There is no evidence to suggest that condom use causes impotence. Impotence has many causes. Some causes are physical, some are emotional. Condoms themselves do not cause impotence. A few men may have problems keeping an erection when using condoms, however. Other men, especially older men, may have difficulty keeping an erection because condoms can dull the sensation of having sex. Using more lubrication may help increase sensation for men using condoms.

Some couples become frustrated and lose some of their sexual excitement when they stop to put on a condom. Some men and women complain that the condom dulls sensation. However, many couples learn to enjoy using condoms as part of their sexual foreplay. In fact, many women and men often say they have better sex when they use condoms, because they can focus on their sexual pleasure without the worry about unintended pregnancy and sexually transmitted infections (STIs).

A couple may wish to use either a textured, ultra thin, or transparent condom to increase stimulation. Pleasure may also be increased by lubricating the inside and outside of the condom with water-based lubricants. A drop or two of lubricant on the inside of the condom before it is unrolled can help increase the sensation of sex for some men. Too much lubricant inside, however, can make the condom slip off. Lubricants made of glycerine or silicone are safe to use with latex condoms. Clean water and saliva also can be used for lubrication. Do not use products made with oil as lubricants for latex condoms as they can damage latex.

The male condom is a sheath, or covering, that fits over a man’s erect penis. It works by forming a barrier that keeps sperm out of the vagina, preventing pregnancy. It also keeps infections that are in semen, on the penis, or in the vagina from infecting the other partner. It is usually made of very thin latex rubber, although a minority are made of either animal tissue or polyurethane (plastic).

Condoms are the only contraceptive method that can protect against both pregnancy and sexually transmitted infections (STIs), including HIV transmission, when used for vaginal, oral, or anal sex. In order for condoms to be most effective they must be used correctly with every sex act. The risk of pregnancy or contracting sexually transmitted infections is greatest when condoms are not used correctly with every act of sex.

When used correctly and consistently (with every act of sex), condoms are 98% effective in preventing pregnancy. This means that when used consistently and correctly, about 2 of every 100 women whose partners use condoms become pregnant over the first year of use.

Condoms do not have holes that HIV can pass through. In fact, when used consistently and correctly, condom use prevents 80% to 95% of HIV transmission that would have occurred without condoms. Plastic condoms are expected to provide the same protection as latex condoms, but they have not been studied thoroughly. Condoms made from animal membrane DO NOT protect against HIV and other STIs.

On average, about 2% of condoms break or slip off completely during sex, primarily because they are used incorrectly. Used properly, condoms seldom break.

Lubrication helps avoid condom breakage. There are three ways to provide lubrication—natural vaginal secretions, adding a lubricant, or using condoms packaged with lubricant on them. Sometimes lubricants made of glycerine or silicone, which are safe to use with latex condoms, are available. Clean water and saliva also can be used for lubrication. Do not use products made with oil as lubricants for latex condoms as they can damage latex.

There are no known serious short or long term side effects associated with the use of condoms. When a condom is used, ejaculation occurs as normal, so there is no sperm "back up." There is no evidence that condoms cause cancer, either in men or women. In fact, the use of condoms may help protect against conditions caused by STIs including recurring pelvic inflammatory disease (PID), cervical cancer, and infertility.

It is possible that a person may experience mild irritation in or around the vagina or penis or mild allergic reaction to a condom (itching, redness, rash, and/or swelling of genitals, groin, or thighs during or after condom use). Severe allergic reactions involve hives or rash over much of the body, dizziness, difficulty breathing, or loss of consciousness after coming in contact with latex. Both men and women can be allergic to latex and latex condoms. Allergy to latex is uncommon in the general population, and reports of mild allergic reactions to condoms are very rare. Severe allergic reactions to condoms are extremely rare.

Plastic condoms made of synthetic materials offer an alternative for individuals who are allergic or sensitive to latex. Plastic condoms are expected to provide the same protection as latex condoms, but they have not been studied as thoroughly. The United States Food and Drug Administration recommends that condoms made of plastic be used for protection from STIs, including HIV, only if a person cannot use latex condoms. Condoms made of animal skin such as lambskin (also called natural skin condoms) are not effective for preventing STIs, including HIV, however.

There are many different kinds and brands of condoms that vary in features such as shape, size, color, lubrication, thickness, texture, and whether or not they are coated with spermicide.

Although there are considerable variations between the sizes of individual penises, there is no established market of different sized condoms, even in developed countries. Users should be advised to try different brands to find out which fits best. Condoms of 49mm width are readily available and are the preferred size for a smaller condom. Although there is no “standard” size for larger condoms, some manufacturers produce condoms of 56mm width.

Some women using injectables experience amenorrhea, or no monthly bleeding. This is only a possible side effect and not a mechanism of action. When a woman is not using hormonal contraceptives, the endometrial lining (lining of the uterus) builds up every few weeks and then breaks down and causes menstrual bleeding. With injectables, the endometrial build-up does not occur so there is no breakdown or resulting bleeding. Blood does not collect in the body.

Women using injectables may also experience irregular bleeding, heavy bleeding, or prolonged bleeding. These bleeding changes are not harmful and usually become less or stop after the first few months of use. Women experiencing heavy or prolonged bleeding may want to increase their iron intake to prevent anemia.

The bleeding pattern a woman had before she used injectables generally returns several months after the last injection.

While vasectomy is one of the safest and most effective forms of contraception, it is not immediately effective because sperm survive in the man’s reproductive tract for a little while after the procedure. A man must wait three months (12 weeks) before it is fully effective. During this time, he can resume sexual activity, but he and his partner will need to use additional contraceptive protection such as condoms or another effective family planning method. A semen examination is recommended at any time after three months following the procedure, but is not essential. The previously recommended alternative, to wait for 20 ejaculations, has proved less reliable than waiting three months and is therefore no longer recommended.

Male sterilization is a safe and simple procedure. All surgical procedures involve some risk, but the chance of serious problems is small with vasectomy. Most postoperative complications of vasectomy such as discomfort in the scrotum and swelling are minor and can be treated with cold compresses and non-aspirin pain relievers such as ibuprofen (200–400 mg) and paracetamol (325–1000 mg). Other potential complications are generally quite rare, but include bleeding under the skin that might cause swelling or bruising (hematoma), infection at the incision site or inside the incision, and sperm granulomas. Sperm granulomas are small lumps that form when sperm leak from the vas into the surrounding tissue. All of these complications usually can be treated easily.

Mortality after a vasectomy operation is extremely rare. Death related to a vasectomy is avoidable if all preventive measures are taken. These include: proper infection-prevention procedures; prompt, proper postoperative management of symptoms of infection; and appropriate follow-up care for any complications.

Vasectomy is a simple and very safe operation in which each vas deferens (the tubes which carry sperm from the testicles to the penis) is either blocked or cut so that sperm cannot enter semen. This is usually done under local anesthesia. It does not involve removal of the testicles or amputation of the penis.

During a vasectomy procedure, the man receives an injection of local anesthetic in his scrotum to prevent pain. He stays awake throughout the procedure. Using the no-scalpel procedure, the provider grasps the tube with specially designed forceps and makes a tiny puncture in the skin of the scrotum with a special surgical instrument. The provider lifts out a small loop of each vas from the puncture. The provider will then cut each tube and tie one or both ends closed with thread or close off the tubes by applying heat or electricity. They may also enclose one end of the vas in the thin layer of tissue that surrounds the vas. The puncture is covered with an adhesive bandage, or the incision may be closed with stitches. The man receives instructions on what to do after he leaves the clinic or hospital.

With the conventional vasectomy technique, still practiced in many places, the provider makes one or two small incisions in the skin of the scrotum with a scalpel. After the tubes are tied or cut, the incision is closed with stitches.

Both no-scalpel and conventional incision procedures are quick, safe, and effective. No-scalpel vasectomy is less traumatic than standard vasectomy and reduces the risk of hematoma, however. Service providers, even those experienced in standard vasectomy, must obtain training before using the no-scalpel technique.

Female sterilization does not increase the risk of cancer of the reproductive organs which are defined below. In fact, several studies have reported a reduced risk of ovarian cancer after tubal occlusion. Very little research has been done to investigate the relationship between breast cancer and female sterilization, but so far there is no evidence of such a link.

Uterine Cancer: Cancer that forms in tissues of the uterus (womb). Two types of uterine cancer are endometrial cancer (cancer that begins in cells lining the uterus), and uterine sarcoma (a rare cancer that begins in muscle or other tissues in the uterus).

Cervical Cancer: Cancer that forms in tissues of the cervix (the lower end of the uterus). It is usually a slow-growing cancer that may not have symptoms, but can be found with regular screening.

Ovarian Cancer: Cancer that forms in tissues of the ovary. Most ovarian cancers are either ovarian epithelial carcinomas (cancer that begins in cells that line the ovary) or malignant germ cell tumors (cancer that begins in egg cells).

There are no documented medical side effects of female sterilization. The few complications that do occur during or following sterilization, such as infection or abscess of the wound, can generally be kept to a minimum if appropriate techniques are used and if the procedure if performed in an appropriate setting. Local anesthesia is best for female sterilization because it has lower risks of complications than use of general anesthesia. The risks are lowest when local anesthesia is used without sedatives. If sedatives are used, providers should closely monitor the woman’s vital signs, such as pulse rate and blood pressure throughout the procedure.

Hysterectomy

Some incorrectly believe that sterilization will cause a woman to need a hysterectomy. Recent research shows that sterilization does not appear to increase the need for a hysterectomy, however. Sterilization has no biologic relationship with hysterectomy. Hysterectomies are often done to treat menstrual disorders and women who are sterilized may be more likely to consider having hysterectomies to treat such disorders because they are not worried about losing their fertility.

Pain

Female sterilization does not cause lasting pain in the back, uterus, or abdomen. There is often some minor pain during the procedure. Women receive local anesthetic to stop pain during the procedure, and, except in special cases, women remain awake. A woman can feel the health care provider moving her uterus and tubes. This can be uncomfortable. If a trained anesthetist or anesthesiologist and suitable equipment are available, general anesthesia may be chosen for women who are very frightened of pain. A woman may feel sore and weak for several days or even a few weeks after surgery, but she will soon regain her strength. She can take ibuprofen (200–400 mg), paracetamol (325–1000 mg), or other pain reliever, but not aspirin. Stronger pain reliever is rarely needed.

Hormone Imbalances

Female hormones are not affected by female sterilization, and there will be neither a loss of femininity nor any change in sexual functioning.

Female sterilization does not stop ovulation or harm a woman’s egg in any way. An egg will still be released each month, but it will dissolve and be reabsorbed by the body.

Female sterilization prevents pregnancy by cutting or blocking the fallopian tubes (the tubes which carry eggs from the ovaries to the uterus) so that sperm cannot move up to meet the egg. There are several ways of blocking the fallopian tubes: tying them (ligation); removing a small piece of the tube (excision); sealing (cauterization); or applying clips or rings.

During the sterilization procedure, the ovaries, uterus, and cervix are left in place. Only the fallopian tubes (the tubes which carry eggs from the ovaries to the uterus) are blocked or cut. The two most common surgical approaches are laparoscopy and minilaparotomy:

•  Minilaparotomy involves making a small incision in the abdomen (measuring 2-5 centimeters), and the fallopian tubes are brought to the incision to be tied and cut or else closed with a clip or ring. The doctor inserts a special instrument (uterine elevator) into the vagina, through the cervix, and into the uterus to raise each of the two fallopian tubes so they are closer to the incision.

•  Laparoscopy involves inserting a long thin tube with a lens in it (a laparoscope) into the abdomen through a small incision (measuring about 1 centimeter). This laparoscope enables the doctor to see and to close each tube with a clip, a ring, or block it by electric current.

No medical conditions prevent the use of withdrawal. While all men can use this method, its effectiveness depends on the user. Men who ejaculate prematurely or who cannot sense consistently when ejaculation is about to occur may have difficulty using withdrawal.

Learning to properly withdraw can take time. Couples may want to use another method until the male feels he can correctly withdraw with every act of sex.

Withdrawal is one of the least effective contraceptive methods as it is commonly used, although it offers better pregnancy protection than no method at all. The effectiveness of withdrawal depends on the man’s ability to correctly withdraw with every act of sex.

With common practice, 27 out of 100 couples using withdrawal will experience a pregnancy during the first year of use. When practiced correctly and consistently, withdrawal is more effective. About 4 out of 100 women will become pregnant over the first year if their partners properly withdraw with every act of sex.

Withdrawal does not prevent the transmission of STIs. Lesions or ulcers on the genitals can transmit various infections. Other STIs can be passed from one partner to the other through skin-to-skin contact. If either partner is at risk, the couple should use condoms.

The semen of HIV-positive men contains HIV-infected cells and is the primary way that HIV is transmitted through sex. Using withdrawal may reduce the risk of transmitting HIV because the woman is not exposed to semen. Even with withdrawal, however, there is a risk of HIV transmission because the pre-ejaculate fluid may also contain HIV. Studies of heterosexual couples found that the transmission of HIV from male to female was decreased by one-half or more when withdrawal was practiced compared with intercourse with ejaculation inside the woman. No studies have examined whether withdrawal reduces female-to-male transmission of HIV.

The pre-ejaculate fluid itself does not contain sperm. As the pre-ejaculate leaves the body, however, it may pick up sperm from a previous ejaculation that remains in the urethra. One study found small clumps of sperm in the pre-ejaculate fluid of some men. Though only a few hundred sperm were present, they could theoretically pose a low risk of pregnancy.

Such small amounts of sperm can likely be flushed out with urination, although no research has verified this. If a man using withdrawal has ejaculated recently, he should urinate and wipe the tip of his penis to remove any remaining sperm before having sex again.

Ovarian and endometrial cancer
Use of COCs helps protect women from two kinds of cancers—cancer of the ovaries and cancer of the lining of the uterus (endometrial cancer). This protection continues for 15 or more years after stopping use.

Breast cancer
Research findings about COCs and breast cancer are difficult to interpret. In studies, breast cancer is slightly more common among women using COCs and those who have used COCs in the past 10 years than among other women. Scientists do not know whether or not COCs actually caused the slight increase in breast cancers. It is possible that the cancers were already there before COC use but were found sooner in COC users. Both COC users and women who do not use COCs can have breast cancer.

The combined oral contraceptive (COC) does not cause infertility. This is true regardless of how long a woman has taken the pill, the number of children the woman has had, or the age of the woman. In fact, some of the non-contraceptive benefits of the pill include preserving fertility by offering protection against pelvic inflammatory disease, endometriosis, and ectopic pregnancy.

There is no evidence that COCs delay a woman's return to fertility after she stops taking them. Women who stop using COCs can become pregnant as quickly as women who stop using nonhormonal methods.

A woman can start using COCs any time she wants if she is reasonably certain that she is not pregnant. To be reasonably certain a client is not pregnant, providers can use the Pregnancy Checklist.

If a client is starting her pack of pills within five days after the start of her menstrual period, there is no need for a backup method as she is immediately protected from pregnancy. If she starts COCs more than five days after the start of her menstrual period, she can start them any time it is reasonably certain she is not pregnant. She will need to use a "back up" method of contraception, such as a male or female condom, for the first seven days of taking pills to ensure protection from pregnancy.

The effectiveness of oral contraception depends on a regular intake of the hormones contained in the pill. Therefore pills must be taken daily, until the pack is empty. Although the specific time of day does not matter, the pills should be taken at the same time every day to reduce side effects and to help women remember to take their pills more consistently. The client should be advised not to interrupt taking the pills before a pack is finished, even if she does not have sexual intercourse. If the pills are taken correctly, the client will always start a new pack on the same day of the week. If a client is taking pills from a 21-pill pack, she will wait seven days after taking the last pill in the pack before beginning a new pack. If a client is taking pills from a 28-pill pack, she will take the next pill from the next pack on the very next day.

Women do not need to take a “rest” from COCs after taking them for a time. There is no evidence that taking a “rest” is helpful. In fact, taking a”rest” from COCs can lead to unintended pregnancy. COCs can safely be used for many years without having to stop taking them periodically.

A woman may experience short term side affects associated with use of combined oral contraceptive (COCs), including changes in bleeding patterns, headaches, and nausea. However such side effects are not a sign of illness, and usually stop within the first few months of using COCs. For a woman whose side effects persist, give her a different COC formulation. In women who are otherwise well, COC use may be continued for many years as there are no adverse effects related to long-term use.

In fact, there are also long-term non-contraceptive health benefits of using COCs as they:

• Help protect against cancer of the lining of the uterus (endometrial cancer)
• Help protect against cancer of the ovaries
• Help protect against symptomatic pelvic inflammatory disease
• May help protect against ovarian cysts
• May help protect against iron-deficiency anemia
• Reduce menstrual cramps
• Reduce menstrual bleeding problems
• Reduce ovulation pain
• Reduce excess hair on face or body
• Reduce symptoms of polycystic ovarian syndrome
• Reduce symptoms of endometriosis

Women using copper-bearing IUDs may experience:
•  Heavy and prolonged monthly bleeding
•  Irregular bleeding
•  More cramps and pain during monthly bleeding

These bleeding changes are normal and usually are not signs of illness. They are most common in the first 3 to 6 months after insertion and usually lessen with time. A provider should evaluate for an underlying condition unrelated to method use if:
•  Cramping continues and occurs between monthly bleeding;
•  Heavy or prolonged bleeding continues, or if bleeding starts suddenly after several months of normal bleeding or long after the IUD was inserted, or;
•  Irregular bleeding persists after 6 months, or starts suddenly after several months of normal bleeding.

Severe anaemia requires careful consideration because if heavier menstrual periods are experienced, the additional monthly blood loss could worsen existing anaemia. The anaemia should be treated before an IUD is inserted. The LNG-IUD may actually help to reduce anaemia by reducing blood loss.

Women using the LNG-IUD may experience heavy, prolonged, or irregular bleeding in the first few months, but then experience
•  Lighter, regular, and predictable bleeding
•  Infrequent, light, or no monthly bleeding

These bleeding changes also are normal and usually are not signs of illness.

Copper-bearing IUDs rarely cause monthly bleeding to stop completely. However, women using an LNG-IUD may not experience monthly bleeding due to strong uniform suppression of the endometrium. If monthly bleeding does not occur while a woman is using a copper-bearing IUD, pregnancy should be excluded. If the woman is not pregnant, other causes of no monthly bleeding should be investigated.

Pain associated with menstruation may increase in some women, but usually this is only for the first month or two. The LNG-IUD may reduce the pain associated with menstruation. Non-steroidal anti-inflammatory drugs may also reduce discomfort.

Infertility

Good studies find no increased risk of infertility among women who have used IUDs, including young women and women with no children. Whether or not a woman has an IUD, however, if she develops pelvic inflammatory disease (PID) and it is not treated, there is some chance that she will become infertile. PID can permanently damage the lining of the fallopian tubes and may partially or totally block one or both tubes enough to cause infertility.

Ectopic Pregnancy

Because any pregnancy among IUD users is rare, ectopic pregnancy among IUD users is even rarer. An IUD does not increase a woman\'s overall risk of ectopic pregnancy. In fact, an IUD user’s risk of an ectopic pregnancy is much lower than the risk to a woman who is not using any method of contraception. In the unlikely event of pregnancy in an IUD user, 6 to 8 in every 100 of these pregnancies is ectopic. Thus, the great majority of pregnancies after IUD failure are not ectopic. Still, ectopic pregnancy can be life-threatening, so a provider should be aware that ectopic pregnancy is possible if an IUD fails.

Miscarriage

IUDs do not cause miscarriages after they have been removed. If correct insertion technique is used, the use of an IUD will not cause any difficulty in future pregnancies.

In the rare event that a client becomes pregnant with an IUD in situ, it is important to explain the risks of leaving the IUD in the uterus during pregnancy. There is a higher risk of preterm delivery or first- and second- trimester miscarriage, including infected (septic) miscarriage which can be life-threatening. Early removal of the IUD reduces these risks, although the removal procedure itself involves a small risk of miscarriage.

If the client does not want to continue the pregnancy and if therapeutic termination of pregnancy is legally available, inform her accordingly. If she wishes to continue the pregnancy and the IUD strings are visible or can be retrieved safely from the cervical canal, gently remove the IUD or refer for removal. The client should return at once if she develops any signs of miscarriage or septic miscarriage (vaginal bleeding, cramping, pain, abnormal vaginal discharge, or fever).

However, if the IUD strings cannot be found in the cervical canal and the IUD cannot be safely retrieved, refer for ultrasound, if possible, to determine whether the IUD is still in the uterus. If the IUD is still in the uterus, if ultrasound is not available, or if the client chooses to keep the IUD, her pregnancy should be followed closely by a nurse or doctor. She should see a nurse or doctor at once if she develops any signs of septic miscarriage.

The myth that young women and women without children cannot use IUDs stems from fears about a higher risk of expulsion in these women and fears about a higher risk of infection in these women.

Expulsion is more likely in certain circumstances, such as young age at insertion (under 20 or 25 years old). Some studies also have found a higher rate of expulsion among women who have no children. The additional risk of expulsion, however, is not sufficient to deny IUDs to women in these circumstances, because the advantages of the IUD outweigh the risks of expulsion.

Women with current gonorrheal or chlamydial infection should not have an IUD inserted. Since laboratory STI tests usually are not available, World Health Organization guidance considers STI risk assessment and physical examination essential to safe use of IUDs, but not laboratory tests. Providers should not determine a woman’s STI risk based on her age or whether she has had children. Rather, the provider can discuss risky behaviors or situations in their communities that they think are most likely to expose women to STIs, for example having more than one sexual partner in the last three months without always using condoms. The client can think about whether such situations occurred recently (in the past 3 months or so).

There is no reason why an IUD should negatively affect sexual pleasure. On the contrary, being free from fear of pregnancy may allow both partners, especially the woman, to enjoy their sexual life.

There is no reason why an IUD should cause discomfort or pain during sexual intercourse unless the woman is already having cramps, which sometimes occur during the first few weeks after insertion. Sexual intercourse cannot displace an IUD.

Sometimes a man can feel the strings if they are too long. If this bothers him, cutting the strings shorter should solve the problem. Sometimes a man can also feel discomfort if the strings are cut too short. To remedy the problem, the provider can cut them even shorter so they are not coming out of the cervical canal. The woman should be told beforehand, however, that this will mean she may not be able to feel the strings to check her IUD, and removing her IUD may be more difficult. Alternatively, she can have the IUD replaced with a new one and the strings cut to the correct length. The strings should be cut so that 3 centimeters hang out of the cervix. A man may feel discomfort during sex if the IUD has started to come out through the cervix. If a woman suspects this, she should see a doctor or nurse immediately. Proper counselling of the male partner may be appropriate.

Both the hormonal and copper-bearing IUDs are highly effective contraceptive methods. In fact, they are among the most effective reversible methods, with pregnancy rates similar to those for female sterilization.

Hormonal levonorgestrel-releasing IUD (LNG-IUD): Less than 1 pregnancy per 100 women using the LNG-IUD over the first year (2 per 1,000 women). That means the LNG-IUD will prevent pregnancy in 998 of 1,000 women. A small risk of pregnancy remains beyond the first year of use and continues as long as the woman is using the LNG-IUD. Over 5 years of LNG-IUD use, about 1 per 100 women (5 to 8 per 1,000 women) will become pregnant. The LNG-IUD is approved for up to 5 years of use.

Copper-bearing IUDs: Less than 1 pregnancy per 100 women using an IUD over the first year (6 to 8 per 1,000 women). That means the IUD will prevent pregnancy for 992 to 994 of 1,000 women using IUDs will not become pregnant. A small risk of pregnancy remains beyond the first year of use and continues as long as the woman is using the IUD. Over 10 years of IUD use, about 2 per 100 women will become pregnant. The IUD is effective for up to 12 years.

Infection related to IUD insertion probably occurs because the instruments or IUD carry with them organisms from the lower genital tract. If the organisms are bacteria normally present in the genital tract, then it seems that some mechanism automatically eliminates this contamination from the uterus soon after the insertion process without infection occurring. Risk of infection can be further reduced by following routine infection-prevention procedures including the “no-touch” insertion technique (not letting the loaded IUD or uterine sounds touch any unsterile surfaces such as hands, speculum, vaginal wall, or table top).

The IUD never travels to the heart, brain, or any other part of the body outside the abdomen. The IUD normally stays within the uterus like a seed within a shell. Rarely, the IUD may come through (perforate) the wall of the uterus into the abdominal cavity. This is most often due to a mistake during insertion. Proper insertion technique can help prevent many problems, such as infection, expulsion, and perforation. If uterine perforation is suspected within 6 weeks after insertion or if it is suspected later and is causing symptoms, refer the client for evaluation to a clinician experienced at removing such IUDs. Usually, however, the out-of-place IUD causes no problems and should be left where it is. The woman will need another contraceptive method.

Cancer

IUDs do not cause cancer in otherwise healthy women, but confirmed or suspected cancer of the genital tract is a contraindication to IUD use, because the increased risk of infection, perforation, and bleeding at insertion may make the condition worse. For the levonorgestrel-releasing IUD, breast cancer is also a contraindication.

Sexually Transmitted Infections (STIs)

IUDs do not increase the risk of contracting STIs, including HIV. However, usually women who have a very high risk of exposure to gonorrhea or chlamydia should not have an IUD inserted. In special circumstances, when other, more appropriate methods are not available or acceptable to her, a qualified provider who can carefully assess a specific woman’s risk may decide that she can use an IUD.

Birth Defects

IUD use neither causes multiple pregnancies after removal nor increases the risk of birth defects, whether the pregnancy occurs with the IUD in place, or after removal.

In the rare event that a client becomes pregnant with an IUD in situ, it is important to explain the risks of leaving the IUD in the uterus during pregnancy. There is a higher risk of preterm delivery or miscarriage, including infected (septic) miscarriage during the first or second trimester, which can be life-threatening. Early removal of the IUD reduces these risks, although the removal procedure itself involves a small risk of miscarriage. There is no evidence of increased risk of fetal malformations,however.

Pelvic Inflammatory Disease (PID)

Overall levels of PID in IUD users are low. A woman with chlamydia or gonorrhea at the time of IUD insertion, however, is at higher risk of PID in the first few weeks after insertion than she is later. After the first few weeks, an STI may be no more likely to progress to PID in an IUD user than for other women with STIs. To reduce the risk of infection during IUD insertion, providers can ensure appropriate insertion conditions, screening, and counseling, as well as regularly monitor and treat infection.

Antibiotics are usually not routinely given before IUD insertion. Most recent research done where STIs are not common suggests that PID risk is low with or without antibiotics. When appropriate questions to screen for STI risk are asked and IUD insertion is done with proper infection-prevention procedures (including the no-touch insertion technique), there is little risk of infection. Antibiotics may be considered, however, in areas where STIs are common and STI screening is limited.

If PID occurs or is suspected with an IUD in place, treatment should be started as soon as possible. There is no need to remove the IUD if a woman wants to continue using it. The PID should be treated and the IUD left in situ. If a woman wants it removed, it can be taken out after starting antibiotic treatment. An IUD should not be inserted in women who currently have a PID. It may be inserted as soon as she finishes treatment, if she is not at risk for reinfection before insertion.

Toxemia

The copper in copper-bearing IUDs is not released into the blood. Levels of serum copper in long-term users of copper IUDs are similar to that of the normal population.

Infection

Infection related to IUD insertion probably occurs because the instruments or IUD carry with them organisms from the lower genital tract. If the organisms are bacteria normally present in the genital tract, then it seems that some mechanism automatically eliminates this contamination from the uterus soon after the insertion process without infection occurring. Risk of infection can be further reduced by following routine infection-prevention procedures including the “no-touch” insertion technique (not letting the loaded IUD or uterine sounds touch any unsterile surfaces such as hands, speculum, vaginal wall, or table top).

Implants stop working once they are removed and their hormones do not remain in the woman's body. Implant use does not affect a woman's ability to become pregnant, although fertility decreases with a woman's age. One major study found that women who have had their implants removed can become pregnant as quickly as women who have stopped using nonhormonal methods.

Implants substantially reduce the risk of ectopic pregnancy. In the United States, the rate of ectopic pregnancy among women who are not using a contraceptive method is 650 ectopic pregnancies per 100,000 women per year. The rate of ectopic pregnancy among women using implants is 6 ectopic pregnancies per 100,000 women per year.

Even in the very rare cases when implants fail and pregnancy occurs, the great majority of these pregnancies are not ectopic. Only 10 to 17 of every 100 pregnancies due to the failure of implants are ectopic.

Nearly all women can use implants safely and effectively. Implants are suitable for women of any age, regardless of whether they have had children or not. Implants do not make women infertile—fertility returns as soon as implants are removed. Breastfeeding women can use implants if at least six weeks have passed since they have given birth.

Implants may not be suitable for women who require a family planning method without hormones. For example, women who have or have had breast cancer and women with active, serious liver disease should choose an alternative method.

Implants work primarily by thickening cervical mucus, which blocks sperm from meeting an egg, and by disrupting the menstrual cycle and preventing ovulation.

Implants do not interrupt pregnancy. Good evidence shows that implants will not affect the pregnancy or harm the fetus if a woman is already pregnant when implants are inserted or becomes pregnant while using implants.

In addition to changes in menstrual bleeding, the most common side effects of implants are headaches, abdominal pain, and breast tenderness. These side effects are not an indication of illness and usually lessen or go away within the first year of use. Studies have not shown increased risk of cancer, blindness or birth defects with the use of implants.

Implants have several known health benefits. They have been shown to greatly reduce the risk of ectopic pregnancy and protect against symptomatic pelvic inflammatory disease. Implants may also help protect against iron-deficiency anemia.

Health professionals with specific training perform a minor surgical procedure to insert implants. The provider gives the patient an injection of local anesthetic under the skin of her arm to prevent pain while the implants are inserted. This injection may sting. The woman remains fully awake during the procedure. Insertion takes an average of 4 to 5 minutes for Norplant, 2.5 minutes for Jadelle, and 1.5 minutes for Implanon. Insertion can take more or less time, depending on the skill of the provider.

The incision is small and stitches are not required. In most cases, insertion does not leave a noticeable scar. Once inserted, the outline of the implants underneath the skin can be felt and sometimes seen. The woman may have bruising and feel pain or soreness for a few days afterward.

Infection at the insertion site can occur, but is uncommon. When infection occurs, it is usually within the first two months after insertion. In rare cases, implants may start to come out of the skin. When this occurs, it is usually due to improper insertion or infection.

A woman can have her implants removed at any time. Similar to insertion, implant removal is done by a specifically trained provider using local anesthesia and does not require stitches. Removal takes an average of 10 to 15 minutes for Norplant, 5 to 8 minutes for Jadelle, and 3 minutes for Implanon. Removal can take more or less time, depending on the skill of the provider. Difficulties with removal are rare if the implants were properly inserted and the provider is skilled.