When a woman has an IUD inserted, she and the provider should plan for a follow-up visit three to six weeks later, after her next menses. While no further scheduled follow-up visits are required for the safe use of the IUD, the woman should be strongly encouraged to return whenever she has questions or problems or if she wants the IUD removed (319, 398). Also, she should return as soon as possible if she notices any warning signs (see sidebar, Important Information About the TCu-380A IUD). The provider should be sure that the woman knows both when and where to seek medical care (164).

At the follow-up visit three to six weeks after IUD insertion, the provider should ask about any menstrual problems, pain, or expulsion. A pelvic examination can be performed not only to check for the IUD strings but also to look for signs of pelvic infection, which is most likely to occur within the first weeks after insertion (see Chapter 5, Infection) (7, 82, 436). The provider also should reassure the client about any common side effects, remind her of the warning signs of IUD complications, and address any other concerns or questions she might have.

Research has demonstrated that there is no reason to require IUD users to return to the clinic repeatedly at regular intervals when they are having no problems. In a study of more than 11,700 routine follow-up clinic visits by IUD users, only 72 visits detected a need for IUD removal that the clients themselves would not have recognized (601). Avoiding unnecessary routine visits saves resources to provide important services to other clients. IUD users are likely to benefit more if they are made to feel welcome to return at any time that they have problems, questions, or concerns.

To handle serious complications, programs should make arrangements with a referral medical center. The center should be staffed with surgeons and gynecologists and have facilities for diagnostic and surgical procedures (436).

Health care providers should remove copper-bearing and hormonal IUDs when the IUD reaches the end of its approved lifespan if it has not been removed sooner at the woman's request or for medical reasons. A new IUD can be inserted immediately afterwards, without any waiting period, if a woman wants to continue using an IUD. If a woman is having no problems, the Lippes Loop and other nonmedicated IUDs do not need to be removed until menopause (7, 162). After menopause removal may be difficult because the uterus shrinks and narrows (179). Of course, removal should be available promptly whenever a woman requests it and whatever her reason.

When a new IUD is being introduced, women using a different IUD may want to replace it with the new one. Because most IUD complications and pregnancies are most common just after insertion, changing IUDs unnecessarily should be discouraged. A woman should be encouraged to wait until her current IUD reaches the end of its approved lifespan or until it must be removed for other reasons.

A World Health Organization (WHO) scientific working group recently developed up-to-date recommended eligibility criteria for all major contraceptive methods including IUDs (565). The group based its recommendations on an assessment of research findings. To date, lists of eligibility criteria, or contraindications, in IUD training protocols have differed widely (574). The consensus reached by the WHO group of scientists from around the world should help resolve these conflicts.

The WHO scientific group classified medical conditions into four categories. In situations where doctors and nurses are not available to assess specific cases, these four categories can be simplified into two categories—conditions in which the method is safe and effective, and conditions in which the method should not be used.

These criteria refer to a client's characteristics or known preexisting medical conditions. For the most part, these characteristics or conditions can be detected by asking the client questions or, in the case of IUDs, making observations during the pelvic examination. Other physical examination or laboratory tests generally are not necessary.

Eligibility criteria for starting use of a copper-bearing IUD, as categorized by the WHO scientific working group, are as follows:

These conditions do not restrict use of copper-bearing IUDs:

1. Had pelvic inflammatory disease (PID) in the past, has been pregnant since, and is not now at risk of STDs.
2. Past ectopic pregnancy.
3. Irregular menstrual patterns without heavy bleeding.
4. Just had an IUD removed because its period of effectiveness had ended.
5. IUD was expelled and client wants to try again.
6. Just had first-trimester abortion or miscarriage and no infection or risk of infection.
7. Breastfeeding.
8. Previous cesarian section.
9. Diabetes.
10. Current or past cardiovascular diseases or cardiovascular problems caused by diabetes; high blood pressure; stroke; deep or superficial venous thrombosis; pulmonary embolism; valvular heart disease without complications; ischemic heart disease; hyperlipidemia.
11. Headaches, including severe headaches and migraines.
12. Current or past breast cancer or benign breast disease.
13. Current or past liver or gallbladder disease.
14. Malaria; schistosomiasis; tuberculosis (other than pelvic tuberculosis); viral hepatitis.
15. Obesity.
16. Smoking.
17. Epilepsy.
18. Cervical intraepithelial neoplasia or cervical ectropion.
19. Thyroid conditions.
20. History of preeclampsia.
21. Benign ovarian tumors including cysts.

Advantages generally outweigh theoretical or proven disadvantages, and copper-bearing IUDs generally can be provided without restriction in these conditions:

1. Less than 48 hours postpartum.
2. Had pelvic inflammatory disease in the past, has not been pregnant since, and is not now at risk of STDs.
3. Childless or age 20 or younger. IUD expulsion more likely than in older women or women with children.
4. Heavy or prolonged menstrual bleeding without clinical signs of anemia.
5. Severe menstrual cramps.
6. Iron-deficiency anemia.
7. Uterine fibroids, very narrow cervical canal, cervical lacerations, or other anatomical abnormality that does not distort the uterus.
8. Vaginitis without purulent cervicitis.
9. Endometriosis.
10. Valvular heart disease with complications. (The woman should take antibiotics before IUD insertion.)
11. Sickle cell disease.
12. Thalassemia.
13. Just had a second-trimester abortion.

1. High risk for STDs (that is, currently has or likely will have more than one sexual partner or a partner who has more than one partner).
2. Heavy menstrual bleeding with clinical signs of anemia.
3. Between 48 hours and four weeks postpartum.
4. HIV infection or AIDS or high risk for HIV infection.
5. Benign trophoblast disease.

Conditions that rule out use of copper-bearing IUDs:

1. Pregnancy.
2. Active STD (including purulent cervicitis) or PID now or in the last three months.
3. Sepsis following childbirth or abortion.
4. Until evaluated, abnormal vaginal bleeding that suggests a serious medical condition.
5. Severely distorted uterine cavity that prevents proper IUD insertion.
6. Cervical, endometrial, or ovarian cancer awaiting treatment; malignant trophoblast disease.
7. Pelvic tuberculosis.