IUDs shunned only in the U.S.

PHILADELPHIA — Rings of nickel, gold or stainless steel. Plastic squiggles, hearts or pretzels. Little 7s and Ts that release copper or a hormone.

The variety of gizmos women worldwide put in their wombs to block pregnancy is startling.

The IUD, used by 160 million women, is the world's second-most popular contraceptive method, after sterilization, says the World Health Organization. It is hassle-free, economical, long-acting and, unlike sterilization, reversible.

Yet in the United States, the method is about as popular as chastity belts. ParaGard and Mirena, the only two IUD brands sold here, account for less than 1 percent of the contraceptive market.

This situation is largely the legacy of the Dalkon Shield. After it was recalled 30 years ago, U.S. demand for other brands faded; IUD makers gave up on the U.S. market in the 1980s.

Now, companies are reviving the method, but many people mistakenly believe all IUDs increase pelvic infection, miscarriage, infertility and ectopic pregnancy.

Research shows contemporary IUDs are not only safe and effective, they cut the risk of ectopic pregnancy and possibly endometrial cancer. Mirena, made by Berlex Inc., also can relieve abnormally heavy menstrual bleeding with its continual release of progestin.

With the U.S. market's liability- and health-insurance issues, the IUD may remain a contraceptive also-ran, health experts say. Still, as they work to dispel misconceptions, the IUD is gaining converts.

Early IUDs

It is not fully clear why a foreign body in the uterus thwarts procreation. An IUD may disrupt ovulation, or thicken cervical mucus so sperm can't swim, or make the uterine lining too thin for implantation.

The first modern IUD, a silver ring, was invented in 1929. But it wasn't until the late 1950s that the IUD caught on in the U.S., starting with a stainless-steel ring developed by two New York City physicians. The advent of plastic led to dozens of bendable, easier-to-insert innovations.

Ironically, the IUD got a boost from another revolutionary contraceptive — the pill.

Early oral contraceptives contained such huge doses of estrogen and progestin that serious, sometimes fatal, side effects were fairly common. By 1969, women's health activists persuaded Congress to hold hearings on the pill's safety.

Janet Wilson, now a staff physician at a Planned Parenthood, remembers her father warning of the pill's dangers. Looking for an alternative, she decided on ... the Dalkon Shield.

"I used it for eight years," she said. "It was great."

The shield's big flaw

Introduced in 1971, the shield had a major design flaw. The string that enabled women to check whether the device was in place consisted of several filaments, instead of the standard single filament.

For most women, this "tail" was no problem. But studies found that for women with many partners, the tail served as a stepladder for dangerous bacteria, increasing the risk of pelvic infections.

Hysterectomies, miscarriages, ectopic pregnancies, infertility and deaths were linked to the Dalkon Shield, and maker A.H. Robins was bankrupted by lawsuits.

The problem was that soon after, studies unfairly claimed other IUDs were dangerous.

"Flaws in early IUD research exaggerated the risk," Princeton University researcher James Trussell and co-authors concluded in their book "Contraceptive Technology." Rigorous recent studies "have established that the risk of infection and infertility among IUD users is very low."

What's more, the authors wrote, the notion that IUDs cause ectopic pregnancy — a pregnancy that develops outside the uterus — "was debunked long ago." Because the IUD prevents all pregnancies, a user has a "dramatically" lower risk of ectopic pregnancy.

IUD users do occasionally get pregnant — but not more often than women who have been sterilized, studies show.

The biggest IUD disadvantages are cramping and pain at the time of insertion and up to a 10 percent chance of expulsion the first year. The ParaGard also can cause heavier, longer periods in the early months.

Negative views

Despite many pluses and few minuses, surveys show that most women and many doctors have a negative view of IUDs.

Kelly Garrison, 25, who is in a monogamous relationship, was refused when she asked her gynecologist to prescribe one. Besides raising the specter of infertility, the doctor said an IUD is difficult to put in a woman who has never been pregnant. In fact, ParaGard is FDA-approved for such users.

"I knew better," said Garrison, an assistant at Planned Parenthood.

Cost may be another disincentive. Insurers have no standard coverage. ParaGard and Mirena each cost about $500. With doctor's services, the bill easily can run more than $1,000.

While that's economical for contraception that lasts 5 years (Mirena) or 10 years (ParaGard), it's a lot for most young women to fork over all at once.