In Our Control (17 page)

Because Mirena uses such low doses of hormones, ovarian action is only partially suppressed. While this means that ovulation is unlikely to occur, it also means that ovarian cysts and ruptured follicles are more common. Women who have gynecological issues like fibroids or endometriosis should probably choose another option.

Both devices, ParaGard and Mirena, are very effective at preventing pregnancy. Data shows that for every thousand women who use the nonhormonal option each year, ten will become pregnant—that’s a failure rate of 1 percent (although “ideal” effectiveness is higher, with a failure rate of .3 percent).
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Mirena is even more effective, and out of a thousand women who use the device for a year, only two will have pregnancies,
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a failure rate of .1 percent to .2 percent. It seems strange to discuss “ideal” and “actual” use statistics for a method that, in theory, shouldn’t be subject to patient fallibility in the way that options like the Pill are. The gaps between theoretical efficacy and what actually happens probably exist in part because of provider mistakes while inserting the devices. It is worth asking if such a device can claim an “ideal” efficacy, or if that is simply rhetorical and misleading in this context. There really isn’t much that a woman can do to make her device “work” better except check the string that protrudes from the cervix occasionally to ensure that the IUD is still there.

Some couples feel this string during sex and sometimes find it unpleasant. Women who use IUDs are less likely to have an ectopic pregnancy—which happens when a fertilized egg starts growing outside the uterus—than women who don’t use contraceptives, but if they do get pregnant, that conception is more likely to be ectopic.
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This is a life-threatening condition that requires immediate medical attention.

Method failure is extremely rare, but for women who experience it, the results can be at best difficult and at worst horrific. The chance of pregnancy occurring is increased when the device becomes embedded or with the occurrence of accidental uterine perforation that happens while it is being put into the body. When a woman becomes pregnant while using an IUD (non-ectopically), she is at a much higher risk of miscarriage than she would be without the IUD. The device is usually removed because it can cause an array of problems including sepsis and premature labor. As worrying, particularly with Mirena, are the potential effects of the IUD on a growing fetus. The potentially tragic influence of estrogen on developing
fetuses has been known since the 1960s and ’70s. Diethylstilbestrol (DES), an estrogen drug, was prescribed from 1938 to 1971 to prevent miscarriage. The Centers for Disease Control estimates that between 5 and 10 million people were exposed, in utero, to a drug that proved not to prevent pregnancy loss and instead caused devastating problems—including increased cancer and reproductive abnormalities—in exposed offspring.
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As the case of women taking the hormone diethylstilbestrol (DES) during pregnancy tragically demonstrated, prolonged exposure to hormones in the womb can have a dangerous outcome, potentially causing cancers and reproductive abnormalities. Even Mirena’s manufacturer admits that “long-term effects on the offspring are unknown” but that congenital abnormalities—including a “slight masculinization of the external genitalia of the female fetus”
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—has been seen in the small number of births that have happened under these conditions.

The majority of experts think IUDs are safe for all ages, but doctors are cautious about recommending them to younger women. Any form of IUD is rarely the first or even second contraceptive to be offered to young patients. In a Guttmacher-funded report, Adam Sonfield notes that even in European countries where IUDs are actually used in higher numbers, doctors are slow to consider them as a first option for younger women.
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Commercials for both the IUD and the IUS recommend it for women who have “completed their families.” Young women who want an IUD may encounter doctors who are unwilling to insert the device, though this is changing as more doctors have come to believe that the devices are generally safe.

Women who don’t think that they want more children but aren’t sure may find that the IUD provides a good alternative to sterilization. It has the same benefits—high long-term efficacy and limited time investment—but unlike tubal ligation, is easily reversible for most women. For those contemplating children imminently, however, the IUD may not be the best choice. The device doesn’t adversely affect fertility in most women, but from a cost perspective, it is a method whose benefits are best seen when women can use it for longer periods of time.

Doctors’ and manufacturers’ reluctance to recommend IUDs to young women also hearkens back to the Dalkon Shield disaster. Because many young women suffered infertility as a result of using that model, and
device makers suffered financial ruin as a result, those marketing IUDs are slow to encourage younger women to try their wares even as large public health organizations insist they are safe for all ages. Safety studies have suggested that for the most part, modern IUDs don’t directly cause pelvic inflammatory disease (PID)—a general term for serious infection of the reproductive organs that can lead to complications such as infertility—although it can happen in some instances. PID is most commonly caused by an untreated sexually transmitted infection. While it is very rare for a modern IUD to initiate PID, it can exacerbate the problems when the PID already exists because of an STI.

When I asked Cynthia Pearson, director of the National Women’s Health Network, about IUDs for younger women, she told me that her organization “never really got over its skepticism of the IUD’s association with infection. I try to read the new studies as they come out and it seems to me that there still is a real, albeit small, risk of infection in the immediate aftermath of the insertion.”
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She added that this risk doesn’t seem to last in the long term, which she notes is “an improvement since the old days.”

The problem, Pearson notes, is that when big family planning groups advocate for the IUD, they stress that complications that develop have to do with individual behavior, not a problem with a doctor’s supervision or the device itself. Blaming women’s health problems on their sexual choices is a dangerous, but not uncommon, way of framing contraceptive conversations. Pearson stresses that while, in theory, doctors could screen out women at greater risk for problems, “they never DO screen out everyone with ‘risk factors’ because no one can say with perfect foresight what they’ll be doing and who they’ll be with in the future.”
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Because of the risks of infection, however small, women at high risk for STIs should closely consider this problem before choosing the option. This is particularly true if patients already have an STI before inserting the device, or if they contract the problem soon after. Women considering an IUD (and all women for that matter) should first be tested for sexually transmitted infections, including chlamydia and gonorrhea, leading causes of PID.

Another concern for younger women considering the IUD is that they are more prone to device expulsion (as are women who have never had a baby), and with Mirena, young women are more likely to have ovarian cysts. One major advantage of the IUD is cost. A 2009 study in the journal
Contraception
found that the ParaGard copper IUD and the Mirena option represent the most cost-effective methods of birth control available to American women.
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In a country where nearly one in three people between the ages of nineteen and twenty-six are uninsured and countless others go without health care, this fact has increased the appeal of the option for some younger women. This cost analysis assumes that a woman will leave the device in for many years; for those looking for shorter-term birth control, it doesn’t have this benefit.

Many women find cost to be more prohibitive when it comes to the nonhormonal IUD, because it is less accessible and not always covered by insurance. Tatiana, a twenty-six-year-old Latina woman who works as a computer specialist in the Washington, DC, area, had suffered with birth control pills that adversely affected her mood and threw her into depression. Unfortunately, when Tatiana reviewed her insurance policy, she found that it would cover Mirena, but not ParaGard. In order to obtain the latter option, she would need to pay out of pocket—money that, even with a good job, she didn’t have.

In addition to insurance hurdles limiting the accessibility of ParaGard, some women find that doctors and nurses pressure them to choose Mirena. One twenty-two-year-old woman describes her experience:

I did research online before going in for my consultation, and was very excited about the copper wire IUD. I really liked that it has no hormones, and it’s 99.9 percent effective and good for up to ten years.

When I went to my gynecologist for my consultation/insertion, the nurse who showed me in had brought in Mirena, the IUD with progesterone, as opposed to ParaGard, the copper wire that I’d been leaning toward. She seemed to assume I would go with Mirena, as did my gynecologist, to the point that I wondered if they had some sort of financial deal with the company. I was only looking for information and it was very hard to get; without presenting me with any statistics or comparative data to comfort me (I was nervous) the nurse basically said that if I wanted ParaGard, then fine, and I should sign a piece of paper to certify that I had read the ParaGard brochure even though I hadn’t, and got rather put out when I asked if I could see the brochure first. “Are you really going to read it?” she said. She brought it and I read the whole thing. Although this was a very scary gynecologist visit, I am
extremely
happy with my IUD and very glad I did research on my own so that I knew that the ParaGard was a better fit for me than the Mirena.
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As with many forms of contraception, there is controversy surrounding IUDs that plays out in complicated and frightening ways. It has been speculated that an IUD works in part by preventing the implantation of a fertilized egg to the uterine wall, a situation that some feel constitutes abortion. It has not been proven that IUDs work in this way—and whether a fertilized, unimplanted egg constitutes a fetus is another matter entirely (this idea is inconsistent with most scientific definitions of pregnancy)—but because some pro-life activists consider the method a form of abortion, certain health care providers are reluctant or unwilling to provide it. A story that made headlines in the early months of 2009 serves as a cautionary tale about the intersection of personal belief, public health, and the danger of so-called conscience rules. An Albuquerque, New Mexico–based nurse, Sylvia Olona, is currently facing a lawsuit from a patient who claims the health care provider pulled out her IUD when she came in seeking care.
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The nurse claims that the device was removed by accident, but a review of past incidences revealed something more sinister. Olona had “accidentally” removed several IUDs from patients and was outspokenly opposed to the devices. As she attempted to comfort the frantic young woman, Olona assured her that it was all for the best—the thing was really just an abortion waiting to happen—she had actually done her a favor. Once the IUD was out, the nurse refused to insert a new one. Under broader conscience rules established in the last gasps of the Bush administration, such refusals may be legally protected (although of course the unwarranted removal does not enjoy such shelter). While the Obama administration has worked to undo some of this last-minute damage, the ability of providers to refuse various services continues to pose a threat to reproductive rights. Even the most infrequently used methods of contraception place women at the center of cultural and political controversy.

Female and Male Sterilization

No methods of birth control are so broadly practiced and so little discussed in American life as female and male sterilization. Most people are shocked to discover that sterilization (when we count women and men together) is the most popular method of contraception in the United States. As of 2002, 27 percent of American women using contraception and 9.2 percent of American men were sterilized. Perhaps one reason we don’t talk more about this very common set of procedures is because of this tends to be the birth control option of people who have had as many children as they want, people who on average are older. But this is changing somewhat as younger couples, for a variety of reasons, increasingly choose to remain child-free. Jeanne, thirty-six, told me about her partner’s decision to undergo a vasectomy in his late twenties: “I never wanted kids, and Mitch feels the same way. I was going to have my tubes tied and he said, ‘No, vasectomy is less invasive, it’s more reversible—I’ll do it.’ I thought, ‘Wow, this guy is a keeper.’ ” Mitch had trouble finding a doctor who was willing to perform the surgery on a young man without any children. They finally did, and both have been happy with the decision despite living in a world where friends are increasingly focused on babies and children. “I’m in my midthirties now,” Jeanne tells me, “and I keep waiting to get blindsided by this desire for kids. But it hasn’t happened yet.”

Tubal ligation is the most common form of nonreversible birth control in America. This outpatient procedure involves cutting, burning, or blocking the fallopian tubes with clips or bands so that eggs are unable to travel to the uterus. Even though the body continues to ovulate after the surgery, the eggs have no way to travel downward and the sperm aren’t able to venture upward. Doctors can perform a tubal ligation in a doctor’s office, clinic, or hospital using either local or general anesthetic. Usually, this is a laparoscopic surgery, meaning that gas is used to inflate the abdomen, and the procedure is performed using a tiny telescope-like instrument inserted into the body through cuts at the navel and above the pelvic bone. The advantage of laparoscopic surgery is that it is less invasive and patients can recover more quickly.