Intra-Uterine Devices: A New Era in Birth Control?

It has been known for a century that a foreign body in the uterus can prevent conception -- at least in animals. But how could such a process work and be put to safe human use? Even though modern medical men have no sure answers, the cautious and respectable Planned Parenthood Federation of America announced last week that its medical advisers are now giving "strong, though preliminary" approval to the newest form of birth control. Information accumulated from more than 10,000 women during 90,000 woman-months of observation, said P.P.F.'s medical committee, "indicates that the modern intrauterine contraceptive devices are both safe and effective."

Said P.P.F.'s president, Dr. Alan Guttmacher: "Intra-uterine devices are being subjected to as much scientific testing as the birth control pills." And it appears that they are almost equally effective. If their sponsors' hopes are fulfilled, IUCDS, as they are called, may soon be the most useful and prevalent contraceptive. They cost only pennies to manufacture; the cost of insertion is no more than a doctor chooses to charge, which may be nothing at a health station in India or the fee for an office visit and examination in the U.S. A woman who wants another child can usually become pregnant within a cou ple of months after the IUCD'S removal. Most important, IUCDS can be left in place for months or years without thought or attention.

Silk to Silver. The man who did most to demonstrate the effectiveness of IUCDS did not live to see the dawn of the new age that he pioneered. German Gynecologist Ernst Graefenberg, born in 1881, began inserting rings in the wombs of his patients in the 1920s. He first used rings made of surgical silk, but soon switched to silver wire. The insertion of wire required dilatation of the cervix, but Dr. Graefenberg reported few complications and fewer unwanted pregnancies. Yet when other doctors decided to follow his example, there were many complaints--mainly excessive bleeding and inflammation in the pelvis. The rings fell into disrepute. After Dr. Grafenberg settled in the U.S. in 1940, he gave up the use of IUCDS.

Research went on elsewhere. The late Dr. Willi Oppenheimer of Shaare Zedek Hospital in Jerusalem, who began working on the devices in 1930, thought that something like the gut used in surgical sutures would be less likely than metal to cause bad reactions. He went back to Graefenberg's rings made from the surgical silk. His 329 patients had a few unwanted pregnancies, but no miscarriages and no malformed babies. There were no cases of permanent sterility, and no diseases, including cancer, that could be attributed to the ring. In Yokohama, Dr. Atsumi Ishihama recorded a total of 19,000 women fitted with IUCDS; his choice was a ring made from a spiral of metal or plastic, and with a disk in the center suspended from three points.

Hong Kong Queues. The design of an IUCD, however, seems hardly to matter. Nor does the nature of the material, provided only that it is inert enough to cause little or no reaction in the woman's tissues. Several IUCDS are flexible, such as those of plastic (a special polyethylene), silk or nylon thread, and can usually be inserted without dilatation of the cervix. Even so, insertion must be done by a doctor, and preferably by a specialist in gynecology. Insertion of a metal ring, with dilatation of the cervix, definitely calls for specialized skill.

IUCDS are now being studied in at least a dozen countries, including several in Latin America. In Hong Kong, Taiwan and Korea IUCDS have become enormously popular; women formed long queues outside family-planning centers in Hong Kong, waiting to be fitted. An extensive test program is getting under way, though slowly, in India.

In the U.S. at least 15,000 women have been fitted with IUCDS at 40 medical centers. Four principal types of devices are being tested:

> A ring, slightly less than an inch in diameter, made of stainless-steel spring, under study since 1949 by Dr. Herbert H. Hall of New York Medical College.

> A polyethylene spiral, designed by Dr. Lazar C. Margulies of Manhattan's Mount Sinai Hospital, can be inserted through a straight tube, and carries a threadlike "tail" punctuated with plastic beads.

>A doubleS loop of plastic, also equipped with a tail, developed by Dr. Jack Lippes of the University of Buffalo.

> A "bow tie," or double triangle, devised by Dr. Charles H. Birnberg of the Jewish Hospital of Brooklyn, which like the rings ordinarily has no tail, but is made of a plastic that shows on X rays.

Still No Clue. The biggest immediate difficulty with IUCDS is that one woman out of ten expels hers--usually within two months. And she may not notice that she has lost it until she becomes pregnant. It is to guard against unsuspected loss of the devices that many of them carry a plastic tail. A woman can then easily examine herself to make sure that the device is in place. Only a few women have intermittent bleeding difficulties that prompt their doctors to remove the devices.

Although no one yet knows just how IUCDS prevent conception, it is certain that--unlike the diaphragm, which covers the cervix--they do not prevent passage of the sperm into the uterus and along the Fallopian tube to meet the egg. Since they definitely trigger excessive contractions of the uterine muscles and of the Fallopian tubes, they may cause displacement of the egg before it has time to be fertilized or to settle in the wall of the womb.

There is no doubt about IUCDS' relatively high effectiveness. If 100 wives use no contraceptives, 90 will become pregnant in a year; with the rhythm method, 40 will, and with diaphragm or condoms, from two to 20. Among 100 women who can retain IUCDS, there is, on the average, only one pregnancy a year. That is as near perfection as the protection from the pills.

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