IUDs (Intrauterine devices) are the most popular non-permanent method of contraception, worldwide. Forty per cent of women of the reproductive age in China use them. From Cuba to Uzbekistan, they account for more than 50 per cent of contraceptive use. And in Egypt they are the method of choice for 63 per cent contraceptive-using women. So why are IUDs used by less than two per cent of women in the United States?

According to experts, the popularity of IUDs declined dramatically in the US during the 1980s after serious pelvic infections were reported as a result of an IUD known as the Dalkon Shield. Insertion errors leading to pregnancy, pain and bleeding were further cause for discontinuance. However, many of the 200 doctors and scientists attending the Fifth International Symposium on Intrauterine Devices and Systems for Women's Health, presented by the Population Council and the UN Population Fund (UNFPA) in New York in October 2006, said the pendulum was swinging back to IUD use - especially among women who already have children. 

Two IUDs are currently available in the US: the copper T380A, a plastic copper-coated T-shaped device that was approved by the Food and Drug Administration (FDA) in 1984 and which is effective for 10 years; and the LNG-IUS (levonorgestrel-intrauterine system), another plastic T-shaped device that was approved by the FDA in 2000. Marketed as Mirena by Berlex Laboratories, this IUD daily releases a pregnancy- preventing hormone for a period of five years.

Advocates of IUDs, some of them associated with Berlex Labs, make a case for health-related benefits from intrauterine devices. They suggest that copper-bearing, non-medicated IUDs offer probable protection against endometrial and, perhaps, cervical cancer, although these IUDs could increase the risk of endometriosis. Among users of the LNG-IUS there appears to be a reduced incidence of pelvic inflammatory disease (PID) as well as a reduction in anaemia resulting from excessive blood loss. (Many women report significantly-reduced blood loss during menstruation.) Since excessive bleeding is often a reason for elective hysterectomy, proponents of LNG-IUS argue that the device can serve as an alternative to surgical removal of the uterus.

David Grimes, a physician with Family Health International, a speaker for Berlex Labs, and a presenter at the symposium, says, "The IUD today poses a global paradox. Although the most common reversible contraceptive method in the world, it has the worst reputation of all contraceptives... except among those using IUDs." But he argues, "Today's IUDs deserve a fresh look. [We have] an ethical obligation to inform women that IUDs are not only safe and effective contraception, but [that] they also have important health benefits. Without this information, women cannot make truly informed choices about contraception."

However, when it comes to ethics, the use of IUDs in the developing world becomes potentially more problematic, say some women's health advocates. Often, the quality of IUD manufacture is not standardized, the quality of services is poor (if services are available at all), training of providers may leave much to be desired, and counseling or informed choice may be absent. The cost of IUDs can be a barrier to use, as can the attitudes of husbands or mothers-in-law. While 17 per cent or 105 million married women, worldwide, claim to have unmet family planning needs - either for spacing or limiting of family size - several key factors must be addressed to meet their needs. These include methods of contraception available, family and community relationships, and health systems or providers.

When proponents of IUDs talk about an increase in IUD use of up to 40 per cent by 2025, some women's health experts start to worry, especially when "repositioning IUDs" is proposed. Talk of "social networking franchises" and slogans like 'Now You Know the Truth' (recently used in a Kenyan public information campaign about IUDs), along with suggestions of 'poor product image' sends up red flags for many women scientists and physicians.

Dr. Mimi Zieman, clinical associate professor at Emory University School of Medicine in Atlanta, is one of those worried by some of what she heard at the symposium. "We need to remember that our focus needs to be on women and enabling them to choose the best and most appropriate method for them that will be successful. So we need to offer all options, including both types of IUDs. I'm happy we are having this conference," she said, "and I'm an advocate for IUD use, but I'm frustrated. Women need to be empowered but often at this conference that doesn't seem to be the emphasis."

Another participant, who asked to remain anonymous, put the point more strongly. "I'm outraged," she said. "Why isn't there one study on what women themselves say about IUD use? Where is the data on what they want? Where is the woman- centered focus? I've been attending conferences like this for 20 years and it's always the same thing. Women's views, needs, experience is just never in evidence. It's always a bunch of men deciding what's best for us!"

The symposium on IUDs was made possible by unrestricted educational grants from Barr Pharmaceuticals, Inc. and Berlex, Inc. The last such conference was held in 1992.