IUDs Cause Uterine Adhesions & Infertility?

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Well, if you've scrolled through your social media feeds recently, you may have seen a video that's causing quite a bit of a stir. There's a prominent infertility physician. She has a large following. She shared her hot take, her personal observation stating that IUDs are a hidden cause of intrauterine adhesions or severe uterine scar tissue. Now listen, of course, if you're not in medicine, it's completely natural to see a specialist standing in a white coat or some kind of authoritative position who makes a claim like this. And it's natural to think, oh my goodness, I have an IUD in place. Am I doing something that's potentially harmful for my future fertility? But here is a reality that we need to establish right out of the gate. Remember, that was an infertility physician, so her patient population is is selection bias. And it's also observational data. But most importantly, that's the kind of medicine that's called anecdotal. Modern medicine now follows evidence based principles and evidence based data. So when a physician says something online, it has to be supported by evidence based facts. So that's where we're going here. This is causing a big social media impact. One of my medical students actually brought this to me and said, hey, do IUDs cause intrauterine adhesions? Because I need to know if this is something that I should not be doing. Well, we've got real data from a recent fact study that stands for Fertility after Contraceptive termination. That's nice, right? Fact Fertility after Contraceptive Termination. We've got real data from 2021 in the agog that Brings some attention to this. Plus we've got society opinions on the return to fertility after this very effective style of LARC. That's Long Acting Reversible Contraceptive. So do IUDs cause uterine adhesions and infertility? Well, unfortunately, what that physician said online is not accurate nor true. We're gonna get into it in this episode. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OBGYN no Spin podcast. All right, everyone, right off the bat, let me just say I'm not mad at anyone. I'm not trying to criticize anyone at all. Trust me, I get my own levels of criticism myself. But whenever we put something out on social media, as you know, talking about personally in our team and our social media following and with our podcast, we always try to reference it with what does the data show? And when there's gaps in the data, we tell you this, there's gaps in this data. But it's very interesting that, you know, when we can't put something out there with our own personal perspective without qualifying that as being, you know, observational or selection bias. Now this physician did say that in this video. I understand that this is potentially, you know, observer bias, selection bias, but it's just something that I've seen is my in my hot take that potentially IUDs cause intrauterine adhesions. The problem is, is that it freaked out a lot of people and that's not what the bulk of the data show. Now, remember I said in the intro, that's not accurate or necessarily true. And that's correct. I'm sticking by that. Although that physician does have some peer reviewed published evidence to back her up. Now, those are not contradictory statements. Let me say this again. What I stated at the beginning is that IUDs and I'm gonna show you where this comes from do not have the evidence behind them for causing intrauterine sequelae like adhesions or scarring. There is a single peer reviewed publication that came out not long ago that came out in 2021 in the Journal of Assisted Reproductive Reproduction and Genetics of three a K series of three null gravit patients who had some infertility. They had an evaluation and lo and behold, they had uterine si with quote, end quote, no other known risk factors or history of uterine manipulation, end quote. All right, that's interesting. Even these authors in 2021 who published this N of 3 case series of nolly gravid women with uterine Synchiae after levonorgestrel IUD or ius rather they state, hey, look, this is just hypothesis generating. This is something to think about and maybe we should take a look at this possibility in larger prospective studies, end quote. Yeah, I agree with that. This is super interesting. But to freak people out that this is what's gonna happen to every who has an IUS or an IUD is a little reckless. Okay, but just to be clear, there is a published peer reviewed case series with an n of three nullogravid women who presented after leaving progesterone IUs at the University of California, San Francisco and were found to have uterine synchiae. Now, all of them were able to conceive through assisted reproductive technology or natural conception. So I don't want to get into it, but I'm reading exactly here from the paper. Quote, all three were eventually able to conceive through assisted reproductive technology or natural conception, end quote. Isn't that a weird statement? And we're talking about three here. Why wouldn't you just say, hey, two required IVF and one didn't, or two got pregnant naturally and one didn't? No, no, all three were eventually able to conceive through assisted reproductive technology or natural conception, end quote. Yeah, so a little weird. Anyway, it's a case series of three. But let's go to the larger data set because last thing we want to be doing here is scaring patients with unnecessary fear or statements that really don't have the bulk of the evidence behind them. We're going to go to the fact study. We're going to tell you what acog, even aap, because AAP does say something about intrauterine contraception in their guidance, because adolescents use contraception and even the broader reproductive medicine community. I'm going to show you what they say here in a minute. But let's start with the FACT study. I love this fact. It stands for fertility after Contraceptive termination. This was multicenter, it was prospective. The N was just over 460. Actually, it was 461. Okay, so 461 women. And here it is, guys, quote, found no impairment of fertility with every use of an iud. End quote. Let me say that again. No impairment of fertility with every use of an iud. The median time to conception was actually shorter with prior IUD use at about 5 months than for non users, which it took about 7.5 months, although this difference was not statistically significant. Okay, this was published in AJOG, that's the Gray Journal, in 2021, the title was Intrauterine Device Use, Sexually Transmitted Infections and Fertility. A Prospective Cohort study. This is part of the fertility after contraceptive termination study called the FACT Study. So did you all get that? No. Impairment of fertility with every use of an iud. I wish that physician would have said, you know, in my practice, it's very select groups of the population, they already have infertility, so that kind of skews the findings. But I did find this correlation maybe of this kind of IUD or IUS and uterine adhesions. Although. Although the recent FACT study found that there was no impairment of fertility. But lo and behold, that physician did not say that. The general body of evidence, guys, because I don't want to belabor this, I just want to tell you what you need to know, and then we're going to walk away from this. Is that IUDs. Listen to me carefully. Do not cause intrauterine adhesions or infertility according to the consensus of major professional medical societies. Actually, as soon as you take it out, there's a rapid return to fertility that you need to give the patient a consultation about that. If you're not ready to get pregnant and then you take this thing out, your fertility can resume very quickly. Maybe take it a little bit longer with levonorgestrel because of the endometrial suppression versus a copper T. But nonetheless, no delay of significant fertility. ACOG states specifically in its guidance. Quote. No evidence. Here it is. Listen to this, guys. No evidence that IUD use is associated with subsequent infertility and that infertility is not more likely after IUD discontinuation than after discontinuation of other reversible contraceptive methods. End quote. So what about this adhesion stuff? So, absolutely, yes, there's a variety of reasons why intrauterine adhesions could form. Some of that could be subacute infection. Remember, a lot of patients with chlamydia, the number one symptom of chlamydia is no infection. So it could be asymptomatic. Not saying that these patients had chlamydia, but there's other things that could be involved, even endometritis of normal vaginal flora. Because we know that while STIs typically get blamed for upper tract genital infection, you can have bacteroide species, E. Coli, enterococcal, whatever other kind of vaginal flora is in the vagina that could potentially lead to ascending infection. It doesn't have to be an sti. All right? Even though STI'S are a predominant factor there. There could be other things at play. And the truth is there is some biological plausibility here, right? I mean, let's just be honest. The copper tea causes a little bit of inflammation. Inflammation can cause a little bit of ulcerations. But those ulcerations have never been proven to be enough in the 60 some odd years of IUD use. Medical IUD use to to cause adhesions or we would have seen this already on trended studies. And the same holds true for Leave nor Gastrel. There is a theory, guys, that as the lining gets very atrophic, it could cause some agglutination of the walls. That is plausible. So does this have plausibility? What that physician said on her little, you know, Instagram and TikTok, does that make sense? Can that happen? Yes. But just because it can happen doesn't mean that's what we see in population level data or in subsequent, you know, trend analysis follow up for fertility. Actually, ACOG states, quote, past studies linking IUD to tubal infertility or uterine infertility were confounded by sexually transmitted infections. And women with tubal infertility were more likely to have antibodies to chlamydial infection, which was the likely explanation rather than the IUD itself. End quote. So that comes out of a variety of places, including ACOG's Committee Opinion 735. That's ACOG Committee Opinion 735 and then Practice Bulletin on Larks, which is 1, 8 6. All right, so Committee Opinion 735 and then Practice bulletin 186. So as of right now, even the AAP guys who wants to, you know, protect adolescents, I mean that's its job. You figure that's what they want to do. They state, quote, IUDs do not cause future or subsequent infertility, end quote. That's right out of the American Academy of Pediatrics guidance. That was in 2025, just last year, because we're doing this in summer of 2026 and that publication is Contraceptive Counseling and Methods for Adolescents, their clinical report.

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So we got ACOG, we got AAP, we've got worldwide data that show no, we just don't see this being an issue alone. There's gotta be something else going on. A 2017 New England Journal of Medicine review by Curtis and Pipert concluded that observational studies have shown infertility was associated more with a history of STIs rather than a history of IUD use. And this may have come again from subclinical pid. And I'm not trying to say that these, you know, these three women obviously had an sti. I don't know that. The point is there's a lot of other factors there that can confound this issue. And the last thing we want to do is scare patients unnecessarily. When LARCs are a valuable, highly effective method of contraception. I mean, they beat the human error of the old bilateral tubal ligation, but probably are equal to total salpingectomy. All right, so very few people now do fallopa bands, which is what I trained with, or partial salpingectomy is a Parkland tubal. My namesake, my alma mater, most people are just taking out the tubes because of the opportunistic salpingectomy guidance. And so now that's opportunistic salpingectomy. If you remove the entire tube, that pretty much has the same efficacy as a lark. I mean, they're on the almost the same page here. In terms of failure, they are highly effective. So while there is some supporting evidence here, with that small case series of three patients who had levonorgestrel iud, there's no evidence that on a larger scale this is something that we need to fear. So as of right now, the position statements of acog, AAP, and the broader women's health community is that current IUDs, we're not talking about the old lippy's loops and the weird Zedoucon shields, all right, that had some issues. We're Talking about modern IUDs are not a cause of intrauterine adhesions. On a population level enough to cause subsequent trending infertility. Okay, so, yes, there were issues in the past. I gotta say, Dalkon Shield was remarkable in causing uterine problems, including pid, because they had wicked strings, but nobody's using those. So as of right now, outside of the potential for endometrial ulcerations from the copper IUD or the potential of uterine atne of endometrial atrophy with the levonorgestrel ius. Yes. So those are all plausible mechanisms here for intrauterine adhesions, but that should definitely not scare women from using this, because what is biologically plausible and what we're seeing in the published data are not in agreement. Okay, So I. You know, I actually. To be honest, I had kind of scrolled by that, and I saw her say that. I was like, man, that's. That's weird. And just kind of kept going. And it wasn't until my medical student brought it to my attention, I'm like, oh, now this is something we actually do need to discuss, because I'm a big fan of LARCs. Okay? They're not for everybody, but whether it's the eternorgestrel or the copper IUD or the IUs, I think they're phenomenal to protect women from undesired or mistimed pregnancies, which is a win. Plus, the ius, of course, takes away dysmenorrhea and heavy menstrual cycles, which is a win in its own issue. So there's a lot of factors here. A lot of factors here. But for an infertility physician to say in her select infertile population that there's a correlation with what she is seeing is a little dangerous, it's a little inaccurate, and it's contradictory to what the bulk of population data say, as well as professional medical guidance. So if something changes, guys, I'll be the first to come up and go, holy moly. We're seeing a trend here. Tell your patients that if they want future fertility, maybe consider something else. But we don't have that, and we haven't had that for 30 years. Podcast family, as always, we're thankful for you. We're glad you're part of our podcast community, Michael, before I get into more trouble. Come on now, let's take it home. This is Dr. Chapa's OBGYN no Spin podcast Sam.