The IUD

The IUD is the third most popular contraceptive after the Pill and the sheath. It’s a small, flexible piece of plastic, between 2 and 4 centimetres long which sits in your womb. IUD stands for intraaterine device, meaning a device inside the womb, but the more common names for it are the ‘coil’ or ‘loop’. These were the original shapes of the IUD when it was first introduced.

Nowadays, they come in various shapes and sizes. Some have copper wound round the plastic, which is released into the womb in small amounts. These types are usually replaced every two or two and a half years, while the ones without copper can be worn indefinitely. They all have threads which hang down into the vagina so that they can be removed easily.

How does an IUD work?

The presence of an IUD causes the cells in the lining of the womb to change in some way; this change discourages a fertilized egg from em-bedding there. If an egg does manage to implant itself, the presence of the IUD usually prevents it developing very far.

No one knows precisely how the change is caused, but we do know that any foreign body in the womb produces the same response as an infection. The production of cells which fight unwanted organisms is stepped up and it may be these cells which make the womb lining unsuitable for the fertilized egg. Copper is used in some IUDs because it is thought to have an extra effect in making these cells accumulate.

The IUD may also cause change in the lining of the Fallopian tubes so that the egg travels down more quickly and misses the time when the womb is ready for it. Whatever its mode of action, it is effective immediately.

This used to be true when only the larger IUDs were available. These were difficult to insert unless the entrance to the womb has been stretched by pregnancy. More recently, the smaller copper-wound types have been developed which overcome this problem.

But an IUD still may not be recommended as the first choice of method if you are young and have never been pregnant. Younger women are particularly fertile and some may feel they want greater protection than the IUD gives; in this case they are likely to prefer the most reliable method available – the combined Pill. Also, younger women who have a variety of sexual partners run a higher risk of pelvic infections, from which twice as many IUD users as Pill users suffer.

The IUD is most popular with women who have had at least one pregnancy and would not mind another child if the device failed. It’s also popular with women in their midthirties who wish to come off the Pill and who don’t fancy the idea of the cap or sheath. They are less fertile at this age so the risk of pregnancy is reduced. For young girls, who have no history of pelvic infection and who wish to use an IUD, the copper-wound types are more suitable than the all-plastic Loop or Coil.

IUDs are considered to be 98 percent effective, which is about the same as the mini Pill and just a bit more reliable than the cap or sheath. These theoretical figures are based on each method being used perfectly. If, instead, you take into account lapses such as forgetting to take the Pill, or not using the sheath correctly, then the chances of becoming pregnant increases for every method except the IUD; once it’s in, there’s nothing you have to remember to do.

But the reliability of IUDs does vary. No one type is better than any other, but the skill with which they are inserted makes a difference. If the device is not pushed up far enough into the womb it won’t be so efficient. IUDs also tend to be more successful with older women because they are less fertile and with women who have had earlier pregnancies, because their wombs are less sensitive and don’t try to eject the device.

Sometimes the IUD comes out ot the womb of its own accord. This ‘expulsion’ usually happens, if it’s going to happen at all, within six weeks from the fitting, often during or just after vour period. It’s a good idea for a woman to learn to feel the threads or’tail’ of the IUD in her vagina.

The risk of pregnancy and the likelihood of an IUD being expelled or having to be removed due to pain or bleeding are very low, but the devices do vary in these respects, as trials have shown . A doctor’s recommendation will be based on this information in conjunction with a woman’s medical background, whether or not she has children, and her age.

Low pregnancy and expulsion rates. Removal rate due to pain andor bleeding also low.

Very easy to fit. Removal rate due to bleeding andor pain lower than for most other devices, but pregnancy rate is higher than others. It has the highest expulsion rate for all IUDs.

Easy to fit Has a very low expulsion and removal rate in comparison with all other devices. The risk of pregnancy is also low, but seem to increase with continued use. May need replacing after two years.

Pregnane)’ rate lower than Copper 7, higher than Copper T but the’same as the Loop. Expulsion rate, too, is higher than the Copper T, but can be compared with the Loop and Copper 7. The Coil has the highest rate of removal.

Has alow pregnancy rate- only the CopperTs is lower. Expulsion rates compare with the Copper T, but are higher than the Coil or Copper 7. Has a low removal rate.

Information based on preliminary trials only + still relatively new, results may be revised.

If you check this regularly it reduces the risk of losing the IUD without realizing- and possibly getting pregnant as a result.

How is the IUD inserted and taken out?

An IUD should be fitted by a specially trained doctor. It is usually done at a hospital or family planning clinic. Your own doctor may be qualified to do it, but if not he will advise you where to go.

You will probably be asked if your periods are regular, whether they tend to be heavy and whether there is any chance that you might be pregnant. Often doctors prefer to insert the IUD during your period to be sure that you’re not pregnant. You should mention any history of infections in the pelvic area. The doctor will give you an internal examination and take a smear test and then your womb will be’sounded’. This involves a thin feeler which is inserted into the womb to determine its exact depth and position so that the right sized IUD can be chosen for you. You may feel some general discomfort while this is being done, but you don’t feel the instrument.

The IUD is then straightened into a thin tube which is pushed up through the cervical canal into the womb. The IUD is released and springs back into shape, resting against the walls of the womb. The tube is pulled out and the strings of the IUD are trimmed so that about three centimetres are left hanging down. The whole procedure only takes a few minutes.

Some women feel nothing at all, some feel the twang as the IUD is released and others find it uncomfortable but not painful. It is similar to having a smear taken – if you are completely relaxed, you hardly feel a thing, but if you are tense it can be a bit unpleasant. A little bleeding often occurs just after the fitting along with mild tummy cramp or back ache, but these don’t last.

The IUD can be removed very simply by pulling the strings with a special instrument. This must always be done by a doctor – you should never attempt it yourself.

What are the benefits of this method of contraception? These really depend on your own priorities and personal medical history. The great advantage of the IUD is that it is always in place when needed. You don’t have to put a stop to lovemaking while you insert your cap or he puts on a sheath, neither do you have to remember to take a Pill regularly. Sex can be completely spontaneous. Although you should have regular check-ups, you don’t have to worn7 about supplies. And, because the IUD is effective from the moment it’s fitted, you don’t have to use some extra protection initially, as you do on the Pill.

A unique feature of the IUD is that it can be used to make sure pregnancy won’t occur as a result of having intercourse without using any contraceptive. This will work if the IUD is fitted up to three days after intercourse.

Do many women have to give up because of pain or bleeding? Each year, about one in 10 women fitted with an IUD abandons it because of pain and bleeding. The first six or 12 weeks after fitting are when problems are most likely to occur. You may bleed between periods and the periods themselves are likely to be heavier and sometimes more painful than before, although their regularity is not normally affected. You may suffer cramps and low back pain in the first weeks.

At your first check-up, which is usually about six weeks after the fitting, you should mention any pain and difficulties with your periods to the doctor. If increased bleeding is a problem he may recommend various treatments for reducing it. If these do not work or the pain continues, he may change the device for a different sort which is a better size and shape for you. Larger IUDs tend to cause more trouble than the smaller ones. But on the whole, periods settle down again and the pains disappear after two months.

Some women give up the IUD because they lose faith in it after it has been expelled once. The expulsion rates for the different types are all very similar but it may be that your womb particularly dislikes one shape or size, so a change may help. But obviously ir you constantly worry about the possibility that the IUD has been expelled, you may find another method suits you better.

Can you use tampons if you have an IUD?

Yes you can. Your doctor may suggest not using them until after your first check-up, but after that there should be no problems. You may find you have to use the super-absorbant type. If you do, it’s important to change them frequently.

What are the dangers of IUDs?

It’s rare for IUDs to cause serious problems but any complications that do arise can be treated. The most common one is pelvic inflammatory disease (PI D) — infections of the womb, ovaries, Fallopian tubes or cervix. Sometimes an infection is caught during the insertion of the IUD, or at a later stage, an infection in the vagina can be drawn up into the womb via the IUD’s threads. The problem seems to be more common with women who have several sexual partners.

PID can lead to abscesses developing in any of these organs and can result in sterility. Any unusual vaginal discharge, pain after intercourse or abdominal pain especially if it is accompanied by fever, should be reported to your doctor immediately. PID needs prompt treatment with antibiotics. If it does not clear up in a few days then the IUD will be removed.

Some women who have used an IUD for a long period catch a fungal infection, This can have the same consequences as PID but it doesn’t always produce noticeable symptoms. If you notice any change, you should see your doctor who will take a swab.

Another rare complication is perforation of the womb or cervix by the IUD. This means that the device has been pushed through the walls of the womb, or very occasionally through the cervix, and an operation may be necessary to remove it. Perforation may cause pain but there are no definite symptoms. When it occurs the IUD user is no longer protected against pregnancy. The problem is usually discovered when the threads of the IUD cannot be felt in the vagina. This is one reason why you should always consult your doctor if you can’t feel the strings.

There has been a great deal of publicity about one particular IUD which was withdrawn from the market in 1975. It is called the Dalkon Shield, and anyone still using one should have it removed even if it has caused no trouble. There have been a number of reports of serious risks associated with it. This may have worried many women about the safety of IUDs in general. But in reality IUDs cam’ very low risks to health.

If you are unlucky enough to become pregnant with an IUD in place there can be complications, so it is important to visit your doctor if you are ever 14 days overdue for a period. If a pregnancy test is positive and the strings of the IUD are visible, it may be possible to remove it if you decide to go ahead with the pregnancy. Mis-carriages are more likely if the IUD is left inside the womb.

About one in twenty IUD pregnancies are ‘ectopic’. This means that the foetus develops not in the womb but in one of the Fallopian tubes. Although it happens rarely, it is a dangerous condition, and one of the symptoms is acute abdominal pain. So any pain occuring after a delayed, light or missed period should be reported to a doctor at once.

B arrier methods of birth control are among the oldest practised. Certainly until the advent of the Pill some 20 years ago, the condom or sheath was, in fact, the most commonly used contraceptive device. Although the choice of contraceptives has grown enormously, the sheath is still an extremely popular method of birth control in Britain, and the diaphragm or’cap’ is widely used by women who cannot or do not want to use the Pill or IUD.

What is the proper way to use a condom? Are they safe to use on their own? A condom, variously known as a sheath, johnny, french letter, rubber or durex, is a close-fitting covering which slips over the whole of the erect penis and collects the semen as the man ejaculates. Usually it has a teat shaped tip to hold the semen safely so that it doesn’t seep down the sides and cause the sheath to slip off.

Family planning experts recommend using some sort of spermicide – a chemical which destroys sperms, but is otherwise not harmfulat the same time as a condom to give extra protection in case it should tear or leak at all. Some types of condom are sold together with spermicidal pessaries, and a few modern sheaths are covered in a lubricant which contains a spermicide.

There isn’t total agreement among the experts about the need for spermicides or how effective they would be if the sheath did tear. One survey of condom users found sheaths were 96 per cent effective when used alone – among every 100 couples using this method for a year, only four pregnancies occurred. Many sheath users prob-ably don’t use a spermicide as well, but to be on the safe side, it is advisable to do so.

Although almost all modern sheaths are lub-ricated, it is a good idea to use some sort of additional lubricant to prevent the woman feeling sore from the friction of the rubber and to decrease the chances of the sheath tearing. Never use vaseline or any greasy non-spermicidal creams or oils – they can damage the rubber of the sheath, and tend to dry up the vagina’s own natural lubrication. If a woman uses some sort of spermicidal foam or jelly it will also work as a lubricant.

Although properly tested sheaths (in Britain these can be identified by a kite-mark on the package) are usually very reliable, it’s important to learn how to put them on before intercourse, and how to take them off afterwards.

Begin by holding the tip of the rolled up condom (they are packed already rolled) carefully between the thumb and forefinger to squeeze out any trapped air. Beware of those fingernails! If the woman is helping her partner to put it on she should do so from behind him, as then she’s less likely to catch the sheath on her thumbnails from that position.

Next, place the condom’s opening on the head of the erect penis and unroll it all the way to the base. If by any chance the sheath does not have a specially shaped tip, then leave about halfan-inch of sheath loose in front of the penis head to collect the semen.

After intercourse, the man should withdraw as soon as possible after actual ejaculation so that no semen leaks into the vagina when his erection subsides, and he should hold the sheath against the base of the penis (to prevent it from slipping off as he withdraws. The sheath is then disposed of; never try to use one twice. Also, be sure to keep sheaths away from heat as this will cause the rubber to deteriorate and weaken.

Are sheaths really one of the most reliable methods of contraception? Properly tested sheaths used carefully with a spermicide have a success rate of 96 to 97 per cent – about the same as the success rate of the diaphragm, and just under the reliability rate for the IUD or mini-pill.

Tested sheaths are available shaped and un-shaped and in a variety of colours. When they bear a standard mark to show that they have been carefully made and tested, they are reliable; but similar devices (usually sold as sex aids to stimulate the woman) are not effective contra-ceptives. Neither are the short condoms, some-times called ‘American tips’, which only cover the head of the penis.

Sheaths come in packets of three, six, or more – but there are no special sizes made for fit Always check the date they were made on the packet. If left unopened in a cool place, sheaths should be good for about two years.

What are the advantages of condoms?

Many people prefer to use condoms rather than other methods of birth control because they have virtually no side effects, and are no risk to health. Unlike hormonal methods of contraception and IUDs, condoms don’t interfere with the body’s internal chemistry, nor do they have to be used continuously, but only when needed.

They don’t require any prescription, fitting or medical examination, or any discussion with doctors or nurses about intimate sexual details.

Furthermore, they are easy to obtain, and not too costly. They can be bought at chemists, by mail order or from special slot machines. They should also be available free from family planning clinics, but Gps do not supply them.

Further benefits of using condoms are that they can give some protection against sexually transmitted diseases, such as gonorrhoea and genital herpes, and that they may protect women against cancer of the cervix.

Are there any drawbacks to using sheaths? Does it lessen pleasure for both partners? Naturally every method of contraception is apt to have drawbacks for some people and sheaths are no exception. A very few people will be allergic to the rubber from which they are made. But today, it’s quite easy to buy special nonallergy sheaths – a chemist can advise you. A few women may be allergic to the lubricant with which the pre-packed condoms are coated. Changing to un-coated ones, and using a separate lubricant may cure this problem.

For the remainder of people, the drawbacks are mainly a matter of habits in love making and aesthetics. Some couples say that they feel embar-rassed or ‘turned off’by having to stop during foreplay and have the man put the sheath on. If the method is otherwise suitable, you may overcome this disadvantage by making the pro-cess part of love play with the woman putting the sheath on the man before he enters her.

Another complaint from both men and women is that the need for the man to withdraw immediately and carefully after he has ejaculated spoils their sense of contentment and well being after orgasm. A few men find that they tend to lose their erection when the sheath is rolled on. Even if they can be stimulated to erection again, the method is not a good one for them.

Many couples dislike using sheaths, no matter how fine in texture, because they complain,that they dull sensation. However, a new ‘ribbed’ condom is now available which, some people report, increases sensation and is still an effective contraceptive.

It’s also worth noting that some men who have a tendency to premature ejaculation actually prefer to use a condom because the reduced sensitivity they experience delays their climax, and so gives the woman more time to reach her orgasm.

What you feel about the loss of sensation and how important it is to you is very personal, and will decide your own attitude to the sheath.

What is the cap or diaphragm?

Caps come in a variety of types, but they all perform the same function- of forming a barrier across the opening of the cervix (neck of the womb), to keep sperms from reaching the womb and fertilizing the egg in the fallopian tube. Again, as an added precaution, a spermicidal preparation must be used.

Is it complicated to fit a cap?

Since all types of caps must fit correcdy to be effective, you will need to consult a doctor or family planning clinic for an individual fitting and for instructions on use.

At a clinic the doctor or trained nurse will examine you, and probably try fitting one or two caps before finding your size. Diaphragms are probably the easiest to use, and are by far the most common. You will be shown how to use them with a spermicide, and then asked to practice the method at home- using additional means of birth control during this time.

You will be asked to return after a week with the diaphragm in place when a check will be made to be sure you are putting it in correcdy. After that you’ll need to return about every six months for a check on size and for weaknesses. If you gain or lose more than seven pounds in weight, have a baby, a miscarriage or a termination, you must have a check-up to see if you need a different size. Most women can use a diaphragm, even those who haven’t made love before.

How do you insert a diaphragm? Do you have to use a spermicide with it? Yes, you should always use a spermicide with the diaphragm or any cap as the’fail-safe’ precaution to avoid pregnancy. You will need to remember that the spermicide only stays active for a limited time. Inserting a diaphragm takes a litde practice but it is not hard to do. Always use a recom-mended spermicidal cream or jelly. Apply two one- or two-inch strips of the spermicide on each side of the cap, and with your finger spread it so that it covers the cap. Smear a litde around the rim of the cap to make insertion easier. Then squeeze the diaphragm into a long, thin shape, and either squat, or rest one foot on a low stool, to make insertion simpler. With your free hand, open the lips of the vagina and slide the cap up until the rim rests behind the pubic bone at the front and the rubber dome covers the cervix at the back. If you have a bath before intercourse, you should put in your cap after your bath rather than before it

You can put in the cap and spermicide any time before making love — many women do so every evening as a matter of course. If you have intercourse more than three hours after inserting the diaphragm, you need to put more spermicidal cream, jelly, foam, or another pessary into the vagina before doing so. Moreover, before each additional time that you have intercourse, you must add more spermicide – and, most importandy, you must not remove the cap for at least six hours after the last intercourse.

You can leave a cap in place for up to 24 hours. After taking it out, you should wash it in warm water with mild soap and dry it carefully. Check it for tiny holes periodically.

The most common variety of cap is known as the or It consists of a shallow rubber bowl (or dome depending on how you look at it) with a flexible rim that allows the device to ‘spring5 back into shape once it is placed in the vagina. When it is in position, it fits above and behind the pubic bone with the dome covering the cervix and the spring rim fitting smoothly against the walls of the vagina. As women vary in their internal size and shape, different sizes of diaphragms are made, and an individual fitting is required.

The cap is much smaller than a diaphragm and looks a bit like a thimble with a thick rim. It fits snugly over the cervix rather than across it Although it is flexible, it has no spring in the rim as does the diaphragm, and so is harder to insert and remove. Two long threads can be attached to the rim to make withdrawal easier.

Other caps, namely the and are held in place by suction; to remove them you must insert your fingers under the rim to break the suction, which again may be awkward for some women to manage. Each of these types has a slightly different shape and are often recommended to women who have either lax vaginal muscles – perhaps after childbirth or cannot retain a diaphragm because of the position of their cervix. All of these odier types of caps require careful individual fitting by a doctor or a trained nurse.

The main advantages of the cap are its reliability (97 per cent when used with spermicide) and the fact that almost any woman of any age can use it without suffering side effects or long-term medical risks. Also, there is some evidence that, like the sheath, it gives a woman some protection against cancer of the cervix.

I f you use it properly there will be no chance of infection, irritation or smelly discharges. But these could happen, just as with tampons, if you leave the cap in for too long, or do not wash and dry it carefully.

Neither the woman nor the man should be able to feel the diaphragm during love-making, and it is very rare for it to become dislodged -even in the most vigorous love-making. If you or your partner do feel any discomfort, you should check whether you have put the cap in correctly: if not, and your cervix is uncovered, you should insert some spermicidal cream into your vagina at once. You should also return to your doctor or clinic for the fitting to be re-checked.

One further advantage of the cap for some couples is that you can use it safely to hold back the menstrual flow during a period, and so make intercourse at this time more pleasant.

The main drawbacks to using the diaphragm are having to be more calculating about your love-making- remembering to put it in ahead of time, and then adding more spermicide every time you have intercourse – and you can’t be squeamish about your body. Putting in and taking out a cap can be a rather messy business, and many a new recruit has found herself chasing a jellied diaphragm across the bathroom floor, despairing of every mastering it! But large numbers of women and in a pretty short time, so you must weigh carefully die drawbacks and the advantages, and not give up in a hurry.

Of course, some women will not find the cap suitable — those who suffer from the very rare rubber allergy, for instance, or those who suffer from regular, serious bouts of cystitis . There may be a greater chance of suffering from cystitis if you wear a diaphragm, either because it presses on the outlet from the bladder, or because you can’t ensure that it is completely sterile, although one of the newer kinds, the’arching spring’ diaphragm is reputedly less likely to provoke cystitis attacks.

An allergy to spermicide is much more likely to occur than one to rubber, and the symptoms may appear to be very similar – soreness and sometimes a rash or redness. This is usually caused by the cream or jelly in which the spermicide is contained, so changing to another recommended brand solves the problem for most, women, but if you are allergic to the spermicide ingredient itself, you may be unable to use this method.

No. None of them is reliable as a contraceptive if used alone- the rate quoted is a failure of about 20 in 100 users per year. However, if you discover after intercourse that a sheath has leaked or torn, you can cut down the risk of pregnancy by placing fairly generous amounts of spermicidal cream or foam or a spermicidal pessary high up in your vagina. However, this is by no means foolproof.