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IUDs and Implants Changing Birth Control Landscape

7:43 AM, Oct 30, 2012   |    comments
The ParaGard IUD is a long-lasting contraceptive.(Photo: Duramed Pharmaceuticals Inc.)
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Kim Painter, Special for USA TODAY

Leah Sanchez, 26, of Los Angeles is a married woman who wants kids someday, but not now. Crystal Nelson, 31, of St. Louis is single, doesn't have kids and doesn't plan to have any. And Lydia Huston, 44, of Florrisant, Mo., is a married mother of three who has decided her family is large enough.

These women have one thing in common: They all are using birth control methods that are gaining new popularity in the USA.

The methods, known collectively as "long-acting reversible contraceptives" or LARCs, are intrauterine devices (IUDs) and hormonal arm implants. A decade ago, such methods were used by just 2.4% of U.S. women who used any method, but by 2009, they had caught on with 8.5%, with IUDs leading the way by a large margin, according to a recent study from the non-profit Guttmacher Institute. New federal data show the same trend.

And that trend is likely to pick up steam in the next few years, family planning experts say.

One reason: Under the new federal health law, insurers must cover all contraceptive methods, meaning the high up-front cost of IUDs and implants (estimated at $500 to $1,000) will disappear for many women. Meanwhile, the influential American College of Obstetricians and Gynecologists has started recommending these methods as first-line contraceptives, not only for adult women but for teens.

The impact could be big, suggests one recent study published in Obstetrics & Gynecology: When 9,000 teens and women in the St. Louis area were offered no-cost birth control, 75% chose IUDs and implants - and teen pregnancies and abortions fell dramatically, compared to national rates. Earlier, data from the same study, published in the New England Journal of Medicine, found that IUDs and implants, with a yearly failure rate of about 0.3 per 100 users, worked up to 20 times better than hormonal pills, patches and rings to prevent pregnancy among participants - who included Nelson, Huston and Sanchez.

When cost is not a barrier, "we learned what is most important to women is that a method works really well," says researcher Jeffrey Peipert, of Washington University School of Medicine, St. Louis. "And many women liked the idea that these were long-term methods. They could get it and forget it."

A Mirena IUD, which contains the hormone progesterone, lasts five years; the copper ParaGard IUD lasts 10 years and the Nexplanon (formerly Implanon) implant, which contains progesterone, lasts three.

Nelson, a hairdresser, says she never felt secure with pills and hormone shots. "I'm not really good at remembering to take a pill at the same time every day." She got her Mirena IUD more than a year ago and says she's happy to have birth control off her to-do list for another four years.

Sanchez was dating her now-husband when she got her five-year IUD three years ago. "We're married now but I just finished a master's degree and we are still young," she says, so avoiding pregnancy for a while longer "definitely fits into our plans."

Huston had just learned her insurer would not cover sterilization surgery when she entered the study in 2008. "I was too old to have to think of something every day," she says. She chose the implant, a matchstick-size rod placed under the skin of her arm, and got another one when it expired. She says it's an option her own doctor never mentioned.

That's not uncommon, says Lawrence Finer, director of domestic research at Guttmacher. "There are many providers who are not giving complete information about the full range of methods available."

One reason is that many doctors have not been trained to insert and remove the devices. Many older doctors also remember problems with IUDs, especially the Dalkon Shield, back in the 1970s, says David Hubacher, senior epidemiologist at Family Health International, Durham, N.C. That device was linked to pelvic infections and infertility.

Studies now suggest the increased risk of infection with IUDs is small and limited to the 20 days after insertion, says Tina Raine-Bennett, research director at the Women's Health Research Institute, Kaiser Permanente Northern California. She led the ACOG committee that recommended the devices for teens and says that the old fear that IUDs would endanger the fertility of women who still want children was unfounded.

In fact, she says, IUDs are great choices for women who become sexually active in their late teens or early 20s but don't want children for many years.

Still, "these methods are not for everyone," Hubacher says. Some women just don't like the idea of an object in their bodies, he says. IUDs are inserted and removed through the cervix; implants are placed just under the skin of the upper arm. Women must see doctors for insertion and removal.

As with any method, there are side effects and risks.

For the copper IUDs, side effects can include increased menstrual bleeding and cramps. The hormonal IUD often stops periods - which many women consider a benefit, Raine-Bennett says - but also can cause irregular bleeding. The Implanon/Nexplanon implants also can cause irregular bleeding and may increase the risk of blood clots, especially in smokers.

And none of these methods protect against sexually transmitted diseases, so they don't eliminate the need for condoms.

Some religious and conservative groups strongly oppose the new birth control coverage rules because they say they violate the conscience of some employers who must provide the insurance coverage. In public arguments over the rules, some singled out IUDs as particularly objectionable because of a long-standing belief that they might stop fertilized eggs from implanting in the uterus. Some view that as abortion.

But studies designed to find out how IUDs work have never shown they work that way, Hubacher says. Instead, the copper IUD "creates an inflammatory environment" that stops sperm from swimming and reaching the egg, he says, and the hormonal IUD inhibits sperm, partly by thickening cervical mucus. It is true, he says, that the hormonal version also thins the lining of the uterus and that might stop any fertilized eggs from implanting and growing.


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