**5. IUD**

#### **5.1. Use cessation**

The procedure to extract the IUD is often uncomplicated. A speculum and a Foerster clamp are needed: The speculum is inserted into the vagina until the cervix and the IUD threads appear through the external cervical os. The threads are fastened with the clamp and pulled until the total extraction of the IUD. The best time for extraction is during menstruation since the cervical os is slightly more dilated than under normal conditions. Non-visualized IUD strings is a potential challenge, the most common cause being string retraction into the uterus. ACOG recommends sweeping the cervical canal with a cytobrush, a maneuver that often reveals them; if this is not effective, the algorithm includes ruling out pregnancy, confirming abdominal location of the IUD and evaluating the need for a laparoscopic removal [83]. Some women might describe slight temporary mood swings after LNG IUD removal.

#### **5.2. Physiology**

**4. Injectable contraceptives**

being 4.5–5 months [1].

226 Family Planning

last injection [92].

duration of use.

**5. IUD**

**5.1. Use cessation**

Injection-based methods differ from other methods in the return to fertility since they are irreversible in the short-term, but fertility rates eventually reach those of them [13]. In this group methods one year pregnancy rates range between 72.5–82.9% with median time to pregnancy

Depot medroxyprogesterone acetate (DMPA) is the most commonly used injectable, being administered as intramuscular injections every 12 weeks. Product leaflet mentions some pregnancies have occurred 14 weeks after a preceding injection but longer delays are common: the observed mean time to ovulation is 5.3 months and the median time to conception is 10 months after the last injection. About 83% women should conceive within 15 months of the

A large study in over 1000 Thai women remarked that return to fertility and proportions of live births in the offspring of women who used MDPA are similar to those of women using other contraceptive methods (OCs or IUDs): in this study the median delay to conception for MDPA was 5.5 months plus the estimated effect duration of the last injection; this can be

Intramuscular injections of norethisterone enanthate acts as a contraceptive for 8 weeks; in 11 of 20 women discontinuing this method follicular activity was observed within 90 days of the last injection [94]. The observed median delay to conception is 6 months after the last injection; 14 of 40 women became pregnant within 12 weeks and 31 of 40 after 1 year. Authors remarked the real figures could be higher. The delays in fertility were not correlated with the

Intramuscular injections of estradiol cypionate and medroxyprogesterone acetate (Cyclofem®) are administered every month. 1.4% women became pregnant at the end of the first month (since the first missed injection), 52.9% after 6 months and 82.9% after 9 months. Pregnancy

The procedure to extract the IUD is often uncomplicated. A speculum and a Foerster clamp are needed: The speculum is inserted into the vagina until the cervix and the IUD threads appear through the external cervical os. The threads are fastened with the clamp and pulled until the total extraction of the IUD. The best time for extraction is during menstruation since the cervical os is slightly more dilated than under normal conditions. Non-visualized IUD strings is a potential challenge, the most common cause being string retraction into the uterus. ACOG recommends sweeping the cervical canal with a cytobrush, a maneuver that often reveals them; if this is not effective, the algorithm includes ruling out pregnancy, confirming abdominal location of the IUD and evaluating the need for a laparoscopic removal [83]. Some

outcomes were favorable: 51 (94.4%) pregnancies ended in a live birth [95].

women might describe slight temporary mood swings after LNG IUD removal.

compared to 3 months for OCs and 4.5 months for IUD [93].

IUDs elicit foreign body reactions, which turns the intrauterine milieu lethal for embryos, without significant extrauterine effects. In addition to this, different types of IUDs can alter previous processes through varying degrees: Mucus thickening, glandular atrophy and stromal decidualization in LNG IUDs, spermatozoa decay and toxicity by Copper ions in the uterine cavity, transmission of noxa from the uterine lumen to fallopian tube, etc. [96, 97]. The histological changes were found to be reversible within some months. Unlike OCs, IUDs have not been observed to be associated with follicular phase length [31].

#### **5.3. Return to fertility**

Fertility is not impaired after IUD removal13. In Diana Mansour's bibliographic review 1 year pregnancy rates for Copper IUDs were 71.2–91.1% for Copper IUDs and 79.1–96.4% for LNG IUDs (median time to pregnancy were 2–3.7 cycles and 4 cycles respectively)1. Currently there is no evidence of a delay in return to fertility after using an IUD [13]; in some studies >50% of women conceived within 3 months after discontinuing it [98]. **Table 1** contains selected studies pertaining return to fertility after contraception.

The history of IUD devices includes some particular case of long-lasting health and reproductive consequences after IUD usage. Despite some previous attempts and projects some decades earlier, it was not until the 1960s that commercial IUDs made their way into the market with the approval of the Lippes Loop and the Safe-t-coil by the FDA in 1966. The **Dalkon shield**, introduced in 1971, attempted to increase the surface of the endometrium in contact with the IUD and to increase retention rate; it included a multifilament tail string encased in Nylon [99]. Several reports associated this IUD with increased infection rates, septic abortions and deaths; apparently the multifilament string could allow vaginal bacteria to access the uterus. Since this IUD was used in many world countries the numbers of women suffering adverse consequences is difficult to estimate. Device sales stopped in 1974 and the company started to recommend device removal if a pregnancy took place, which is now standard practice; women experiencing the adverse events, which includes fertility impairment as sequel, filled many lawsuits and in 1980 the company recommended removal of the Dalkon shield in women who were still wearing them. Distrust and doubt regarding IUDs lasted for several years after this, especially in the USA [100].

The relationship between IUD usage and pelvic inflammatory disease (PID), a well-known cause of infertility, has been studied extensively for decades [101] and many studies had pitfalls [102]: Sexual habits as a confounding factor, diagnosis bias… The described incidence of pelvic inflammatory disease on IUD users is very low (1.6/1000 person-years) and particularly confined to the first weeks after insertion. Preventive strategies include adequate selection of IUD candidates, prophylactic antibiotic during insertion, careful monitoring and treatment of infections, etc.

Long-term usage is not associated with posterior infertility; several studies have shown pregnancy rates are not delayed in women who used copper IUDs for several years [106]. Zhu et al. performed a study with 1770 Chinese women who had their IUDs removed after a catastrophic earthquake in the Sichuan region and were followed up for two years [103]. 71% women conceived within 1 year after removal and 80% conceived within 2 years. In the multivariate logistic regression analysis age was negatively associated with fertility (OR 0.7548, 95% CI: 0.7148–0.7933), while duration of IUD use (OR 1.0596, CI: 1.0244–1.0960) and previous gravidity were positively associated. The authors described a clear reduction in fertility and increased miscarriage rates with age; 1 year pregnancy rate among women older than 40 years was 49.67%. They reported duration of IUD use was associated with decreased fertility but did not stratify the analysis of this variable and age could be a confounding factor. Women with longer IUD usage are also older women, and fertility and miscarriage rates are known to depend on age.

**Method Participants Term** 

women

New Zealand

TCu380Ag 17 pregnant

Copper IUDs 1051 IUD.

Copper IUDs 95 pregnant

women

66 pregnant women

671 pregnant women

Croatian women

women

women

women

women

women

Belhadji et al. [110]

Wilson et al. [106]

Skjeldestad and Bratt [111]

Andersson et al. [116]

Sivin et al. [114]

Tadesse, [124]

Randić et al. [115]

Andersson et al. [116]

Sivin et al. [114]

Belhadji et al. [110]

Buckshee et al. [118]

Sivin et al. [114]

Sivin et al. [114]

Diaz et al. [125]

IUD TCu380Ag

IUD Copper T-200

IUD. 3461

LNG-20 IUS 104 pregnant women

LNG-20 IUS 68 pregnant

LNG-20 IUS 22 pregnant

Norplant II 136 pregnant women

Norplant II 86 pregnant

Norplant 33 pregnant

Norplant 75 pregnant

**pregnancy (%)**

88% 12%

**Miscarriage (%)**

**Ectopic (%)**

88.4% 8.4% 2.1% 1.1%

82% 15% 0% 3%

Ectopic pregnancy: Control: 3.9%, planned pregnancy (parous women) 2.7%: accidental pregnancy 0%; expulsion/displacement 1.2%; bleeding/pain + PID 6%.

85.6% 5.8% 1% 2.9%

89.7% 4.4% 5.9%

9% 5%

8% 1% 1% 2%

4% 0% 4%

86% 14% 17 women

IUD 50 users 84% 6% 2% 4% 2% outcome

87.8% 8.5% 3.7%

89% 2%

(Non-significant differences)

88% (term delivery)

93% (term delivery)

79% (term delivery)

83.2% 11.6% 0.5% 2.0% 2.7% Similar rates

**Preterm birth (%)**

Contraceptive Methods and the Subsequent Search for a Pregnancy

**Induced abortion**

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**Comment**

229

to women from New Zealand, but higher rates of induced abortion. Authors attributed this to women's attitudes and choices after the recall of another IUD.

unknown and 2% still birth

Lower rates than general population

still pregnant at time of analysis

In the study by Doll et al [41] long-term IUD usage was associated with reduced fertility (log rank test for linear trend, P = 0.0035); authors hypothesized that this might be related to pelvic inflammatory disease This article received media coverage in the UK [104, 105], but remarking that most IUDs in this study were not available for women anymore and that current standard practice included better diagnosis of infections. The posterior NICE Guidelines evidence review highlights that IUD female users were older and had higher rates of miscarriage, termination and ectopic pregnancy [13] and concludes that there is no evidence on delay in the return of fertility after discontinuing IUD usage. This also applies to nulliparous women, whose uterine cavity is usually smaller [15].

#### **5.4. Pregnancy outcomes**

One common concern of IUD users is the outcome of their future pregnancies. The different pregnancy outcomes observed in many studies with Copper IUD range from 84 to 88% for live births, 88–82% for term deliveries, 6–12% for spontaneous abortions, 1–4% for induced abortions and 0–2% for ectopic pregnancies (the studies classifications were not uniform) [1]. For LNG IUD the pregnancy outcomes are similar. Pregnancy outcomes of several studies are reported in **Table 2**.

Many studies have assessed the effects of IUD complications on fertility. In a 1989 study with copper IUDs by Wilson et al. with Neo-Zealand woman 16% (164) of IUD removals took place due to complications. 92.4% of these women had conceived after 36 months (compared with 94.2% for the rest of IUD removals). Regarding pregnancy complications slight significant differences were observed only between some subgroups, which could be related to multiple comparisons in this study; for example in women who used IUD for less than 24 months, nulligravid women had smaller conception rates than gravid women (86.7 vs. 93.6%, p < 0.005) [106]. Authors noted the observed outcomes in IUD users were similar or better compared to population ones. Other studies have also noted IUD removal was not associated to ectopic pregnancy risks [115].

In the unlikely event that a woman using IUD becomes pregnant it is advised that the device is removed before 12 completed weeks' gestation, regardless of whether she wants or not to continue with the pregnancy [13]. These situations are associated with significant miscarriage and septic abortion risks.

Regarding PID, a dose–response has been established between the severity and number of episodes and ectopic pregnancy risk; for example in women aged 25–44 with 2 or more severe episodes the probability has been statistically modeled to be 84% [107]. These women have many options: careful follow-up, laparoscopy, in vitro fertilization, etc.


gravidity were positively associated. The authors described a clear reduction in fertility and increased miscarriage rates with age; 1 year pregnancy rate among women older than 40 years was 49.67%. They reported duration of IUD use was associated with decreased fertility but did not stratify the analysis of this variable and age could be a confounding factor. Women with longer IUD usage are also older women, and fertility and miscarriage rates are known

In the study by Doll et al [41] long-term IUD usage was associated with reduced fertility (log rank test for linear trend, P = 0.0035); authors hypothesized that this might be related to pelvic inflammatory disease This article received media coverage in the UK [104, 105], but remarking that most IUDs in this study were not available for women anymore and that current standard practice included better diagnosis of infections. The posterior NICE Guidelines evidence review highlights that IUD female users were older and had higher rates of miscarriage, termination and ectopic pregnancy [13] and concludes that there is no evidence on delay in the return of fertility after discontinuing IUD usage. This also applies to nulliparous

One common concern of IUD users is the outcome of their future pregnancies. The different pregnancy outcomes observed in many studies with Copper IUD range from 84 to 88% for live births, 88–82% for term deliveries, 6–12% for spontaneous abortions, 1–4% for induced abortions and 0–2% for ectopic pregnancies (the studies classifications were not uniform) [1]. For LNG IUD the pregnancy outcomes are similar. Pregnancy outcomes of several studies are

Many studies have assessed the effects of IUD complications on fertility. In a 1989 study with copper IUDs by Wilson et al. with Neo-Zealand woman 16% (164) of IUD removals took place due to complications. 92.4% of these women had conceived after 36 months (compared with 94.2% for the rest of IUD removals). Regarding pregnancy complications slight significant differences were observed only between some subgroups, which could be related to multiple comparisons in this study; for example in women who used IUD for less than 24 months, nulligravid women had smaller conception rates than gravid women (86.7 vs. 93.6%, p < 0.005) [106]. Authors noted the observed outcomes in IUD users were similar or better compared to population ones. Other studies have also noted IUD removal was not associated to ectopic

In the unlikely event that a woman using IUD becomes pregnant it is advised that the device is removed before 12 completed weeks' gestation, regardless of whether she wants or not to continue with the pregnancy [13]. These situations are associated with significant miscarriage

Regarding PID, a dose–response has been established between the severity and number of episodes and ectopic pregnancy risk; for example in women aged 25–44 with 2 or more severe episodes the probability has been statistically modeled to be 84% [107]. These women have

many options: careful follow-up, laparoscopy, in vitro fertilization, etc.

to depend on age.

228 Family Planning

**5.4. Pregnancy outcomes**

reported in **Table 2**.

pregnancy risks [115].

and septic abortion risks.

women, whose uterine cavity is usually smaller [15].


*The most appropriate method? In this case the most appropriate method would be barrier contraceptives, since she does not yet have a stable relationship. If the patient requested it combined oral contraception could be considered, but in that case we will recommend to keep using barrier methods to* 

Contraceptive Methods and the Subsequent Search for a Pregnancy

http://dx.doi.org/10.5772/intechopen.72525

231

*Female, 26 years old. Stable couple for 2 years. She wants advice on contraception. She remarks she* 

*The most appropriate method? In this case we can recommend her oral combined contraceptives, since she has no remarkable diseases, has a stable partner and this will help in her dysmenorrhea and menstrual pattern. We can assure her the reversibility of oral contraceptives has been observed for decades and that after interrupting them women's fertility will be similar to the rest of women. She opts for* 

*30 years old Woman with stable couple for 8 years. Uses oral combined contraceptives. She wants to stop taking a pill every day. She wants to have children at some point in the future and is afraid of* 

*The most appropriate method? After explaining her the alternatives, she decides that she prefers the vaginal ring. We recommend how to start using this method after taking oral contraception. The ring should be administered as later the next day after the termination with the current pill. If the pill pack* 

*33 years old woman, she gave birth to a healthy son 2 years ago. She carries a subdermal implant and* 

*also has inactive tablets, she should start using the ring the day after the last inactive tablet.*

*prevent STDs (double contraception).*

*Personal and family history: no interest.*

*Menarche at age 13.*

*oral contraception.*

*pregnancy complications.*

*Case 4: Subdermal Implant.*

*Pregnant: 3 years ago. Menarche: at 15 years.*

*wants to become pregnant again. Personal history: without interest.*

*Family history: Mother with breast cancer.*

*Menarche: 15 years.*

*Personal and family history: no interest.*

*Planning: Combined oral contraceptives.*

*Menstruation: 4/28, from taking contraceptives.*

*Case 2: Combined contraceptives (oral contraception).*

*wants to have children at some later point in her life.*

*Nulliparous. Last cytology less than 1 year ago. Menstruation: 6/30, quite irregular. Dysmenorrhea. Previous recommendation: Barrier method (condom).*

*Case 3: Combined hormonal contraceptives (vaginal ring).*

*Not pregnancies. Last cytology 2 years ago, results: normal.*

**Table 2.** Pregnancy outcomes after using contraceptives.

#### **6. Other methods**

Return to fertility with barrier methods is prompt and expectable, given the lack of effects on female physiology compared to other methods. The figures have been reported previously as reference group. One year delivery rate after discontinuation was found to be 54% in an English study, which was higher than COCs or IUDs [41].

Natural family planning does not involve persistent physiological changes on women; 1 year pregnancy rates and spontaneous abortion risks can be considered as similar to general population ones. For example, a study observed abortion rates of 10.1% [108].

#### **7. Clinical cases pertaining return to fertility**

*Case 1: barrier method of contraception.*

*An 18-year-old woman comes to a consultation for contraceptive advice. She has just started a relationship.*

*Personal history: without interest.*

*Family history: DM type II father. Mother HTA.*

*Menarche at 14 years.*

*Not pregnancies.*

*Planning: has not started relationships.*

*The most appropriate method? In this case the most appropriate method would be barrier contraceptives, since she does not yet have a stable relationship. If the patient requested it combined oral contraception could be considered, but in that case we will recommend to keep using barrier methods to prevent STDs (double contraception).*

*Case 2: Combined contraceptives (oral contraception).*

*Female, 26 years old. Stable couple for 2 years. She wants advice on contraception. She remarks she wants to have children at some later point in her life.*

*Personal and family history: no interest.*

*Menarche at age 13.*

*Nulliparous. Last cytology less than 1 year ago.*

*Menstruation: 6/30, quite irregular. Dysmenorrhea.*

*Previous recommendation: Barrier method (condom).*

*The most appropriate method? In this case we can recommend her oral combined contraceptives, since she has no remarkable diseases, has a stable partner and this will help in her dysmenorrhea and menstrual pattern. We can assure her the reversibility of oral contraceptives has been observed for decades and that after interrupting them women's fertility will be similar to the rest of women. She opts for oral contraception.*

*Case 3: Combined hormonal contraceptives (vaginal ring).*

*30 years old Woman with stable couple for 8 years. Uses oral combined contraceptives. She wants to stop taking a pill every day. She wants to have children at some point in the future and is afraid of pregnancy complications.*

*Personal and family history: no interest.*

*Not pregnancies. Last cytology 2 years ago, results: normal.*

*Menarche: 15 years.*

**6. Other methods**

Bahamondes et al. [95]

230 Family Planning

Hahn et al. [60]

Chen et al. [79]

Cyclofemmonthly

Medical abortion (mifepristone) vs. surgical abortion vs. no abortion

Return to fertility with barrier methods is prompt and expectable, given the lack of effects on female physiology compared to other methods. The figures have been reported previously as reference group. One year delivery rate after discontinuation was found to be 54% in an

Natural family planning does not involve persistent physiological changes on women; 1 year pregnancy rates and spontaneous abortion risks can be considered as similar to general popu-

*An 18-year-old woman comes to a consultation for contraceptive advice. She has just started a* 

English study, which was higher than COCs or IUDs [41].

**Method Participants Term** 

58 pregnant women

13928, Chinese

**Table 2.** Pregnancy outcomes after using contraceptives.

**pregnancy (%)**

98.4% 3.4%

**Miscarriage (%)**

OC 4862 Danish 85.7% 14.3% (SAB) No evidence

**Ectopic (%)**

**Preterm birth (%)**

2.9 vs. 3.0 vs. 3.7 (P<0.05) **Induced abortion**

**Comment**

that pregravid OC use is associated with spontaneous abortions

Authors concluded no long-term consequences

**7. Clinical cases pertaining return to fertility**

*Case 1: barrier method of contraception.*

*Family history: DM type II father. Mother HTA.*

*Personal history: without interest.*

*Planning: has not started relationships.*

*relationship.*

*Menarche at 14 years. Not pregnancies.*

lation ones. For example, a study observed abortion rates of 10.1% [108].

*Menstruation: 4/28, from taking contraceptives.*

*Planning: Combined oral contraceptives.*

*The most appropriate method? After explaining her the alternatives, she decides that she prefers the vaginal ring. We recommend how to start using this method after taking oral contraception. The ring should be administered as later the next day after the termination with the current pill. If the pill pack also has inactive tablets, she should start using the ring the day after the last inactive tablet.*

*Case 4: Subdermal Implant.*

*33 years old woman, she gave birth to a healthy son 2 years ago. She carries a subdermal implant and wants to become pregnant again.*

*Personal history: without interest. Family history: Mother with breast cancer. Pregnant: 3 years ago. Menarche: at 15 years.*

*Menstruation: 4/28.*

*Plan: Remove the implant, preconceptional counseling.*

*The implant is palpable and removed successfully. We advise her to wait for her period before attempting to conceive.*

Previous OCs usage is not associated with birth defects and their effect on birth weight or preterm birth seems small and controversial (some associations have been detected in recent

In adequate large studies previous IUDs (Cu or LNG) usage has not been consistently associated with adverse pregnancy outcomes. There is not enough evidence to support the hypoth-

Preconceptional counseling is advisable for all women who want to abandon contraception

\*, Luis Alfredo Bautista Balbás<sup>2</sup>

[1] Mansour D, Gemzell-Danielsson K, Inki P, Jensen JT. Fertility after discontinuation of contraception: A comprehensive review of the literature. Contraception. 2011 Nov;

[2] Gnoth C, Godehardt E, Frank-Herrmann P, Friol K, Tigges J, Freundl G. Definition and prevalence of subfertility and infertility. Human Reproduction. 2005 May;**20**(5):1144-

[3] Lindsay TJ, Vitrikas KR. Evaluation and treatment of infertility. American Family Phy-

[4] Nordqvist C. Infertility: Causes, Diagnosis, Risks, Treatments. Medical News Today. 21 January 2016. Available from: www.medicalnewstoday.com. [Accessed: 10 October

[5] Ammon Avalos L, Galindo C, Li DKA. Systematic review to calculate background miscarriage rates using life table analysis. Birth Defects Research. Part A, Clinical and Molecular

[6] Nybo Andersen AM, Wohlfahrt J, Christens P, Olsen J, Melbye M. Maternal age and fetal loss: Population based register linkage study. BMJ. 2000 Jun 24;**320**(7251):1708-1712

Teratology. 2012 Jun;**94**(6):417-423. DOI: 10.1002/bdra.23014. Epub 2012 Apr 18

and Alicia Pouso Rivera<sup>3</sup>

Contraceptive Methods and the Subsequent Search for a Pregnancy

http://dx.doi.org/10.5772/intechopen.72525

233

large and powerful studies, but a causal link remains to be confirmed).

\*Address all correspondence to: blancabautista91@gmail.com

2 Clinical Analysis Laboratory, Hospital la Paz, Madrid, Spain

esis that long-term IUD harms future fertility.

1 Midwife at Hospital Can Misses, Ibiza, Spain

3 Midwife at Hospital Belen, Madrid, Spain

to get pregnant.

**Author details**

**References**

2017]

**84**(5):465-477

1147 Epub 2005 Mar 31

sician. 2015 Mar 1;**91**(5):308-314

Blanca Patricia Bautista Balbás<sup>1</sup>

*Case 5: IUD.*

*Female 34 years old. She does not want more children at the moment, but she does not want irreversible contraception since she does not know if she will want children in the future. She does not want to take oral contraception.*

*Personal and family history without interest.*

*Menarche to the 14 years.*

*Two vaginal births, 2 and 4 years ago.*

*Menstruation: 4/27, are not very abundant.*

*Planning: use a condom.*

*The most appropriate method? In this case we could offer the administration of an IUD, since it is reversible, but can last up to 5 years. We explain her that there is no conclusive evidence that long-term use of IUD leads to impaired fertility. Many other factors influence fertility, like aging or smoking.*

*Case 6: Irreversible.*

*A 42-year-old woman who visits her doctor after a 7-day menstrual delay. Demand planning advice.*

*Personal history: Hypothyroidism under treatment, varicose syndrome, smoking 15 cig / day. Intolerant to metallic chromium.*

*Menarche at age 12.*

*Two pregnancies and vaginal births, babies of 3900gr and 4100gr at 31 and 38 years.*

*Menstruation: 7/26, abundant since always.*

*Planning: coitus interruptus, because her husband does not "tolerate" the condom. Gynecological review less than 1 year ago with ultrasound and cytology, without alterations.*

*Conduct to follow: pregnancy test is performed, being negative. Menstruation at 3 days.*

*Which contraceptive method is the most appropriate? Given her age, having two children, the personal history, for this couple the best method of contraception would be vasectomy or tubal ligation.*

### **8. Conclusions**

None of the contraceptive methods described (OCCs, POP, emergency contraception, implants, rings, Cu IUD or LNG IUD) is associated with impaired fertility. A temporary delay in fertility can occur with COCs, but this does not alter 1 year conception rates significantly. Injectable contraceptives are associated with delays in fertility buy not with fertility impairments.

Previous OCs usage is not associated with birth defects and their effect on birth weight or preterm birth seems small and controversial (some associations have been detected in recent large and powerful studies, but a causal link remains to be confirmed).

In adequate large studies previous IUDs (Cu or LNG) usage has not been consistently associated with adverse pregnancy outcomes. There is not enough evidence to support the hypothesis that long-term IUD harms future fertility.

Preconceptional counseling is advisable for all women who want to abandon contraception to get pregnant.
