- Email: [email protected]
Fertility After Removal of the Intrauterine Ring
Vol. 21, No.7, July 1970 Printed in U.S.A.
FERTILITY AND STERILITY
Copyright © 1970 by The Williams & Wilkins Co.
FERTILITY AFTER REMOVAL OF THE INTRAUTERINE RING G. WAJNTRAUB Outpatient Department,
General.Tewi.~h
Hospital "Shaare Zedek," Jerusalem, Israel
Intrauterine contraceptives have aroused universal interest during the last years since Oppenheimer3 and Ishihama 2 renewed the method of Grafenberg. 1 The possibility of a safe method of contraception realized the old dream of every couple and offered new absolute control of fertility to all classes of society throughout the world. Of major interest at the present time is the issue: does the intrauterine ring (IUR) cause sterility? For this vital reason the obstetrician is today asked the following questions by every patient desiring to use this kind of contraceptive. 1. How long will she have to wait after removal of the IUR before becoming pregnant? 2. Will the new pregnancy be different from the last one? 3. Can she expect a healthy baby or could this contraceptive in any way increase the occurence of malformations? Four groups of women are interested in using contraceptives: 1. Those who already have as many children as they planned or even more, and therefore wish to suppress their fertility for their remaining reproductive years. 2. Those who wish to postpone childbearing or to regUlate it after having one or two children, for different reasons. 3. Women who need to postpone the first child for financial or educational reasons, especially students and others. 4. Unmarried women. The last group is not included here as we do not insert the IUR into unmarried women. The purpose of our study was to determine the fertility rate and the malformation rate of those women who had been
using the IUR for a long time, after this was removed. Our group was comprised of 574 women from which 324 (56.4%) desired removal of the ring because the couple wanted another child. It was only possible for us to followup 305 cases (94.1%) because 19 (5.9%) did not come for control. Table 1 shows the followup of these 305 women during 18 months, divided by months, up to 1 year, and later from 13-18 months. From then on, 284 conceived and 21 did not conceive after 18 months. It is evident that, as time progresses, more women conceive except for a small percentage of 21 women (6.9%). This is statistically valid for fertility averages after removal of the IUR. From the percentage column we see that during the first months after removal of the IUR, 1 in every 3 women (32. 1%) conceived. With every progressive month, the percentage increased and that of those who did not conceive, decreased. Within 18 months after removal of the IUR 93. 1% in toto conceived, a statistic which coincides with the results of the World Health Organization, which reported that among the women that wore the IUR, after removal, 3 out of every 5 conceived within 3 months and 9 out of 10 within 1 year.6 Concerning the 6.9% that did not conceive, we cannot definitely say that sterility was caused by the IUR, because in every group, among users and nonusers of the IUR, there is such a number that does not become pregnant. Should we have been able to continue observation for a longer period, we are certain that this number would also have eventually decreased. Table 2 shows the cumulative conception
555
TABLE 1. Cumulative Conception Rate from the Date of Removal of the Intrauterine Ring During the Different Months Up to 18 Months* 2
3
4
5
6
7
8
9
to
11
98
52
31
15
14
16
10
8
6
7
3
5
19
98
150
181
196
210
226
236
244
250
257
260
265
284
Month .........................
1
Number of women that conceived Cumulative number of women that conceived Per cent Number of women that did not conceive
12
13-18 Total
%
-- -- -- -- -- -- -- -- -- -- -- -- -- --
32.1 49.2 59.3 64.2 207 155 124 109
68.8 95
74.1 79
77.3 69
80.0 61
81.9 55
84.2 48
85.2 45
86.8 40
93.1 21
Total
284
21
93.1 6.9
305
100.0
• This study involved 305 patients.
TABLE 2. Cumulative Conception Rate After Removal of the Intrauterine Ring by Age at the Time of Removal Younger group' Month
No. of patients that conceived
2 3 4 5 6 7 8 9 10 11 12 13-18
54 30 22 7 7 6 5 5 7 6 5 7
Total
Cumulative no. of patients that conceivedt 54 84 106 113 120 124 130 135 140 147 153 158 165
(31.0) (48.2) (60.9) (65.0) (69.0) (71.2) (74.7) (77.6) (80.5) (84.5) (87.9) (90.8) (94.8)
165
Older groupt
No. of patients that did not conceivet 120 90 68 61 54 50 44 39 34 27 21 16 9
(69.0) (51.8) (38.1) (35.0) (31.0) (28.8) (25.3) (22.4) (19.5) (15.5) (12.1) (9.2) (5.2)
Total
No. of patients that
Cumulative no. of patients that conceived conceivedt 39 24 13 6 5 4
5 3 2 100.0
4
174
9
39 63 76 82 87 91 97 103 108 111 113 115 119
(29.8) (48.1) (58.0) (62.6) (66.4) (69.5) (74.0) (78.6) (82.4) (84.7) (86.3) (87.8) (90.9)
No. of patients that did not conceivet 92 68 55 49 44 40 34 28 23 20 18 16 12
(70.2) (51. 9) (42.0) (37.4) (33.6) (30.5) (26.0) (21.4) (17.6) (15.3) (13.7) (12.2) (9.1)
12
119
Total
100.0 131
• Consists of 174 women, ages 18-30 yr. t Consists of 131 women, ages 31-44 yr. ~ ( ), percentage.
TABLE 3. Cumulative Conception Rate by Duration of the Use of the Intrauterine Ring Longer duration groupt
Shorter duration group· Month
2 3 4 5 6 7 8 9 10 11 12 13-18
Total
No. of Cumulative patients no. of patients that that conceived conceivedt 47 22 20 10 7 7 6 6 5 4 2 2
47 69 89 99 106 113 119 125 130 134 136 138 147 147
(29.0) (42.6) (55.0) (61.1) (65.4) (69.8) (73.5) (77.2) (80.2) (82.7) (83.9) (85.2) (90.8)
No. of patients that did not conceivet 115 93 73 63 56 49 43 37 32 28 26 24 15
Total
(71.0) (57.4) (45.0) (38.9) (34.6) (30.2) (26.5) (22.8) (19.8) (17.3) (16.1) (14.8) (9.2)
15
No. of Cumulative patients no. of patients that that conceived conceivedt 36 20 16 6 4 5 5 4 5 5 5 7
162
• Consists of 162 women with duration of 1-18 months. t Consists of 143 women with duration of 19-36 months. ~ ( ), percentage.
556
36 56 72 78 82 86 91 96 100 105 110 115 122 122
(25.2) (39.1) (50.3) (54.6) (57.3) (60.0) (63.6) (67.1) (70.0) (73.4) (76.9) (80.0) (85.4)
No. of paitents that did not conceivet 107 87 71 65 61 57 52 47 43 38 33 28 21 21
Total
(74.8) (60.9) (49.7) (45.4) (42.7) (40.0) (36.4) (32.9) (30.0) (26.6) (23.1) (20.0) (14.6) 143
July 1970
557
FERTILITY AND INTRAUTERINE RING
rates of our study of 305 women, divided into two groups, younger and older. The average age of the younger group was 23.8 years and of the older group 37.3 years. The cumulative conception rates of the two groups are different. The younger group conceived more quickly. Nevertheless, the difference is small. Only after 18 months is the percentage of those women who did not conceive significantly higher. Of course it is a well-known fact that the conception rates of older women who do not use the IUR are also lower. Table 3 shows the cumulative conception rates measured in the period of duration of use of the ring. The first group kept the IUR for a shorter duration, at least 18 months, and the second longer duration group from 19-36 months. Average time for the first group was 13.7 months and for the second group 27.6 months. The fertility rate of the second group was much lower. These differences are especially significant after a followup of 18 months, a fact which cannot be explained solely by their higher age. We suppose, therefore, that the longer that the IUR is inside, the longer is the temporary sterility time between removal and conception. For this reason we propose to leave the IUR for no more than 2 years, remove it, and, after 1-2 months, reinsert it for the same period. 5 Our findings suggest that the IUR, after removal, may postpone conception in some cases but does not cause, in any way, permanent sterility. Furthermore, any apprehension that its use could endanger a later desired pregnancy is not justified. Regarding the women that became pregnant with the IUR, Tietze 4 reports that 40% aborted. In our experience the majority came to term with normal labor and the IUR was expelled together with the
placenta. Because we did not see any babies with malformations born from women who became pregnant while wearing the IUR, or from those women from whom the IUR had been removed before conception, it is our opinion that the IUR does not cause malformations. SUMMARY
Most women desiring to use an intrauterine contraceptive inquire of their obstetrician whether this contraceptive causes sterility and if, after its removal, they can expect a healthy child. For these reasons we studied 305 women who decided to remove the IUR in order to become pregnant. After 18 months we found that 93.1 % conceived, which coincides with the report of the World Health Organization on this subject. Our findings prove that the IUR, after removal, may postpone conception in some cases, but does not in any way cause permanent sterility, and also that the IUR does not cause malformations, either in pregnancies after removal of the IUR or even by women who became pregnant while wearing the IUR. REFERENCES 1. GRAEFENBERG, E. "An Intrauterine Method of Contraception." In Seventh International Birth
Control Conference, 1930. 2. ISHIHAMA, A. Clinical studies on intrauterine rings, specially the present state of contraception in Japan and the experience in the use of intrauterine rings. Yokohama Med Bull 10:89, 1959. 3. OPPENHEIMER, W. Prevention of pregnancy by the Graefenberg method. Amer J Obstet Gynec 78 :466, 1959. 4. TIETZE, CH. Contraception with intrauterine devices. Amer J Obstet Gynec 96 :1043, 1966. 5. WAJNTRAUB, G. Ten years experience in the use of the intrauterine ring. Fertil Steril 18 :570, 1967. 6. WORLD HEALTH ORGANIZATION. Technical Report No. 397, Intrauterine Devices. Geneva, 1968.
FERTILITY AND STERILITY
Copyright © 1970 by The Williams & Wilkins Co.
FERTILITY AFTER REMOVAL OF THE INTRAUTERINE RING G. WAJNTRAUB Outpatient Department,
General.Tewi.~h
Hospital "Shaare Zedek," Jerusalem, Israel
Intrauterine contraceptives have aroused universal interest during the last years since Oppenheimer3 and Ishihama 2 renewed the method of Grafenberg. 1 The possibility of a safe method of contraception realized the old dream of every couple and offered new absolute control of fertility to all classes of society throughout the world. Of major interest at the present time is the issue: does the intrauterine ring (IUR) cause sterility? For this vital reason the obstetrician is today asked the following questions by every patient desiring to use this kind of contraceptive. 1. How long will she have to wait after removal of the IUR before becoming pregnant? 2. Will the new pregnancy be different from the last one? 3. Can she expect a healthy baby or could this contraceptive in any way increase the occurence of malformations? Four groups of women are interested in using contraceptives: 1. Those who already have as many children as they planned or even more, and therefore wish to suppress their fertility for their remaining reproductive years. 2. Those who wish to postpone childbearing or to regUlate it after having one or two children, for different reasons. 3. Women who need to postpone the first child for financial or educational reasons, especially students and others. 4. Unmarried women. The last group is not included here as we do not insert the IUR into unmarried women. The purpose of our study was to determine the fertility rate and the malformation rate of those women who had been
using the IUR for a long time, after this was removed. Our group was comprised of 574 women from which 324 (56.4%) desired removal of the ring because the couple wanted another child. It was only possible for us to followup 305 cases (94.1%) because 19 (5.9%) did not come for control. Table 1 shows the followup of these 305 women during 18 months, divided by months, up to 1 year, and later from 13-18 months. From then on, 284 conceived and 21 did not conceive after 18 months. It is evident that, as time progresses, more women conceive except for a small percentage of 21 women (6.9%). This is statistically valid for fertility averages after removal of the IUR. From the percentage column we see that during the first months after removal of the IUR, 1 in every 3 women (32. 1%) conceived. With every progressive month, the percentage increased and that of those who did not conceive, decreased. Within 18 months after removal of the IUR 93. 1% in toto conceived, a statistic which coincides with the results of the World Health Organization, which reported that among the women that wore the IUR, after removal, 3 out of every 5 conceived within 3 months and 9 out of 10 within 1 year.6 Concerning the 6.9% that did not conceive, we cannot definitely say that sterility was caused by the IUR, because in every group, among users and nonusers of the IUR, there is such a number that does not become pregnant. Should we have been able to continue observation for a longer period, we are certain that this number would also have eventually decreased. Table 2 shows the cumulative conception
555
TABLE 1. Cumulative Conception Rate from the Date of Removal of the Intrauterine Ring During the Different Months Up to 18 Months* 2
3
4
5
6
7
8
9
to
11
98
52
31
15
14
16
10
8
6
7
3
5
19
98
150
181
196
210
226
236
244
250
257
260
265
284
Month .........................
1
Number of women that conceived Cumulative number of women that conceived Per cent Number of women that did not conceive
12
13-18 Total
%
-- -- -- -- -- -- -- -- -- -- -- -- -- --
32.1 49.2 59.3 64.2 207 155 124 109
68.8 95
74.1 79
77.3 69
80.0 61
81.9 55
84.2 48
85.2 45
86.8 40
93.1 21
Total
284
21
93.1 6.9
305
100.0
• This study involved 305 patients.
TABLE 2. Cumulative Conception Rate After Removal of the Intrauterine Ring by Age at the Time of Removal Younger group' Month
No. of patients that conceived
2 3 4 5 6 7 8 9 10 11 12 13-18
54 30 22 7 7 6 5 5 7 6 5 7
Total
Cumulative no. of patients that conceivedt 54 84 106 113 120 124 130 135 140 147 153 158 165
(31.0) (48.2) (60.9) (65.0) (69.0) (71.2) (74.7) (77.6) (80.5) (84.5) (87.9) (90.8) (94.8)
165
Older groupt
No. of patients that did not conceivet 120 90 68 61 54 50 44 39 34 27 21 16 9
(69.0) (51.8) (38.1) (35.0) (31.0) (28.8) (25.3) (22.4) (19.5) (15.5) (12.1) (9.2) (5.2)
Total
No. of patients that
Cumulative no. of patients that conceived conceivedt 39 24 13 6 5 4
5 3 2 100.0
4
174
9
39 63 76 82 87 91 97 103 108 111 113 115 119
(29.8) (48.1) (58.0) (62.6) (66.4) (69.5) (74.0) (78.6) (82.4) (84.7) (86.3) (87.8) (90.9)
No. of patients that did not conceivet 92 68 55 49 44 40 34 28 23 20 18 16 12
(70.2) (51. 9) (42.0) (37.4) (33.6) (30.5) (26.0) (21.4) (17.6) (15.3) (13.7) (12.2) (9.1)
12
119
Total
100.0 131
• Consists of 174 women, ages 18-30 yr. t Consists of 131 women, ages 31-44 yr. ~ ( ), percentage.
TABLE 3. Cumulative Conception Rate by Duration of the Use of the Intrauterine Ring Longer duration groupt
Shorter duration group· Month
2 3 4 5 6 7 8 9 10 11 12 13-18
Total
No. of Cumulative patients no. of patients that that conceived conceivedt 47 22 20 10 7 7 6 6 5 4 2 2
47 69 89 99 106 113 119 125 130 134 136 138 147 147
(29.0) (42.6) (55.0) (61.1) (65.4) (69.8) (73.5) (77.2) (80.2) (82.7) (83.9) (85.2) (90.8)
No. of patients that did not conceivet 115 93 73 63 56 49 43 37 32 28 26 24 15
Total
(71.0) (57.4) (45.0) (38.9) (34.6) (30.2) (26.5) (22.8) (19.8) (17.3) (16.1) (14.8) (9.2)
15
No. of Cumulative patients no. of patients that that conceived conceivedt 36 20 16 6 4 5 5 4 5 5 5 7
162
• Consists of 162 women with duration of 1-18 months. t Consists of 143 women with duration of 19-36 months. ~ ( ), percentage.
556
36 56 72 78 82 86 91 96 100 105 110 115 122 122
(25.2) (39.1) (50.3) (54.6) (57.3) (60.0) (63.6) (67.1) (70.0) (73.4) (76.9) (80.0) (85.4)
No. of paitents that did not conceivet 107 87 71 65 61 57 52 47 43 38 33 28 21 21
Total
(74.8) (60.9) (49.7) (45.4) (42.7) (40.0) (36.4) (32.9) (30.0) (26.6) (23.1) (20.0) (14.6) 143
July 1970
557
FERTILITY AND INTRAUTERINE RING
rates of our study of 305 women, divided into two groups, younger and older. The average age of the younger group was 23.8 years and of the older group 37.3 years. The cumulative conception rates of the two groups are different. The younger group conceived more quickly. Nevertheless, the difference is small. Only after 18 months is the percentage of those women who did not conceive significantly higher. Of course it is a well-known fact that the conception rates of older women who do not use the IUR are also lower. Table 3 shows the cumulative conception rates measured in the period of duration of use of the ring. The first group kept the IUR for a shorter duration, at least 18 months, and the second longer duration group from 19-36 months. Average time for the first group was 13.7 months and for the second group 27.6 months. The fertility rate of the second group was much lower. These differences are especially significant after a followup of 18 months, a fact which cannot be explained solely by their higher age. We suppose, therefore, that the longer that the IUR is inside, the longer is the temporary sterility time between removal and conception. For this reason we propose to leave the IUR for no more than 2 years, remove it, and, after 1-2 months, reinsert it for the same period. 5 Our findings suggest that the IUR, after removal, may postpone conception in some cases but does not cause, in any way, permanent sterility. Furthermore, any apprehension that its use could endanger a later desired pregnancy is not justified. Regarding the women that became pregnant with the IUR, Tietze 4 reports that 40% aborted. In our experience the majority came to term with normal labor and the IUR was expelled together with the
placenta. Because we did not see any babies with malformations born from women who became pregnant while wearing the IUR, or from those women from whom the IUR had been removed before conception, it is our opinion that the IUR does not cause malformations. SUMMARY
Most women desiring to use an intrauterine contraceptive inquire of their obstetrician whether this contraceptive causes sterility and if, after its removal, they can expect a healthy child. For these reasons we studied 305 women who decided to remove the IUR in order to become pregnant. After 18 months we found that 93.1 % conceived, which coincides with the report of the World Health Organization on this subject. Our findings prove that the IUR, after removal, may postpone conception in some cases, but does not in any way cause permanent sterility, and also that the IUR does not cause malformations, either in pregnancies after removal of the IUR or even by women who became pregnant while wearing the IUR. REFERENCES 1. GRAEFENBERG, E. "An Intrauterine Method of Contraception." In Seventh International Birth
Control Conference, 1930. 2. ISHIHAMA, A. Clinical studies on intrauterine rings, specially the present state of contraception in Japan and the experience in the use of intrauterine rings. Yokohama Med Bull 10:89, 1959. 3. OPPENHEIMER, W. Prevention of pregnancy by the Graefenberg method. Amer J Obstet Gynec 78 :466, 1959. 4. TIETZE, CH. Contraception with intrauterine devices. Amer J Obstet Gynec 96 :1043, 1966. 5. WAJNTRAUB, G. Ten years experience in the use of the intrauterine ring. Fertil Steril 18 :570, 1967. 6. WORLD HEALTH ORGANIZATION. Technical Report No. 397, Intrauterine Devices. Geneva, 1968.