Lemondrop

When I first mentioned I had an upcoming appointment for an IUD, my roommate thought I had a job interview at a law firm. Mmm, close, but no.

Another friend said, "That's the birth control, right?" Right. Then she went on to ask how regularly I had to get shots in my arm -- which the IUD absolutely does not involve.

Can you blame them? Despite being 99-percent effective in preventing pregnancy and a popular form of birth control worldwide, the IUD remains relatively obscure in the U.S. In a study done at the Nassau Department of Public Health, 60 percent of 14- to 24-year-olds had never so much as heard of an IUD. Doctors seem hesitant to prescribe it. And on top of the hush-hush attitude about it, the price of the Mirena has recently doubled. It's like there's a conspiracy against women getting their hands on the most effective contraceptive around.

So why hasn't your doctor asked you if you want one?

What Exactly Is the IUD?
The IUD (intrauterine device) is a small, T-shaped contraceptive that a medical provider inserts into the uterus during an office visit. There are two types: the Mirena, a low-hormone version made of soft plastic, effective for five years; and the Paragard, a non-hormonal option made of plastic and wrapped in copper wire, effective for up to 10 years.

IUDs are thought to work by inhibiting sperm from reaching or fertilizing the egg, and both types are reversible at any time. Other than checking that it's still in place, the IUD requires no month-to-month upkeep. According to Planned Parenthood, the total cost -- for the exam, the IUD, the insertion, and follow-up visits -- ranges from $175 to $650.

And women around the world are far more aware of its efficacy than Americans are, as evidenced below.


IUD usage by country, via the Guttmacher Institute.


Comparative efficacy of the IUD, via Paragard's Web site.

The Holy Grail of Birth Control?
Effective, economical, long-term, reversible, and most importantly, easy: If we could fantasize about birth control, the IUD would be it. Unfortunately, despite a 2007 Committee Opinion statement by the American Congress of Obstetricians and Gynecologists that IUDs be considered a first-line choice in birth control for both women who had had children and those who had never been pregnant, the device is still unfamiliar to the majority of American women. (The FDA recommends Mirena for women who have had at least one child; Paragard is recommended for women in all stages of their reproductive cycle.)

Why don't doctors recommend the IUD for women who have never had children? Probably the tarnished reputation left by the Dalkon Shield, a faulty IUD dating back to the 1970s. Used by 2.8 million women at its peak -- or almost 10 percent of American women on birth control -- the Dalkon Shield caused pelvic inflammatory disease and infertility for a disproportionate number of users, resulting in millions of dollars in lawsuits. Even after modern, functionally sound devices like the Paragard and Mirena were introduced, the IUD never quite recovered from the bad press. Today, less than 2 percent of women on contraceptives have one, and common misconceptions about the IUD remain widespread.

One Woman's Pursuit of the IUD (That Woman Being Me)
After first learning about the IUD from a blogger friend, I began conducting my own research. Having previously never been in a long-term, monogamous relationship, I'd always shied away from birth control (with the exception of vigilant condom use, of course). Moreover, as someone with serious aversion to even over-the-counter pill-popping, I never liked the idea of hormonal birth control. But having acquired one of those "long-term boyfriend" things and come across the option of the hormone-free Paragard, I started to reconsider.

Where I would typically turn to friends with sexually robust love lives for contraceptive counsel, I found that few of them knew what the IUD was -- and even fewer actually had it (one, to be exact). I went to the women's health center on campus, only to find that not only did my gynecologist there not administer the IUD, she was unable to answer several of my questions about the birth control method. Instead, she wrote me an unsolicited prescription for the Pill and sent me on my way.

Undeterred, I made an appointment for a women's health consult at another medical center. Though the doctor there appeared surprised at my request for an IUD, he agreed to perform the insertion after warning me of possible complications -- namely, perforation of the uterus and unexplained bleeding.

On the day of insertion, I took two ibuprofens prior to my appointment. During the procedure, which can vary in length (mine lasted less than five minutes), the doctor applies antiseptic to the vagina, passes a thin plastic tube into your uterus, withdraws the plastic tube, leaving the IUD in the uterus, then trims the threads to the appropriate length. It felt like this: moist dabbing, a slight pinching -- cramping, cramping, cramping -- and before I knew it, it was done. I've been lucky in that I've never really experienced menstrual cramps, so I laid there overdramatically for a couple of minutes. But all in all, the pain was very tolerable, and I was in and out of the office in under 20 minutes. Irregular bleeding occurred for a couple of weeks (which is to be expected, says my gynecologist), but since it stopped, it's been smooth sailing ever since.

You Want to Get a What?
Since the first health-care provider I'd approached about obtaining an IUD didn't exactly cheer me on, I was curious about other women's experiences. So I started asking around.

Kathryn, 27, had been on hormonal birth control for nine years. "As I got older, I was more and more convinced that my anxiety, depression, mood swings, sleeplessness and weight gain were due to my [hormonal birth control], as I couldn't remember going through all of it before." The first doctor she talked to was somewhat discouraging, saying that Kathryn wasn't a good candidate because she had never had children. But since she was a general practitioner and untrained to do the insertion, she referred her to another doctor. "I was expecting the same thing from him, but he was actually fine with it -- and encouraging," says Kathryn.

21-year-old Julie went to her gynecologist seeking alternative birth control after encountering problems with the Pill and was prescribed the NuvaRing. When asked about a more permanent, maintenance-free option, Julie's provider warned against the IUD, claiming that she would have more severe cramps and heavier bleeding. She ended up keeping the Ring.

Melissa, age 22, says she first became interested in IUDs when she was 19. At the time of her research, IUDs were not mentioned in her school's birth control info pamphlet. "The first time I met [with my doctor], I brought up IUDs and she was very dismissive." However, after she transferred schools, she says, "I went to my new school's clinic, where the doctor was super enthusiastic about IUDs and recommended a clinic. It was such a relief to finally have someone listen to me!"

Tracy, who had her IUD inserted last week, did her own preliminary research and went into Planned Parenthood ready to defend her IUD decision. To her surprise, the nurse actually had a Mirena herself and didn't try to deter her from getting the IUD. "But I am actually afraid to tell people in real life that I have one because of all the misconceptions," she says.

While very few of the women I spoke to encountered strong resistance in obtaining their IUDs, a common pattern did emerge: Most were frustrated with their current choice of birth control, which led them to discover and research the IUD on their own. When they did locate doctors who were happy to perform the insertion, the women felt relieved -- as if wanting to acquire affordable, effective birth control was something we should feel guilty about.

Bottom line is this: The IUD may be gaining momentum, but negative prevailing attitudes about the device still linger.

Straight From the Source -- Are Doctors Hesitant to Prescribe the IUD?
As one might expect, the possibility of complications exists, including (not to sound like a pharmaceutical ad) heavier or longer menstrual flow, pelvic inflammatory disease, perforation of the uterus, expulsion, and difficult removals. But every birth control method has its downsides. As long as patients are well-informed and making knowledgeable choices, why the hesitation in prescribing or even mentioning the IUD?

A recent survey of OB/GYNs in the St. Louis city and county may have the answer -- it cites inadequate training of clinicians, misperceptions regarding who the IUD is right for, and inaccurate knowledge of the IUD and its side effects as barriers.

University of Virginia's Director of Gynecology, Dr. Christine M. Peterson, says that though professional organizations like ACOG encourage IUD use in younger women, it has not been studied extensively in adolescents, and therefore it isn't as clear how they respond in terms of side effects and complications. "So I'm less enthusiastic for my youngest patients and more enthusiastic for more mature women who have had a child," she says.

Another source of reluctance may be the Mirena's lack of FDA approval for women who have not yet had children -- Dr. Ann Laros, staff gynecologist at the University of Iowa, says that previously that was somewhat a source of discomfort for her in prescribing the hormonal device.

Even among health care providers, there is a discrepancy of beliefs about the dangers of the IUD. OB/GYN and sexual health expert Dr. Jennifer Guntner says, "Previously, many doctors erroneously thought they increased the risk of pelvic infections and infertility. Some doctors and patients think IUDs cause abortions. However, studies show that is not the case."

OB/GYN nurse practitioner Kei Dalsimer says, "Many will not recommend the IUD to a woman who is not in a monogamous relationship because of the risk of pelvic inflammatory disease ... an infection of a woman's reproductive organs that can cause scar tissue and may lead to infertility, pelvic pain and tubal pregnancy."

PID can lead to infertility, agrees Dr. Randy Fink, Medical Director at the Miami Center of Excellence for OB/GYN -- but there is no evidence that IUDs themselves cause infertility. He offers a statistic that sheds some light: The risk for PID is greatest in the first 20 days after insertion (1-10 per 1000 insertions), and is rare thereafter (1.4 per 1000 users). "The single most important risk factor for PID is having multiple sexual partners, or a partner who has multiple partners. If your risk of acquiring an STI is low, so is your risk of developing PID while using an IUD," clarifies Dr. Scott.

"To me, the FDA's approval of the copper Paragard is a resounding statement that it's very safe," says Dr. Laros. Moreover, even though the Mirena is recommended for women who have had children, it's not contraindicated either, she adds.

Despite all controversy surrounding the contraceptive, it sounds like the IUD gospel is slowly circulating as long-standing myths are dispelled. Dr. Guntner notes that IUDs are now one of the most popular forms of contraception among female OB/GYNs. Moreover, gynecologists say that more women -- especially younger, college-age women -- have been coming in asking about or requesting the IUD, having already researched it themselves. Like me, "last year in particular, a number of graduating students unsure of their health insurance for the following year sought out IUDs," says Dr. Laros. When compared to the $5 to $60 one might continue to pay monthly for birth control, a one-time investment is much more economical.

Says Dr. Fink, "An intrauterine device is an exceptionally good form of birth control for the right patient, and I enthusiastically recommend them every day. For a woman seeking long-term, reversible contraception, the IUD is unparalleled."

Tell us! Do you or a friend of yours have an IUD? Share your experiences below.

Teresa Wu is a 21-year-old writer and IUD enthusiast who is happy to discuss the goings-on of her uterus in the name of journalism. She lives in San Diego, Calif., with four sorority girls and one overweight mini-dachshund. You can email her about her IUD experience, read her blog or follow her on Twitter here.