Why Don't We Just Put IUDs in the Water?

By so many measures, intrauterine devices are the best form of birth control. Why are they still so rarely used?


The intrauterine device is everything that most young women look for in birth control. The upfront cost, though high, is a one-time expense. It prevents unintended pregnancy at a rate as high as 20 times that of hormonal birth control pills, especially in women under the age of 21. And once in, it stays there for ten years. That second fact helps to explain the former: the birth control pill, which has to be taken daily, leaves open a wide window for human error that the IUD does not.

Use in the U.S. is increasing, but the IUD, endorsed as safe and (the most) effective and specifically recommended for sexually active adolescents by the American College of Obstetricians and Gynecologists, remains one of the least commonly used contraceptives by U.S. women.

This may be, in part, due to the legacy of the Dalkon shield, the poorly designed IUD of the '70s that caused injuries and infertility before its discontinuation. Traumas involving induced infertility die hard, and IUDs have continued to be plagued by a series of restrictions -- most notably, they're often informally recommended only for people in long-term, monogamous relationships, to minimize the STI risk, and sometimes only for women who have already given birth.

But a new study in Obstetrics & Gynecology adds to growing evidence that the IUD can and should be recommended even for teens. It demonstrates that serious complications like ectopic pregnancy or PID were extremely rare -- occurring in fewer than one percent of subjects -- and no more common in young users than in older women, in a national sample of over 90,000 women. (The hormonal IUD was associated with fewer complications, and a lower discontinuation rate, than the copper version.) Women aged 15-19 were more likely to stop getting their periods during the first year, which, as the authors point out, most probably saw as a benefit. 

Most of the study's younger participants only received their IUDs after already having a child. So what's the next step toward it being accepted enough that it can actually be used to help prevent teen and unintended pregnancy?

Parental concerns may still be a barrier: A recent study found that parents are far more comfortable with the pill than with IUDs -- or, for that matter, with condoms -- for their teenage daughters. However, they were specifically asked about birth control prescribed without their knowledge, and may have balked mostly over the idea of their daughters undergoing a procedure without their consent. If they were involved in the process, and were their doctors to specifically endorse the IUD, they might very well change their minds.

But not all doctors are ready to do that. A recent study involving in-depth interviews with gynecologists and family physicians in the New York City area found that the main barrier to recommending the IUD to teens was that despite evidence in its favor, the doctors remained unsure whether they should. Most had underwent their medical training at time when recommending the IUD wasn't, well, recommended, and may not have adjusted their thinking since then. government study found that when it comes to the IUD, most doctors are prone to holding on to outdated beliefs. 

Even some who are familiar with the newer research remain convinced that STI risk is a big concern. In the New York study, it was precisely the idea that the IUD is "out of sight, out of mind" that gave some doctors pause. A large number of the respondents believed that taking the pill each day, instead of becoming a rote part of routine, was a daily reminder of the risks of sex. The pill's small margin of error, they also argued, is an extra motivator for teens to double-up on birth control and use condoms as an extra measure against pregnancy. The physicians seemed to worry that if teens were too reassured about their unlikeliness of getting pregnant, they'd forget about the dual need to protect against STIs. As one was quoted as saying, "They're protected from their worst fear, which is having a baby. I think it gives [adolescents] license to do whatever they want without protection."  

Regardless of how plausible that is, it's something that needs to be addressed, especially if it's keeping doctors from helping IUD use to become more widespread. Now that researchers have determined that the bigger complications are unlikely, they'll need to do the same for more common STIs, and determine whether IUD users really are less likely to use condoms than women on the pill.

In either case, it seems like the real concern should be whether we're adequately preparing adolescents for the realities of being sexually active, so that even if their risk of getting pregnant were to be reduced to almost zero, we could still trust that they'd understand the importance of using a condom.