NL 2006/12

The intrauterine Device

Dear friends of the Museum of Contraception and Abortion,

”It is true that every foreign body in utero has some contraceptive effect; Copper-bearing intra-uterine contraceptive devices have an even greater effect on contraception than any device consisting solely of plastics.” This quote origins from (internationally standardized) ISO 7439:2002 applicable to single-use copper-bearing intra-uterine contraceptive devices and their insertion instruments.

It was in fact the observation of foreign bodies’ contraceptive effect in the womb which triggered the development of coils: As early as in the 1890s, physicians observed that women with polyps in their uteri could rarely become pregnant.
However, at this time counselling healthy women on contraception was viewed as unethical and not part of a physician’s tasks. On the other hand, physically ill and weak women were advised to not become pregnant, although no physician would advise on how to carry out this advice. Druggists, barbers and pedlars spotted this vacuum and sold all sorts of appliances.

However in 1909, Dr. Richard Richter from Silesia noted the social and economical imperatives to limit the number of children. He writes: “Knowing life as it is, one sees that hundreds of mums sacrify their health and happiness year after year. In the light of statistics I have once presented, these sacrifices are of no earthly use, since more than half of their viable offspring dies early. In such a situation it is a mission of health and morality to limit their progeny…”

For contraceptive purposes, Richter inserted plaited silk threads into women’s uteri. The threads’ ends were knotted and covered with celluloid to prevent irritation. To facilitate their removal, Richter joined them with very thin aluminium-bronze-wire.

Walter Pust, doctor in charge at the gynaecological department of Jena University, presented another “suitable female protector” in 1920. It consisted from a glass button, a “neck” of 30 silk windings plus a coil made of silk thread. This device did not block the monthly bleeding and had to be exchanged every 3 to 4 months. In 1923, in Germany there were as many as 23 000 units in use. This large number suggests that their users were not exclusively the sick who could not bear children. However, Pust focused on these: “Since it is a doctor’s duty to prevent pregnancies of women who are ill and cannot give birth, it is duty as well to cooperate in developing and testing appropriate methods.”

Dr. Pust thought about his development: “The glass button leads the sperm off the mucus’ basic stopper and exposes it for such a long time to the vagina’s acid secretion that only a few of them reach the inside. Already weakened in their vitality they must pass the 30 silk windings in the cervical canal. When they reach the cave of the uterus even so, they are adhered by the sticky welled silk threads and an incorporation into the egg seems to be impossible.” But Dr. Pust’s first developments did not work well: They bridged infections from the vagina to the uterus. Furthermore they were so large that ejection happened very often.

The next protagonists in the history of the coil were the German Ernst Gräfenberg and Japanese gynaecologist Tenrei Ota. Gräfenberg, who became popular as “inventor” of the female G-spot, presented in 1928 his successful results in 480 women using coils made of silk threads, produced of the silkworms’ intestines prior to contact with outside oxygen. In another 150 women, he used a ring made of silver. Less than 1 percent became pregnant. We know now what he didn’t know then: his silver material was tinged with copper. Since copper prevents sperm from fertilising, it had boosted the efficiency of Gräfenberg’s coils. But another problem emerged: removal of the device was difficult.
Since the Nazi-leaders had no interest for contraception – in fact quite the contrary – Gräfenberg had to stop his tests and in 1940 escaped Germany for USA by the skin of his teeth.

Gräfenberg’s coils survived in Japan. Tenrei Ota used gold and silver as material and included a rigid disk into the ring to prevent it from being expelled. Ota-rings and Gräfenberg-rings are still in use in the Far East.

The next notable developments came from the USA: In 1958, New York gynaecologist Lazar Margulies developed a flexible plastic coil. But in the end, its flexibility did not bring much benefit.

The coil’s removal thread was invented in 1964 when Jack Lippes added it to his Lippes’ Loop, No 1 plastic coil before copper coils were developed. The use of copper was introduced in 1969 by Chilenian gynaecologist Jaime Zipper. The continuous release of copper ions prevents sperm from fertilising. For that reason the so called copper coils reduce the rate of pregnancies outside the uterus (extrauterine pregnancy, tubal pregnancy).
Copper-less coils solely act as foreign bodies which prevent the nidation of a fertilised egg. Adding copper raises their effect and prevents tubal pregnancy.

By the early 1970s in the USA, a special coil removal thread was used with fatal consequences for many women: the cute looking “Dalkon shield” was very large. To facilitate removal it was equipped with an extra-strong knotted two-filament thread. Due to this platelike pessary’s low efficiency many women became pregnant. During pregnancy coil plus bacteria-covered thread were pulled deeply up the womb. The insufficiently tested pessary caused fatal miscarriage and severe tubal inflammation and had to be withdrawn from the market very quickly. All other pessary-models are equipped with a thin one-filament thread which cannot cause such problems.

Nowadays, the use of IUDs is second only to sterilisation: approximately 160 million of women use it, many of them in China. It combines great safety (low rate of pregnancies and low expulsion rate), durability and low price. Since more than 20 years only modern coils are in use, around which a copper thread is wound. So it is incorrect to say that coils only prevent the nidation of a fertilised egg. This was true for devices consisting only of plastics and this problem was overcome long ago by modern coils.

In 1976, Jack Lippes, the inventor of former No 1 coil, found its efficacy in emergency contraception, when fertilisation has already happened after unprotected sex. In this case the coil functions as foreign body preventing the nidation of the egg into the uterus.

Despite the existing progress more research is underway in the development of coils:
• For example the progesterone-releasing IUD Mirena®, which releases a very small dose of corpus luteum hormone (or progesterone). This IUD, too, is effective for 5 years and leads to a reduced menstrual bleeding. Some women will even experience no menstrual bleeding at all. From the medical point of view this is a beneficial effect without any risk.
• The especially well tolerated frameless coil Gynefix® was developed in 1984 by Dutch Dirk Wildemeersch: A nylon filament containing copper beads is anchored into the wall of the uterus. Due to the flexible form of the filament side effects are very rare.

Another stiff-necked superstition says, the arabs would implant stones for contraception into their camels’ wombs. Ask camel-experts about it. Their amused answer will be: “Have you ever tried yourself to manipulate anything into a camel’s womb? Try it and you will know!”