A Brief History of the IUD: The Strange Ways We've Tried to Stop Pregnancy
Picture a series of copper beads on a fine titanium alloy wire curved in a graceful sphere. It looks like an earring, but you won’t find it in a jewelry store because it’s not jewelry. It’s made to go in your uterus.
IUDs are the fastest growing kind of birth control in the U.S. One study showed that use doubled in just two years, from four percent of contracepting women in 2007 to eight percent in 2009. That appears to be just the beginning of a trend. When over 9,000 St. Louis women in an “Obamacare simulation” were offered the birth control of their choice for free, a whopping 58 percent chose a hormonal or copper IUD. Around the globe today, intrauterine devices are the most popular form of reversible birth control, with over 160 million users.
The idea of putting something small into the uterus to prevent pregnancy goes way, way back, but the history of intrauterine contraception is full of fits, starts and complications. What is that history? Why are IUDs suddenly the hottest thing in birth control for young women? And what should you tell your daughter when she says she wants one?
Stones in Camels?
When nomadic traders needed to keep a female camel from getting pregnant during long treks across the desert, they put stones into the animal’s uterus. The stones acted as a mild irritant, activating the body to fend off sperm and any fertilized eggs. Or so the story goes. When Arab gynecologists hear Europeans repeating the story, they snort and ask, “Have you ever tried to put a stone in a camel’s uterus?”
Since the time sun-beaten trader might have contemplated camel contraception, intrauterine birth control has come a long way.
Silver and Gold Pessaries
The ancient Greek father of medicine, Hippocrates, is credited with first suggesting that small objects in the human uterus might prevent pregnancy. But such a practice would not become commonplace for another two millennia. The first precursors of modern IUDs emerged in the late 19th century in the form of something called stem pessaries. Often made of a precious metal or glass, the typical pessary was mushroom-shaped, with a curved disk that fit into the upper part of the vagina like a cervical cap, and a “stem” passing through the cervix to hold it in place. Sometimes the stem had more of a wishbone shape—two arms that were held together during the insertion process by gelatin, which then dissolved. The most elegant pessaries were made of 14 karat gold and finely crafted. But in the absence of flexible materials and antibiotics and sterile technique, women who used pessaries risked serious injury and infection. One has to understand the enormous dangers of childbirth at the time to appreciate why determined pioneers took the chance.
Silk Thread, G-spots, and War
In the early 20th century, doctors began to experiment with other materials, trying to improve contraceptive design, and by the 1930s pessaries had been replaced by devices that fit entirely in the uterus. Silk thread wrapped with silver wire was offered as one alternative. Unfortunately, two of the leading innovators, doctors Ernst GrÃ¤fenberg and Tenrei Ota, were German and Japanese respectively, and—although GrÃ¤fenberg is immortalized via the “G” spot, which bears his initial—their contraceptive efforts were derailed by World War II. We tend to count the cost of war in terms of persons lost and cities destroyed, but one can’t help wondering how the lives of our grandmothers and mothers might have been different if war hadn’t thrown contraceptive research off course.
As plastics emerged after the war, it was only natural that gynecologists began dreaming about how the new materials might be used to give women better contraceptive options. In fact Dr. Ota may have been the first person to explore the use of plastics to make a better IUD, but the poor quality of early plastics meant that developing a safe, durable device at his time was impossible. The most popular all-plastic IUD was the Lippes Loop, a sinuous length of plastic wire that straightened for insertion but then curved back and forth in the uterine cavity. Copycats and other designs rapidly followed. The flexibility and shape-memory of plastic allowed a leap forward in terms of safety, but plastic alone provides poor birth control.
Copper Ions as Sperm Neutralizers
Then, in 1969, a Chilean doctor, Jaime Zipper, discovered the power of copper to increase contraceptive effectiveness. Copper was known by farmers because it keeps some plant diseases like apple rust or peach blight from reproducing. It turns out that copper ions also disable sperm. Farmers dissolve copper and spray it at the start of the growing season, but medical researchers simply wrapped a plastic IUD with copper wire so that a few ions at a time could dissolve locally into the uterus. Copper boosted the efficacy of IUDs well above 95 percent. Things were looking up.
The Dalkon Shield Disaster
And then—in the U.S. at least—disaster struck in the form of an IUD that looked like an oversized bacterium. The Dalkon Shield, as it was called, had little feet protruding out on the sides to keep it from being expelled prematurely from the uterus. The problem was that the feet dug into the uterine wall and stuck. In order for doctors to get the device out, a super-strong multifilament string was added, which turned out to be the perfect highway for germs to travel up into the normally sterile uterus. Most of the 2.8 million users were fine, but some women suffered serious pelvic infections and lost their fertility as a consequence. A handful died.
By the time the Shield was taken off the market, it was thought to be responsible for 18 deaths and 200,000 infections or other complications. Women were traumatized. Doctors who had promoted the product were traumatized. The FDA was traumatized. The ordeal resulted in legal claims and class-action suits that brought relief to many women, but intrauterine contraception largely disappeared from the U.S. market. A whole generation was left to rely on less effective and less safe methods including estrogen-heavy pills. Some shunned contraception altogether, which had its own cost in health and lives lost.
By 1995 only 1 percent of American women used IUDs. In the meantime, in European countries where the Dalkon Shield never got a foothold, intrauterine contraception continued to gain ground, and over time designs emerged that were effective, durable and vastly safer than pregnancy even under the best conditions of modern medical care. A small plastic T wrapped in copper with a nylon filament tail became the international gold standard. It is 20 times more effective than the Pill at preventing pregnancy, lasts up to two decades, and is hormone-free, making it the cheapest reversible contraception available as well as one of the best. Fertility returns to normal rates almost immediately after removal. Most of those 160 million IUD users globally have a variation on this theme.
But this technology still has its drawbacks. The T doesn’t fit every womb. More significantly, menstrual flow and cramps tend to increase by half over the first six months before gradually returning to pre-insertion levels, so copper isn’t a good option for women who have problem periods or who teeter on the edge of anemia.
A Cure for Miserable Monthlies
Beginning in the 1970s, the next generation of IUD researchers tackled the cramping and bleeding problem with a new approach to intrauterine devices. Instead of releasing copper ions, this new wave of technology releases a micro-dose of a hormone, levonorgestrel, sometimes found in birth control pills. From the standpoint of menstrual symptoms, hormonal IUDs have the opposite effect of copper Ts. They decrease cramps and bleeding by, on average, 90 percent. Because they thin the uterine wall, aka endometrium, they can be used to treat endometriosis, allowing some women to avoid hysterectomies. Recent research suggests that they even lower the risk of some cancers. The annual pregnancy rate drops to around 1 in 700.
Mind you, after the trauma of the Dalkon Shield, American regulators watched the trends in Europe for over a decade before giving their thumbs up in 2000. Even then, at first they cautiously gave approval only for monogamous women who had already had babies. It was not until 2012, 20 years after hormonal Ts became available to European women, that the American College of Obstetricians and Gynecologists recommended IUDs broadly for young women and teens. No contraceptive method works for everyone. But, given the risks associated with pregnancy, IUDs are now considered safer for healthy, sexually active women than any other contraceptive method—or none at all.
It is this round of innovation that has gotten American doctors and women to take a fresh look at intrauterine contraception and has prompted the recent surge. Ironically, as the newer, hormonal IUDs have gained popularity they have driven renewed interest in copper models, especially among women who worry about contraception and weight gain or want to be done altogether with manufactured hormones.
But a large part of the surge is among young women who like the idea of lighter periods or none at all. In an age where women work, work out, and get their skin tattooed or pierced and body hair removed, deciding to have or not have a period seems like a natural part of living a chosen life. Fortunately, the best evidence available suggests that our ancestors had far fewer periods than modern women and that from a health standpoint, less menstruation is better. “When would you like to have a child?” ask family planning doctors. “What would you like to do before then?” “How often do you want to have your period?” Based on the answers, they recommend contraceptive technologies that fit. How far we have traveled from the dusty days of stones and camels!
What comes next? Increasingly, IUDs and other kinds of medical implants are thought of as future platforms for delivering medications or even personal enhancements. A uterus is a hidden pocket that can stretch to hold a baby, but it also can hold something much smaller. The makers of the lithe sphere described at the opening of this article envision their “Intrauterine Ball” as a means to slow-release not only copper ions or hormones, but potentially other medications that help to treat chronic conditions. A “frameless” IUD, made in Belgium, is seen by its designer as having similar potential. An IUD in China gives off very small amounts of indomethacin, an anti-inflammatory. Imagine an IUD that suppressed those monthly chocolate cravings. Now that would be a jewel!