The IUD, Permanent Methods and Choosing a Method

1Why this matters

The most effective reversible method is not a pill but a small device that sits in the uterus, and the most effective methods of all are permanent. Understanding these methods completes your picture of contraception, and it lets you compare every method on the same scale, as health workers do when they counsel a couple.

2The intra-uterine device (IUD)

An IUD is a small T-shaped device, about 3 cm long, that a trained health worker places inside the uterus through the cervix. Two fine threads hang through the cervix so that it can be checked and later removed. There are two kinds:

• Copper IUD: a plastic T wound with copper wire. Copper is toxic to sperm and eggs, so fertilisation does not take place. It works for up to 10 years or more and contains no hormones. Fitted within five days after unprotected intercourse, it also works as emergency contraception.
• Hormonal IUD: releases a small amount of progestogen, which thickens cervical mucus and thins the uterus lining. It works for several years, from 3 to 8 depending on the type.

Both are more than 99% effective. They can be removed at any time, and fertility returns quickly. Possible side effects include heavier or more painful periods (copper IUD) and irregular spotting (hormonal IUD). An IUD gives no protection against STIs.

3Permanent methods (sterilisation)

• Vasectomy (men): in a small operation, each sperm duct (vas deferens) is cut and tied, so sperm can no longer join the semen. The testes still make testosterone, and the man still has erections and ejaculates semen, but the semen contains no sperm. It is not effective at once: sperm already stored beyond the cut remain for about three months, so another method must be used until a test shows no sperm.
• Tubal ligation (women): each oviduct (fallopian tube) is cut, tied or blocked, so an egg cannot meet sperm. The ovaries still work and periods continue.

Both are more than 99% effective and are meant to be permanent: reversing them needs difficult surgery that may not work. They are for people who are certain they want no more children, and they give no protection against STIs.

4Comparing all the methods

5Choosing a method

No method is best for everyone. A health worker helps a person or couple weigh up:

• effectiveness, and how much daily effort the method needs;
• whether they also need protection against STIs and HIV (then a condom is needed);
• whether and when they want children in future (reversible or permanent);
• their health, and possible side effects;
• availability and cost, and their partner's views and religious values.

Worked example: counselling a couple

Mr and Mrs Habimana have four children and are sure they want no more. Mrs Habimana had side effects from the pill. Neither has any other partner, and both have tested negative for HIV. Which methods should they consider?

1. Their need: permanent or very long-term prevention of pregnancy. STI protection is not a priority, because both are tested and faithful.
2. Rule out: the pill (side effects); natural methods and condoms (less effective than they need).
3. Consider: a vasectomy for him, a simpler operation than tubal ligation, or tubal ligation for her; or, if they prefer something reversible, a copper IUD, which has no hormones.
4. Remember: after a vasectomy they must use another method for about three months, until a test confirms there are no sperm.

Practice