**6. Correcting misunderstandings, myths, and barriers**

#### **6.1. IUD and PID**

Since the introduction of IUDs, scientists manifested a concern that this contraception method may cause or facilitate gynecologic infection. In fact, the relationship between IUD and PID has a long and controversial history dating since 1940 [59]. Moreover, in the 1970s, the reputation of IUD was tarnished in many countries, as the use of a Dalkon Shield IUD was linked to several cases of potentially fatal pelvic sepsis [60]. Today, although there is common reserve regarding the PID incidence in the IUD users' population, valuable research has shown that the risk of PID is no greater with IUD use than the general population [61]. WHO admits a risk of six times greater of PID in the first 20 days after the insertion of IUD [61]. One randomized trial found that the hormonal IUD might provide some protection against PID when compared to the group of copper IUD users and the group of IUD non-users [62]. Due to this risk, prophylactic antibiotics were proposed before IUD insertion, especially doxycycline and/or azithromycin. Multiple large, randomized control studies have demonstrated that the prophylactic antibiotic has no significant beneficial role in reducing the risk of PID before IUD insertion [63].

#### **6.2. IUD and tubal infertility**

Tubal infertility was thought to be a consequence of IUD use. Specific research has been conducted and found that the past use of copper IUD did not increase the risk of tubal infertility [59]. Chlamydia infection is the primary cause of PID and tubal infertility in women who use or do not use IUD [31]. A cervix already infected with Chlamydia was considered to be a risk factor for placing an IUD, but proved to have no association with PID on later development [64].

#### **6.3. IUD and the risk of ectopic pregnancy**

In the past, IUD was perceived as a high risk factor for ectopic pregnancies (EPs). Actually, a pregnancy with an IUD in situ has an increased risk of being an EP, but the absolute risk of any pregnancy is extremely low in the group of IUD users, much lower than in the group of women with no contraception method [65, 66]. Another important aspect to highlight is that a history of previous EP does not represent a contraindication for IUD insertion [67].

#### **6.4. IUD in nulliparous women**

Adolescents and nulliparous women represent a special group that was considered, in the past, not eligible for IUD contraception. Approximately half of adolescents have never heard of IUD contraception [68]. What is more, approximately one-third to one-half of health providers do not offer IUD contraception method to nulliparous women due to several myths and misconceptions [69]. Nowadays, there is sufficient evidence to support the use of IUDs in the nulliparous women as a suitable contraception method, regardless of all false myths and misconceptions including high risk of PID, tubal infertility, EP, gynecological neoplasia, difficulties of the insertion technique, and IUD expulsion [70].

#### **6.5. IUD and gynecological neoplasia**

thromboembolic events, bleeding diathesis, or under anticoagulation. Also, IUD contraception can be a preferable option in women with uterine fibroids after uterine artery emboliza-

However, the IUD does not protect from sexually transmitted diseases; therefore, caution

Since the introduction of IUDs, scientists manifested a concern that this contraception method may cause or facilitate gynecologic infection. In fact, the relationship between IUD and PID has a long and controversial history dating since 1940 [59]. Moreover, in the 1970s, the reputation of IUD was tarnished in many countries, as the use of a Dalkon Shield IUD was linked to several cases of potentially fatal pelvic sepsis [60]. Today, although there is common reserve regarding the PID incidence in the IUD users' population, valuable research has shown that the risk of PID is no greater with IUD use than the general population [61]. WHO admits a risk of six times greater of PID in the first 20 days after the insertion of IUD [61]. One randomized trial found that the hormonal IUD might provide some protection against PID when compared to the group of copper IUD users and the group of IUD non-users [62]. Due to this risk, prophylactic antibiotics were proposed before IUD insertion, especially doxycycline and/or azithromycin. Multiple large, randomized control studies have demonstrated that the prophylactic antibiotic

has no significant beneficial role in reducing the risk of PID before IUD insertion [63].

Tubal infertility was thought to be a consequence of IUD use. Specific research has been conducted and found that the past use of copper IUD did not increase the risk of tubal infertility [59]. Chlamydia infection is the primary cause of PID and tubal infertility in women who use or do not use IUD [31]. A cervix already infected with Chlamydia was considered to be a risk factor for placing an IUD, but proved to have no association with PID on later development [64].

In the past, IUD was perceived as a high risk factor for ectopic pregnancies (EPs). Actually, a pregnancy with an IUD in situ has an increased risk of being an EP, but the absolute risk of any pregnancy is extremely low in the group of IUD users, much lower than in the group of women with no contraception method [65, 66]. Another important aspect to highlight is that a

Adolescents and nulliparous women represent a special group that was considered, in the past, not eligible for IUD contraception. Approximately half of adolescents have never heard

history of previous EP does not represent a contraindication for IUD insertion [67].

tion, endometrial ablation, or magnetic resonance-guided focused ultrasound.

**6. Correcting misunderstandings, myths, and barriers**

must be considered when selecting IUD users.

**6.1. IUD and PID**

264 Family Planning

**6.2. IUD and tubal infertility**

**6.3. IUD and the risk of ectopic pregnancy**

**6.4. IUD in nulliparous women**

There is a lack of awareness and understanding of IUD contraception by women worldwide, possibly due to lack of medical education and proper information. A frequent misconception of IUD use is that it increases the risk of genital cancer. Mandatory screening for cervical cancer is a requirement of many guidelines before IUD insertion. In fact, several epidemiological studies suggested that IUDs might protect against cervical carcinogenesis [71]. The role of hormonal IUD as a protective factor against endometrial hyperplasia is well known [58]. Accurate information regarding the use of hormonal IUD must underline the risk of ovarian cysts, but not ovarian cancer.

#### **6.6. IUD and female sexual dysfunction**

Female sexual dysfunction was thought to be determined by IUD but in fact has a multifactorial etiology and studies found no difference between IUD users or non-users [72].
