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The adverse litigation climate created by the Dalkon shield threatened to drive all IUDs off the market in the United States. While IUDs are widely used worldwide, in the United States they are generally reserved for women for whom oral contraceptives are physiologically or behaviorally contraindicated. Once the IUD is placed and risk of uterine perforation is passed, the risks of the IUD are related to venereal diseases and other pelvic infections. IUDs are a poor choice of contraceptive for patients who do not have a long-term mutually monogamous relationship. There are several forms of epidemic venereal disease that can render a woman sterile or damage a fetus that are made worse by the presence of an IUD and may be prevented by the use of barriers or spermicides. Since a history of high-risk sexual activity or venereal disease is the best indicator of future risk, a complete sexual history is a necessary starting point for the decision whether to prescribe an IUD.

IUDs are not 100 percent effective. Generally they fail through expulsion from the uterus, but sometimes they are retained during the pregnancy. If they are removed during a pregnancy, there is a potential that the fetus will be miscarried. If they are left in place, they substantially increase the chance of serious infection during the term of the pregnancy. These risks must be explained before insertion. Unlike oral contraceptives or barrier contraceptives, IUDs provide no protection against ectopic pregnancy. This becomes a particular concern if the women is in a high-risk group for ectopic pregnancies.

IUDs should be inspected at one month postinsertion and annually thereafter until replacement.[168] Since the progesterone-impregnated IUDs must be replaced yearly, they will necessitate two patient encounters each year. At the first sign of infection, the patient must return for prompt treatment and potential removal of the IUD. These considerations make an IUD unsuitable for patients who are unlikely to return for periodic medical care.

As with other high-maintenance implantables, physicians have a duty to keep track of patients with IUDs. The patient should be given written information about the importance of follow-up care and the symptoms that should prompt an immediate call to the physician. The physician should contact the patient for the one-month postinsertion visit and for the yearly checkup or replacement visit. If the patient cannot be contacted, the physician should send a certified letter to the patient's last known address and document that it was either received or returned.

[168]ACOG: Technical Bulletin 104, The IUD. (May 1987).

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