Is the intrauterine device on the comeback trail?

It is an effective, reversible form of birth control, and from an economic viewpoint, it offers the most cost-effective benefits after five years. So why is the IUD underutilized?

The barriers created by the negative experiences surrounding the Dalkon Shield have been tough to surmount. A spate of lawsuits forced Dalkon Shield manufacturer A. H. Robins Co. of Richmond, VA, to declare bankruptcy in 1985 after more than 4,000 product liability cases had been filed against it.

Now, with a new generation of IUDs on board, backed by research demonstrating their safety, patients and providers are taking a fresh look at the IUD.

For women who are good IUD candidates, such as those in monogamous relationships who have contraindications to oral contraceptives and want a long-acting, reversible method, the IUD ranks high in satisfaction, says Patsy Sulak, MD, of the obstetrics and gynecology department at Scott and White Clinic, part of a three-entity hospital, clinic, and health maintenance organization in Temple, TX.

"Women who keep their IUD in, love it," says Sulak, who also is an associate professor at Texas A&M University’s College of Medicine. "Women who do well with the IUD, who don’t have any problems with it, who have it in at one year, are ranking it a nine or a 10."

According to a 1996 paper published by Jacqueline E. Darroch, senior vice president and vice president for research at Alan Guttmacher Institute in New York, an analysis of surveys performed in 1991 and 1995 suggest that younger women, who are not aware of the problems surrounding the Dalkon Shield, may be more receptive toward information on today’s IUDs.1

This interest, combined with an emphasis on education, has lead to increased sales for the ParaGard T 380A copper-T IUD since Ortho Pharmaceutical Corp. of Raritan, NJ, took over the method from GynoPharma in the early 1990s.

"IUD sales have increased over 20% since we acquired ParaGard," says Ortho spokesperson Abbe Schiffman. "The medical community has been very receptive to what we’ve been doing. Our focus has been on educational programs. More than 16,000 MDs, nurse practitioners, and nurse midwives have attended symposia and lectures on the method. It’s been an overwhelming reception."

For many years following the Dalkon Shield debacle, only one IUD remained on the American market: the Progestasert progesterone IUD marketed by Alza Pharmaceuticals of Palo Alto, CA. This method, which relies on its hormonal load to prevent pregnancy, must be replaced annually. The Progestasert represents a small portion of Alza’s total sales, says company spokeswoman Aneka Cole.

In a 1995 analysis, researchers modeled the direct medical costs, such as method use, side effects, and unintended pregnancies, of 15 contraceptive methods from the perspective of private payer (managed care) and publicly funded programs.2 When using the managed care payment model, the injectable contraceptive was found to be the least costly method of use after one year, followed by oral contraceptives and the progesterone IUD. After two years, though, the copper-T IUD was found to be the least costly. (See chart showing annualized costs for managed care model, above.)

In the publicly funded payment model, the injectable contraceptive, the progesterone IUD, and the copper-T IUD had the lowest costs at one year. When extended to five years, the copper-T IUD was listed as least costly, followed by vasectomy and the implant.

Cost should not be the driving factor, though, when it comes to choosing a contraceptive method. The cost-modeling exercise shows that the best strategy is to offer all methods, says James Trussell, PhD, director of the Office of Population Research at Princeton (NJ) University and associate dean of the university’s Woodrow Wilson School of Public and International Affairs.

"I favor making the choice of methods as wide as possible," says Trussell, who served as lead author of the 1995 analysis, which is now being updated to compare the cost-effectiveness of contraceptive use among teens with that among all women. "The best contraceptive for a woman or couple is one that will actually be used correctly and consistently. The IUD is an important option because it provides highly effective long-term protection against pregnancy, yet is reversible."

At present, the Scott and White health plan covers the costs for sterilization, but not reversible contraception such as the IUD, says Sulak.

Most plans, regardless of type, cover maternity care, induced abortion, and sterilization, states a 1996 Issues in Brief prepared by the New York City-based Alan Guttmacher Institute.3 But coverage is less consistent when it comes to routine gynecologic care or reversible contraception, the findings show. "For example, only 15% of traditional indemnity plans cover all of the five most commonly used reversible medical methods (the IUD, diaphragm, Norplant, Depo Provera injection, and pill); 49% of plans cover none of these methods," the paper states.

Coverage for IUDs and other forms of contraception may be on the way if U.S. Senate Bill 766 is enacted. The Equity in Prescription Insurance and Contraceptive Coverage Act is designed to achieve parity between the coverage of family planning and other types of basic medical care covered by medical insurance policies.4 A companion bill is expected to be filed in the House.

Managed care professionals are looking at the long-term use of the IUD as an alternative to female surgical sterilization in assessing whether to cover the device and its insertion costs for their members. In a published report, a roundtable of experts concluded that the copper-T IUD offers significant benefits over sterilization, a permanent form of family planning.5

A trial project, in which IUDs were offered at no cost to female patients, has just been completed at the Scott and White Clinic. Preliminary data show the continuation rate for the method at one year is about 80%. Final results will be published next year after analysis is complete, says Sulak. "What we hope to do is to show the health plan that there is a high continuation rate, that it is cost-effective, and that it is something perhaps they should consider covering as a benefit in the future," she says.

(Editor’s note: Use the patient handout on the copper-T IUD inserted in this issue to help discuss the contraceptive method with your patients.)

References

1. Forrest JD. U.S. women’s perceptions and attitudes about the IUD. Obstet Gynecol Surv 1996; 51:530-534.

2. Trussell J, Leveque JA, Koenig JD, et al. The economic value of contraception: a comparison of 15 methods. Am J Public Health 1995; 85:494-503.

3. Alan Guttmacher Institute. Issues in Brief: Reproductive Health Services and Managed Care Plans: Improving the Fit. New York; 1996.

4. Alan Guttmacher Institute. Bill calling for contraceptive coverage parity introduced in Senate. Washington Memo 1997; May 27:3.

5. Managed care approaches to encouraging the utilization of intrauterine devices. Medical Interface 1997; April(suppl).