IUDs, inflammation, and infection: assessment after two decades of IUD use.

PIP: In the 1950s social and technological changes allowed experimental use of an inert plastic IUD which was successful and regarded as safe. The devices were pliable, chemically inert, sterilizable, disposable, and equipped with a small inserter so that cervical dilation was not needed for insertion. But many IUDs were withdrawn because they were found to cause endometritis and provide poor protection against pregnancy. In the 1970s there were cases of serious inflammatory and infectious diseases with pelvic inflammatory disease (PID) the most common. The Dalkon Shield has been associated with midtrimester septic abortions and with unilateral actinomycotic tube-ovarian abscesses and there is evidence to support a chemically caused IUD-related endometritis in the moderate inflammation associated with IUDs containing copper and with the Majzlin spring. The most common factor among IUD users with Actinomycetales infection is not the type of IUD but the duration of use; almost 85% of cases were in women who had worn IUDs over 3 years. Also the likelihood of an ectopic pregnancy is almost 3 times greater for longterm IUD users. It is hypothesized that with time the IUD is capable of inducing changes that can lead to infection and that changes can occur to the IUD itself. A surface coating on the IUD and the tail has been found which is composed of mucoid and cellular elements which consist of an inflammatory response; the IUD then becomes recognized as a foreign body to the host and may contribute to the development of PID. Other problems such as perforation, cramping, bleeding, and unwanted pregnancy may be at least indirectly related to IUD surface alterations. It is now agreed that all IUD-associated inflammatory and infectious disease can no longer be considered gonorrheal type PID and that the biodegradation of the nylon-6 tail of the Dalkon shield may also be a factor in PID. Some recommendations are to: 1) change IUDs every 2 years, 2) counsel women on IUD complications and examine IUDs upon removal, and 3) bring IUD technology up to date to develop an IUD that is thoroughly safe and effective.^ieng

Contraception with intrauterine devices.

PIP: A review of the history of contraception with intrauterine devices, characteristics of present devices, and directions of current research is presented. The serious need for population control is not yet being met by today's inconvenient, ineffective, or unsafe methods. Intrauterine devices have been best for international family planning programs because they are cheap, easily installed, and provide continuous protection. There are many different models that have been and are being used, with different effectiveness and complication rates. The most commonly used today is the Lippes Loop, with a pregnancy rate of 2.8/100 years of woman use and an expulsion rate of 10.4. Most of these failures occur in the first few months of use, after which these rates are greatly reduced. The removal rate because of bleeding or pain for the Lippes device is 14.0. Other devices commonly used have pregnancy rates ranging 1.3-4.7, expulsion rates of 2.6-25.8, and removal rates of 13.5-22.1. Expulsion is directly related to the size and design of the IUD and the age and parity of t,e recipient. It is important to match the size of the device used to the individual characteristics of the patient. Research is seeking a design that will implant itself in the endometrium to resist expulsion, but not too deeply so that it is covered. Removal for bleeding and pain remains the most frequent complication of the IUD, and it partly depends on the skill of the inserting physician and how well the patient is psychologically prepared for side effects in the first months of use. Pregnancy is the most significant IUD complication. The key to an effective IUD is an understanding of its antifertility mechanism, which has thus far eluded researchers. The IUD prevents implantation of the blastocyst in the uterine wall, which may be due to a foreign-body reaction in the endometrium. IUDs with copper cause a greater reaction than plastic devices and provide hope for a very effective device; particularly the T-shaped design, which resists expulsion. The most promising new IUD is the Dalkon Shield. It has small projections that imbed in the endometrium and a broad surface for contact with the uterine wall. In preliminary experiments the pregnancy rate with this device was 1.1, the expulsion rate 2.3, and the removal rate 2.0, much lower than that with any other device yet developed. It is concluded that IUDs such as the Dalkon Shield can provide safe contraception with high effectiveness.^ieng

Translocation of the Dalkon Shield into the broad ligament.

Perforation of the uterus is a serious complication in users of intrauterine devices for contraception. The incidence varies with the type of device. The perforation can occur in different parts of the uterine wall. Perforation into the broad ligament is rare; only 4 cases have been described. Two additional cases, both occurring with the Dalkon Shield, are reported here.

PIP: A serious complication following the insertion of an IUD is perforation of the uterus and translocation of the device into the abdominal cavity. Uterine perforation can be divided into "primary" ones, the most common, which are related to the insertion procedure, and "secondary" ones, which are caused by uterine contractions. A rare type of secondary perforation is to the broad ligament. Heretofore, only 4 such cases have been reported. 2 additional cases, occurring with the Dalkon shield, are reported here. Although the translocation of an IUD into the leaves of the broad ligament is rare, this complication should be considered whenever an IUD cannot be removed by pulling the strings. 2 possible complications--rupturing of the uterine vessels causing serious intraabdominal bleeding and infection, with potential danger of peritonitis and sepsis--could greatly endanger the patient's life. The 2 cases reported here were resolved satisfactorially.

Letter: Case of the "missing strings".

PIP: A method of removing an IUD whose strings may be lost is discussed. Having identified the intrauterine location of the IUD by touch with probe, a second Lippes loop was placed and the long strings not trimmed at all. When the patient returned later the most recently placed loop was removed and the strings of the first loop became visible; the extraction of the loop was very easy. The author feels that the above method is innocuous and entails a minimum of discomfort and expense. If this method were to be used in the case of loops with lost strings instead of surgery, the savings in hospital costs would be a minimum of a half million dollars.^ieng

Uterine perforation by Lippes loop.

PIP: After a 32-year-old women was unable to locate a C Lippes Loop (inserted approximately 9 weeks postpartum) at any time during a four week period after insertion, the position of the device was shown by x-ray to be extrauterine. Removal of the IUD necessitated a colpotomy, resulting in bleeding which could not be controlled vaginally. Following laparotomy, grasping of the extremely friable uterus caused tearing of the Fallopian tubes from the uterus. A hysterectomy was performed. This case demonstrate the real, if rare, possibility of perforation of the uterus with the Lippes Loop.^ieng

Dislocated IUD and intrauterine ectopic pregnancy with uterine rupture.

A case of uterine rupture due to an ectopic pregnancy in the uterine fundus is presented. A Lippes Loop was found rotated in the uterine cavity. A possible relation between implantation and the dislocated intrauterine device is proposed.

PIP: A case report of uterine rupture due to an ectopic pregnancy in the uterine fundus in a 33-year-old women, gravida 4, para 3, inserted with a Lippes loop C in 1969 is presented. A pregnancy was diagnosed early in 1973 and the patient admitted for laparotomy with a preoperative diagnosis of left extrauterine pregnancy. The uterus was enlarged and the fundus was protrusive with a bleeding rupture unassociated with the tubes which were normal. Supravaginal hysterectomy was performed. In the fundus a large hematoma was found which was partly embedded in the uterine wall and had ruptured the serosa. A Lippes loop was found rotated 180 degrees in the uterine cavity. Microscopic examination of the hematoma revealed fetal material. A possible relation between implantation and the dislocated IUD is proposed.

Unilateral tubo-ovarian abscess and intrauterine contraceptive devices.

The association of unilateral tubo-ovarian abscess and the presence or use of an intrauterine contraceptive device (IUD) appears to be a definite clinical entity. Four cases of unilateral tubo-ovarian abscess in patients using the IUD are presented. Three patients had a Dalkon Shield IUD and one had a Lippes Loop. Two patients had unilateral salpingo-oophorectomy while the other 2 had total abdominal hysterectomy and bilateral salpingo-oophorectomy. The differential diagnosis, possible etiology, route and mode of infection, and management are discussed.

PIP: 4 cases of unilateral tuboovarian abscess in patients using an IUD are presented; 3 of the 4 patients had a Dalkon shield and 1 had a Lippes loop. These cases present the problem of diagnosis and treatment as the presence of pelvic mass in an IUD user may be due to an ectopic pregnancy, ovarian cyst, or a pelvic or tuboovarian abscess. Unruptured tuboovarian abscess requires conservative treatment with antibiotics initially and surgery if there is an unsatisfactory response. These patients display a high fever and purulent cervical discharge. An ascending infection is associated with IUD use and recent investigations implicate the tail, especially the compound variety. Trauma to the endometrium by the IUD may initiate the infection and the finlike projections of the IUD may cause further trauma. The connection of unilateral tubooovarian inflammatory mass with the IUD user should alert more clinicians to this possibility.

Removal of intrauterine contraceptive devices after uterine perforation.

PIP: Rates of perforation for different types of IUDs vary from 1 per 150 insertions with the bow to 1 per 2500 with the loop. Incidence of perforation varies with insertion technic. Not all perforations occur at the time of insertion but most do. These perforations may be partial or complete, with or without symptoms, and complications range from mild anxiety to life-threatening situations. With the older closed-loop devices intestinal strangulation was a threat. Partial perforations have been identified as sources of intestinal volvulus and septic abortions. With the increase use of IUDs and the increased frequency of perforations, a technic simpler than laparotomy was desired to remove intraperitoneal devices. Laparoscopy seems safer and is associated with fewer side effects than laparotomy. Before attempting removal, the patient is examined to determine if the string attached to the IUD can be seen. In 18% of women with retracted strings perforation is present. The uterus is probed to detect the IUD. A plain x-ray of the abdomen is taken to rule out unnoticed expulsion. If the x-ray reveals the IUD, a hysterosalpingogram is performed with both autero-posterior and lateral views using 40% iodized oil. Laparoscopy is performed under general anesthesia with the patient in the lithotomy position. The uterus is manipulated by a tenaculum on the cervix. The abdomen is distended with gas, 3-4.5 liters. The patient is then slowly moved into the Trendelenburg position to allow the omentum and intestines to withdraw from the pelvis. When the IUD is found, it can be grasped by Eder tongs and withdrawn. Lippes Loops were removed from 5 patients by this method. All recovered uneventfully. Left lower quadrant pain was the only symptom complained of before the operation. 1 patient had been pregnant and after a successful delivery the extrauterine IUD was removed 1 day postpartum. Laparoscopy produces minimal surgical trauma, the postoperative course is short, and morbidity has not been encountered. Tubal coagulation could be done at the same time if desired.^ieng

Intrauterine contraceptive devices: a comparison between their use in indigent and private patients.

PIP: Use of intrauterine contraception for an aggregate 8291 months in a group of 706 private patients (mean age 27.5 years, mean number of pregnancies 2.75, 9 nulligravidas) was analyzed and compared briefly with use in a group of 623 women from a lower socioeconomic level. Considering private patients only, 195 (27.6%) had intermenstrual bleeding after IUD insertion and 27 (3.8%) experienced an increase in the amount or duration of menstrual flow. All women had cramping after insertion of the Lippes loop (or Permaspiral in 2 patients); 43 (6.1%) expelled the device. Infection developed in 9 (1.3%), and perforation of the uterus during insertion of the loop occurred in 2 patients. The pregnancy rate for all users was 2.6 pregnancies per 100 years of use. Termination of intrauterine contraception in 216 (30.6%) was because of intermenstrual bleeding (89 women), increased menstrual flow (7), cramping (19), infection (8), spontaneous ejection (22), a sterilizing operation on either spouse (8), pregnancy when IUD inserted (2), pregnancy desired (37), and other personal reasons (6). The IUD continued to be acceptable to 535 (75.8%, including those sterilized or desiring pregnancy) of 706 upper and middle class women an aggregate of 6655 months of use. Private patients compared to clinic ones had a lower incidence of irregular bleeding (195 of 706 vs. 391 of 623), but more of them discontinued intrauterine contraception because of irregular or excessive bleeding (96 or 13.6% of private patients vs. 28 or 4.5% of clinic patients). The infection rate, total expulsion rate, and final rate for discontinuation due to expulsion were lower for private vs. clinic patients (1.3% vs. 8%, 6.1% vs. 15%, and 3% vs. 5.7%, respectively). It was found that the main advantage of the IUD, constant unburdensome protection against pregnancy, was important to both groups and that couples of any social class could effectively use intrauterine contraception. Differences in use are due to lesser dependence on the IUD among upper strata women, who can use other contraceptive methods successfully.^ieng

A randomized comparison of the Ypsilon-Y and Lippes loop D intrauterine devices in parous women.

A randomized single-blind clinical study was performed to determine whether there was any difference in the termination event rates between parous women using the Ypsilon-Y intrauterine device (IUD) and those using the Lippes loop D. A total of 174 women received the Ypsilon-Y IUD and 173 women received the loop D. A significant higher incidence of expulsion occurred with use of the Ypsilon-Y IUD.

PIP: A randomized single-blind study was performed to determine whether there was any difference in the termination event rates between parous women using the Ypsilon-Y IUD and those using the Lippes loop D. 174 women (mean age, 25.7; mean parity, 2.4) received the Ypsilon-Y and 173 women (mean age, 25.6; mean parity, 2.7) received the Lippes loop. There were 939 total woman-months of experience with the Ypsilon-Y and 977 with the Lippes loop. A significantly higher incidence of expulsion occurred with use of the Ypsilon-Y, 30 cases vs. 7 for the Lippes loop. 16 of the expulsions of the Ypsilon-Y went unnoticed by the user. Despite a lower rate of termination because of pain and bleeding, the high expulsion rate, confirmed in other studies, indicates that the Ypsilon-Y is not an improved model of IUD.

Experience with the Dalkon Shield as a contraceptive device.

PIP: 291 woman recieved Dalkon shields for 2143 woman-months of cummulative use. The failure rate was 6.2% (18 pregnancies). 4.5% of these pregnancies occurred during the first year of use, and 6.8% during the second year. The overall pregnancy rate was 10.1 per 100 woman years, with no discernable diminution with the passage of time. The pregnancy rate rose rapidly during the first 6 months of usage and remained high thereafter. The expulsion rate was 1.7% and expulsions occurred only within the first 6 months after insertion. Removals totaled 19.2% for bleeding, pain, and/or infection. There was a "moderate degree of difficulty" in removing the device. The institution in which this study occurred recommended discontinuing use of the Dalkon shield because of its unacceptably high pregnancy rate.^ieng

Perforation of the uterus and partial extrusion of a Lippes loop. Report of a case.

PIP: This is a case report of a woman having an IUD which became partially extruded through the uterine wall and went undetected until the patient became pregnant. Severe metritis followed premature rupture of the membranes during the early part of the third trimester. Cesarean section hysterectomy led to a salutary outcome.^ieng

Ectopic endometrium in omentum. Uterine perforation by Lippes loop.

A case of ectopic endometrium in the omentum following perforation of the uterus by a Lippes Looptm is reported. Evidence is presented substantiating Sampson's theory of endometrial implantation.

PIP: This is a case report of a patient who had an IUD inserted the year following a spontaneous abortion. The next year she became pregnant and delivered a full-term infant. Another IUD was then inserted. After 2 years lower abdominal pain and vaginal bleeding of 2 months duration caused her to ask to have the IUD removed. The thread broke during the removal attempt so the patient was admitted to the hospital where a hysterogram revealed a Majzlin spring partially embedded in the uterine wall and a Lippes loop outside the uterine cavity. The Majzlin spring was removed through the vagina and curettage done. At laparotomy to remove the other IUD the Lippes loop was found embedded in a large mass of omentum. The loop and adherent omentum were removed. Histologic study revealed an area of well-preserved endometrium, an area of hemorrh agic endometrium with leukocytic infiltration, and dense fibrous tissue surrounding the endometriotic foci. These findings support the theory of endometrial transplantation rather than the theory of metaplasia.

Pregnancy outcome with removal of intrauterine device.

PIP: Of 201 women who became pregnant with an IUD in situ, 120 had the device left inserted and 81 had it removed. Patients excluded from the study were those who showed evidence of threatened or incomplete abortion, those in whom the thread was not visible and the IUD not recovered during or after termination of pregnancy, and those known to have had attempts at induced abortions. The IUDs were removed only when the thread was still visible at the cervical os, when pregnancy was within the first trimester, and when the 1st attempt at pulling the thread offered no undue resistance. 12 weeks gestation was taken as the cut-off period for attempted removal since the conceptus does not fully occupy the uterine cavity until the 4th month. In the group in which the devices, mostly Lippes loops, had been left in situ there were 5 cesarean sections for obstetric indications including 1 case of placenta previa. 2 of the premature infants died during the neonatal period. Among those with the devices left in situ 48.44% aborted, compared wtih 29.62% in the removal group (p less than .02 greater than .01). When the incidence of abortion and prematurity were combined, the in situ group showed a significant increase (p less than .01). The incidence of ectopic pregnancy in this series also confirms previous reports of the relative increase (5%) among women who become pregnant with the IUD in situ. In this series of incidence was 6%. These data suggest that when continuation of pregnancy is desired, the IUD should be removed if possible.^ieng

Fertility control by intrauterine release of progesterone.

PIP: The contraceptive effectiveness of small amounts of progesterone released in the uterine cavity via a silastic progesterone T IUD was studied. Over 1600 woman-months of use in 249 women were evaluated. The amount of progesterone remaining in 14 capsules revoved 161-200 days after insertion was variable, indicating a possible effect of individual uterine environment on release rates. No pregnancies occurred while devices releasing adequate amounts of progesterone were in situ. 7.9% of the devices were displaced or expelled. Serial plasma hormonal determinations showed no differences between patients with inert and progesterone IUDs. There was no inhibition of ovulation or change in cervical mucus. The mechanism of action is probably related to the decidual changes induced in the endometrial receptors.^ieng

Progesterone and estradiol patterns in women using an intrauterine contraceptive device.

Levels of progesterone, estradiol, LH, and FSH were measured in daily serum samples obtained from 4 subjects during a control cycle and during the first and fourth menstrual cycles after insertion of an intrauterine device (IUD). In addition, progesterone and estradiol were measured in serum samples obtained from 6 women 3, 4, or 5 months after IUD insertion, and from 6 women more than 1 year after IUD insertion. These measurements were compared to the data obtained from study of a large group of normal cycles. The results indicated that the IUD does not influence follicular maturation, time of ovulation, or corpus luteum function. The IUD did exert a local effect on the endometrium, causing the onset of menses to take place when steroid levels were higher than in control cycles.

PIP: In an attempt to resolve differing results on the effect of the IUD on steroid and gonadotropic levels in women wearing the IUD, levels of progesterone, estradiol, luteinizing hormone, and follicle stimulating hormone were measured in daily serum samples obtained from 4 subjects during a control cycle and during the 1st and 4th menstrual cycles after insertion of an IUD (Lippes loop D or TCu 200). Progesterone and estradiol were measured in serum samples obtained from 6 other women 3, 4, or 5 months after IUD insertion (Copper T) and from these another group of 6 women 1 year or more after insertion. These measurements were compared to data obtained from study of a large group of normal cycles. The results indicated that influence on follicular maturation, time of ovulation, or corpus luteum function by an IUD is absent. The IUD exerted a local effect on the endometrium, causing the onset of the menses to take place when steroid levels were higher than in control cycles.

Oral contraceptives and intravenous glucose tolerance. I. Data noted early in treatment.

PIP: The effect of oral contraceptives (OCs) on intravenous glucose tolerance tests (iv GGT) to see if the results in a "pseudopregnancy state" parallel those of actual pregnancy was evaluated. 65 women (41 nondiabetic; 24 diabetes suspects) took Enovid (5 mg norethynodrel with .075 mg mestranol) for 2-3 months. 12 women (7 nondiabetic; 5 diabetes suspects) took Ovulen (1 mg ethhynodiol diacetate and .1 mg mestranol) and 14 women (7 nondiabetic; 7 diabetes) with intrauterine devices (IUD) served as controls. All subjects had the iv GTT before and after treatment. The GTT was expressed as K, the % fall/min of the blood glucose level from 10-60 min after injection of 25 gm glucose. Enovid caused a significant k decline (p .005) but no change in fasting blood sugar levels. No women in the Ovulen or IUD group had abnormal k values. 6 women with previosly normal k values developed abnormally low values while taking Enovid. 2 of these were in the diabetes suspect group. Diabetes suspects using OCs appeared to show a greater loss in GT than nondiabetic subjects. No correlation was found between carbohydrate metabolism during pregnancy and that of the "pseudopregnancy state" of progestin-estrogen administration. The possible mechanisms responsible for these changes, in particular the role of estrogen, were discussed.^ieng

Comparison of immunofluorescence and culture for the detection of Actinomyces israelii in wearers of intra-uterine contraceptive devices.

A direct immunofluorescence (IF) method was compared with traditional culture methods for the detection of Actinomyces israelii in endocervical and intra-uterine-device (IUD) smears from 124 IUD wearers. Of 11 specimens that gave positive results by IF, only one was positive by culture. Of the 10 patients with positive IF specimens, three (30%) had signs and symptoms suggestive of pelvic infection and no other pathogen was detected. Direct IF of cervical smears offers a simple, relatively cheap method to screen IUD wearers for A. israelii. Clinical management of such cases is discussed.

PIP: An immunofluorescent microscopic method (IF) was compared with conventional culture methods for detection of Actinomyces israelii in smears from the endocervix and IUD of 124 women over a 4-month period at the Royal Women's Hospital, Melbourne. Genital actinomycosis is a non-contagious, chronic, suppurative infection caused by a slowly growing, filamentous, gram-positive anaerobe, and it can lead to fibrosis, abscess or death. The women, attending the Family Planning, Gynecology or Emergency Departments for termination of contraception, replacement of an IUD or for signs or symptoms of pelvic infection, work plastic or copper IUDs. All were screened for Chlamydia and cervical cytology. Actinomyces cultures were screened for 4 weeks and A. israelii identified by morphology, Gram stain and gas-liquid chromatography. The immunofluorescence method involved pepsin treatment of heat-fixed slides, staining with fluorescein-conjugated antibody to A. israelii types I and II, counter-staining, and examination under fluorescence microscopy. Slides were graded subjectively in comparison with positive and negative controls. 9 (11%) of 82 cervical smears, and 2 (4%) of 49 IUD smears were positive by IF, while only 1 was positive by culture: all from 10 patients. One patient has a positive chlamydia culture, and also symptoms of pelvic infection requiring hospitalization. There were 6 others who had symptoms such as pain and discharge, who were treated with IUD removal and antibiotics. 3 women asymptomatic women merely had their IUDs removed. There were no incidents of severe actinomycosis requiring surgery or prolonged hospital treatment although this infection can in rare case be life-threatening. Management of pelvic actinomycosis was discussed.

Effects of contraceptive pills and intrauterine devices on urinary bladder.

The incidence of bacteriuria and cystoscopic changes in women on oral contraceptives or users of IUD (intrauterine devices) were evaluated compared with a control group. Subjects with bacteriuria accounted for 40.5 per cent of pill users, 20 per cent of women fitted with IUD, and 16 per cent of the control group. Bladder trabeculations were found in 50.5 per cent of the pill group, 8.7 per cent of the IUD group, and 8 per cent of the controls. Congested bladder trigone was observed in 24.6 per cent of women fitted with an IUD. The mode of action of ovarian hormones and their possible side effects on the bladder are discussed. The relation of IUD to pelvic inflammatory disease and its effect on the urinary bladder are evaluated.

PIP: The incidence of bacteriuria and cystoscopic changes in 200 women using oral contraceptives from 1 month to 2 years and 150 users of IUD were compared with 50 women using neither method. Bacteriuria in midstrean urine samples of all subjects were identified qualitatively and quantitatively by the method of Stamey et al. Cystoscopy was performed on all subjects. Positive bacteriuria were found in 40.5% of patients on oral contraceptives, 20% of IUD users, and 16% of the control group. Positive pathogenic bacterial cultures in women using oral contraceptives were proportional to the length of time the pill had been used: 27% for 1 year users, 35% for 2 year users, and 50% for longer users. The potency and dosage is correlated with the pathogenic effects observed. Bladder trabeculations were found in 50.5% of oral contraceptive users, 8.7% of IUD users, and 8% of control subjects. The highest incidence was in subjects using pills for 2 years or more, and is correlated with the dosage used. Bladder trigone congestion was observed in 24.6% of IUD users; 56% of users from 1 to 3 months, 35% of users more than 2 years, and no users between these time extremes. The high incidence of bladder trabeculations might be explained by the effect of progestogens and estrogens on bladder tone; progestogens producing hypotonia and estrogens hypertonia. The IUD should not be used more than 2-3 years continuously to avoid urinary bladder effects and inflammatory pelvic disease.

Experiences with an IUCD (Margulie's coil).

PIP: A study was conducted with Margulie's coil on 96 women at Malmo General Hospital, Sweden. The 96 women were observed for 143 woman-years. 15% of the women had the coil slip out, most within the 1st year. Repeated insertion in these cases was unsuccessful. 15% had the coil removed for pain and bleeding. For women treated with epsikapron, a fibrinolytic inhibitory medicine, the bleeding was lessened. 10 women became pregnant, 5 with the coil in position at the time of conception. A high frequency of extrauterine pregnancy in women wearing coils was noted, and the risks related to such pregnancies are discussed. Experience with IUDs in Sweden is similar to that in other countries. IUDs are recommended for use in Sweden only where women cannot or will not use more effective contraceptives. All women should be warned of the risks.^ieng