The intrauterine device and ectopic pregnancy

Common misperceptions and public knowledge about intrauterine devices among US-based online respondents

OBJECTIVES

Misperceptions about intrauterine devices (IUDs) may dissuade potential users and public beliefs are not well understood. We sought to describe public knowledge of mechanism of action, failure rate, and IUD health risks. Secondary objectives included identifying inaccurate information and information sources about IUDs.

STUDY DESIGN

We conducted a convenience-based survey of participants living in the United States 18 years and older using Amazon Mechanical Turk and ResearchMatch. We collected information on demographics, reproductive history, and IUD knowledge. We asked about IUD mechanism of action, failure rate, potential health risks, and information sources. We used multivariable logistic regression to test the association between gender and perceived lower (vs. higher) risks of IUDs.

RESULTS

We included 1597 individuals with 726 (45.5%) self-reported men and 871 (54.5%) self-reported women. For both hormonal and non-hormonal IUDs, participants most often selected implantation prevention as the primary mechanism of action. In our sample, 55.5% of individuals believed the failure rate was greater than five percent. Weight gain, uterine perforation, and expulsion were cited as health risks likely to occur ≥5% of the time by 42.1%, 34.3%, and 38.4% of participants, respectively. Participants identified healthcare providers as their primary source of contraceptive information. Our multivariable logistic regression analysis revealed women had higher odds of perceiving IUDs as higher risk (aOR=1.35, 95% CI 1.09-1.68) compared to men.

CONCLUSIONS

Individuals underestimated IUD effectiveness while overestimating perceived health risks. Our results highlight areas to target education about IUDs to support informed contraceptive decision-making.

IMPLICATIONS

Participants misunderstood IUD mechanism of action, underestimated efficacy, and overestimated failure rates and health risks. Providers should begin clinical counseling by assessing baseline knowledge, since mechanism of action, side effect profiles, and concepts like female anatomy should not be assumed to be known.

The environmental risk factors associated with ectopic pregnancy: An umbrella review

INTRODUCTION

Ectopic pregnancy(EP) is the implantation of a fertilized ovum outside of the uterine cavity. The incidence of EP has steadily increased around the world. The present umbrella review evaluated risk factors prior to conception associated with EP based on meta-analyses and systematic reviews.

METHODS

We searched PubMed, Scopus, and Web of Science until June 25, 2021. All meta-analyses that had focused on assessing the risk factors associated with EP were included. We calculated summary effect estimates, 95% CI, heterogeneity I², 95% prediction interval, small-study effects, excess significance biases, and sensitive analysis. The quality of the meta-analyses was evaluated with A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2).

RESULTS

Two risk factors including chlamydia trachomatis (OR: 3.03) and smoking (OR: 1·77) were graded as suggestive evidence (class III). IUD with pregnant control (OR: 10.63) and endometriosis for case-control studies (OR: 2·66) and tubal ligation with pregnant control (OR: 9.3) were graded as risk factors with weak evidence (class IV). Tubal ligation with non-pregnant control was a protective factor (class IV). IUD with non-pregnant control and endometriosis for cohort studies were not as risk factors for EP.

CONCLUSION

Two risk factors including chlamydia trachomatis and smoking were graded as suggestive evidence. IUD with pregnant control and endometriosis for case-control studies and tubal ligation with pregnant control were graded as risk factors with weak evidence. Strong evidence for risk factors of EP was not achieved, indicating the degree of uncertainty and bias, which bring an emergency to conduct further no-bias studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42021281632).

Sonographic Evaluation of Ectopic Pregnancy

Ectopic pregnancy is a high-risk condition that occurs in 1.9% of reported pregnancies. Although the clinical triad of pain, bleeding, and amenorrhea is considered very specific for an ectopic pregnancy, ultrasound plays important role in detecting the exact location of the ectopic pregnancy and also in providing guidance for minimally invasive treatment. This article discusses the main sonographic features of ectopic pregnancy at various common and unusual locations. In addition, it provides insight into the role of hormonal markers in the diagnosis and management of ectopic pregnancy.

Ectopic pregnancy among past IUD users

The relationship between return to fertility and pregnancy outcome in women with IUD removal for planned pregnancy as well as the frequency of ectopic pregnancy among all former IUD users in comparison with the general population was studied. The cumulative conception rate in the group of women with IUD removal for planned pregnancy (n = 748) was 93.7% after 5 years, 93.4% being intrauterine and 0.3% ectopic. Rates of ectopic pregnancy in women with IUD removed for planned pregnancy were 2.7/1000 women, 3.6/1000 deliveries and 2.9/1000 pregnancies vs. 3.9, 13.4 and 5.6 in the general population. Only when the number of deliveries is used as denominator, have these differences reached statistical significance (P less than 0.05). Except for bleeding/pain and PID removals (6.0 vs. 3.9), in all other groups of former IUD users the incidence of ectopic pregnancy was also lower than in the control group. From the results of this study it was concluded that former IUD users are not at an increased risk for ectopic pregnancy.

Ectopic pregnancy among non-medicated and copper-containing intrauterine device users: a 10-year follow-up

OBJECTIVE

To compare ectopic pregnancy (EP) rates among users of non-medicated and copper-containing IUDs.

STUDY DESIGN

The number of women with non-medicated and copper devices were 3491 and 11,682, respectively. Cumulative woman-months of use (CWMU), Pearl Index (PI) and gross cumulative lifetable EP rates for 1000 women were calculated.

RESULTS

The numbers of users at the end of the 10th year were 550 and 569 for non-medicated and copper-containing IUDs, respectively. CWMU for plastic and copper devices was 191,678 and 473,533, respectively, at the 169th month of maximum follow-up. The PIs were 0.8 and 1.0 calculated for 1000 users per year. The gross cumulative lifetable EP rates for 1000 women were 1.4 and 0.9 at 12 months, and 6.8 and 8.9 at the end of the 10th year, respectively, for the plastic and the copper IUDs.

CONCLUSION

Although the rates were lower for the plastic IUD in the majority of the observations, there were no statistically significant differences between the two groups.

IUD use and the risk of ectopic pregnancy: a meta-analysis of case-control studies

Because of inconsistent findings among case-control studies on the relationship between IUD use and the risk of ectopic pregnancy, a meta-analysis of published literature was conducted. From 1977 through 1994, 19 publications regarding 16 studies of ectopic pregnancy and IUD use were found by MEDLINE and manual search. The odds ratio (ORs) of ectopic pregnancy with current and past IUD use in each study were pooled. A quality score system was developed to assess each study. Funnel plot was used to assess potential publication biases. For current IUD use, when cases were compared to pregnant controls, there was an increased risk of ectopic pregnancy (pooled OR: 10.63, 95% confidence interval (CI): 7.66-14.74); when cases were compared to non-pregnant controls, there was no risk of ectopic pregnancy (pooled OR: 1.06, 95% CI: 0.91-1.24). Past IUD use could mildly increase the risk of ectopic pregnancy (pooled OR: 1.40, 95% CI: 1.23-1.59). Selecting pregnant or non-pregnant women as controls, however, did not affect the OR estimates of past IUD use. Current IUD use does not increase the risk of the ectopic pregnancy. However, a pregnancy with an IUD in situ is more often an ectopic one than a pregnancy with no IUD. Past IUD use could mildly elevate the risk of ectopic pregnancy.