Contraception Editorial September 2022
By: J. Joseph Speidel, Cynthia C. Harper, and Wayne C. Shields
Unintended pregnancies have turned out to be a major concern worldwide. In the US alone, the year 2021 encountered 6.1 million pregnancies, of which half were considered unintended. UNFPA believes that over 60% of unintended pregnancies somehow end up with abortions.
With so many pregnancies around the world, people are getting concerned and using contraceptives as an aid to tackling childbirth.
Is it functional?
Contraceptive pills and condoms have been the most known form of tackling childbirth, but their efficacy has been jeopardized many times.
This is why many believe that the potential of long-acting reversible contraception is superior.
What Is Long-Acting Reversible Contraception?
LARC uses IUDs to contain pregnancy. It is a T-shaped device that is inserted inside the uterus to slow down or restrict fertility in women.
Also known as intrauterine contraception, this device needs to be inserted using a surgical procedure, unlike contraceptive pills. It has better efficacy than other common forms of contraceptives.
There Are Two Types of IUD
Now that you know that an IUD implant is the most effective way of containing pregnancy, you should know that there are two main types of this device. They are –
1. Copper IUD
Paragard is a copper IUD brand that uses a copper coil rather than any hormones. Sperms are repelled by copper, so sperm simply cannot reach the egg when copper IUD is present.
2. Hormonal IUD
Skyla, Mirena, and Liletta are some of the common brands that are approved by the FDA in the US region. What it does is, traps the sperm cells by thickening the mucus in the cervix wall. Secondly, the hormones on the IUD can also restrict the eggs from getting out of the ovaries. No exposed eggs, meaning the sperms have no place to fertilize themselves.
The 80 million unintended pregnancies that occur worldwide each year (38% of all pregnancies) can justifiably be deemed an ‘Epidemic.’
These pregnancies result in 42 million induced abortions and 34 million unintended births — births that contribute substantially to the annual world population growth of 78 million.1,2
Among developed countries, the US record of family planning is uniquely deficient. Of 6.1 million pregnancies in 2001, half were unintended (as were more than 80% of the 800,000 annual teen pregnancies), resulting in 1.3 million abortions, 4 million births (of which one-third were unintended), and 800,000 miscarriages.3
As Frost et al.4 noted in a recent study published by the Guttmacher Institute -“Unintended pregnancy can force women and their families to confront difficult abortion decisions or the potentially negative consequences associated with unplanned childbearing—including child health and development issues, relationship instability, and compromises in education and employment that may exacerbate ongoing poverty.”
This same study attributes 52% of unintended pregnancies in the USA to the nonuse of contraception, 43% to inconsistent or incorrect use, and only 5% to method failure.4
Leading causes of unintended pregnancy are closely related to contraceptive method choice. In 2002, more than half of contraceptive users relied on methods with high failure rates under typical use: 31% used the pill, 18% the male condom, and 5% the 3-month injectable.5
While with perfect use, these methods are highly effective, 9% of pill users, 17% of condom users, and 5% of injectable users will become pregnant during the first year of typical use.5,6
To make matters worse, about half of condom and injectable contraception users — and almost one-third of pill users — will discontinue within a year.6
The Potential of Long-Acting Reversible Contraception Methods
Long-acting reversible contraception (LARC) methods, including intrauterine contraceptives and implants, have a proven record of very high effectiveness, many years of effectiveness, convenience, cost-effectiveness, suitability for a wide variety of women, and in general, high user satisfaction.7,8,9,10,11,12,13,14
With typical use, the first-year failure rate of the copper T 380A (ParaGard®) is 1%, the LNG-IUS (Mirena®) is 0.1%, and the implant available in the USA (Implanon®) is 0.1%5.
One-year continuation rates are also markedly superior to short-acting reversible contraceptives being 78% for the copper T 380A, 80% for the LNG IUS, and 84% for Implanon®.6
Yet, LARC methods make up a very small share of world contraceptive use. For example, implants and IUCs account for only about 2% of contraceptive use in the USA.5
Figures can be deceiving: while the IUC is used worldwide by 14% of women who are married or in some type of committed relationship, this number is skewed as more than half of the 150 million women in the world using an IUC are in China. A more accurate picture emerges when focusing on regional data: the percentage of women using IUC who are married or in a union is 7% in Latin America, 6% in Asia (excluding China), and just 1% in Africa.7 Use in developing countries is only 6% when China is excluded. There are notable exceptions to this global pattern. IUC has been used extensively in a small number of countries, including Uzbekistan (50%), China (40%), Egypt (37%), Vietnam (36%), Cuba (35%), Tunisia (28%), Jordan (24%), Turkey (20%), France (17%) and Mexico (14%)7.
Recent events also bode well for increased utilization of LARC worldwide, such as the liberalization of World Health Organization (WHO) medical eligibility criteria for IUC use8,9 and the introduction of Implanon® in the USA.
Unfortunately, outdated perceptions about appropriate patient candidates for LARC among healthcare providers continue to negatively impact their use.
An emerging body of research has disproved a number of contraindications to IUC use. Specifically, women of any age or parity and those who are postpartum or post first or second-trimester abortion are eligible for IUC.
The benefits of IUC also outweigh the risks of a wide variety of medical conditions that might contraindicate the use of combined hormonal contraceptives.8,9,11,12,14,15,16,17,18
The issue of increased risk or greater severity of infection among IUC users has been a prominent concern. However, the rate of pelvic inflammatory disease (PID) in IUC users is low, with cases concentrated in the first 20 days after insertion.19,20
Shelton21 has developed a mathematical model that estimates the risk of PID attributable to IUC. For example, in a client population with a 10% prevalence of STI and no STI screening before insertion, the risk of PID attributable to the IUC would be 0.3% and about half that if clients were screened using a risk-assessment protocol.
WHO guidelines allow for the use of IUC by those with HIV; however, women with AIDS should be monitored for pelvic infection.8,9
Even though it is a potent method to control pregnancy, IUD usage is still very low compared to contraceptive pills. As per studies, IUD options like the Copper T-380A showed superior results in studies compared to orthodox pills. The copper device had a low failure rate of just 1 per 100 women.
When used as contraceptives, these devices are extremely efficient, and it is believed to be 99% effective compared to their compatriots (pills). What makes IUDs special is that they can work for up to 12 years.
You’ve seen it right, and one installation can keep you away from pregnancy no matter how much intercourse you go through.
There is no need to take pills and no chance of forgetting as well. As long as the device is there in the vagina, you will be infertile.
Positives of Using LARC
With an IUD implant, you don’t need to worry about taking pills. No chance of missed dose.
- It can protect you from unintended pregnancy and can be serviceable for up to 12 years. Way superior protection than contraceptive pills. The time depends on the type of implant. Once the limit expires, it can be removed and reinserted.
- Fertility will be reinstated once the IUD is removed.
- Chances of uterine cancer can be lowered with copper-releasing IUDs. They don’t show any hormonal side effects. Even levonorgestrel-releasing can protect from cervical cancer.
Drawbacks of IUD Implantations
- IUDs cannot protect against STDs. It’s better to use condoms even if you have an insert.
- The implant procedure can be painful for some women, but the process is pretty fast, so the discomfort will last for a short amount of time.
- It can promote weight gain in some cases
- Inserts can move out of position and might need a replacement. It can be a tiresome event for some people.
- Many women face spotting and cramp issues with copper-releasing IUD inserts.
- Progestin-releasing devices can be the cause of irregular bleeding. The uncertainty can be observed for the first few months.
Will IUD Make Women Infertile Permanently?
Absolutely no! As long as the IUD is inserted in the vagina, a woman will be infertile, but if they change their mind, the installation can be removed from the uterus, and the person will be able to conceive again.
Barriers to Increased Use of LARC
The use of LARC in both the USA and worldwide will not reach its full potential until a number of barriers are addressed –
Providers both lack information and are misinformed. Providers continue to be concerned about IUC use due to unsubstantiated risks related to STIs, ectopic pregnancy, infertility, use postpartum, use postabortion, use by nulliparous women, use by teens, patient acceptability, and legal matters. A study of 816 contraceptive providers serving low-income clients through California’s publicly funded Family PACT Program showed that almost 95% consider the IUC to be safe, but fewer than 65% generally discuss the option with patients seeking contraception. Providers also were misinformed about side effects; for example, about one-quarter described hormonal side effects of ParaGard®, a nonhormonal method.22
Providers lack adequate training in IUC and implant insertion. In the same Family PACT survey, 69% of providers reported that they were trained in IUC insertions, and 61% had IUC available at their practice, but only 60% felt “very comfortable” inserting ParaGard®, and just 40% felt “very comfortable” inserting Mirena®. Although IUCs are reimbursable for Family PACT providers, more than 40% have never dispensed IUC, and just 1.3% of female clients were given IUC in 200522.
Patients’ fears, misinformation, and lack of knowledge have resulted in low demand. A 1996 survey of reproductive-age US women revealed that 32% had little or no knowledge about IUC; only 21% felt that the term “safe” closely described it, and only 16% had a favorable opinion of it23. Negativity towards IUC stems largely from the misconception that it is an abortifacient and the Dalkon Shield controversy. A more recent 2007 study among adolescents and young women found that most (60%) had never heard of IUC24. Manufacturers have invested relatively little to improve perceptions of IUC, particularly compared to the advertising budgets for oral contraceptives25.
LARC is expensive, and provider reimbursement is low, especially in the USA. Manufacturers have kept product pricing high in the USA, and up-front costs can make these methods unaffordable for many women. While companies have a strong incentive to market pills that might bring in more than $1000 profit over a 10-year period, the one-time sale of a copper IUC yields only about $200 profit for the same time period.25,26 In the USA, the current public sector price for ParaGard® is $200 (more than 100 times the cost of manufacture), Mirena® is $330 (with the exception of a small number available through the ARCH Foundation), and Implanon® is $436. Private sector pricing is substantially greater. Although IUC is inexpensive when the cost is prorated over 5 years,26 the high copayments of many health insurance plans result in a prohibitive initial cost for women — and women who lack health insurance are least likely to be able to afford IUC.
Recommendations for Action
Past experience with the successful introduction of new contraceptives, or reintroduction in the case of the IUC, provides guidance to improve provision and use. Recommended activities include the following:
Undertake research to determine why provider practices are not evidence-based, to elucidate health system barriers, and to inform the design of interventions to encourage provision.
Develop information and training materials to address knowledge gaps and misinformation, as well as evidence-based screening tools and training curricula that incorporate the latest adult learning principles.
Provide training and technical assistance. Training and medical education at the preservice level must include the full healthcare team of professionals involved in contraceptive counseling and provision. In addition to Ob/Gyn and family practice physicians, advanced practice clinicians, nurses, social workers, and other counselors need to be knowledgeable about LARC. Provider training must include supervised hands-on experience with LARC methods and mentoring as needed. Ongoing technical assistance must address the health system issues such as intake, counseling, clinic protocols, consent forms, malpractice insurance, record keeping, insurance claims, and management of side effects and complications.
Address the high cost of LARC methods through better insurance coverage, lower prices for public sector use, and price competition with generic or alternative IUCs and implants.
Increase patient awareness with audience-appropriate educational materials and direct-to-consumer marketing.
Fully fund family planning programs for low-income clients. An annual expenditure of about $3.5 billion is needed to serve the 17 million US women in need of publicly funded contraceptive services.27,28 This can be compared to public outlays of $1.85 billion in FY2006 — about half of the total needed29. Fifteen billion dollars a year is needed for family planning programs in developing countries, yet only 10% of the funds needed from foreign aid donors are now being committed.30,31,32
Are You Concerned About Safety?
Birth control implants have shown positive results all over the world, but the process is still to surface properly. It is effective, there is no doubt, but not everyone will be able to have IUD implants on them.
You should not have an IUD inserted if you have –
- A uterus or cervical cancer
- Pelvic infections or any form of STD
- Issues with blood clotting
- Overly large or small uterus
- If you have breast cancer
Does that mean you can use contraceptives?
No, it’s just that IUD might not be the best fit, but there are oral contraceptives that you can purchase from medical stores.
Do talk to a doctor before indulging in any form of medication or implants.
Will Supplementing Affect IUD Implants?
You will be surprised to know that copper IUDs and even contraceptive pills can lower the zinc count in the body. Lower zinc can result in a low sex drive.
So many doctors can prescribe zinc that you can find in testosterone–boosting supplements or female enhancement supplements.
It is quite common to gain weight with IUD inserts on the body. This happens due to excessive water retention and not fat buildup.
Some physicians may advise taking diet pills and diuretics to lower the bloating and relieve cramping. Before using supplements as weight loss aid, always seek recommendations from a professional physician.
Here Is What People Need to Understand
- Missing contraceptive pills is quite common, and that can lead to pregnancy
- IUDs, when installed in the body, will work for as long as it is there, and you don’t have to worry about anything.
- With contraceptive pills, women have a 61% chance of pregnancy even if they take the pills timely for 10 years. Whereas IUDs can be more functional and restrict the limit to just 1 or 2% in a decade.
There are many examples of successful introductions of LARC around the world.
With the adoption of better family planning policies, effective health professional training programs, and commitment to the needed resources, these success stories can be replicated on a large scale in an increasing number of countries.