Q:I have heard that there is a new intrauterine device on the market which does not have any of the copper attachments of the older version on it. Since it was the copper element in the older style IUDs which was the cause of so much worry, does thi

A:The IUD, also known as the coil or loop, seems to have come full circle. Original devices, such as the Lippes Loop, were made of inert plastic. Copper IUDs became available in the 1970s, the first models being the copper 7 (no longer in use) and the copper T (still available). Their “active” copper element was thought to enhance the contraceptive effect of the coil by releasing copper at a rate of 38 microgrammes a day (Br J Fam Plan, 1981; 6(4): 104-8). At one time there were even plans to make a non rigid IUD filled with saline which was injected after insertion to make a “custom fit”. Today there is another model available in the UK called the levonorgestrol coil which is made of plastic, but which also contains a hormonal contraceptive more of this in a minute.

Some women like the idea of the coil because, once inserted, they can forget about it. But forgetting about it may be a bad idea, because even though some women do not experience problems with its use, it is associated with a number of side effects. Nobody is absolutely sure how the IUD works to prevent pregnancy. It is believed to cause a local inflammatory action inside the uterus. The inflammation which occurs is a reaction to a foreign body (the IUD) and to irritation and does not necessarily mean there is an infection, even when there is an increase in vaginal discharge. Women who have never been pregnant sometimes have a hard time tolerating the IUD a uterus which has not been stretched by pregnancy tends to react to the device with cramping, backache and expulsion. Unlike with the Pill, which works in a generalized way on the body, the problems with the IUD are at least localized and mostly easy to recognize. If something goes wrong, your uterus will (usually, though not always) hurt.

The medical establishment remains enthusiastic about these devices, and yet the IUD has been associated with a number of debilitating, even dangerous, side effects. Women who have an IUD fitted are more likely to have a miscarriage if they do become pregnant 50 per cent as opposed to 17 per cent for those using any other kind of contraceptive (Lancet, 1974; i: 495-8; Am J Ob Gyn, 1974; 119: 124-30). Pelvic inflammatory disease is common, and the risk is six times greater in the first 20 days after insertion (Lancet, 1992; 339: 785-8); it remains a greater risk for women who have a history of sexually transmitted diseases. There is an increased risk of ectopic pregnancy, probably due to ascending infection, and the IUD can perforate the uterus and travel into the abdominal cavity. Often the increased risk of sexually transmitted diseases is put down to the woman’s lifestyle, rather than the device, though this has never been conclusively proven.

The use of the IUD is associated with greater incidence of tubal infertility (N Eng J Med, 1985; 312: 937-41; N Eng J Med, 1992; 326: 203-4). Excessive copper is associated with skin rashes and an increased susceptability to infection (Am J Clin Nutri, 1985; 4(1): 5-16; Am J Clin Nutri, 1982; 35: 417-68).

The levonorgestrel coil is a T shaped device with a collar reservoir of the hormone levonorgestrel enclosed in a membrane, which allows slow, sustained release. It is not known as an IUD but an IUS (intrauterine system), and is described in promotional literature as a “laser targeted minipill” since the coil becomes merely a vehicle to help target the progesterone only contraceptive directly into the endometrium (Medical Monitor, Sept 4, 1996). The other way of looking at it is that the levonorgestrel element (which is also the active ingredient in the Norplant contraceptive patch) will have all the same side effects as any hormonal contraceptive, including an increased risk of breast and cervical cancer, hypertension and stroke.

Doctors tend to leave IUDs in for longer than the recommended period because taking them out and replacing them can cause further damage. But IUDs left in for long periods of time have been known to break apart, often without the wearer knowing it. Some of the fragments may be expelled and others retained. Retained parts of IUDs can implant themselves in the womb and lead to severe infections. There has recently been a case reported of a woman with an implanted IUD contracting the actinomyces israeli germ, more commonly found in the mouth and throat but also found in the abdomen after trauma (N Eng J Med, 1992; 326: 692-9). It can also bring on or exacerbate attacks of candida (N Eng J Med, 1994; 330: 1395).

It also throws up certain contradictions. For instance, women with very heavy periods are not recommended to use IUDs, and yet the levonorgestrel IUS is being touted for this, because its hormonal element levonorgestrel works by thinning the lining of the womb and also by interfering with the functioning of the corpus luteum (the yellow mass which forms in the wall of the ovary at the time of ovulation and which releases hormones which help prepare the body for pregnancy). It also helps to reduce menstrual bleeding, says its manufacturer, “so much so that some women will cease having any show during their menstrual phase.” After one year 20 per cent of women will be rendered amenorrheic they will still ovulate, but because there will be so little womb lining a show of blood may not occur. Such is the enthusiasm for this device that it has also been touted as an alternative to hysterectomy in cases of menstrual irregularities.

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