IUD PROTOCOLS FOR INTERNATIONAL TRAINING

A review of 9 reference protocols for IUD training in the US and in developing countries revealed conflicting instructions on antibiotic prophylaxis, postpartum insertion of IUDs, management of complications, and sterilization and disinfection procedures. The protocols only agreed on the contraindication status of pregnancy and active gynecological or chlamydial infections (all listed as absolute contraindications) which were just 2 of 32 different contraindications. US physicians considered some conditions to be contraindications to IUD use, but they usually are not applicable to women in developing countries. In developing countries with maternal mortality rates 2 times greater than those in developed countries, 8 contraindications may be inappropriate: prior expulsion of or perforation by an IUD, IUD insertion during the postpartum period, prior pregnancy with and IUD in place, prior ectopic pregnancy, copper allergy, coagulopathy, valvular heart disease, and Wilson's disease. The only inappropriate contraindication addressing infection (1 of 8) was a distant history of pelvic inflammatory disease. This history should not exclude IUD use in a woman not at risk of sexually transmitted diseases. Contraindications referring to cancer of the reproductive tract should be consolidated in a statement warning against hormonal contraceptive and IUD use in women, especially those over 35, who have recent, undiagnosed, irregular vaginal bleeding, until the cause has been determined. The reviewers also discussed justifications for other contraindications, including those related to menstrual blood loss, small uterus, structural abnormality of the uterus, severe vasovagal reactivity or fainting and severe cervical stenosis, no access to services, and future fertility. THis analysis indicated a need to simplify, rationalize, and update current IUD protocols as well as make them consistent. This will improve service quality and reduce unnecessary medical obstacles to contraception.