Series B, Number 7
Intrauterine Devices

CONTENTS

Home (Key Points)

The IUD: An Important Method with Potential
Table 1. Overview of IUDs
Figure 1. Most IUD Users Are in China
Web Table 1. Current Use of Contraceptive Methods Reported by Married Women 15-49, 1976-2005
Table 2. Estimated Worldwide Use of IUDs Among Married Women Ages 15–49, 2005

Providing High-Quality IUD Services

Spotlight: Kenya Commits To Renewing Interest in the IUD

Feature: Good Counseling Increases Client Satisfaction

Very Low Overall Risk of Infection with IUDs
Figure 2. Risk of Pelvic Inflammatory Disease (PID) Greatest in First Few Weeks After IUD Insertion

Box: Evidence Shows Many Women with HIV Can Use IUDs

Minimizing the Risk of Infection

Clinical Characteristics of IUDs
Web Box 1. Managing Problems with IUD Use

Bibliography

Credits

Go to the IUD Toolkit at http://www.iudtoolkit.org for full-text resources, including tools and best practices, on IUDs.

• Checklist: Program Plan for Providing High-Quality IUD Services
• Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, from Family Health International
• Counseling Aid for Communicating IUD Effectiveness

• IUD Use, STIs, and HIV-Related Conditions: 2004 WHO Medical Eligibility Criteria
• Do IUDs Increase the Risk of PID in Women with STIs?

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Minimizing the Risk of Infection

• Risky Behaviors Can Suggest a Woman’s Risk of STIs
• Pelvic Exam Detects Some but Not Most Cervical Infections
• Care Can Reduce Infection Risk at IUD Insertion

Laboratory tests for STIs could contribute to safer use of IUDs (269), WHO notes, but such tests usually are not feasible for lack of facilities, equipment, and trained personnel (265). Programs and providers need to balance the risks of not performing the tests against the benefits of making the IUD available (269). Refusing women the choice of IUDs in the absence of laboratory tests for STIs would deny the great majority a method they could use safely and would create an unnecessary medical barrier.

Since STI tests usually are not available, WHO guidance considers STI risk assessment and physical examination essential to safe use of IUDs (269). Risk assessment conventionally has been based on the client’s answers to a provider’s questions about her and her partner’s sexual behavior. Having the client assess her own risk of STIs is another approach.

While risk assessment seems focused on whether a woman might get an STI in the future, its real purpose as far as IUD insertion is concerned is to gauge whether she might have a gonorrheal or chlamydial infection now, which would rule out IUD insertion. A pelvic exam will identify some women with gonorrhea or chlamydia, but these infections often have no symptoms in women. Therefore a pelvic exam that finds no symptoms does not, by itself, rule out infection.

Risky Behaviors Can Suggest a Woman’s Risk of STIs

Difficulty arises in deciding what indicates very high individual risk of STIs, and in particular of gonorrhea or chlamydia. Indicators of STI risk differ among communities, depending on patterns of sexual behavior and other factors (147, 162, 265). Few family planning programs, however, have the resources to develop locally validated tools to assess women’s individual risk of STIs.

In these situations the best that providers may be able to do is to discuss the behaviors or situations in their communities that they think are most likely to expose women to STIs. Examples of common risky behaviors include:

• Diagnosed with an STI in the last three months
• Partner diagnosed with an STI in the last three months
• Partner with STI symptoms such as pain or burning during urination, an open sore in the genital area, or pus coming from his penis
• More than one sexual partner in the last three months without always using condoms
• Unprotected sex with partner who has had more than one partner in the last three months (305).

Certain situations suggest the possibility of these risky behaviors. For example, if a man works far from home for long periods of time, he is more likely to have had other sex partners. Providers can address the situations that are locally relevant based on their knowledge of their clients or on program or clinic guidelines.

Programs might find a checklist developed by Family Health International to screen potential IUD clients helpful (see 'Checklist for Screening Clients Who Want to Initiate Use of the Copper IUD, from Family Health International'). Using the checklist, the provider can assess whether the client has any conditions that would rule out IUD use—first by asking the client a series of yes-or-no questions and then by performing a pelvic exam. Some of the questions that the provider asks the client are related to her STI risk, based on the risky behaviors mentioned above. If her answers do not suggest very high individual risk of exposure to STIs, the provider goes on to examine the cervix for signs of infection just before the IUD would be inserted.

Pelvic Exam Detects Some but Not Most Cervical Infections

Where laboratory testing is not available, WHO recommends that providers conduct a careful speculum examination to look for signs of gonorrhea or chlamydia. These signs are:

• Mucopurulent discharge (yellowish discharge containing mucus and pus);
• The cervix bleeds easily when touched with a swab; or
• A positive swab test—a swab of cells collected from the cervical canal appears yellow when held against white paper (270). (Some experts do not think the swab test is helpful in detecting cervical infections (123, 172, 185, 202) because it takes into account only color and not consistency of the discharge (123) and because it requires providers trained to assess swabs (185). )

WHO recommends that the provider treat a woman who has any of these three signs for both gonorrhea and chlamydia and delay IUD insertion until she completes the full course of treatment and no longer shows any sign of infection (270).

Most women’s infections have no symptoms, however. Research finds that these three signs detect only 30% to 40% of cervical infections under ideal study conditions. Providers working under typical clinical conditions may detect an even lower percentage of infections (270). To date, there is no simple, inexpensive, and accurate alternative to laboratory diagnostic tests for STIs.

Women’s assessment of their own STI risk may indicate current infection better than the results of a physical examination, once women know what risky behavior is. In a Mexico City study family planning clients took part in 20 minute one-on-one information sessions with a nurse. The sessions covered different contraceptive methods including the IUD, STIs, and risky behavior. Each woman then selected the contraceptive method that she thought was most appropriate for her. Meanwhile, physicians noted whether or not these women should receive IUDs based only on findings from a physical examination including pelvic exam. Laboratory tests of the women’s cervical specimens indicated that 2% of the women had gonorrhea or chlamydia. The physicians had inappropriately approved IUD use for 87% of these women. A much lower percentage of the women themselves—48% of those who had gonorrhea or chlamydia—chose the IUD inappropriately (118).

Care Can Reduce Infection Risk at IUD Insertion

Providers can reduce the risk of infection during IUD insertion, and thus minimize infection-related complications, by:

• Assessing or asking the client to assess whether she faces very high individual risk of exposure to STI .
• Just before inserting the IUD, conducting a careful speculum examination to look for signs of cervical infection.

• One step in the "no touch" insertion technique is loading the IUD in the inserter while both are still in the sterile package. The "no touch" technique minimizes the risk of contaminating the uterus during IUD insertion. Proper IUD insertion minimizes the risks of many complications of IUD use. From JHPIEGO, IUD guidelines for family planning service programs: A problem-solving manual

  Carefully following routine infection-prevention procedures for pelvic examinations and IUD insertion, including the “no-touch” insertion technique—that is, not letting the loaded IUD or uterine sound touch any unsterile surfaces (for example, hands, speculum, vaginal wall, table top). This involves (1) loading the IUD into the inserter while both are still in the sterile package, to avoid touching the IUD directly, and (2) passing the uterine sound and the loaded IUD through the opening of the cervix each one time only, while avoiding touching the vaginal wall or speculum blades (102). Also, if no other procedure, such as taking a swab of cervical cells, is planned, conducting the bimanual exam before the cervical inspection avoids inserting the speculum twice and lessens discomfort for the client (95).
• Not replacing IUDs unnecessarily, before their effective lifetime expires, to reduce the number of removals and reinsertions for long-term users.
• Considering use of prophylactic antibiotics just before insertion in settings where gonococcal and chlamydial infections are common and STI screening is limited, while recognizing that routine use of such prophylaxis is not recommended (269). (Some experts go further and recommend presumptive treatment for chlamydia and gonorrhea before insertion, which involves giving IUD clients a full course of antibiotics rather than a lower prophylactic dose (82). The optimal dose for prophylaxis to prevent PID is unknown (300). )
• Counseling all IUD users about signs and symptoms of STIs and PID and advising them to come back immediately if any develop.
• Asking about symptoms of infection at the scheduled routine follow-up visit (three to six weeks after insertion) and performing a pelvic exam if there is a reason to suspect infection. If signs of infection are present, treating the infection in a timely manner and allowing the client to keep her IUD in place during treatment. Screening and early treatment help prevent progression of STIs to PID (89, 91, 159, 197, 256).