Published by the Population Information Program, Center for Communication Programs, The Johns Hopkins School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202-4012, USA

The intrauterine devices (IUDs) now available offer almost complete protection from pregnancy. Some models are effective longer than any other reversible family planning method. Correctly inserted, IUDs are safe for women at low risk of sexually transmitted disease. In fact, because IUDs prevent pregnancy so well, they save many lives.

Large international comparisons continue to collect evidence that IUDs are both safe and effective for long periods of time. In 1994 the United States Food and Drug Administration approved the TCu-380A IUD for use up to 10 years, recognizing it as the longest-lasting copper IUD. The TCu-380A is now the most widely available IUD and one of the most effective methods of contraception ever developed. In large studies fewer than one woman per 100 became pregnant in the first year of use and, in the longest comparative study, only 2.1 per 100 became pregnant in 10 years of use.

In practice the TCu-380A and other currently available IUDs—the TCu-220C, the Multiload-375, the Nova T, and the LNG-20—are more effective than oral contraceptives and on a par with injectables, implants, and voluntary sterilization. The hormone-releasing LNG-20 IUD, now approved in 10 countries, may be the most effective of all IUDs, with just 0.3 pregnancies per 100 women after five years of use.

Because modern IUDs prevent pregnancy so effectively, they avert many maternal deaths. Thus IUDs rank among the best family planning methods for protecting women's lives.

Recent research has helped to lift a cloud that hung over the IUD in the 1980s. It is now clear that an increased risk of pelvic inflammatory disease, or PID (infection in the upper genital tract), is concentrated in the first month after IUD insertion and among women exposed to sexually transmitted diseases (STDs). Also, there appears to be virtually no increased risk of infertility for a woman using a copper IUD who has a mutually monogamous relationship and thus is not exposed to STDs. Recent research suggests that IUDs work by preventing sperm and egg from joining. Evidence shows that copper and all-plastic IUDs help protect against ectopic pregnancy while in use.

Better scientific understanding has enabled experts to recommend updated guidance for providing IUDs. These recommendations eliminate unscientific limits on IUD use and better define who can use IUDs safely. For example:

• IUDs can be inserted at any time during the menstrual cycle if it is reasonably certain the woman is not pregnant.
• Current genital infection and high STD risk rule out IUD use, but past ectopic pregnancy and past PID do not.
• IUDs should be inserted only where infection-prevention procedures can be followed.
• Only one follow-up visit is necessary—three to six weeks after insertion to check for infection and expulsion. Still, IUD users should be encouraged to return any time they have questions or concerns or want the IUD taken out.
• A woman of any age can use an IUD, so long as she will face little risk of acquiring STDs.
• A rest or a wait for reinsertion is pointless, could increase PID risk, and is wasteful for both clients and programs.
• Properly trained providers can safely insert IUDs immediately after childbirth or early abortion.
• With training, not only doctors but also nurses, midwives, and other health care providers can safely insert IUDs.

The provider's good judgment, training, and skill help ensure:

(1) Screening to see that women who have STDs or are at high risk of STDs do not use IUDs.
(2) Careful and gentle insertion using high-level disinfected instruments, a sterile IUD, and "no touch" insertion technique. This minimizes pain at insertion and the chances of infection, perforation, pregnancy, and expulsion.
(3) Use of the longest-lasting IUD that meets a woman's needs, to minimize any PID risk associated with re-insertion.
(4) Informative and empathetic counseling. An IUD user needs to know when her IUD should be replaced, to return any time if she has any problems or questions, and that the IUD does not protect her against AIDS and other STDs.