Another Front Page Article in Today’s New York Times

07/07/2015

There is an extremely interesting article on the front page of today’s New York Times entitled, “Colorado Finds Startling Success in Effort to Curb Teenage Births.” The article talks about a private grant that allowed free IUDs or subdermal implants to prevent pregnancy that was a six-year experiment in Colorado. During this period of time, the birth rate among teenagers plunged 40% and the rate of abortions fell by 42%. Apparently, this was most evident in unmarried women under 25 who had not finished high school. In addition, the article talks about how the changes were “particularly pronounced in the poorest areas of the state… where many young women have unplanned pregnancies.” Understand, from a societal point of view, preventing unintended pregnancy, especially in women who would then have an unintended child, has merit. However, the endorsement of the American Academy of Pediatrics in the use of this type of LARC (long acting reversible contraception) for adolescents as a blanket statement is somewhat distressing to me.

When I trained, we were taught that intrauterine devices (IUDs) were best suited for patients who had had a child (the uterus grows with child bearing) and those in a stable monogamous relationship. If one catches a sexually transmitted disease from a partner, the IUD can serve as a wick helping to spread it up through the uterus and into the fallopian tubes often causing pelvic inflammatory disease (PID) and often compromising the future fertility of these patients. Thus, while I agree that in patients who because of their lack of education or socio-economic status or lack of insight cannot be counted on for appropriate contraception without a device like an IUD or an implant that does not require any participation on their part—in such patients this may, in fact, make sense and as evidenced by the Colorado experiment will cut down on unintended births and abortions.

However, recently, I’ve had two young women referred to me from the student health service at NYU downtown (Washington Square) who had two IUDs each that they expelled. Each of these young women was sent to me to evaluate her uterus to see if there was some abnormality causing her to expel the IUD. Evaluation with saline infusion sonohysterogram and 3-D ultrasound revealed they had absolutely normal uteri. However, the width at the top of the uterus was only 2.9 cm in each of them, whereas, the IUD devices are 3.2 cm wide. In other words, each woman’s uterus was too small to accommodate the intrauterine device.

My overall point is that decisions should be made on a case-by-case basis and individualized. Most of my patients do not need to accept even the small risk of future tubal damage from an intrauterine device in order to prevent unintended pregnancy. These forms of LARC may be appropriate for some groups of patients but I have not routinely embraced them for young women in my practice who have not had children and are not in a stable, monogamous relationship. That is not to say that occasionally the rules may be broken, depending on the individual situation.