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Understanding the relationship of the intrauterine device (IUD) to sexually transmitted
diseases (STDs), pelvic inflammatory disease (PID) and infertility has improved in recent
years.
Studies have shown that the risks of infection associated with IUD use are greater for
certain clients (those at high risk of acquiring a sexually transmitted disease) and at
certain times (within the first few months after insertion). This new knowledge has
enabled family planning programs to develop criteria to determine who is an appropriate
candidate for IUD use, and who is not.
Numerous studies have shown that IUDs by themselves do not cause PID, and for most IUD
users, fertility returns quickly after the device is removed. However, IUD use does carry
some risk of infection for some women, primarily due to nonsterile insertion techniques or
the clients' STD exposure.
"The screening of the client is important. The skills of the provider are
important," says Dr. O.A. Ladipo, director of the South to South Cooperation for
Reproductive Health in Brazil, who has studied IUD use in developing countries. "If
the insertion is performed properly and the client is well-screened, the risk of infection
is very low. Consequently, the risk of infertility also will be low."
Providers can minimize risks by following these important guidelines:
- screening clients carefully to determine their probability of being currently infected
with STDs
- counseling clients about STD risks and any future symptoms of lower and upper genital
tract infection
- practicing aseptic techniques when inserting IUDs
- encouraging clients to return for a follow-up visit approximately one month after
insertion to determine if infection is present.
The Technical Guidance Working Group, a panel of family planning experts from around
the world organized by the U.S. Agency for International Development, recommends that
clinicians not insert IUDs unless they can follow basic infection prevention measures,
including handwashing, preparation of the cervix, use of sterile IUDs and equipment,
decontamination of instruments and safe disposal of contaminated materials.
In addition, the working group recommends that IUDs not be inserted if there is evidence
of PID, abnormal vaginal discharge, or infection of the cervix or the vagina. If the
client has an STD but is no longer at risk of a new infection, the infection should be
treated and the IUD inserted when the infection is gone. When the client has acute PID,
PID should be treated, and providers should wait three months after successful treatment
before inserting an IUD. If the client has an STD and continues to be at risk of
reinfection, she should be advised to consider another contraceptive method and to use
condoms to protect against STDs.1 Clients at high risk of STDs
include those with multiple partners, or whose partner has multiple partners.
The World Health Organization (WHO) also has recently developed guidelines for
contraceptive use. WHO recommends that IUDs not be used by women who currently have or in
the three months prior to insertion have had PID or STDs. For women who are not in
mutually monogamous relationships or women who are HIV-positive, IUD insertion usually is
not recommended unless no other contraceptive method is available or acceptable.2
Greater risk?
Pelvic inflammatory disease -- an inflammation of the upper reproductive tract,
including the uterus, fallopian tubes and ovaries -- can be fatal if not treated promptly.
In addition, PID can cause scarring and blockage of the fallopian tubes and result in
infertility.
Controversy over IUD use began in the 1970s, when epidemiologic studies reported a greater
risk of PID among IUD users, compared with users of other contraceptives. In the late
1980s, researchers learned that the sexual behavior of a woman or her partner played an
important role in PID risk. A reanalysis of data in the United States found that IUD users
at low risk for acquiring STDs (women in mutually monogamous relationships) were unlikely
to develop PID. Those at higher STD risk had higher risks of developing PID.3
A study published by WHO analyzed clinical trial data from 13 studies in Africa, Asia,
Europe and the Americas and found that the incidence of PID was greatest within the first
20 days following IUD insertion. Afterward, the risk of PID dropped and remained low
throughout the eight-year study.4 Other research has found
that risks of infection are high during the first four months following insertion, but
decline afterward.5
The reason for the increased risk of infection after insertion is that microorganisms in
the vagina can be transported through the cervix and into the uterine cavity during
insertion. Even organisms that occur naturally in the vagina can lead to PID if they
ascend into the upper genital tract. STD pathogens, specifically Neisseria gonorrhoeae,
Chlamydia trachomatis and Mycoplasma hominis, are a cause of PID and can also be
transferred from the cervix and vagina to the uterine cavity during IUD insertion.
In reviewing the methods used to collect data on IUDs in the 1970s, scientists now believe
that methodological flaws may have affected early study results. For example, IUD users
were compared with women who used oral contraceptives and barrier contraceptives, both of
which have a protective effect against PID. Also, early studies did not consider factors
such as sexual behavior or the time between insertion and onset of PID. Many IUDs in use
during the 1970s are no longer made. Newer copper IUDs are considered safer and more
effective.
Provider concerns about pelvic inflammatory disease and infertility are major barriers to
IUD use in Asia and Latin America, according to comments at workshops sponsored by FHI.6 In Jamaica, when 367 private physicians were asked their
reasons for not recommending certain contraceptive methods, more than 35 percent said they
opposed the IUD because they believed, incorrectly, that it caused infections.7
While bacterial STDs and pelvic inflammatory disease can nearly always be treated with
antibiotics, the health and socioeconomic consequences for infected women can be severe.
In cultures where women's roles are defined by childbearing and childrearing, infertility
resulting from PID can have devastating results, including abandonment, divorce, and
community ostracism.
"This is why women's health advocates are so passionate about reminding us that we
cannot just look at the scientific data on a contraceptive method," says Karen
Beattie of AVSC International. "We also must look at the culture, the healthcare
system and the program in which that method may be offered, and the individual who may use
the method."
While provider training can minimize the risks of PID during IUD insertion, counseling
women about STD risks can be more difficult. Providers may be reluctant to question women
about their sexual practices or the behavior of their partners. Women may not know their
partner's behavior. Women with STDs are often asymptomatic, which makes it difficult for
providers to diagnose a disease.
"We know now that women exposed to STDs are not good candidates for IUD use,"
says Dr. Roberto Rivera, FHI's corporate director of international medical affairs.
"What we don't have is a good, easy-to-use instrument to assess whether a woman or a
couple is at high risk." Family planning experts, including members of the Technical
Guidance Working Group, are considering simple, inexpensive ways to determine risk for
STDs.
AVSC International, in collaboration with the Population Council, the International Center
for Research on Women and the Pacific Institute for Women's Health, is conducting a
four-year study to examine the use of IUDs in poor communities where laboratory tests are
not available. Researchers will examine different approaches for screening IUD clients for
STDs, including self-assessments by clients. This approach would avoid interviewing a
client about her sexual behavior and might be useful for women who have no STD symptoms.
The study also will analyze client-provider interaction when clients come to family
planning clinics for IUDs, the costs of family planning and STD treatments, and the
acceptability of using two methods -- IUDs for contraception and barrier methods for STD
prevention.
In the meantime, local family planning clinics also are considering ways to screen IUD
clients for STDs. Providers at the Asociación Pro-Bienestar de la Familia de Guatemala
(APROFAM) clinic explain to all IUD clients that their risks of PID and infertility
increase if they are exposed to STDs. "We do not ask if they have more than one
partner, but we explain that if they do, they have increased risks," says Dr. Carlos
Contreras, medical director.
As part of client screening, Dr. Ladipo of South to South Cooperation for Reproductive
Health encourages providers to ask about both PID symptoms and STD risks. Clients may not
know if they have had an episode of infection, because their ailment may not have been
diagnosed, but they will remember if they have had symptoms, such as vaginal discharge,
painful intercourse, or tenderness in the pelvic area. A pelvic examination prior to
insertion is essential. A pelvic exam can identify conditions that would contraindicate
use, such as pregnancy, PID or endocervical infections.
In addition, providers should question clients about their age at first sexual intercourse
and about their current sexual behavior. Ideally, the provider should question both
partners about these issues.
Antibiotics
Since microorganisms in the vagina may be introduced into the uterine cavity during
insertion, scientists have debated the use of antibiotics as a prophylaxis before
insertion. Studies on the preventive use of these drugs have not shown effectiveness in
lowering the occurrence of PID.
FHI has sponsored two studies to evaluate antibiotic use. A study at Kenyatta National
Hospital in Nairobi, Kenya investigated the effects of doxycycline on users of four types
of IUDs -- Lippes Loop, Copper T, Nova T, and Multiload. Half of the group of more than
1,800 study participants received 200 mg of doxycycline before IUD insertion, and the
remainder received a placebo. Screenings for gonorrhea and chlamydia were performed before
insertions. Findings showed the number of return visits to the hospital for lower
abdominal pain, a symptom of PID, and bleeding were reduced by 40 percent among the
antibiotic recipients.8 The study in Kenya and a study of
nearly 1,300 IUD users in Ibadan, Nigeria found PID rates were lower than expected among
all women. However, the Kenya study found that doxycycline reduced the likelihood of PID,
while the Nigeria study found antibiotics had no significant effect on PID.9
The use of prophylactic antibiotics remains controversial. Some scientists speculate that
use of antibiotics prior to IUD insertion could result in drug-resistant strains of
bacteria. "Antibiotics might provide some benefit, but the evidence does not support
it as a global treatment procedure," says Gaston Farr, associate director of FHI's
clinical trials division and one of the authors of the Nigerian study. "If you screen
clients for STDs and follow aseptic insertion procedures, you could limit risks
essentially as much as if you followed a course of antibiotic treatment."
In the past, researchers have speculated that the IUD strings might play a role in the
development of PID by allowing the ascent of bacteria from the vagina into the uterine
cavity. Studies found that users of the Dalkon shield, an early IUD no longer available
that had a multifilament tail, had an increased risk of PID when compared with users of
other IUDs, such as Lippes Loop and copper IUDs with single-filament tails. In subsequent
studies comparing IUDs with single-filament tails and no tails, researchers concluded that
strings do not play a role in PID. This reinforced the findings that PID is due primarily
to nonsterile insertion techniques or exposure to STDs.10
IUDs and HIV
As AIDS becomes more prevalent, family planning providers are raising questions about
IUDs and HIV infection. An FHI-sponsored study in Kenya found that providers feared they
would transmit HIV to clients by using nonsterilized or contaminated equipment or dirty
gloves. Providers also worried they would contract HIV from clients. "The fear of HIV
seems to prompt providers to be more rigorous in the sterilization of instruments and
other aspects of aseptic technique," says a summary of the study. "However, this
fear may also contribute to the current situation in which providers do not encourage
clients to accept the IUD."11 In Zimbabwe, a study of
provider attitudes of long-term contraceptive methods found that nurses who performed IUD
insertions also feared contracting HIV from clients.12
Currently, FHI is collaborating with researchers in Nairobi to examine the short-term
effects of IUD use among HIV-positive women. Researchers are following 150 HIV-positive
women and 450 HIV-negative women for four months after IUD insertions to determine if side
effects and complications are different for the two groups. Researchers will look for
evidence of PID, uterine perforations, IUD expulsions and the incidence of removal due to
pain and bleeding.
Women who wish to participate in the study are being counseled about family planning
methods and HIV risks, including the use of condoms to prevent STD transmission. Women are
excluded from the study if they have a history of ectopic pregnancy, active PID,
reproductive cancers, or high risk for STDs. If a woman chooses an IUD and consents to
participate in the study, HIV testing is conducted and she is counseled about the results.
"The primary objective of this study is to determine if HIV-infected women have a
different risk of short-term complications following insertion than women who are not HIV
infected," says Dr. Charles Morrison, an FHI epidemiologist who designed the study.
The study will also explore whether IUD use increases the infectiousness of HIV-infected
women by comparing the presence of HIV in cervical secretions before and after IUD
insertions.
-- Barbara Barnett
Footnotes
- Curtis KM, Bright PL, eds. Recommendations for
Updating Selected Practices in Contraceptive Use: Results of a Technical Meeting, Volume I.
Chapel Hill: Technical Guidance Working Group, U.S. Agency for International Development,
1994.
- Improving Access to Quality Care in Family Planning:
Medical Criteria for Initiating and Continuing Use of Contraceptive Methods. Geneva:
World Health Organization, 1995.
- Lee NC, Rubin GL, Borucki R. The intrauterine device and
pelvic inflammatory disease revisited: New results from the Women's Health Study. Obstet
Gynecol 1988;72(1):1-6.
- Farley TMM, Rosenberg MJ, Rowe PJ, et al. Intrauterine
devices and pelvic inflammatory disease: An international perspective. The Lancet
1992;339:785-88.
- Wright EA, Aisien AO. Pelvic inflammatory disease and
the intrauterine contraceptive device. Int J Gynecol Obstet 1989;28(2):133-36. Lee.
- Barnett B. Improving Provider Practices: Highlights
of the Workshop "Reduction of Medical Barriers to Contraception," Manila, the
Philippines, 12-14 November, 1993. Research Triangle Park: Family Health
International, 1994.
- Bailey W, McDonald OP, Hardee KH, Clyde M, Villinski MT.
Family Planning Service Delivery Practices of Private Physicians in Jamaica: Final
Report. Research Triangle Park: The Futures Group OPTIONS II Project, Family Health
International, University of the West Indies, 1994.
- Sinei SKA, Schulz KF, Lamptey PR, et al. Preventing
IUCD-related pelvic infection: the efficacy of prophylactic doxycycline at insertion. Br
J Obstet Gynaecol 1990;97(5):412-19.
- Ladipo OA, Farr G, Otolorin E, et al. Prevention of
IUD-related pelvic infection: The efficacy of prophylactic doxycycline at IUD insertion. Adv
Contracept 1991;7:43-54.
- Rivera R. Is there an effect of the IUD string in the
development of pelvic inflammatory disease in IUD users? Proceedings from the Fourth
International Conference on IUDs. Ed. Bardin CW, Mishell DR. (Newton, MA:
Butterworth-Heinemann, 1994) 171-78.
- Stanback J, Omondi-Odhiambo, Omuodo D. Final Report:
Why Has IUD Use Slowed in Kenya? Part A -- Qualitative Assessment of IUD Service
Delivery in Kenya. Research Triangle Park: Family Health International, 1995.
- Gaffikin L, Mvandi I, Phiri A. A Study of the
Acceptability of IUDs and other Long-term Methods Among Family Planning Providers in
Zimbabwe. American Public Health Association Meeting, San Francisco, 26 Oct. 1993.
For more information, visit Family Health International's Website at www.fhi.org
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