IUDs: Dispelling the Myths

1. IUDs: Dispelling the Myths Objectives: List the indications and contraindications to IUD use Describe the pros and cons of hormonal vs. non-hormonal IUD use Explain the role of higher efficacy, non-user dependent, contraceptive methods like the IUD in the prevention of unintended pregnancy Objectives: List the indications and contraindications to IUD use Describe the pros and cons of hormonal vs. non-hormonal IUD use Explain the role of higher efficacy, non-user dependent, contraceptive methods like the IUD in the prevention of unintended pregnancy

2. 62 million women/teens of childbearing age in US 43 million are sexually active and do not want to become pregnant. 93% of them use some form of contraception. There are 6 million pregnancies per year in the US. About percent of contraception: women ever using contraception 98%; women 15-44 using contraception 62% (includes pregnant, infertile), calculated number of women who could get pregnant NOT using contraception: 7% (all guttmacher stats from Contraception Fact sheet) � 2002; so I changed the percent to 93% (instead of 95%) About percent of contraception: women ever using contraception 98%; women 15-44 using contraception 62% (includes pregnant, infertile), calculated number of women who could get pregnant NOT using contraception: 7% (all guttmacher stats from Contraception Fact sheet) � 2002; so I changed the percent to 93% (instead of 95%)

3. Most unintended pregnancies occur when women fail to use contraceptives or use their method inconsistently. Slightly more than half of unintended pregnancies occur among women who used no method of contraception during the month in which they conceived, and more than four in 10 occur among women who used a method inconsistently or incorrectly. Only one in 20 are attributable to method failure. Slightly more than half of unintended pregnancies occur among women who used no method of contraception during the month in which they conceived, and more than four in 10 occur among women who used a method inconsistently or incorrectly. Only one in 20 are attributable to method failure.

4. Contraceptive Methods: US From Guttmacher 2010 IUD is gaining traction - now up to 5.5%From Guttmacher 2010 IUD is gaining traction - now up to 5.5%

5. Shani is a 21 year old G2P2 single mother who returns for her 6 week post-partum visit, telling you that she wants to get her tubes tiedShani is a 21 year old G2P2 single mother who returns for her 6 week post-partum visit, telling you that she wants to get her tubes tied

6. Looked at >11,000 women who had sterilization under 30 yrs, 20.3% regretted; older than 30, 5.9% regretted. Women in study up to 14 yrs post-procedure Hillis, SD, et al. (1999) Poststerilization Regret: Findings From the United States Collaborative Review of Sterilization. Obstet Gynecol. 93:889-895. Looked at >11,000 women who had sterilization under 30 yrs, 20.3% regretted; older than 30, 5.9% regretted. Women in study up to 14 yrs post-procedure Hillis, SD, et al. (1999) Poststerilization Regret: Findings From the United States Collaborative Review of Sterilization. Obstet Gynecol. 93:889-895.

7. There is a big disparity in the US regarding sterilization and education level: women with less education are more likely to get a BTL than an IUD. Education level is a proxy for socioeconomic status. National Survey of Family Growth, 2004 Discuss - is this provider bias? There is a big disparity in the US regarding sterilization and education level: women with less education are more likely to get a BTL than an IUD. Education level is a proxy for socioeconomic status. National Survey of Family Growth, 2004 Discuss - is this provider bias?

8. Lower discontinuation rates in post-partum women 6 weeks postpartum is a good time to insert (WHO says can be done at 4 weeks) Increased expulsion from 2 days to 6 weeks postpartum Non-patient-dependent method enhances adherence Chi � immediately post partum had lower rates of expulsion than delayed PP Chi, IC, et al, Performance of the copper T-380A intrauterine device in breastfeeding women, Contraception 39(6):603-18. 1989 Grimes, D et al. Immediate postpartum insertion of intrauterine devices. Cochrane Review, 2005 Chi � immediately post partum had lower rates of expulsion than delayed PP Chi, IC, et al, Performance of the copper T-380A intrauterine device in breastfeeding women, Contraception 39(6):603-18. 1989 Grimes, D et al. Immediate postpartum insertion of intrauterine devices. Cochrane Review, 2005

9. Laparoscopic BTL $3545 Essure $2367 Oral contraceptive $2579 3-month injectable $2195 IUD Copper $1646 Levonorgestrel $1678 Chiun-Fang, Trussel, et al (2003). �Economic analysis of contraceptives for women.� Contraception. 68(1): 3-10. Kraemer DF Contraception. 2009 Sep;80(3):254-6 for the BTL and Essure - and these are insertion costs only Chiun-Fang, Trussel, et al (2003). �Economic analysis of contraceptives for women.� Contraception. 68(1): 3-10. Kraemer DF Contraception. 2009 Sep;80(3):254-6 for the BTL and Essure - and these are insertion costs only

10. Contraceptive CHOICE Project Study in St. Louis where cost barriers to LARC removed 2500 women enrolled so far 66% chose a LARC method 56% chose IUC 11% chose implant

11. Intrauterine Devices There are 2 IUDS available in the US: the copper IUD and the progestin IUD. They�re both safe and highly effective. They�re both underused � especially in poor women & teens. Because IUDs� side effects & advantages differ, we use a simple info sheet to help patients choose between the 2 types. Copper IUD can be used for 7 days as emergency contraception after unprotected sex. Progestin IUD CANNOT be used for EC. References: Hubacher D, Cheng D. Intrauterine devices and reproductive health: American women in feast and famine. Contraception. 2004 Jun;69(6):437-46. Hatcher RA, Zieman M et al. A Pocket Guide to Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2004 Mirena: 5 yr cumulative failure rate is .7% 7 yr cumulative failure rate is 1.1% References: Sivin, et al. Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS. Contraception. 1991 Nov;44(5):473-80. Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J, Oda K, Borenstein J. Economic analysis of contraceptives for women. Contraception. 2003;68(1):3-10. . There are 2 IUDS available in the US: the copper IUD and the progestin IUD. They�re both safe and highly effective. They�re both underused � especially in poor women & teens. Because IUDs� side effects & advantages differ, we use a simple info sheet to help patients choose between the 2 types. Copper IUD can be used for 7 days as emergency contraception after unprotected sex. Progestin IUD CANNOT be used for EC. References: Hubacher D, Cheng D. Intrauterine devices and reproductive health: American women in feast and famine. Contraception. 2004 Jun;69(6):437-46. Hatcher RA, Zieman M et al. A Pocket Guide to Managing Contraception. Tiger, Georgia: Bridging the Gap Foundation, 2004 Mirena: 5 yr cumulative failure rate is .7% 7 yr cumulative failure rate is 1.1% References: Sivin, et al. Prolonged intrauterine contraception: a seven-year randomized study of the levonorgestrel 20 mcg/day (LNg 20) and the Copper T380 Ag IUDS. Contraception. 1991 Nov;44(5):473-80. Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J, Oda K, Borenstein J. Economic analysis of contraceptives for women. Contraception. 2003;68(1):3-10. .

12. IUDs are NOT abortifacients!

13. Copper-releasing IUD (ParaGuard�):  380 mm2 copper on plastic T ? mainly spermicidal effects The copper IUD prevents pregnancy by: Interfering with sperm motility. Causing spermicidal foreign-body reaction. Altering uterine environment, making endometrium �hostile� to sperm. Rivera, R. (1999). "The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices." American Journal of Obstetrics & Gynecology 181(5): 1263-1269The copper IUD prevents pregnancy by: Interfering with sperm motility. Causing spermicidal foreign-body reaction. Altering uterine environment, making endometrium �hostile� to sperm. Rivera, R. (1999). "The mechanism of action of hormonal contraceptives and intrauterine contraceptive devices." American Journal of Obstetrics & Gynecology 181(5): 1263-1269

14. Hormone-releasing IUD (Mirena�): 52 mg of levonorgestrel on its arms and stem released at a rate of 20 mcg /day ? thickens cervical mucus inhibits ovulation The progestin IUD prevents pregnancy by: Thickening cervical mucus (acting as a physical barrier) Inhibiting sperm capacitation & survival Thinning uterine lining Partially inhibiting ovulation Barbosa, I. (1995) Ovarian function after seven years' use of a levonorgestrel IUD. Advances in Contraception. 11(2):85-95.The progestin IUD prevents pregnancy by: Thickening cervical mucus (acting as a physical barrier) Inhibiting sperm capacitation & survival Thinning uterine lining Partially inhibiting ovulation Barbosa, I. (1995) Ovarian function after seven years' use of a levonorgestrel IUD. Advances in Contraception. 11(2):85-95.

15. Maggie is a 35 year old heavy smoker with a new partner who wants to have a child with her. She does not want to have more children and wants a method he won�t notice.Maggie is a 35 year old heavy smoker with a new partner who wants to have a child with her. She does not want to have more children and wants a method he won�t notice.

16. Nulliparity No restriction for either IUD Smoking: regardless of amount No restriction for either IUD WHO gives women < 20 category 2. Concern centers around risk of expulsion, STI risk in younger populations Also a �2� for nulliparity in 2009 edition Still a �2� in the 2009 edition� WHO. Medical eligibility criteria for contraceptive use - 4th edition, 2009. WHO gives women < 20 category 2. Concern centers around risk of expulsion, STI risk in younger populations Also a �2� for nulliparity in 2009 edition Still a �2� in the 2009 edition� WHO. Medical eligibility criteria for contraceptive use - 4th edition, 2009.

17. 1 Method can be used without restriction 2 Advantages generally outweigh theoretical or proven risks 3 Method not usually recommended unless other, more appropriate methods are not available or not acceptable 4 Method not to be used 1 Method can be used without restriction 2 Advantages generally outweigh theoretical or proven risks 3 Method not usually recommended unless other, more appropriate methods are not available or not acceptable 4 Method not to be used

18. Is discreet. Patient and partner do not feel IUD body. Although unlikely, partner may feel strings. Data is out there for not being bothered by the IUD (or feeling the T), but some partners feel the strings. Data is out there for not being bothered by the IUD (or feeling the T), but some partners feel the strings.

19. Pregnancy Uterine infection Unexplained vaginal bleeding *** Cervical or endometrial cancer (awaiting treatment) *** Breast cancer (Progestin IUD only) Trophoblastic disease Current PID or STD *** Pelvic Tuberculosis *** Initiation is category 4, continuation is category 2 WHO medical eligibility 2009WHO medical eligibility 2009

20. Krystal is a 24 year old G2P1 who presents to the office requesting birth control. She had chlamydia twice as a teenager. Krystal is a 24 year old G2P1 who presents to the office requesting birth control. She had chlamydia twice as a teenager.

21. IUDs do NOT increase rates of STIs. PID rate rises for 20 days after IUD insertion, then declines to baseline population levels. STI rate depends on local prevalence In high-prevalence areas, it makes sense to screen for STIs at IUD insertion Do NOT remove IUD for STI treatment No need for antibiotic prophylaxis at IUD insertion Even lower PID rates with good insertion technique and low baseline STI rate Modern IUD strings do not facilitate ascent of infection Do not remove IUD for initial PID treatment PID incidence <1 in 1000 women Farley, TM (1992). Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 339: 785-788. Grimes DA, et al (1999). Prophylactic antibiotics for intrauterine device insertion: a meta-analysis of the randomized controlled trials. Contraception. 60:57�63. Cochrane review Oct 2009 STI rate depends on local prevalence In high-prevalence areas, it makes sense to screen for STIs at IUD insertion Do NOT remove IUD for STI treatment No need for antibiotic prophylaxis at IUD insertion Even lower PID rates with good insertion technique and low baseline STI rate Modern IUD strings do not facilitate ascent of infection Do not remove IUD for initial PID treatment PID incidence <1 in 1000 women Farley, TM (1992). Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 339: 785-788. Grimes DA, et al (1999). Prophylactic antibiotics for intrauterine device insertion: a meta-analysis of the randomized controlled trials. Contraception. 60:57�63. Cochrane review Oct 2009

22. Current PID or current gonorrhea or chlamydia: �4� for insertion. PID, gc, chlamydia: �2� for continuation. Trichimonas and Bacterial Vaginosis: �2� for insertion. HIV infected or clinically well on ARV: �2� Very high risk for STI or HIV, not well, �3� for insertion, �2� for continuation WHO. Medical eligibility criteria for contraceptive use - 4th edition, 2009Current PID or current gonorrhea or chlamydia: �4� for insertion. PID, gc, chlamydia: �2� for continuation. Trichimonas and Bacterial Vaginosis: �2� for insertion. HIV infected or clinically well on ARV: �2� Very high risk for STI or HIV, not well, �3� for insertion, �2� for continuation WHO. Medical eligibility criteria for contraceptive use - 4th edition, 2009

23. Kerry is a 28-year-old who has had one abortion and who has type 1 diabetes and borderline blood pressure. She is in a steady relationship and does not want to get pregnant.Kerry is a 28-year-old who has had one abortion and who has type 1 diabetes and borderline blood pressure. She is in a steady relationship and does not want to get pregnant.

24. Women with most chronic medical illnesses can use IUDs. Rogovskaya, S (2005). Effect of a levonorgestrel intrauterine system on women with type 1 diabetes: a randomized trial. Obstetrics and Gynecology. 105 (4): 811-815. WHO. Medical eligibility criteria for contraceptive use - 4th edition, 2009. Women with most chronic medical illnesses can use IUDs. Rogovskaya, S (2005). Effect of a levonorgestrel intrauterine system on women with type 1 diabetes: a randomized trial. Obstetrics and Gynecology. 105 (4): 811-815. WHO. Medical eligibility criteria for contraceptive use - 4th edition, 2009.

25. Nulliparity is NOT a contraindication to IUD use! Educate nulligravid women about increased risk of expulsion WHO gives nulliparity a category 2 WHO. Medical eligibility criteria for contraceptive use - 4th Edition 2009 Grimes, DA. �Intrauterine Devices�. Contraceptive Technology. NY: Ardent Media, 2004, pp. 495-530. ACOG Practice Guideline suggests IUDs should be considered as first line choice for teens: No 392, Dec 2007Educate nulligravid women about increased risk of expulsion WHO gives nulliparity a category 2 WHO. Medical eligibility criteria for contraceptive use - 4th Edition 2009 Grimes, DA. �Intrauterine Devices�. Contraceptive Technology. NY: Ardent Media, 2004, pp. 495-530. ACOG Practice Guideline suggests IUDs should be considered as first line choice for teens: No 392, Dec 2007

26. Tammy is a 35 y/o G8P3 with very heavy periods resulting in anemia, who is considering an IUD. She comes in today, LMP was 10 days ago.Tammy is a 35 y/o G8P3 with very heavy periods resulting in anemia, who is considering an IUD. She comes in today, LMP was 10 days ago.

27. Spotting, bleeding, and cramping: Increased in 1st 3 months Amenorrhea: 20% of users by 1 year, 60% by 5 years The most common side effects are spotting & amenorrhea. Expulsion: 2-12% in 1st yr Perforation: <0.01% at time of insertion Headaches, acne, mastalgia: < 3% in 1st months Grimes, DA. �Intrauterine Devices�. Contraceptive Technology. NY: Ardent Media, 2004, pp. 495-530. Managing Contraception Hubacher D, Grimes DA. Obstet Gynecol Surv. 2002;57(2):120-8. Crosignani PG, Vercellini P, Mosconi P, et al. Obstet Gynecol. 1997;90(2):257-63. Hurskainen R, Teperi J, Rissanen P, et al. Lancet. 2001;357:273-7. Varila E, Wahlstrom T, Rauramo I. Fertil Steril. 2001;76(5):969-73. Chiou CF, Trussell J, Reyes E, et al. Contraception. 2003;68(1):3-10.The most common side effects are spotting & amenorrhea. Expulsion: 2-12% in 1st yr Perforation: <0.01% at time of insertion Headaches, acne, mastalgia: < 3% in 1st months Grimes, DA. �Intrauterine Devices�. Contraceptive Technology. NY: Ardent Media, 2004, pp. 495-530. Managing Contraception Hubacher D, Grimes DA. Obstet Gynecol Surv. 2002;57(2):120-8. Crosignani PG, Vercellini P, Mosconi P, et al. Obstet Gynecol. 1997;90(2):257-63. Hurskainen R, Teperi J, Rissanen P, et al. Lancet. 2001;357:273-7. Varila E, Wahlstrom T, Rauramo I. Fertil Steril. 2001;76(5):969-73. Chiou CF, Trussell J, Reyes E, et al. Contraception. 2003;68(1):3-10.

28. Improves cramps & menorrhagia Causes 90% decrease in overall blood loss Decreases number of invasive treatments for DUB, fibroids Decreases risk of ectopic pregnancy May protect against endometrial cancer, STIs Decreases perimenopausal symptoms The progestin IUD (LNG IUS) has been used as an alternative to endometrial ablation or hysterectomy in the treatment of menorrhagia. One clinical trial found that the LNG IUS was as effective as endometrial ablation at reducing blood loss when assessed one year after insertion A five-year study found that the hysterectomy cancellation rate was much higher for users of the LNG IUS than for other patients (80 percent versus 9 percent). The LNG IUS is approved for the treatment of menorrhagia in many countries and may be approved in the United States for this indication in the near future. The LNG IUS also has been investigated for use as a substitute for oral progestin in hormone therapy for postmenopausal women and is approved for this indication in many countries. One study followed postmenopausal women who used oral or transdermal estrogen with the LNG IUS continuously for five years. Histological examination demonstrated that the LNG IUS protected the women against endometrial hyperplasia. References: Hubacher D, Grimes DA. Noncontraceptive health benefits of intrauterine devices: a systematic review. Obstet Gynecol Surv. 2002;57(2):120-8. Crosignani PG, Vercellini P, Mosconi P, Oldani S, Cortesi I, De Giorgi O. Levonorgestrel-releasing intrauterine device versus hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding. Obstet Gynecol. 1997;90(2):257-63. Hurskainen R, Teperi J, Rissanen P, Aalto AM, Grenman S, Kivela A, Kujansuu E, Vuorma S, Yliskoski M, Paavonen J. Quality of life and cost-effectiveness of levonorgestrel-releasing intrauterine system versus hysterectomy for treatment of menorrhagia: a randomised trial. Lancet. 2001;357:273-7. Varila E, Wahlstrom T, Rauramo I. 5-year follow-up study on the use of a levonorgestrel intrauterine system in women receiving hormone replacement therapy. Fertil Steril. 2001;76(5):969-73. Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J, Oda K, Borenstein J. Economic analysis of contraceptives for women. Contraception. 2003;68(1):3-10.The progestin IUD (LNG IUS) has been used as an alternative to endometrial ablation or hysterectomy in the treatment of menorrhagia. One clinical trial found that the LNG IUS was as effective as endometrial ablation at reducing blood loss when assessed one year after insertion A five-year study found that the hysterectomy cancellation rate was much higher for users of the LNG IUS than for other patients (80 percent versus 9 percent). The LNG IUS is approved for the treatment of menorrhagia in many countries and may be approved in the United States for this indication in the near future. The LNG IUS also has been investigated for use as a substitute for oral progestin in hormone therapy for postmenopausal women and is approved for this indication in many countries. One study followed postmenopausal women who used oral or transdermal estrogen with the LNG IUS continuously for five years. Histological examination demonstrated that the LNG IUS protected the women against endometrial hyperplasia. References: Hubacher D, Grimes DA. Noncontraceptive health benefits of intrauterine devices: a systematic review. Obstet Gynecol Surv. 2002;57(2):120-8. Crosignani PG, Vercellini P, Mosconi P, Oldani S, Cortesi I, De Giorgi O. Levonorgestrel-releasing intrauterine device versus hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding. Obstet Gynecol. 1997;90(2):257-63. Hurskainen R, Teperi J, Rissanen P, Aalto AM, Grenman S, Kivela A, Kujansuu E, Vuorma S, Yliskoski M, Paavonen J. Quality of life and cost-effectiveness of levonorgestrel-releasing intrauterine system versus hysterectomy for treatment of menorrhagia: a randomised trial. Lancet. 2001;357:273-7. Varila E, Wahlstrom T, Rauramo I. 5-year follow-up study on the use of a levonorgestrel intrauterine system in women receiving hormone replacement therapy. Fertil Steril. 2001;76(5):969-73. Chiou CF, Trussell J, Reyes E, Knight K, Wallace J, Udani J, Oda K, Borenstein J. Economic analysis of contraceptives for women. Contraception. 2003;68(1):3-10.

29. Treats: Menorrhagia Dysmenorhea Prevents: Endometrial hyperplasia Treatment of menorrhagia, including in women with uterine fibroids and adenomyosis. Treatment of pain in women with endometriosis. Alternative to hysterectomy for women w/ menorrhagia Prevention of endometrial hyperplasia in menopausal women using estrogen therapy. Prevention of endometrial proliferation and polyps in breast cancer survivors taking tamoxifen. Kaunitz, AM (2005). Beyond the pill: New data and options in hormonal and intrauterine contraception. Am J Obst Gyn 192(4):998-1004. Treatment of menorrhagia, including in women with uterine fibroids and adenomyosis. Treatment of pain in women with endometriosis. Alternative to hysterectomy for women w/ menorrhagia Prevention of endometrial hyperplasia in menopausal women using estrogen therapy. Prevention of endometrial proliferation and polyps in breast cancer survivors taking tamoxifen. Kaunitz, AM (2005). Beyond the pill: New data and options in hormonal and intrauterine contraception. Am J Obst Gyn 192(4):998-1004.

30. As a result of the evolution of civilization, women today have a higher number of total natural menstrual cycles during their reproductive years than their ancestors.1 Compared with a typical contemporary woman who may experience about 450 natural menstrual cycles over her reproductive life, hunter/gatherer women had many more pregnancies and breast-fed each of their children for up to 3 years. Consequently, they would have experienced about 160 menstrual cycles over their lifetime.2 In general, foraging women experienced later menarche, earlier childbearing, higher parity, more prolonged breastfeeding and earlier death compared with contemporary women�all of which contribute to a higher lifetime number of menstrual cycles.1,2 1. Eaton SB, Pike MC, Short RV, et al. Women�s reproductive cancers in evolutionary context. Quart Rev Biol. 1994;69:353-363. 2. Coutinho EM. Is Menstruation Obsolete? New York. Oxford University Press, Inc. 1999.As a result of the evolution of civilization, women today have a higher number of total natural menstrual cycles during their reproductive years than their ancestors.1 Compared with a typical contemporary woman who may experience about 450 natural menstrual cycles over her reproductive life, hunter/gatherer women had many more pregnancies and breast-fed each of their children for up to 3 years. Consequently, they would have experienced about 160 menstrual cycles over their lifetime.2 In general, foraging women experienced later menarche, earlier childbearing, higher parity, more prolonged breastfeeding and earlier death compared with contemporary women�all of which contribute to a higher lifetime number of menstrual cycles.1,2 1. Eaton SB, Pike MC, Short RV, et al. Women�s reproductive cancers in evolutionary context. Quart Rev Biol. 1994;69:353-363. 2. Coutinho EM. Is Menstruation Obsolete? New York. Oxford University Press, Inc. 1999.

31. IUDs can be inserted at any point in menstrual cycle. Copper IUD can be used for emergency contraception within 5 days of unprotected sex-with nearly 100% efficacy. Progestin IUD cannot be used for EC. IUDs may be inserted at any point of cycle if it is unlikely the patient is pregnant. Urine HCG should be performed if there is any risk of pregnancy, but conversation with patient should guide insertion. If uncertain: Mirena may be inserted 7 days from 1st day of period Paraguard may be inserted up to 5 days after unprotected intercourse (secondary to EC effect) EC study: Fasoli et al inserted 879 IUDs post-coitus, with only 1 pregnancy resulting Fasoli M, Parazzini F, Cecchetti G, La Vecchia C. Post-coital contraception: an overview of published studies. Contraception 1989;39:459-468. IUDs may be inserted at any point of cycle if it is unlikely the patient is pregnant. Urine HCG should be performed if there is any risk of pregnancy, but conversation with patient should guide insertion. If uncertain: Mirena may be inserted 7 days from 1st day of period Paraguard may be inserted up to 5 days after unprotected intercourse (secondary to EC effect) EC study: Fasoli et al inserted 879 IUDs post-coitus, with only 1 pregnancy resulting Fasoli M, Parazzini F, Cecchetti G, La Vecchia C. Post-coital contraception: an overview of published studies. Contraception 1989;39:459-468.

32. IUDs do NOT cause Abortion IUDs do NOT increase risk of PID IUDs do NOT increase risk of ectopic pregnancy. IUDs can be used by nullips. IUD insertion doesn�t require prophylactic antibiotics. It�s OK to test for infection @ time of insertion and treat with the IUD in place. If a patient becomes pregnant with an IUD, she has a 1 out of 3 chances of the pregnancy being an ectopic pregnancy. However, pregnancies with IUDs are extremely rare. Grimes, DA. �Intrauterine Devices�. Contraceptive Technology. NY: Ardent Media, 2004, pp. 495-530. Andersson, K. (1994). "Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: A randomized comparative trial." Contraception 49: 56-72. MacIsaac �IUDs, The pendulum swings back� Obstet Gynecol Clin N Am 34 (2007) 91?111 If a patient becomes pregnant with an IUD, she has a 1 out of 3 chances of the pregnancy being an ectopic pregnancy. However, pregnancies with IUDs are extremely rare. Grimes, DA. �Intrauterine Devices�. Contraceptive Technology. NY: Ardent Media, 2004, pp. 495-530. Andersson, K. (1994). "Levonorgestrel-releasing and copper-releasing (Nova T) IUDs during five years of use: A randomized comparative trial." Contraception 49: 56-72. MacIsaac �IUDs, The pendulum swings back� Obstet Gynecol Clin N Am 34 (2007) 91?111

33. The newer progestin IUDs are smaller, designed especially for nullips.The newer progestin IUDs are smaller, designed especially for nullips.

34. The Gynefix is the smallest IUD.The Gynefix is the smallest IUD.

35. Most economic reversible contraceptive method on market Highly effective reversible method, comparable to tubal ligation High continuation rates: 78% (Copper), 81% (Progestin) Common side effects: increased spotting and cramping initially, then decreased Amenorrhea common with progestin IUD STI rates unaffected by IUD PID risk only transiently higher for 20 days after insertion

36. Encourage prompt initiation. Use patient-centered counseling to enhance adherence. Inform about high-efficacy methods - don�t limit IUDs unnecessarily. Educate about all contraceptive options: if she qualifies, let her decide.

37. Hatcher et al, Contraceptive Technology 2004 Managing Contraception � book online @ www.managingcontraception.org Medical Eligibility Criteria for Contraceptive Use 2004 by WHO http://www.who.int/reproductive-health/publications/mec/iuds.html Association of Reproductive Health Professionals www.arhp.org Alan Guttmacher Institute www.agi-usa.org www.contraceptiononline.org Planned Parenthood www.plannedparenthood.org The Cochrane Collaboration www.cochrane.org www.Not-2-Late.com Reproductive Health Access Project www.reproductiveaccess.org Hatcher et al, Contraceptive Technology 2004 Managing Contraception � book online @ (www.managingcontraception.org) Medical Eligibility Criteria for Contraceptive Use 2004 by WHO (www.who.int/reproductive-health) Association of Reproductive Health Professionals (ARHP) (www.arhp.org) Alan Guttmacher Institute (www.agi-usa.org) www. contraceptiononline.org www.plannedparenthood.org www.cochrane.org www.Not-2-Late.com Hatcher et al, Contraceptive Technology 2004 Managing Contraception � book online @ (www.managingcontraception.org) Medical Eligibility Criteria for Contraceptive Use 2004 by WHO (www.who.int/reproductive-health) Association of Reproductive Health Professionals (ARHP) (www.arhp.org) Alan Guttmacher Institute (www.agi-usa.org) www. contraceptiononline.org www.plannedparenthood.org www.cochrane.org www.Not-2-Late.com