• Careful infection-prevention procedures, including cleaning the cervix during IUD insertion, and careful checking, at the follow-up visit, for signs of infection (see Chapter 3, and sidebar, Infection Prevention for IUD Insertion and Removal);

• Careful screening to assure that women who choose IUDs face little risk of STDs. Screening involves both asking questions and conducting a pelvic examination. Because PID is linked to sexually transmitted diseases, the best candidate for an IUD is a woman living in a stable, mutually faithful sexual relationship (127, 437, 442). Providers can ask questions to find out about a woman's patterns of sexual behavior. During the pelvic exam, the provider can check for signs of cervical infection. Cervical infection should be treated, if possible. Once the infection is resolved, the IUD can be inserted, provided the woman will not face a high risk of STDs in the future.

• Use long-lasting IUDs and do not remove them unless a woman requests removal, complications develop, or the IUD reaches the end of its effectiveness (634). Since much of the increase in risk of PID is linked to IUD insertion, the longer-lasting the IUD, the less need for periodic replacement and the less risk of infection over the long term. From this perspective, a very long-acting IUD, such as the TCu-380A, is the best IUD for the woman who wants many years of contraceptive protection.

IUDs without strings also have been considered. The evidence is conflicting. Two laboratory studies of IUDs removed from women reported more bacterial colonization on IUDs with monofilament strings than on IUDs without strings (350, 434). In addition, two studies comparing women using IUDs with and without monofilament strings reported a difference in rates of infection (92, 493), as did research on inserting the IUD strings into the uterus together with the device (536). An international clinical trial of 1,265 women randomly assigned TCu-200 IUDs with and without strings, however, found no significant difference in the incidence of PID, STDs, or other infections or inflammation (538). Other clinical trials also have not found an association between the presence of strings and the incidence of infection (38, 68, 114, 210, 428).

Many authorities recommend that, if a woman develops PID while using an IUD, it should be removed 24 to 48 hours after she starts taking antibiotics (7, 93, 368, 397, 420, 437, 559). Three small studies comparing women whose IUDs were removed and those whose IUDs were left in place after a diagnosis of PID found little difference in their course of recovery, however (346, 525, 554). In fact, women whose IUDs were removed had longer hospital stays than women whose IUDs were left in place in two of the studies (525, 554). A WHO scientific group recently advised that the IUD might be allowed to remain in place if the woman no longer faces a high risk of STD infection and she understands the risks of repeated PID (565).