Intrauterine Contraceptive Device Complicated by a Pelvic Abscess: A Case Report

Intrauterine devices (IUDs) are a form of long-acting reversible contraception (LARC). As with all medical therapies, their use carries several risks and potential adverse effects. For patients who elect to continue IUD use, pain and irregular bleeding are the most commonly reported complications, but more serious and less common complications include expulsion, contraception failure, pelvic inflammatory disease (PID), and perforation. We report a case where a patient with a history of IUD placement in the immediate postpartum period developed significant complications including multiple intra-abdominal abscesses and pelvic inflammatory disease.

Incidence and Risk Factors for a Malpositioned Intrauterine Device Detected on Three-Dimensional Ultrasound Within Eight Weeks of Placement

OBJECTIVES

To estimate the incidence of intrauterine device (IUD) malpositioning detected on three-dimensional (3D) transvaginal ultrasound within 8 weeks of placement and identify risk factors for malpositioning.

METHODS

Retrospective study of women who had an IUD placed at a large obstetrics and gynecology practice from January 1, 2015, to December 31, 2020. All patients underwent two-dimensional ultrasound at the time of insertion and routine three-dimensional ultrasound within 8 weeks. Baseline characteristics and potential risk factors were compared between women with correctly positioned and malpositioned IUDs. Odds ratios were calculated by logistic regression to identify risk factors independently associated with malpositioning.

RESULTS

A total of 763 IUD placements were included, and 127 malpositioned IUDs were identified representing an overall rate of malpositioning of 16.6% (95% confidence interval [CI] 14.0-19.3) with 8.8% (95% CI 6.8-10.8) requiring removal. Patients with malpositioned IUD had higher rates of morbid obesity (13.4% versus 3.8%, adjusted odds ratio [aOR] 2.46, 95% CI 1.10-5.50), prior uterine window or rupture (9.0% versus 2.2%, aOR 2.78, 95% CI 1.06-7.30), copper IUD placement (64.2% versus 47.4%, aOR 1.99, 95% CI 1.31-3.03), and symptoms such as bleeding or pain at follow-up (35.8% versus 20.1%, aOR 2.58, 95% CI 1.67-3.98). Parity, breastfeeding, difficult insertion, and uterine size and positioning were not significant.

CONCLUSIONS

The incidence of malpositioned IUD within 8 weeks of placement on 3D ultrasound is 16.6%, with 8.8% requiring removal. Significant risk factors for malpositioning include morbid obesity, prior uterine window or rupture, and copper IUD placement. These findings support the importance of routine follow-up 3D ultrasound after seemingly successful IUD placement.

Medicaid Reimbursement Program for Immediate Postpartum Long-Acting Reversible Contraception Improves Uptake Regardless of Insurance Status

OBJECTIVE

To evaluate whether a Medicaid reimbursement program for immediate postpartum long-acting reversible contraception (LARC) is associated with an increased rate of LARC uptake.

STUDY DESIGN

We conducted a retrospective cohort study comparing patients who delivered at a large, urban, tertiary medical center one year before and after Missouri Medicaid coverage changed to reimburse immediate postpartum LARC in October 2016. Patients were identified through the electronic medical record and excluded if they delivered prior to 24 weeks gestation or had a contraindication to immediate postpartum LARC. The primary outcome was placement of immediate postpartum LARC, which we examined overall and stratified by insurance type. We used multivariable logistic regression to determine the impact of the policy change while adjusting for appropriate confounders.

RESULTS

A total of 6,233 eligible patients delivered during the study period: 3,105 before and 3,128 after the change in reimbursement for immediate postpartum LARC. Patients delivering after the policy change were more likely to be Hispanic, have commercial insurance or be uninsured, and have a BMI >30. Placement of immediate postpartum LARC increased from 0.7% pre- to 9.7% post-policy change (aOR 15.6; 95% CI 10.1-24.2). In our stratified analysis, immediate postpartum LARC uptake increased for patients with Medicaid (aOR 15.8; 95% CI 9.9-25.4) and commercial insurance (aOR 9.7; 95% CI 3.0-31.8).

CONCLUSION

The change in Missouri Medicaid reimbursement for placement of immediate postpartum LARC had systemic impact with an increase in postpartum LARC uptake in all patients, regardless of insurance provider.

IMPLICATIONS

Insurance reimbursement has the power to influence hospital policy and patient care. Overall, changes to Medicaid reimbursement increased access to postpartum LARC for all patients at a large academic institution, regardless of insurance status.

Update on incidence of inpatient tubal ligation and long-acting reversible contraception in the United States

BACKGROUND

Inpatient insertion of long-acting reversible contraception and immediate postpartum tubal ligation allow women to initiate highly effective contraception before hospital discharge.

OBJECTIVE

We measured rates of intrauterine device and contraceptive implant initiation and tubal ligations performed during delivery hospitalizations from 2016 to 2018 from a representative sample of US hospital discharges.

STUDY DESIGN

We used the 2016 to 2018 National Inpatient Sample database, a 20% sample of all community hospital discharges in the United States, to identify delivery hospitalizations with concomitant intrauterine device insertion, contraceptive implant insertion, or tubal ligation. We performed weighted multivariable logistic regression to examine associations between possible predictors (age, delivery mode, payer, geographic region, and year) and odds of long-acting reversible contraception and tubal ligation, and to compare characteristics of users.

RESULTS

This sample included 2,216,638 discharges, representing 20% of 11,083,180 delivery hospitalizations across the United States. Intrauterine device insertion increased from 2.2 per 1000 deliveries (2016) to approximately 5.0 per 1000 deliveries (2018; P<.0001); implant insertion increased from 0.3 per 1000 deliveries (2016) to 2.5 per 1000 deliveries (2018; P<.0001); tubal ligation procedures decreased (64.2 to 62.1 per 1000 deliveries; P<.0001). Women who underwent a cesarean delivery had higher odds of having a tubal ligation than those who had a vaginal delivery (adjusted odds ratio, 8.83; 95% confidence interval, 8.73-8.97). Women aged <25 years had 7 times higher odds of receiving long-acting reversible contraception than of receiving tubal ligation (adjusted odds ratio, 7.38; 95% confidence interval, 6.90-7.90). Women with public insurance had almost 5 times the odds of receiving long-acting reversible contraception compared with those with commercial insurance (adjusted odds ratio, 4.83; 95% confidence interval, 4.59-5.06).

CONCLUSION

Rates of long-acting reversible contraception insertion continue to increase while the rates of inpatient postpartum tubal ligations slowly decline. Variations in patient characteristics are associated with receiving long-acting reversible contraception or tubal ligation.

Association between intrauterine device type and risk of perforation and device expulsion: results from the Association of Perforation and Expulsion of Intrauterine Devices study

BACKGROUND

Intrauterine devices, including levonorgestrel-releasing and copper devices, are highly effective long-acting reversible contraceptives. The potential risks associated with intrauterine devices are low and include uterine perforation and device expulsion.

OBJECTIVE

This study aimed to evaluate the risk of perforation and expulsion associated with levonorgestrel-releasing devices vs copper devices in clinical practice in the United States.

STUDY DESIGN

The Association of Perforation and Expulsion of Intrauterine Devices study was a retrospective cohort study of women aged ≤50 years with an intrauterine device insertion during 2001 to 2018 and information on intrauterine device type and patient and medical characteristics. Of note, 4 research sites with access to electronic health records contributed data for the study: 3 Kaiser Permanente-integrated healthcare systems (Northern California, Southern California, and Washington) and 1 healthcare system using data from a healthcare information exchange in Indiana (Regenstrief Institute). Perforation was classified as any extension of the device into or through the myometrium. Expulsion was classified as complete (not visible in the uterus or abdomen or patient reported) or partial (any portion in the cervix or malpositioned). We estimated the crude incidence rates and crude cumulative incidence by intrauterine device type. The risks of perforation and expulsion associated with levonorgestrel-releasing intrauterine devices vs copper intrauterine devices were estimated using Cox proportional-hazards regression with propensity score overlap weighting to adjust for confounders.

RESULTS

Among 322,898 women included in this analysis, the incidence rates of perforation per 1000 person-years were 1.64 (95% confidence interval, 1.53-1.76) for levonorgestrel-releasing intrauterine devices and 1.27 (95% confidence interval, 1.08-1.48) for copper intrauterine devices; 1-year and 5-year crude cumulative incidence was 0.22% (95% confidence interval, 0.20-0.24) and 0.63% (95% confidence interval, 0.57-0.68) for levonorgestrel-releasing intrauterine devices and 0.16% (95% confidence interval, 0.13-0.20) and 0.55% (95% confidence interval, 0.44-0.68) for copper intrauterine devices, respectively. The incidence rates of expulsion per 1000 person-years were 13.95 (95% confidence interval, 13.63-14.28) for levonorgestrel-releasing intrauterine devices and 14.08 (95% confidence interval, 13.44-14.75) for copper intrauterine devices; 1-year and 5-year crude cumulative incidence was 2.30% (95% confidence interval, 2.24-2.36) and 4.52% (95% confidence interval, 4.40-4.65) for levonorgestrel-releasing intrauterine devices and 2.30% (95% confidence interval, 2.18-2.44) and 4.82 (95% confidence interval, 4.56-5.10) for copper intrauterine devices, respectively. Comparing levonorgestrel-releasing intrauterine devices with copper intrauterine devices, the adjusted hazard ratios were 1.49 (95% confidence intervals, 1.25-1.78) for perforation and 0.69 (95% confidence intervals, 0.65-0.73) for expulsion.

CONCLUSION

After adjusting for potential confounders, levonorgestrel-releasing intrauterine devices were associated with an increased risk of uterine perforation and a decreased risk of expulsion relative to copper intrauterine devices. Given that the absolute numbers of these events are low in both groups, these differences may not be clinically meaningful.

Effectiveness, safety and overall satisfaction of early postpartum placement of hormonal IUD compared with standard procedure: An open-label, randomized, multicenter study

INTRODUCTION

In this open-label, randomized controlled, non-inferiority, multicenter study we aimed to study the risk of termination of pregnancy within 1 year postpartum, the safety profile and patient acceptability after early postpartum insertion of a hormonal intrauterine device (LNG-IUS, Mirena®) compared with standard placement 6-8 weeks postpartum.

MATERIAL AND METHODS

April 2018 to January 2020 women with uncomplicated vaginal delivery at four urban birth centers in Sweden, were randomized to either early placement within 48 h after delivery (early group) or standard placement 6-8 weeks postpartum (standard group) of a hormonal intrauterine device. The main outcome measure was the proportion of terminations of pregnancies in each group during the first year after placement of the intrauterine device. Registration EudraCT database no. 2017-001945-29.

RESULTS

The study was prematurely stopped according to the protocol due to an expulsion rate >20% in the early group. No pregnancies occurred. Fifty-two women were randomized to early and 49 women to standard insertion. In the early group, 23/52 (44.2%) of the intrauterine devices were expelled. After expulsion, 10 women chose to have another hormonal intrauterine device placed but still significantly fewer women (39/52, 75%, p = 0.22) in the early group used the hormonal intrauterine device method at study completion. No expulsions occurred in the standard group, but 5/49 (10.2%) requested removal and 41/49 (83.7%, p = 0.22) had used the hormonal intrauterine device method continuously for 1 year.

CONCLUSIONS

Early hormonal intrauterine device insertion after vaginal delivery is associated with high expulsion rates. Despite this, a high continuation rate of the hormonal intrauterine device method is seen among women once choosing the method. In the light of high continuation rates, the advantages of early insertion could balance the risk of expulsion for well-informed women.

Adolescent/Young Adult Long-Acting Reversible Contraception: Experience from a Multisite Adolescent Medicine Collaborative

OBJECTIVE

To report on long-acting reversible contraception (LARC) experience and continuation rates in the Adolescent Medicine LARC Collaborative.

STUDY DESIGN

LARC insertion data (682 implants and 681 intrauterine devices [IUDs]) were prospectively collected from January 1, 2017, through December 31, 2019, across 3 Adolescent Medicine practices. Follow-up data through December 31, 2020, were included to ensure at least 1 year of follow-up of this cohort. Continuation rates were calculated at 1, 2, and 3 years, overall and by Adolescent Medicine site, as were descriptive statistics for LARC procedural complications and patient experience.

RESULTS

Implant and IUD insertion complications were uncommon and largely self-limited, with no IUD-related uterine perforations. Uterine bleeding was the most frequently reported concern at follow-up (35% implant, 25% IUD), and a common reason for early device removal (45% of implant removals, 32% of IUD removals). IUD malposition or expulsion occurred following 6% of all insertions. The pooled implant continuation rate at 1 year was 87% (range, 86%-91% across sites; P = .63), 66% at 2 years (range, 62%-84%; P = .01), and 42% at 3 years (range, 36%-60%; P = .004). The pooled IUD continuation rate at 1 year was 88% (range, 87%-90% across sites; P = .82), 77% at 2 years (range, 76%-78%; P = .94), and 60% at 3 years (range, 57%-62%; P = .88).

CONCLUSIONS

LARC is successfully provided in Adolescent Medicine clinical settings, with continuation rates analogous to those of well-resourced clinical trials. Uterine bleeding after LARC insertion is common, making counselling imperative. Future analyses will assess whether the medical management of LARC-related nuisance bleeding improves continuation rates in our Adolescent Medicine patient population.

Expanding Access to Contraception: Identifying Accessibility Gaps Across Hawai'i Communities

In 2019, Hawai'i ended its Title X program resulting in a loss of federal family planning funds. Additionally, physician shortages have decreased family planning resources available to patients. The objective of this study was to assess contraception availability by determining the number and location of healthcare providers in Hawai'i that prescribed at least one form of contraception. A list of healthcare providers was compiled using Google searches, major health insurance, and hospital provider directories. Providers were organized by physical location (ie, address). Each location was contacted to inquire about each provider's ability to prescribe different forms of contraception (eg, intrauterine device, implant, injection, pill, patch, or ring). Of the 1,020 locations contacted, 274 prescribed at least one form of contraception. Of the 1,810 providers surveyed at these locations, 744 prescribed at least one form of contraception. In regard to insurance, 201 locations and 609 providers accepted at least one form of Medicaid. Most prescribing providers were located on the island of O'ahu. The majority of providers across the state prescribed the pill, patch, or ring. There are many additional barriers that were not addressed in this study, including factors that affect physician prescribing practices. Identifying these barriers is important to further address gaps in contraceptive accessibility. Consideration of improved support for training in specialties such as Family Medicine, Internal Medicine, and Pediatrics can expand access to contraception within primary care settings.

A rare cause of acute abdominal pain: Actinomyces infection of colon mimicking a malignant neoplasm due to intrauterine device

Actinomycosis is a rare, chronic granulomatous disease that is challenging to diagnose because the clinical symptoms and signs are nonspecific. Usage of intrauterine device (IUD) or being immunocompromised is facilitating factors. Clinical and radiological findings can mimic malignant neoplasm, inflammatory bowel disorder, or acute diverticulitis. We report a case of actinomyces infection of the colon secondary to IUD, which is a rare cause of acute abdominal pain and can mimic a malignant neoplasm. We also provide a review of the literature. Unnecessary surgery can be avoided with the correct diagnosis of granulomatous infectious diseases that can be treated with antibiotics.

Association between menorrhagia and risk of intrauterine device-related uterine perforation and device expulsion: results from the Association of Uterine Perforation and Expulsion of Intrauterine Device study

BACKGROUND

Intrauterine devices are effective instruments for contraception, and 1 levonorgestrel-releasing device is also indicated for the treatment of heavy menstrual bleeding (menorrhagia).

OBJECTIVE

To compare the incidence of intrauterine device expulsion and uterine perforation in women with and without a diagnosis of menorrhagia within the first 12 months before device insertion STUDY DESIGN: This was a retrospective cohort study conducted in 3 integrated healthcare systems (Kaiser Permanente Northern California, Southern California, and Washington) and a healthcare information exchange (Regenstrief Institute) in the United States using electronic health records. Nonpostpartum women aged ≤50 years with intrauterine device (eg, levonorgestrel or copper) insertions from 2001 to 2018 and without a delivery in the previous 12 months were studied in this analysis. Recent menorrhagia diagnosis (ie, recorded ≤12 months before insertion) was ascertained from the International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes. The study outcomes, viz, device expulsion and device-related uterine perforation (complete or partial), were ascertained from electronic medical records and validated in the data sources. The cumulative incidence and crude incidence rates with 95% confidence intervals were estimated. Cox proportional hazards models estimated the crude and adjusted hazard ratios using propensity score overlap weighting (13-16 variables) and 95% confidence intervals.

RESULTS

Among 228,834 nonpostpartum women, the mean age was 33.1 years, 44.4% of them were White, and 31,600 (13.8%) had a recent menorrhagia diagnosis. Most women had a levonorgestrel-releasing device (96.4% of those with and 78.2% of those without a menorrhagia diagnosis). Women with a menorrhagia diagnosis were likely to be older, obese, and have dysmenorrhea or fibroids. Women with a menorrhagia diagnosis had a higher intrauterine device-expulsion rate (40.01 vs 10.92 per 1000 person-years) than those without, especially evident in the first few months after insertion. Women with a menorrhagia diagnosis had a higher cumulative incidence (95% confidence interval) of expulsion (7.00% [6.70-7.32] at 1 year and 12.03% [11.52-12.55] at 5 years) vs those without (1.77% [1.70-1.84] at 1 year and 3.69% [3.56-3.83] at 5 years). The risk of expulsion was increased for women with a menorrhagia diagnosis vs for those without (adjusted hazard ratio, 2.84 [95% confidence interval, 2.66-3.03]). The perforation rate was low overall (<1/1000 person-years) but higher in women with a diagnosis of menorrhagia vs in those without (0.98 vs 0.63 per 1000 person-years). The cumulative incidence (95% confidence interval) of uterine perforation was slightly higher for women with a menorrhagia diagnosis (0.09% [0.06-0.14] at 1 year and 0.39% [0.29-0.53] at 5 years) than those without it (0.07% [0.06-0.08] at 1 year and 0.28% [0.24-0.33] at 5 years). The risk of perforation was slightly increased in women with a menorrhagia diagnosis vs in those without (adjusted hazard ratio, 1.53; 95% confidence interval, 1.10-2.13).

CONCLUSION

The risk of expulsion is significantly higher in women with a recent diagnosis of menorrhagia. Patient education and counseling regarding the potential expulsion risk is recommended at insertion. The absolute risk of perforation for women with a recent diagnosis of menorrhagia is very low. The increased expulsion and perforation rates observed are likely because of causal factors of menorrhagia.

Who is providing contraception care in the United States? An observational study of the contraception workforce

BACKGROUND

Contraception care is essential to providing comprehensive healthcare; however, little is known nationally about the contraception workforce. Previous research has examined the supply, distribution, and adequacy of the health workforce providing contraception services, but this research has faced a series of data limitations, relying on surveys or focusing on a subset of practitioners and resulting in an incomplete picture of contraception practitioners in the United States.

OBJECTIVE

This study aimed to construct a comprehensive database of the contraceptive workforce in the United States that provides the following 6 types of highly effective contraception: intrauterine device, implant, shot (depot medroxyprogesterone acetate), oral contraception, hormonal patch, and vaginal ring. In addition, we aimed to examine the difference in supply, distribution, the types of contraception services offered, and Medicaid participation.

STUDY DESIGN

We constructed a national database of contraceptive service providers using multiple data sets: IQVIA prescription claims, preadjudicated medical claims, and the OneKey healthcare provider data set; the National Plan and Provider Enumeration System data set; and the Census Bureau's American Community Survey data on population demographics. All statistical analyses were descriptive, including chi-squared tests for groupwise differences and pairwise post hoc tests with Bonferroni corrections for multiple comparisons.

RESULTS

Although 73.1% of obstetrician-gynecologists and 72.6% of nurse-midwives prescribed the pill, patch, or ring, only 51.4% of family medicine physicians, 32.4% of pediatricians, and 19.8% of internal medicine physicians do so. The ratio of all primary care providers prescribing contraception to the female population of reproductive age (ages, 15-44 years) varied substantially across states, with a range of 27.9 providers per 10,000 population in New Jersey to 74.2 providers per 10,000 population in Maine. In addition, there are substantial differences across states for Medicaid acceptance. Of the obstetrician-gynecologists providing contraception, the percentage of providers who prescribe contraception to Medicaid patients ranged from 83.9% (District of Columbia) to 100% (North Dakota); for family medicine physicians, it ranged from 49.7% (Florida) to 91.1% (Massachusetts); and for internal medicine physicians, it ranged from 25.0% (Texas) to 75.9% (Delaware). For in-person contraception, there were large differences in the proportion of providers offering the 3 different contraceptive method types (intrauterine device, implant, and shot) by provider specialty.

CONCLUSION

This study found a significant difference in the distribution, types of contraception, and Medicaid participation of the contraception workforce. In addition to obstetrician-gynecologists and nurse-midwives, family medicine physicians, internal medicine physicians, pediatricians, advanced practice nurses, and physician assistants are important contraception providers. However, large gaps remain in the provision of highly effective services such as intrauterine devices and implants. Future research should examine provider characteristics, programs, and policies associated with the provision of different contraception services.

Intrauterine Device Use: A New Frontier for Behavioral Neuroendocrinology

Intrauterine devices (IUDs) are the most-used reversible contraceptive method for women in the world, but little is known about their potential modulation of brain function, cognition, and behavior. This is disconcerting because research on other hormonal contraceptives, especially oral contraceptives (OCs), increasingly shows that exogenous sex hormones have behavioral neuroendocrine consequences, especially for gendered cognition, including spatial skills. Effects are small and nuanced, however, partially reflecting heterogeneity. The goal of this paper is to introduce IUD use as a new frontier for basic and applied research, and to offer key considerations for studying it, emphasizing the importance of multimodal investigations and person-specific analyses. The feasibility and utility of studying IUD users is illustrated by: scanning women who completed a functional magnetic resonance imaging mental rotations task; taking an individualized approach to mapping functional connectivity during the task using network analyses containing connections common across participants and unique to individual women, focusing on brain regions in putative mental rotations and default mode networks; and linking metrics of brain connectivity from the individualized networks to both mental rotations task performance and circulating hormone levels. IUD users provide a promising natural experiment for the interplay between exogenous and endogenous sex hormones, and they are likely qualitatively different from OC users with whom they are often grouped in hormonal contraceptive research. This paper underscores how future research on IUD users can advance basic neuroendocrinological knowledge and women's health.

Brain abscess as a rare complication of pelvic inflammatory disease

OBJECTIVE

Description of the case history of a brain abscess as a rare complication of pelvic inflammatory disease.

CASE REPORT

We discuss a woman of reproductive age who had inserted a non-hormonal intrauterine device for seven years and developed pelvic inflammatory disease with no response to antibio-tic therapy. After surgery, some neurological symptoms led to a dia-gnosis of a brain abscess.

CONCLUSION

Brain abscess is a rare but potentially lethal complication from pelvic inflammatory disease, needing prompt dia-gnosis and interdisciplinary cooperation.

Uterine perforation during intrauterine procedures and its management

OBJECTIVE

Uterine perforation is a potential, not rare complication of all intrauterine procedures and may be associated with injury of surrounding organs and structures. The incidence, risk factors, possible prevention, dia-gnosis, management and impact on future reproduction is reviewed here.

METHODS

Systematic review of available sources on the topic was carried out using the PubMed database and textbooks of Czech authors.

CONCLUSION

Some risk factors that make access to the uterine cavity difficult may be prevented, however, others remain unpreventable. For patients in whom the perforation occurred during sondage, dilatation or insertion of blunt and cold instrument, without significant bleeding and who are hemodynamically stable, observation is recommended rather than immediate abdominal exploration. The exception are young women planning pregnancy in whom endoscopic suture is indicated. Abdominal exploration is required in patients who have been injured by electrosurgical or sharp device, laser, vacuum curette, who are hemodynamically unstable or show signs of severe bleeding or visceral injury.

Examining the association between short interpregnancy interval births and the type and timing of postpartum long acting reversible contraception

OBJECTIVE

To determine whether the type (intrauterine device or implant) or timing (immediately postpartum vs interval) of postpartum long-acting reversible contraception was associated with a reduction in short interpregnancy interval births.

STUDY DESIGN

We conducted a retrospective cohort study using linked Medicaid claims and birth certificate data from Oregon and South Carolina, 2010 - 2018. Our primary outcome was short interpregnancy interval, defined as repeat pregnancy within 18 months of the index delivery. We determined postpartum contraceptive method and timing of receipt. To assess the association of timing of long acting reversible contraception with short interpregnancy interval, we calculated adjusted probabilities from a logistic regression model incorporating covariate balanced propensity score weights, sociodemographic factors, and clustered at the woman-level.

RESULTS

Our study sample included 121,422 births to 97,084 individuals who had more than one birth during the study period; 41% had a short interpregnancy interval. A majority of individuals had not received any contraception by six months postpartum (68.6%). Overall, 15,477 individuals used long acting reversible contraception postpartum, with the majority receiving interval rather than immediate postpartum long acting reversible contraception (92.9% vs 7.1%). In multivariable analyses, both immediate postpartum (23.0%, 95% CI: 20.5 - 25.8%) and interval long acting reversible contraception (15.2%, 95% CI: 14.4 - 16.1%) are associated with a lower probability of short interpregnancy interval than short acting methods (42.1%, 95% CI: 41.2 - 43.0%).

CONCLUSION

Compared to short-acting methods, receipt of both immediate postpartum and interval long-acting reversible contraception is associated with lower probabilities of a subsequent short interpregnancy interval.

Inflammatory Markers in Uterine Lavage Fluids of Pregnant, Non-Pregnant, and Intrauterine Device Implanted Mares on Days 10 and 15 Post Ovulation

Simple Summary

While intrauterine devices (IUDs) are used to prevent disturbing oestrous behaviour in sport mares, their mechanism of action has not been elucidated. The presence of an embryo or an IUD prevents cyclooxygenase-2 (COX-2) and subsequently prostaglandin (PG) release and luteolysis. It has been suggested that a plastic sphere would mimic the embryo by mechanotransduction. However, there is some evidence that IUDs also cause endometrial inflammation, which might contribute to luteostasis. The aim of this study was to investigate the presence and time course of possible inflammation by evaluating changes in uterine fluid composition. On Day 10 after ovulation, events leading to COX-2 and prostaglandin F_2α (PGF_2α) inhibition start, whereas either luteolysis occurs or the corpus luteum is maintained on Day 15. Therefore, uterine lavage fluid was evaluated at two time points in inseminated mares, either pregnant or not, and in mares inserted with an IUD. On Day 10, PGF_2α concentration in the fluid was significantly lower in the IUD group than in the pregnant mare one but did not differ from the non-pregnant mare group. On Day 15, the IUD group had significantly higher levels of the modulatory cytokine IL-10 and inhibin A, which could indicate previous inflammation and resolution stage.

Abstract

Intrauterine devices (IUDs) are used in mares to suppress oestrous behaviour, but the underlying mechanism is yet to be elucidated. The presence of an embryo or an IUD prevents cyclooxygenase-2 (COX-2) and, subsequently, prostaglandin (PG) release and luteolysis. However, inflammation may also be involved. Endometrial inflammatory markers in uterine lavage fluid were measured on Day 10 (EXP 1, n = 25) and Day 15 (EXP 2, n = 27) after ovulation in inseminated mares, non-pregnant or pregnant, and in mares in which a small plastic sphere had been inserted into the uterus 4 (EXP 1) or 3 days (EXP 2) after ovulation. Uterine lavage fluid samples were analysed for nitric oxide (NO), prostaglandin E₂ (PGE₂) (only EXP 1), prostaglandin F_2α (PGF_2α), inhibin A and cytokines, and blood samples for progesterone and oestradiol. On Day 10, the concentration of PGF_2α was lower (p < 0.05) in the IUD group than in pregnant mares. The concentration of the modulatory cytokine IL-10 was significantly higher in the IUD group in comparison to non-pregnant mares, and inhibin A was significantly higher in IUD mares than in the pregnant counterparts on Day 15. The results suggest that the presence of IUD causes endometrial inflammation which is at a resolution stage on Day 15.

The Intrauterine Device Experience Among Transgender and Gender-Diverse Individuals Assigned Female at Birth

INTRODUCTION

The intrauterine device (IUD) is a long-acting and highly efficacious form of contraception that can also be used for menstrual suppression. Although IUD use is increasing, the type chosen, appeal, and satisfaction among individuals who are transgender and gender diverse and assigned female at birth (TGD-AFAB) is unknown. The purpose of this study is to evaluate IUD usage among TGD-AFAB individuals.

METHODS

TGD-AFAB individuals who had an IUD for a minimum of 6 months at the time of completing the survey or had one in the past completed an anonymous online survey. Descriptive statistics were used to analyze the data.

RESULTS

One hundred and five TGD-AFAB individuals completed the survey. Among participants who were sexually active, 88% reported they were in a relationship in which it was possible to get pregnant. There were 85 individuals who currently had an IUD: 62 (73%) chose a 52-mg levonorgestrel (LNG) IUD, 5 (6%) chose a lower-dose LNG IUD, 17 (20%) chose the copper IUD, and one chose an IUD unavailable in the United States. Menstrual suppression was the primary reason for choosing a 52-mg LNG IUD (58%). Most individuals who opted for a copper IUD did so to avoid hormonal contraception (71%). Participants reported experiencing IUD side effects; however, few desired removal. Among the 36 respondents who had an IUD in the past, the most frequent reasons for removal were expiration of the device (LNG IUDs) and undesired side effects (copper IUD). Approximately half of participants who had an IUD removed had it replaced with another IUD.

DISCUSSION

Pregnancy can occur among TGD-AFAB individuals even if they are on testosterone and amenorrheic. IUDs are well tolerated in this population, with few current users desiring removal for unwanted side effects. Clinicians should counsel TGD-AFAB individuals about the contraceptive and noncontraceptive benefits of IUDs and expected side effects.

Levonorgestrel intrauterine system for the treatment of intermenstrual spotting in patients with previous cesarean delivery scar defect

AIM

To evaluate the efficacy of levonorgestrel 52 mg intrauterine system for intermenstrual bleeding in patients with previous cesarean delivery scar defects (PCDSs).

METHODS

The medical records of 28 consecutive patients with previous cesarean delivery scar defect and intermenstrual bleeding who had undergone conservative treatment with levonorgestrel 52 mg intrauterine system were reviewed. The efficacy of treatment and frequency of adverse events were measured retrospectively.

RESULTS

After 1 year of treatment, 22 patients (78.6%) reported an improvement in symptoms. The mean duration of menstruation were 18 and 5 days before and after treatment, respectively. No uterine perforations or pelvic inflammatory diseases occurred during or after the insertion procedures. Eighteen (64.3%) patients did not experience any adverse events, and the patients with adverse events reported that they could be managed by adjusting their medications or observation.

CONCLUSION

Levonorgestrel intrauterine system may have a role in the safe and effective management of intermenstrual spotting in patients with PCDSs.

Expulsion and continuation rates of the levonorgestrel 52 mg intrauterine system was similar among nulligravid and parous users

OBJECTIVE

To compare the expulsion and continuation rates of the levonorgestrel (LNG) 52 mg intrauterine system (IUS) in a cohort of nulligravid and parous users.

METHODS

We conducted a retrospective cohort study that included 996 participants in whom we placed an LNG-IUS, and the participants were monitored for up to 5 years after device placement. We identify 498 nulligravid participants in the medical record database between 2012 and 2020. Each nulligravida was paired with a parous users who had an LNG-IUS inserted on the same day, just before or after the nulligravida. The Kaplan-Meier method and the log-rank test were used to compare the survival curves of the two groups.

RESULTS

By the fifth year of use, the expulsion rates were 7.6/100 and 8.2/100 women-years (W-Ys) and the continuation rates were 641/100 W-Ys and 65.4/100 W-Ys without difference among nulligravid and parous users, respectively (P = 0.782 and P = 0.564, respectively). We observed 29 and 31 expulsions among nulligravid and parous users, respectively.

CONCLUSION

Nulligravid and parous participants who used the 52 mg LNG-IUS showed similar expulsion and continuation rates during five years of use.

The added value of three-dimensional ultrasonography in uterine pathology

The rapid development achieved over the last decades in volume rendering of ultrasound data, known as three-dimensional (3D) ultrasound technique, leads to new opportunities for refining the diagnosis in many gynaecologic conditions. The aim of the present study was to evaluate the advantages of 3D ultrasound over two-dimensional (2D) ultrasound in uterine pathology and to establish the optimal time point during the menstrual cycle to perform 3D ultrasound examination in order to achieve the maximum of useful information. A cross-sectional study on 200 patients who underwent gynaecologic 2D and 3D ultrasound examinations was performed. The addition of 3D examination to 2D ultrasound in uterine pathology provided the most useful information concerning: Congenital uterine anomalies, intrauterine devices (IUDs), adenomyosis, and submucous myomas. The findings showed that the 3D ultrasound scan is a useful tool in gynaecology, especially in cases with congenital uterine anomalies, myoma, and IUD. Although initially it was used for research purposes only, recent findings suggest its usefulness in routine ultrasound scan and the possibility of witnessing its introduction as a recommended examination procedure in the foreseeable future. Further research should be conducted in order to establish the sensitivity of 3D ultrasound in the detection of minor endometrial conditions, by correlating the imaging findings with the hysteroscopic results.

Predictors for Discontinuation of Intrauterine Devices That Underwent Ultrasound-Guided Placement in a Long-term Follow-up Cohort

OBJECTIVES

To investigate long-term outcomes of ultrasound-guided intrauterine device (IUD) insertion. The rate of and reasons for IUD discontinuation were reviewed, including the prevalence of uterine fibroids.

METHODS

A retrospective cohort of patients who underwent transabdominal ultrasound (TAUS)-guided IUD insertion was reviewed. Information collected included age, body mass index, insertion date, indication for IUD use, indication for using TAUS guidance, and presence of uterine fibroids. The date of and reason for discontinuation were recorded.

RESULTS

One hundred sixteen patients with successful TAUS-guided IUD placement were identified. Of these, 51 patients (43.97%) no longer had an IUD in place. An overall actual-to-expected use ratio was calculated to be 63.49%. The most common reason for IUD discontinuation was spontaneous expulsion (11.21%). The prevalence of fibroid uteri was 27.6% in our cohort. The actual-to-expected use ratio of those with a fibroid uterus was calculated to be 43.28%, which was significantly lower than that for a nonfibroid uterus (73.80%; P = .002). There were 27 of 104 patients with IUD use of less than 1 year, and fibroids were present 44.4% of the time. Comparatively, of the 77 patients that had IUD continuation of greater than 1 year, only 24.7% had fibroids (P = .022). The yearly continuation rates over 5 years were 74.04%, 55.84%, 41.67%, 35.14%, and 32.0% respectively. Of the 18 patients who received TAUS-guided insertion for a previous IUD expulsion, 33.3% had another spontaneous expulsion.

CONCLUSIONS

Uterine fibroids and a previous expulsion appear to be the most likely predictors of IUD discontinuation, particularly within 1 year after insertion.

Evaluation of satisfaction with a model of structured contraceptive counseling: Results from the LOWE trial

INTRODUCTION

Intervention trials of structured contraceptive counseling have proved to increase use of long-acting reversible contraceptives (LARCs) and decrease numbers of unintended pregnancies. However, these interventions have not been evaluated from a user perspective. This study aimed to evaluate both healthcare providers' and participants' satisfaction with an intervention used in a large trial in Sweden.

MATERIAL AND METHODS

A cross-sectional study on the intervention group from a cluster randomized trial conducted at 28 clinics in Stockholm, Sweden. Clinics were randomized (1:1 allocation ratio) to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of four parts; an educational video to be seen by the participant prior to contraceptive counseling, key questions to be asked by the healthcare provider, an effectiveness chart, and a box of contraceptive models. Eligible participants were 18 years or older, sexually active without a wish to conceive, and with the main purpose of contraceptive use being pregnancy prevention. Healthcare providers completed an electronic semi-structured survey to evaluate the intervention. This study analyses provider and participant satisfaction with the counseling material used in the intervention and if the intervention was found to be supportive in contraceptive counseling and contraceptive choice.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03269357).

RESULTS

Fourteen intervention clinics enrolled 658 participants from September 2017 to May 2019. Response rate among providers was 88.0% (55/62) and among participants 97.1% (639/658). Providers found the intervention to be supportive in their counseling. Each separate part of the intervention package received high ratings from both providers and participants. Participants found the educational video and the effectiveness chart to be more helpful than the box of contraceptive models in their contraceptive choice. Providers reported the time taken to complete the intervention outside the study to be time-neutral to standard counseling, and most providers wished to continue to use all parts of the intervention package.

CONCLUSIONS

The intervention of structured contraceptive counseling had high provider and participant satisfaction. The structured counseling package could be used in several clinical settings to improve quality in contraceptive counseling and to enhance informed decision making about use of contraceptive methods.

Profile of the Jada® System: the vacuum-induced hemorrhage control device for treating abnormal postpartum uterine bleeding and postpartum hemorrhage

INTRODUCTION

Abnormal postpartum uterine bleeding occurs commonly after birth and can quickly become an obstetric emergency. With postpartum hemorrhage representing the leading cause of maternal mortality, accounting for 25% of maternal deaths due to obstetric complications, there is a critical need for effective and easy to use treatment options.

AREAS COVERED

This profile describes the Jada System, a novel intrauterine vacuum-induced hemorrhage control device that provides a rapid and effective treatment option for abnormal postpartum uterine bleeding and postpartum hemorrhage. In addition to explaining the mechanism of action of vacuum-induced hemorrhage control and reviewing the device's safety and effectiveness, this profile elucidates how the Jada System compares to currently available medications and devices for treatment of this obstetric emergency.

EXPERT OPINION

New therapies to address this life-threatening condition are needed to reduce the risk of maternal mortality and severe maternal morbidity. Data demonstrate that the Jada System provides rapid, effective control of abnormal postpartum uterine bleeding and postpartum hemorrhage, while offering reported ease of use and short treatment duration. These results suggest that use of the Jada System in treatment algorithms may improve outcomes.