Intrauterine device

"Legend has it that Arab camel drivers inspired the modern IUD. According to the story, tiny stones were inserted into the uterus of each female camel to prevent pregnancy during long caravan journeys across the desert (Bullough & Bullough, 1990). The story was a tall tale told to entertain delegates at a scientific conference on family planning, but it was repeated so many times that many people have assumed it is true (Thomsen, 1988)."

"During the ninth century, a Persian physician recommended inserting into the cervix paper wound tightly into the shape of a probe, tied with a string and smeared with ginger water (Manisoff, 1973). Also, during certain rituals, the Maori people of New Zealand put small pebbles into women’s vaginas to make them “sterile as stones” (Himes, 1963). Similarly, Casanova, who claimed to have invented almost everything that has to do with sex, soaked a small gold ball in an alkaline solution and inserted it in his lover’s vagina (Suitters, 1967)."

"The IUD is now safer than ever than ever before and it has excellent credentials. Both the World Health Organization and the American Medical Association name it among the safest, most effective, and least expensive reversible methods of birth control available to women (Knowles &Ringel, 1998)"

"There are two inconsistencies in the “pro-life” movement from the viewpoint of pro-choices: There appears to be relatively little mention of IUD’s (Intra-uterine devices). The precise mechanism by which IUDS prevent pregnancy is unknown. Some researchers believe that the IUD immobilizes sperm, preventing them from reaching the ovum. Others believe that it causes the ovum to pass through the fallopian tube so fast that it is unlikely to be fertilized. Most believe that the IUD interferes with the implantation of fertilized ovum in the uterine wall. If the third property is true, then IUDs terminate the development of a fertilized ovum after conception, and cause its expulsion from the body. To a person who believes that human personhood begins at the instant of conception, there is no difference between using an IUD, having a first trimester abortion, or having a partial birth abortion, or –for that matter –strangling a newborn just after birth. Yet pro-life groups actively campaign against PBA’s, picket abortion clinics, and attempt to pass restrictive legislation limiting choice in abortion. Some have made negative statements about IUDs. But none have, to our knowledge, picketed IUD manufacturing facilities, or sponsored anti-IUD legislation. This is surprising, because in those countries where IUDs are widely used, the number of fertilized eggs which IUDs apparently expel from women’s bodies far exceeds the number of surgical abortions. About 43% of American women will have had a surgical abortion sometime during their lifetime. Women who use an IUD will expel about one fertilized ovum annually (assuming that they engage in intercourse once per week) IUDS are becoming increasingly popular. Two studies have reported effectiveness rates of 99.4 and 99.9%"

"Tietze’s new studies showed that population control programs with conventional methods “were getting nowhere fast.” Intensive review of old methods continued, but reported results remained contradictory, probably reflecting differences in motivation between populations. Some members of the Population Council were convinced by the futility of programs based on conventional methods that something better had to be found. Frank Notestein, who succeeded Fredrick Osborn as president of the Population Council in 1958, remembers his frustration in knowing that something had to be done to control rapid population growth but lacking the contraceptive means that would enable the council to take decisive action. “I’ve never been in another situation in my life that made me feel so helpless.” It was this sense of urgency which prompted a reevaluation of intrauterine devices."

"Alan F. Guttmacher, chief of obstetrics at Mount Sinai Hospital in New York City and a member of the medical advisory committee of the council, had warned against intrauterine devices in his popular marriage manual, but when a member of his department at Mount Sinai approached him in 1958 with an idea for a new kind of IUD, Guttmacher listened. Dr.Lazar Margulies, who was Berlin trained and who had used an intrauterine device in the late twenties in Berlin came to me with the idea that an intrauterine device could be made of molded plastic and the advantage was that you could stretch it to a linear form. . . and it would resume its original shape. Marguies has been inspired to give the old method a second look when he heard John Rock, the Harvard gynecologist who had served on the AMA committee on contraception in the 1930s and who has the object of an intense lobbying effort by Robert Dickinson, lecture on the dangers of overpopulation. The substitution of plastic for wire meant that the device could be inserted without dilating the cervix (stretching the mouth of the womb), a painful procedure that required local anesthesia. The molded plastic coil was unwound into a thin rod, the rod slipped into the uterus, and the coil pushed out of the rod into the uterus, where it regained its original shape. Guttmacher allowed Margulies to try out the device “with some fear and hesitation because I was taught in medical school how dangerous the intrauterine device was.” They worked. Patients did not die of pelvic inflammatory disease or develop galloping cancer."

"In 1962, Population Council gave Guttmacher a grant “to travel around the world to assess what methods of birth control they should back.” He reported that conventional contraceptives were not working and advised the council to invest in development of the IUD. The council invited forty-two clinicians to a conference on intrauterine contraception. Tietze remembered the “conspirational air” that surrounded the conference “It was a very exiting period. . . . we were working with something that had been absolutely rejected by the profession . . . we had a great feeling of urgency to produce a method that worked. It seemed to work. Now we had to establish it. And we had to start from scratch.” The council invested more than $2.5 million in the clinical testing, improvement, and statistical evaluation of the IUD, which proved to be highly effective for the approximately seven out of ten women who could retain one. Tietze, an unusually candid man with the habit of precise expression, recalls the care with which clinicians were recruited and the effort poured into making sure that their records were accurate. There was such a feeling of urgency among professional people, not among the masses, but something had to be done. And this was something that you could do to the people rather than something people could do for themselves. So it made it very attractive to the doers. Armed at last with a method that was inexpensive and required little motivation from the user beyond initial acceptance, family planning programs began to have an effect on birth rates in South Korea, Taiwan, and Pakistan. By 1967 a review article in Demography criticized the over optimism of the Population Council technocrats about the prospects for controlling world population growth. Other social scientists claimed that population control was getting too much of the development dollar and pointed out that population control was no substitute for social justice. Lower birth rates did not guarantee a better society. Whether or not world population growth could be controlled remained an unanswered question."

"By the late 1960s discussion of the population problems of underdeveloped countries had helped to stimulate renewed interest in family planning programs in the United States. Happy, there was a growing discussion about the social and philosophical issues involved in the management of human reproduction, whereas only a decade before, informed interest had been limited to a few social scientists. The whole nature of the debate, however, as well as the prospects for controlling population growth, had been radically altered by the availability of the plastic intrauterine device, an American gift to the world."

"The history of the intrauterine device is remarkably short and its survival has been jeopardized several times from the beginning when Gräfenberg introduced the intrauterine ring in 1928, and later when product liability claims in the USA forced companies to withdraw the IUD from the market. However, a revival is happening, and one of the withdrawn copper IUDs has been re-introduced in the USA. In the 1980s, pessimism about the future of the IUD was based on the fact that there are still two major imperfections inherent in intrauterine contraception: its lack of protection against both 'gyne' and sexually transmitted disease."

"Intrauterine devices (IUDs) were derived from what Marie Stopes (1924) called the interuterine devices, conceived for therapeutic purposes and used in later years for providing contraception. Because an interuterine device connects the external environment (vagina) with the internal genital tract, pelvic inflammatory disease was a frequent complication in an era when gonorrhea was endemic and no adequate therapeutic measures were available. To avert the inherent infective hazard, interuterine devices were replaced by IUDs. The IUD has had a troubled history. Initially ignored by the medical profession, it courted a flourishing period during the early 1930s, which soon came to an end due to largely non-medical reasons. The rehabilitation of intrauterine contraception started in the USA in the early 1960s, as a result of a change of mentality concerning the acceptability of birth control in general, the discovery of the phenomenon of the population explosion, and the introduction of improved IUDs. This review gives an overview of the evolution of intrauterine contraception, focusing on the scientists who were innovative in this field."

"In 1909, an authoritative German medical journal, Deutsche medizinische Wochenschrift, published a paper by Dr Richter of Waldenburg (near Breslaw) entitled 'Ein Mittel zur Verhütung der Konzeption' (a means of preventing conception). Because of the taboo surrounding contraception, the very title of the article will no doubt have surprised many readers and shocked some. The device described by Dr Richter was the first genuine IUD. It consisted of two strands of coarse silkworm gut (crin de Florence) wound in a particular pattern, the free ends of which were capped with celluloid to prevent injury to the endometrium. The threads were united by a thin bronze filament to diagnose expulsion and to facilitate retrieval of the IUD, which was inserted using a metal female bladder catheter. Dr Richter's invention had no impact on the practice of birth control and clinical data were never supplied. Contraception continued to use the traditional interuterine devices, for example, the metal wishbone spring pessary patented by Dr Carl Hollweg (1902) and the cervico-uterine pessary made of silkworm gut attached to a cervical glass button described by Dr Karl Pust."

"Conscious of the hazards inherent in the use of interuterine devices, Dr Grafenberg took up the search for the serviceable IUD in the early 1920s. Whether he knew about Dr Richter's pessary remains an open question. Initially, he used star-shaped devices and coils of silkworm gut (1924). Because they were expelled too readily, he conceived the Ring IUD, made of helicoidal1y wound silver filaments, which still bears his name. He did not hesitate to publish clinical results (1928-30), thus making his invention known beyond the boundaries of his native Germany. Shortly thereafter, other European physicians added statistics, issuing an increasing number of damaging reports of pelvic inflammatory disease associated with IUD use. Gräfenberg's last presentation on the subject was in 1931 at the German Congress of Gynecology in Frankfurt. His report was denounced by virtually all leaders of German gynecology attending the congress, who branded intrauterine contraception as a medically unacceptable method of birth control. Shortly thereafter, the streamroller of the Nazi regime started poisoning the air of Germany. Jewish physicians were removed from the hospital posts and contraception was proclaimed to be a threat to the physical and mental health of Aryan women. Ultimately, the advertising of contraceptives and/or contraceptive advice became illegal in Germany and the other Axis States. Barred from practice and research, ostracized by his colleagues and persecuted by the authorities, Dr Gräfenberg left Germany in 1940. He arrived in New York in 1941, where he resumed a busy life as an obstetrician and gynecologist. His scientific reputation opened the doors of a teaching hospital (Mount Sinai Medical Center) and the New York Birth Control Clinical Research Bureau (later renamed Margaret Sanger Research Bureau after the nurse who convinced America that control of conception is a basic human right). Dr Gräfenberg was able to resume his research, but in America, as well as in Europe, the fight for the acceptance of family planning had not yet been won. Notwithstanding these barriers, Dr Gräfenberg, according to his friend and his former Berlin assistant Dr Hans Lehfeld, transgressed medical rules and continued to use the Ring, albeit in private practice and in secret."

"In Japan, Dr. Tenrei Ota, born in 1900, began pioneering intrauterine contraception in the 1930s. Once his country had joined the Axis and contraception was forbidden, Dr Ota became a political target, changed his name and finally went into hiding. As a consequence, knowledge of the Ota Ring would reach the Western world only after the end of World War II. Dr Ota had initiated his experiments in intrauterine contraception by inserting objects made from a great variety of materials and shapes, from gold spheres to coils of human hair. Since the rudimentary IUDs were expelled too easily, he decided, in 1933, to modify the Gräfenberg Ring (of which he had heard but never seen). He stiffened the Silver Ring by providing it with a central disc attached to the outer ring by spokes. Dr Ota called his silver or gold IUD the 'Precea Ring', ‘precea' being Anglo-Japanese for 'pressure'. The Pressure Ring was to remain popular in Japan well into the 1980s. Less well-known is that Dr Ota may have been the first physician to devise a plastic IUD. However, the inferior quality of plastic material put at his disposal ruined the idea."

"In the 1940s, alarm about the worlds burgeoning population, and the naive belief that the phenomenon could be curbed by the introduction of improved contraceptive methods, led to extensive research in the USA. The results of these endeavors were the pill and the plastic IUD. Plastic devices solved the problem inherent in the insertion and retrieval of the Rings of Gräfenberg and Ota. Made of thermoplastics, the new IUDs were given a memory of their original shape, could be straightened to fit inside a narrow straw-type inserter tube and regained their initial contour after introduction into the uterus. The notion that intrauterine contraception is safe and effective was proven in the early 1960s by the medical statistician Dr Christopher Tietze (1908-84), a Jewish emigrant to the USA, and a great admirer of Gräfenberg (Figure 2). Having collected and analyzed clinical results obtained with the Gräfenberg and Ota Rings, Dr Tietze organized the first international symposium on intrauterine contraception in New York City in 1962, sponsored by the Population Council. At the conference, the pioneers of the plastic devices, Dr Margulies and Dr Lippes, were invited to demonstrate their invention and report preliminary clinical results."

"Dr J. Lippes (Figure 3) is an example of the thoroughbred American (born at Buffalo, NY in 1925), who since 1957 has been Head of the Department of Obstetrics and Gynecology of the State University of New York at Buffalo. Although he had become acquainted with the Gräfenberg Ring in 1952, he had not dared to use it for fear of being accused of malpractice. Seven years later, two papers on intrauterine contraception appeared, both in English. The first, written by the Japanese gynecologist Ishihama and published in the Yokohama Medical Journal, gave an enthusiastic clinical assessment of the Ota Ring. In the second paper, Dr W. Oppenheimer of Jerusalem overviewed the results of three decades of personal experience with the modified Silk Ring. The fact that the latter paper had been accepted by the authoritative American journal of Obstetrics and Gynecology was perceived by Dr Lippes as a sign that intrauterine contraception had become a discussable subject in his country. That same year he started inserting Silk and Presea Rings under the auspices of the Buffalo PIanned Parenthood Center. The former device being too flexible, and the latter too stiff, Dr Lippes decided to remove the spokes from the Ota Ring and affix a piece of monofilament nylon to the IUD to facilitate removal and to allow the wearer to check that the device was still present. However, the modified Ring tended to rotate in utero and to wind the marker thread into the cavity, eliminating its intended uses. Therefore, to prevent IUD rotation, a radical change of shape was needed. After many experiments, the double-S Loop (the Lippes Loop) emerged in 1961. Due to its particular shape (trapezoid), the Lippes Loop fits the (relaxed uterine cavity snugly. The Lippes Loop was to become extremely popular and, of all first-generation IUDs, had the greatest worldwide impact."

"In fact, Dr Lippes had a predecessor in this field; Dr Lazar C. Margulies (Figure 4). Dr Margulies was born in Galicia (now part of Poland) in 1895. As a medical student, he had served in the Austro-Hungarian army during World War I. Following the armistice, he graduated from the University of Vienna in 1921, where he specialized in obstetrics and gynecology. He started practising in Vienna, but, expelled from the hospital, this Jewish gynecologist emigrated to the USA in 1941. In New York City he joined the staff of the Mount Sinai Medical Center in 1954 and was promoted to Associate Professor 9 years later. Dr Margulies died of a cerebral hemorrhage in 1982. His Chief at Mount Sinai, Dr Alan Guttmacher, who had opposed intrauterine contraception during Gräfenberg's life (Gräfenberg himself had practised at Mount Sinai for a decade and a ha1f) encouraged Dr Margulies to attempt to improve the Silver Ring. Most certainly, Guttmacher's change of mind was prompted by the alarm over the world's demographic surge, and was reinforced by the 1959 IUD papers from Israel and Japan. Gambling on the use of thermoplastics, Dr Margulies conceived his famous spiral-shaped IUD in 1960, the Perma-Spiral, marketed by the Ortho Pharmaceutical Company as Gynecoil. To insert the Margulies Spiral, the unwound device was introduced into a thin plastic tube and expelled with a plastic plunger. Dr Lippes later borrowed this technique for the insertion of his Loop IUD."

"In subsequent years, resourceful investigators produced scores of originally (and sometimes peculiarly) shaped plastic IUDs. One of these was the notorious Dalkon Shield fitted by the inventor (Dr H.J. Davis, 1970) with a soft sheath filled with hundreds of nylon filaments instead of the usual stiff monofilament polyethylene thread. Serious, and even lethal, infections were observed, and it was claimed that the tailpiece of the Shield IUD acted as a wick conveying bacteria from the vagina upward into the uterine cavity. The thousands of lawsuits which followed discredited the inventor of the Dalkon Shield, caused financial ruin to the producer ( A.H. Robbins Corporation) and had a deleterious effect on the practice of intrauterine contraception."

"Because the first intrauterine contraceptive device proposed by Dr Richard Richter in 1909 was ignored, the Silver Ring of Dr Ernst Gräfenberg (1928) is currently labeled as the prototype of modern IUD generations. The Ring of Gräfenberg, however, was proscribed in the 1930s, and, although the basis for the condemnation was more political than scientific, three decades had passed before the rebirth and general acceptance of intrauterine contraception. The development of the plastic IUDs, announced by Dr Lazar Margulies and Dr Jack Lippes in 1960-61, solved the insertion problem of metallic IUDs, but did not eliminate the main side-effects, that is, bleeding and pain. In 1969, the first copper-bearing device was introduced by Dr Jaime Zipper and Dr Howard Tatum. The metallic contraceptive adjuvant, though allowing reduction of the platform size, did not solve the menorrhagia problem. This was achieved by Dr Tapani Luukkainen thanks to the invention of the gestagen- releasing IUD (Ng Nova-T) in 1977. The final step in IUD engineering was the invention of the GyneFix, a flexible, frameless copper-bearing IUD anchored permanently to the uterine tissues, which the inventor (Dr Dirk Wildemeersch) calls an intrauterine contraceptive implant or IUCI."