to the editor: We read with great interest the article¹ in American Family Physician on intrauterine devices by Dr. Johnson. The author states that the contraceptive effects of the intrauterine device (IUD) are reversible after removal, but adds that long-term use of IUD (i.e., more than 78 months [6.5 years]) may be associated with increased risk for fertility impairment.¹ However, researchers in one study observed that pregnancy rates in women who have the IUD removed because of a desire to become pregnant are similar to those in women who discontinued use of other methods of contraception.² In women involved in monogamous relationships, there is no evidence of an increased risk of infertility after use of an IUD. Further, the World Health Organization (WHO) practice recommendations state: "The use of contraceptive methods, with the exception of male and female sterilization, does not result in an irreversible change in fertility. Return to fertility is immediate with all methods, with the exception of DMPA [depot medroxyprogesterone acetate (Depo-Provera)] and NET-EN [norethisterone enanthate]."³

Although no cases of bacteremia have been reported following insertion of an intrauterine device,⁴ prophylaxis for endocarditis may be warranted when an infection is presented in the genital tract of patients who have susceptibility to endocarditis.⁵ Prophylaxis could be especially considered in developing countries where cardiac conditions might be more frequent or where genital tract infections could not be ruled out easily.

Recent systematic reviews⁴ do not recomend prophylactic antibiotics before insertion of an IUD. However, WHO recommends that “…in settings of both high prevalence of cervical gonococcal and chlamydial infections and limited sexually transmitted infection (STI) screening, such prophylaxis may be considered.”³ Studies addressing the question, “Are prophylactic antibiotics for IUD insertion of any benefit in preventing pelvic inflammatory disease in settings with a high prevalence of sexually transmitted infections?” are needed.

In developing countries like Turkey, where the use of modern contraceptive methods is lower than in western countries, the use of IUDs might be an excellent contraceptive option for women in long-term monogamous relationships.⁶ Despite misperceptions about IUDs, a major task should be to provide correct information to women and to increase the availability and use of this effective method of contraception.

in reply: I appreciate the response from Drs. Yaman and Akdeniz. An important aspect of incorporating any guideline into practice is determining the demographics of the specific population. Many authors who are writing for American Family Physician (myself included) fail to remember that the journal is distributed worldwide. It is a benefit to the reader when our international colleagues share their experiences from a global perspective.