Association of age and parity with intrauterine device expulsion

Menstrual cup use and intrauterine device expulsion in a copper intrauterine device randomized trial

OBJECTIVE

To evaluate menstrual cup use and intrauterine device (IUD) expulsion.

STUDY DESIGN

We performed a secondary analysis of a 3-year contraceptive efficacy trial comparing two copper 380 mm2 IUDs. Investigators randomized participants approximately 1:4 to the TCu380A or NTCu380-Mini IUD. Approximately 12 months after enrollment began, we advised participants against menstrual cup use due to observed IUD expulsions in cup users. We evaluated IUD expulsion (including spontaneous partial and complete expulsion and accidental self-removal) at 12 and 36 months. We used multivariable logistic regression to evaluate IUD expulsion by age, baseline menstrual volume, body mass index, IUD type, menstrual cup use, parity, and uterine length.

RESULTS

This analysis included 1046 participants (203 TCu380A and 843 NTCu380-Mini), with 879 (84.0%) nulliparas. Through 12 and 36 months, expulsion occurred in 74 (7.1%, 95% CI 5.5-8.6%) and 133 (12.7%, 95% CI 10.7-14.7%) participants, respectively. Overall, 250 (23.9%) reported menstrual cup use. More menstrual cup users than non-users experienced expulsion through 12 months (32/203 [15.8%] vs. 42/843 [5.0%]) and 36 months (58/250 [23.2%] vs. 75/796 [9.4%]). Through 36 months, NTCu380-Mini menstrual cup users had higher expulsion odds, while TCu380A cup users did not. Menstrual cup users more frequently experienced accidental self-removal than non-users in participants using the TCu380A (3/53 [5.7%] vs. 0/150 [0.0%]) and the NTCu380-Mini (20/197 [10.2%] vs. 7/646 [1.1%]). In multivariable regression, we found increased odds of expulsion through 36 months in participants using menstrual cups with the NTCu380-Mini (aOR 3.13, 95% CI 1.16-8.46) and <25 years (aOR 1.59, 95% CI 1.07-2.34).

CONCLUSIONS

We found higher odds of IUD expulsion with menstrual cup and concurrent NTCu380-Mini IUD use over 36 months of use, but not with concurrent TCu380A IUD use. Menstrual cup users experienced higher likelihood of accidental self-removal regardless of IUD type.

IMPLICATIONS

Menstrual cup and NTCu380-Mini use may increase IUD expulsion risk and may increase accidental self-removal risk with TCu380A and NTCu380-Mini use. Clinicians should advise patients of these risks and consider warning patients using an IUD shaped like the NTCu380-Mini (Nova-T frames) of expulsion risk with menstrual cup use.

Body Mass Index and Levonorgestrel Device Expulsion in Adolescents and Young Adults

STUDY OBJECTIVE

To evaluate the relationship between body mass and levonorgestrel intrauterine device (LNG-IUD) expulsion in adolescents and young adults (AYA).

DESIGN, SETTING, PARTICIPANTS & INTERVENTIONS

A retrospective chart review was conducted of nulliparous females aged 10-24 years who had a 52-milligram LNG-IUD placed between November 2017 and May 2021 by pediatric and adolescent gynecology providers at a tertiary children's hospital, including those who underwent metabolic and bariatric surgery (MBS). Primary analysis focused on 10-19 year olds as they had comparable anthropometrics (namely BMI percentile [BMIP] as defined by the Centers for Disease Control). Descriptive statistics included means, standard deviations (SD), and ranges for continuous variables counts and percentages for categorical variables. Chi-square or Fisher's exact tests were used to assess associations. Logistic regressions were fit to test the associations between BMIP, MBS, and the odds of expulsion.

MAIN OUTCOME MEASURES & RESULTS

A total of 588 patients were included in the primary analysis (10-19 years). Mean age was 15.8 years (±2.0). Using BMIP, 15.5% (n = 91) of the sample was overweight and 22.3% (n = 131) were obese. Within 12 months, 33 patients (5.6%) experienced expulsion. Every one-unit increase in BMIP was associated with a 3% increase in the odds of expulsion (P = .008), and each increase in BMIP category (eg, overweight vs average/underweight) was significantly associated with increased odds of expulsion (OR = 2.77-4.28). Patients who had LNG-IUD placement during MBS (n = 43) had higher odds of expulsion (OR = 3.23; P = .024) than other patients.

CONCLUSION

AYA with higher BMIP and/or who undergo MBS are at increased risk of LNG-IUD expulsion within one year of placement.

Five-year Contraceptive Use of 52-mg Levonorgestrel Releasing Intrauterine System in Young Women, Menstrual Patterns, and New Contraceptive Choice

OBJECTIVE

 To evaluate the continuation rates of the 52-mg levonorgestrel-releasing intrauterine system (LNG-IUS) during the first 5 years of use, reasons for its discontinuation, bleeding patterns, and new contraceptive choice after the 5th year, in adolescents and young women.

METHODS

 The present study was a 5-year prospective cohort conducted in a Family Planning Service of a tertiary hospital in Brazil. We selected 100 healthy women between 15 and 24 years old who used 52-mg LNG-IUS for contraception. The clinical follow-up of these women took place from June 2017 to December 2022. The study evaluated the continuation rates of the method, reasons for its discontinuation, bleeding patterns, and new contraceptive choice after the 5th year. Continuous data were reported as mean ± standard deviation (SD) and range (minimum-maximum). Categorical variables were described as percentages.

RESULTS

 The continuation rates of LNG-IUS were 89.1% (82/92), 82.9% (72/87), 75.3% (64/85), 70.5% (60/85), and 64.2% (54/84) in the 1st, 2nd, 3rd, 4th, and 5th years of use, respectively. The main reason for discontinuation was acne (11/30). Amenorrhea rates were 50, 54.1, 39, 35.7, and 51.8% at 12, 24, 36, 48, and 60 months, respectively. All patients who completed the study and needed contraception after the 5th year opted for long-acting contraceptive methods (LARC).

CONCLUSION

 The LNG-IUS showed high continuation rates in adolescents and young women in the first 5 years of use. Most patients who completed the study chose a LARC method after the 5th year.

TEMPORARILY WITHDRAWN: Does the shape of the copper intrauterine device play a role in expulsion? Results from the ongoing European Active Surveillance Study on LCS12

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Expulsion and continuation rates of the 52 mg levonorgestrel intrauterine system in adolescents and adult women

OBJECTIVE

To compare the continuation rates, expulsion, and other reasons for discontinuation of the hormonal intrauterine device with 52 mg of levonorgestrel (52 mg LNG-IUD) in adolescents and adult women.

METHODS

We conducted a retrospective cohort study that included 393 women in whom we placed a 52 mg LNG-IUD and followed up to 5 years. We created two retrospective cohorts, one with 131 adolescents (aged between 12 and 19 years) and the other with 262 women aged ≥20 years. Each adolescent was paired with two adult women who had the same parity and who had a 52 mg LNG-IUD inserted on the same day. We used the Mann-Whitney test to compare numerical variables in both groups, the Kaplan-Meier method, and the log-rank test to compare the continuation, expulsion and other reasons for IUD discontinuation of the two groups.

RESULTS

Age of the adolescents and adult women were mean ± SD 18.1 (±1.1) and 31 (±6.8) years, respectively (p = 0.015). Continuation rates by the fifth year of use were 55.6/100 women-years (W-Y) and 70.3/100 W-Y among adolescents and adult women (p = 0.106); and expulsion rates were 8.4/100 and 6.0/100 W-Y, respectively (p = 0.463). Adolescents had a lower continuation rate during 3 to 5 years of follow-up (p = 0.011) and a high rate of removals due to bleeding/pain (18.5 ± 5.7/100 W-Y vs 6.4/100 ± 2.1 W-Y, p = 0.039).

CONCLUSION

Adolescents who used the 52 mg LNG-IUD showed a lower continuation rate 3-5 years after device placement than adult women. The expulsion rates were similar in both groups.

Complications of Long-Acting Reversible Contraceptive Modalities

ABSTRACT

Long-acting reversible contraception has risen in popularity in recent decades and is becoming one of the more common modalities of contraception in the United States, with a growing adolescent population among its users. The 2 modalities of long-acting reversible contraception-intrauterine devices and subcutaneous hormonal implants/etonogestrel implants (referred to as Nexplanon in the US)-are beneficial for their excellent effectiveness, ease of use, and safety profile. This article reviews the pharmacology of these modalities, common complications and their presentations, and the initial evaluation and management in the pediatric emergency department setting. Where applicable, attention will be paid to problems unique to the adolescent population.

Long-Acting Reversible Contraception for Adolescents: A Review of Practices to Support Better Communication, Counseling, and Adherence

Long-acting reversible contraception (LARC) methods, including levonorgestrel and copper intrauterine devices (IUDs) and the subdermal contraceptive implant, are the most effective reversible forms of contraception and thus are an important aspect of adolescent pregnancy prevention. While LARC efficacy, safety, and appropriateness are supported by major medical organizations and usage rates are increasing, overall LARC uptake among United States (US) adolescents remains lower than uptake of short-acting contraceptive methods. A better understanding of the barriers affecting adolescent LARC uptake and reasons for discontinuation could help facilitate effective communication. For example, learning how to improve adolescent-centered communication, shared decision-making, and motivational counseling strategies may be the first step to improving utilization rates. This narrative review includes three sections. First, this review will describe the history, mechanisms of action, and epidemiology of adolescent LARC use in the US and globally. Next, this review will describe key factors influencing adolescent LARC uptake, reasons for discontinuation, and multilevel barriers specific to adolescent LARC use. Finally, this review will characterize communication techniques and LARC counseling strategies for adolescents in the context of a reproductive justice approach set in the health belief model framework. The distinction between moving away from a presumptive counseling approach towards an adolescent-centered, shared decision-making approach to encourage parent-adolescent sexual health communication to lay the foundation of empowering adolescent reproductive autonomy should be the underpinning of all effective reproductive communication strategies.

Heavy Menstrual Bleeding Treatment With a Levonorgestrel 52-mg Intrauterine Device

OBJECTIVE

To evaluate heavy menstrual bleeding treatment outcomes with levonorgestrel 52-mg intrauterine device (IUD) use in participants without body mass index (BMI) or parity restrictions.

METHODS

Investigators included participants aged 18-50 years with no pelvic or systemic pathology causing heavy menstrual bleeding at 29 U.S. centers in a prospective trial. Participants had up to three screening cycles with menstrual product collection for alkaline hematin blood-loss measurements. Investigators enrolled those with two menses with blood loss of 80 mL or more (values averaged for baseline blood loss), placed the IUD, and followed participants for up to six 28-day cycles. Participants collected any menstrual products used during cycles 3 and 6 for blood-loss measurement. We evaluated outcomes in participants with at least one follow-up assessment for the primary outcome of median absolute blood-loss change and, secondarily, treatment success, defined as the proportion with a final measured blood loss less than 80 mL and at least 50% reduction from baseline. We evaluated exploratory outcomes of differences in blood-loss changes by BMI and parity using Wilcoxon rank sum test.

RESULTS

Of 105 enrolled participants, 47 (44.8%) had obesity (BMI 30.0 or higher) and 29 (27.6%) were nulliparous. Baseline mean blood loss ranged from 73 to 520 mL (median 143 mL, interquartile range 112-196 mL). Eighty-nine (84.8%) had at least one evaluable follow-up evaluation. Participants had median (interquartile range) absolute blood-loss decreases at cycles 3 (n=86) and 6 (n=81) of 93.3% (86.1-97.7%) and 97.6% (90.4-100%), respectively. At cycle 6, participants without obesity (n=43) and with obesity (n=38) had similar median [interquartile range] decreases (97.6% [91.8-100%] and 97.5% [90.3-100%], respectively; P=.89), with comparable findings for nulliparous (n=25) and parous (n=56) participants (97.0% [91.7-99.1%] and 98.1% [89.9-100%], respectively; P=.43). Treatment success occurred in 81.8% (95% CI 74.2-89.4%) of 99 participants, excluding those with no outcomes due to lost to follow-up or consent withdrawal, and did not vary by BMI or parity. The most common adverse events leading to discontinuation were bleeding or cramping (n=6 [5.7%]) and expulsion (n=5 [4.8%]).

CONCLUSION

This levonorgestrel 52-mg IUD reduces blood loss by more than 90% over 6 months compared with baseline for most users with heavy menstrual bleeding.

FUNDING SOURCE

Medicines360.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03642210.

Clinical outcomes of intrauterine device insertions by newly trained providers: The ECHO trial experience

Objectives

To assess the rates of failed insertion, expulsion, and perforation when intrauterine device (IUD) insertions were done by newly trained clinicians, and to examine factors that may affect these outcomes.

Study design

We evaluated skill-based outcomes following IUD insertion at 12 African sites in a secondary analysis of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) randomized trial. Before trial initiation, we provided competency-based IUD training to clinicians and offered ongoing clinical support. We used Cox proportional hazards regression to examine factors associated with expulsion.

Results

Among 2582 IUD acceptors who underwent first attempted IUD insertion, 141 experienced insertion failure (5.46%) and seven had uterine perforation (0.27%). Perforation was more common among breastfeeding women within three months postpartum (0.65%) compared with non-breastfeeding women (0.22%). We recorded 493 expulsions (15.5 per 100 person-years, 95% confidence interval [CI] 14.1─16.9): 383 partial and 110 complete. The risk of IUD expulsion was lower among women older than 24 years (aHR 0.63, 95% CI 0.50─0.78) and may be higher among nulliparous women. (aHR 1.65, 95% CI 0.97─2.82). Breastfeeding (aHR 0.94, 95% CI 0.72─1.22) had no significant effect on expulsion. IUD expulsion rate was highest during the first three months of the trial.

Conclusions

IUD insertion failure and uterine perforation rates in our study were comparable to those reported in the literature. These results suggest that training, ongoing support, and opportunities to apply new skills were effective in ensuring good clinical outcomes for women receiving IUD insertion by newly trained providers.

Implications

Data from this study support recommendations to program managers, policymakers, and clinicians that IUDs can be inserted safely in resource-constrained settings when providers receive appropriate training and support.

Use of 52-mg Levonorgestrel-Releasing Intrauterine System in Adolescents and Young Adult Women: 3-Year Follow-Up

STUDY OBJECTIVE

To evaluate continuance rates, bleeding patterns, and patient satisfaction with 52-mg levonorgestrel-releasing intrauterine system (LNG-IUS) use in adolescents and young adult women during the first 3 years of use DESIGN: We conducted an observational prospective study.

SETTING

Family Planning Service of a tertiary hospital in Brazil PARTICIPANTS: One hundred adolescents and young women aged 16-24 years.

INTERVENTION

Insertion of 52-mg LNG-IUS for the main purpose of contraception. Follow-up visits were conducted at 12, 24, and 36 months after insertion.

MAIN OUTCOME MEASURES

Continuance rates, reasons for discontinuation of the method, and women's satisfaction and bleeding patterns RESULTS: Among those who were not lost to follow-up, LNG-IUS continuance rates were 89.1% (82/92), 82.9% (72/87), and 75.3% (64/85) in the first, second, and third years of use, respectively. The main reason for discontinuation was acne, followed by expulsion of/malpositioned LNG-IUS. Other reasons for discontinuation were irregular uterine bleeding, dysmenorrhea, and abdominal pain. The amenorrhea rates were 50%, 54.1%, and 39% at 12, 24, and 36 months, respectively. Spotting rates increased during the first 3 years of use (20.8%, 16.7%, and 26.6%, respectively). Adolescents and young women using the LNG-IUS showed high rates of satisfaction, with 93.9%, 100%, and 96.8% of women being very satisfied/satisfied in the first 3 years of use. Only 2 participants who continued using the LNG-IUS reported being very dissatisfied/dissatisfied in the third year of follow-up.

CONCLUSION

The LNG-IUS showed high rates of continuation and satisfaction in the first 3 years of use in Brazilian adolescents and young adults. Most women reported a favorable bleeding pattern.

Intrauterine Device Outcomes in Young Women with Heavy Menstrual Bleeding: Comparing Patients with and without Inherited Bleeding Disorders

STUDY OBJECTIVE

To evaluate the use of intrauterine devices (IUDs) in two young women's hematology clinics and compare adverse events in adolescents with and without inherited bleeding disorders (BDs) DESIGN: Retrospective multicenter cohort study from February 2014 through February 2020 SETTING: Young women's hematology clinics at Nationwide Children's Hospital in Columbus, Ohio, and Children's Medical Center in Dallas, Texas PARTICIPANTS: Female patients evaluated for heavy menstrual bleeding (HMB) who underwent IUD placement INTERVENTIONS AND MAIN OUTCOME MEASURES: Rates of IUD expulsion, malposition, and ongoing HMB requiring additional medical treatment RESULTS: We identified 43 patients with BDs and 35 patients without BDs who underwent placement of an IUD for HMB. The mean age was 14.9 years (range 11.0-21.4 years) at the time of presentation and 15.8 years (range 11.0-21.4 years) at IUD placement. Those with BDs were younger at the time of IUD insertion. Most patients (90%) had previously failed other methods to control HMB. The annual rate of IUD adverse events was 0.25 per year of use, and all adverse events occurred in the first 20 months after placement. There were no significant differences in adverse IUD events in patients with and without BDs, although those without BDs requested IUD removal more frequently.

CONCLUSIONS

In this cohort of adolescent females, the presence of a BD was not associated with a higher IUD expulsion rate. IUD placement should be considered a first-line option for adolescents with BDs who experience HMB.

Demographic, Reproductive, and Medical Risk Factors for Intrauterine Device Expulsion

OBJECTIVE

To explore to what extent intrauterine device (IUD) expulsion is associated with demographic and clinical risk factors.

METHODS

The APEX-IUD (Association of Perforation and Expulsion of IntraUterine Devices) study was a U.S. cohort study using electronic health records from three integrated health care systems (Kaiser Permanente Northern California, Southern California, and Washington) and a health care information exchange (Regenstrief Institute). These analyses included individuals aged 50 years or younger with IUD insertions from 2001 to 2018. Intrauterine device expulsion cumulative incidence and incidence rates were estimated. Using Cox regression models, hazard ratios with 95% CIs were estimated before and after adjustment for risk factors of interest (age, race and ethnicity, parity, body mass index [BMI], heavy menstrual bleeding, and dysmenorrhea) and potential confounders.

RESULTS

In total, 228,834 individuals with IUD insertion and no delivery in the previous 52 weeks were identified (184,733 [80.7%] with levonorgestrel-releasing intrauterine system). Diagnosis of heavy menstrual bleeding-particularly a diagnosis in both recent and past periods-was the strongest risk factor for IUD expulsion. Categories with the highest risk of IUD expulsion within each risk factor included individuals diagnosed with overweight, obesity, and morbid obesity; those in younger age groups, especially among those aged 24 years or younger; and in those with parity of four or more. Non-Hispanic White individuals had the lowest incidence and risk, and after adjustment, Asian or Pacific Islander individuals had the highest risk. Dysmenorrhea was not independently associated with expulsion risk when adjusting for heavy menstrual bleeding.

CONCLUSION

Most risk factors for expulsion identified in this study appear consistent with known physiologic factors that affect uterine anatomy and physiology (age, BMI, heavy menstrual bleeding, parity). The increased risk of IUD expulsion among individuals of color warrants further investigation. Intrauterine devices are an effective long-term contraceptive; expulsion is uncommon, but patients should be counseled accordingly.

FUNDING SOURCE

Bayer AG.

CLINICAL TRIAL REGISTRATION

EU PAS register, EUPAS33461.

Real-world outcomes of the levonorgestrel-releasing intrauterine system for heavy menstrual bleeding or dysmenorrhea in Japanese patients: A prospective observational study (J-MIRAI)

OBJECTIVES

We collected real-world data on the safety and clinical outcomes of the levonorgestrel-releasing intrauterine system (LNG-IUS) for heavy menstrual bleeding and dysmenorrhea.

STUDY DESIGN

This was a prospective, multicenter, single-cohort, open-label, post-authorization 12-month follow-up study of Japanese patients initiating the LNG-IUS for heavy menstrual bleeding and/or dysmenorrhea. The primary endpoint was the safety profile based on adverse events and adverse drug reactions (ADRs), including expulsions and abnormal bleeding, within 12 months of LNG-IUS insertion. Secondary endpoints included changes from baseline in menstrual blood loss based on bleeding days and dysmenorrhea graded on a visual analog scale (VAS).

RESULTS

Of the 595 patients included, many had underlying conditions such as adenomyosis (39.5%), uterine leiomyoma (30.8%), or endometriosis (12.9%). The incidences of ADRs and serious ADRs were 59.7% and 0.3%, respectively. Frequently reported ADRs were metrorrhagia (48.9%), procedural pain (14.1%), and ovarian cyst (6.2%). The cumulative incidence of expulsions at 12 months was 8.7%. Risk factors for expulsion were obesity (body mass index ≥25 kg/m²), adenomyosis, and uterine cavity length ≥8 cm. The median [interquartile range] VAS score for dysmenorrhea improved from 46.5 [13.0-68.0] at insertion to 1.0 [0.0-13.0] at 12 months, and improvements were also observed in chronic pelvic pain and painful defecation.

CONCLUSIONS

The LNG-IUS safely and effectively reduced dysmenorrhea, chronic pelvic pain, and painful defecation. Risk factors for expulsion suggest that patients with underlying organic disease should be monitored carefully when using the LNG-IUS.

IMPLICATIONS

The LNG-IUS is an effective treatment for secondary dysmenorrhea with organic disease, and for the reduction of chronic pelvic pain; however, physicians should be aware of the increased risk of expulsion in patients with organic conditions.

Continuation rates of two different-sized copper intrauterine devices among nulliparous women: Interim 12-month results of a single-blind, randomised, multicentre trial

BACKGROUND

The most widely used copper intrauterine device (IUD) in the world (the TCu380A), and the only product available in many countries, causes side effects and early removals for many users. These problems are exacerbated in nulliparous women, who have smaller uterine cavities compared to parous women. We compared first-year continuation rates and reasons/probabilities for early removal of the TCu380A versus a smaller Belgian copper IUD among nulliparous users.

METHODS

This 12-month interim report is derived from a pre-planned interim analysis of a sub population and focused on key secondary comparative endpoints. In this participant-blinded trial at 16 centres in the USA, we randomised participants aged 17-40 in a 4:1 ratio to the NT380-Mini or the TCu380A. In the first year, participants had follow-up visits at 6-weeks and 3, 6, and 12-months, and a phone contact at 9 months; we documented continued use, expulsions, and reasons for removal. Among participants with successful IUD placement, we compared probabilities of IUD continuation and specific reasons for discontinuation using log-rank tests. This trial is registered with ClinicalTrials.gov number NCT03124160 and is closed to recruitment.

FINDINGS

Between June 1, 2017, and February 25, 2019, we assigned 927 nulliparous women to either the NT380-Mini (n = 744) or the TCu380A (n = 183); the analysis population was 732 (NT380-Mini) and 176 (TCu380A). Participants using the NT380-Mini, compared to the TCu380A, had higher 12-month continuation rates (78·7% [95% CI: 72·9-84·5%] vs. 70·2% [95% CI: 59·7-80·7], p = 0·014), lower rates of removal for bleeding and/or pain (8·1% vs. 16·2%, p = 0·003) and lower IUD expulsion rates (4·8% vs. 8·9%, p = 0·023), respectively.

INTERPRETATION

The NT380-Mini offers important benefits for a nulliparous population compared to the TCu380A in the first twelve months, when pivotal experiences typically occur. Higher continuation rates with the NT380-Mini may avert disruptions in contraceptive use and help users avoid unintended pregnancy.

FUNDING

Bill & Melinda Gates Foundation, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Mona Lisa, N.V. (Belgium).

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.

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.

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.

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.

Safety, Quality, and Acceptability of Contraceptive Implant Provision by Community Health Extension Workers versus Nurses and Midwives in Two States in Nigeria

Task sharing is a strategy with potential to increase access to effective modern contraceptive methods. This study examines whether community health extension workers (CHEWs) can insert contraceptive implants to the same safety and quality standards as nurse/midwives. We analyze data from 7,691 clients of CHEWs and nurse/midwives who participated in a noninferiority study conducted in Kaduna and Ondo States, Nigeria. Adverse events (AEs) following implant insertions were compared. On the day of insertion AEs were similar among CHEW and nurse/midwife clients—0.5 percent and 0.4 percent, adjusted odds ratio (aOR) 0.92 (95 percent CI 0.38–2.23)—but noninferiority could not be established. At follow‐up 6.6 percent of CHEW clients and 2.1 percent of nurse/midwife clients experienced AEs. There was strong evidence of effect modification by State. In the final adjusted model, odds of AEs for CHEW clients in Kaduna was 3.34 (95 percent CI 1.53–7.33) compared to nurse/midwife clients, and 0.72 (95 percent CI 0.19–2.72]) in Ondo. Noninferiority could not be established in either State. Implant expulsions were higher among CHEW clients (142/2987) compared to nurse/midwives (40/3517). Results show the feasibility of training CHEWs to deliver implants in remote rural settings but attention must be given to provider selection, training, supervision, and follow‐up to ensure safety and quality of provision.

Comparing options for females seeking permanent contraception in high resource countries: a systematic review

BACKGROUND

Multiple options for permanent or long-acting contraception are available, each with adverse effects and benefits. People seeking to end their fertility, and their healthcare providers, need a comprehensive comparison of methods to support their decision-making. Permanent contraceptive methods should be compared with long-acting methods that have similar effectiveness and lower anticipated adverse effects, such as the levonorgestrel-releasing intrauterine contraception (LNG-IUC). We aimed to understand the comparability of options for people seeking to end their fertility, using high-quality studies. We sought studies comparing laparoscopic tubal ligation, hysteroscopic tubal occlusion, bilateral salpingectomy, and insertion of the LNG-IUC, for effectiveness, adverse events, tolerability, patient recovery, non-contraceptive benefits, and healthcare system costs among females in high resource countries seeking to permanently avoid conception.

METHODS

We followed PRISMA guidelines, searched EMBASE, Pubmed (Medline), Web of Science, and screened retrieved articles to identify additional studies. We extracted data on population, interventions, outcomes, follow-up, health system costs, and study funding source. We used the Newcastle-Ottawa Scale to assess risk of bias and excluded studies with medium-high risk of bias (NOS < 7). Due to considerable heterogeneity, we performed a narrative synthesis.

RESULTS

Our search identified 6,612 articles. RG, BV, BC independently reviewed titles and abstracts for relevance. We reviewed the full text of 154 studies, yielding 34 studies which met inclusion criteria. We excluded 10 studies with medium-high risk of bias, retaining 24 in our synthesis. Most studies compared hysteroscopic tubal occlusion and/or laparoscopic tubal ligation. Most comparisons reported on effectiveness and adverse events; fewer reported tolerability, patient recovery, non-contraceptive benefits, and/or healthcare system costs. No comparisons reported accessibility, eligibility, or follow-up required. We found inconclusive evidence comparing the effectiveness of hysteroscopic tubal occlusion to laparoscopic tubal ligation. All studies reported adverse events. All forms of tubal interruption reported a protective effect against cancers. Tolerability appeared greater among tubal ligation patients compared to hysteroscopic tubal occlusion patients. No high-quality studies included the LNG-IUC.

CONCLUSIONS

Studies are needed to directly compare surgical forms of permanent contraception, such as tubal ligation or removal, with alternative options, such as intrauterine contraception to support decision-making.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO [CRD42016038254].

One-year follow up on post-placental IUD insertion: A randomized clinical trial

INTRODUCTION

Our objectives were to compare the 1-year follow-up clinical performance of the TCu380A intrauterine device (TCu380A-IUD) and levonorgestrel (LNG) 52-mg intrauterine system (IUS) inserted at post-placental period.

MATERIAL AND METHODS

We conducted an open-label, parallel-group, randomized clinical trial, 1:1 with pregnant women admitted for childbirth independently of the mode of birth. Our primary outcome was expulsion up to 1 year after device placement by type of IUD and mode of delivery. During the follow up (42, 90 and 365 days (±7 days) after device placement), an ultrasound was performed to evaluate the device position. Kaplan-Meier with log-rank test was used to compare the survival curves of the TCu380A IUD and the LNG IUS. Couple-Years of Protection after insertion of both devices was calculated.

RESULTS

One hundred and forty women were randomized to the TCu380A IUD (n = 70) or the LNG IUS (n = 70). By the end of the first year after device placement, 38 women experienced device expulsion (27.1%), most of them (33/38; 86.8%) within the first 42 days after delivery. The expulsions were significantly higher among users of TCu380A IUD (39.4%) than among users of the LNG IUS (22.2%; P = .039), and among those with vaginal delivery (43.8%) than among women with cesarean delivery (15%; P = .003). The 1-year cumulative continuation rate was 64.2%, significantly higher for LNG IUS (73.1%) than for TCu380A IUD (54.4%; P = .03), and among women with cesarean delivery (77.6%) than for vaginal delivery (52%; P = .00). The post-placental IUD insertion provided 356.4 Couple-Years of Protection.

CONCLUSIONS

Two-thirds of women who accepted a post-placental IUD placement still used the device 1 year after childbirth. However, expulsion was the most prevalent reason for discontinuation, mainly within 42 days after device placement. The expulsion rate was significantly higher among TCu380A IUD users and among women with vaginal delivery.

Relationship of parity and prior cesarean delivery to levonorgestrel 52 mg intrauterine system expulsion over 6 years

OBJECTIVE

Assess the relationship between parity and prior route of delivery to levonorgestrel 52 mg intrauterine system (IUS) expulsion during the first 72 months of use.

STUDY DESIGN

We evaluated women enrolled in the ACCESS IUS multicenter, Phase 3, open-label clinical trial of the Liletta levonorgestrel 52 mg IUS. Investigators evaluated IUS presence at 3 and 6 months after placement and then every 6 months and during unscheduled visits. We included women with successful placement and at least one follow-up assessment. We evaluated expulsion rates based on obstetric history; for prior delivery method subanalyses, we excluded 12 participants with missing delivery data. We determined predictors of expulsion using multivariable regression analyses.

RESULTS

Of 1714 women with IUS placement, 1710 had at least one follow-up assessment. The total population included 986 (57.7%) nulliparous women. Sixty-five (3.8%) women experienced expulsion within 72 months, 50 (76.9%) within the first 12 months. Expulsion rates among nulliparous women (22/986 [2.2%]) or parous women with any pregnancy ending with a Cesarean delivery (6/195 [3.1%]) differed from parous women who only experienced vaginal deliveries (37/517 [7.2%]) (p < 0.001). In multivariable regression, obesity (adjusted odds ratio [aOR] 2.2, 95% confidence interval [CI] 1.3-3.7), parity (aOR 2.2, 95% CI 1.2-4.1), and non-white race (aOR 1.8, 95% CI 1.1-3.2) predicted expulsion. Among parous women, obesity (aOR 2.2, 95% CI 1.2-4.2) increased the odds and having ever had a cesarean delivery (aOR 0.4, 95% CI 0.1-0.9) decreased the odds of expulsion.

CONCLUSION

IUS expulsion occurs in less than 4% of users over the first 6 years of use and occurs mostly during the first year. Expulsion is more likely among obese and parous women.

IMPLICATIONS

Levonorgestrel 52 mg intrauterine system expulsion occured more commonly in parous than nulliparous women; the increase in parous women is primarily in women who had vaginal deliveries only. The association between obesity, delivery route, and IUS expulsion needs further elucidation.

Intrauterine device use is safe among nulligravidas and adolescent girls

The use of intrauterine devices (IUDs), including the copper-bearing device and the levonorgestrel intrauterine system (LNG-IUS), is safe among nulligravidas and adolescent girls. However, several misconceptions limit their use in clinical practice; health-care providers are hesitant to prescribe IUDs, and several myths associated with their usage in nulligravidas and adolescents exist among both providers and women themselves. The high rates of unplanned pregnancies (which in many settings constitute a public health issue, primarily among adolescent females) can be attributed at least partially to lack of awareness and limited use of highly effective contraceptives such as IUDs. In this review, we discuss the role of non-hormonal and hormonal IUDs as effective contraceptives in nulligravidas and adolescent girls. We present a literature review of data that highlight contraceptive efficacy, side effects (including reasons for discontinuation), and continuation rates with the method. We searched the PubMed/MEDLINE, Cochrane Library, Embase, and Scopus databases for all articles published in English between January 1990 through September 2020. A large body of evidence confirmed the effectiveness of IUD/IUS, independent of age and parity. Studies showed a high expulsion rate among adolescents but not among nulligravidas. Additionally, bleeding patterns among adolescents and nulligravidas were similar to those observed among adults and parous women. The high early removal rates observed in adolescents were attributable to bleeding and/or pain, which indicate that compared with adults, adolescents are less likely to accept IUD-induced side effects. IUD placement is an excellent strategy to avoid the high rates of unplanned pregnancies in adolescents and nulligravidas. IUDs are more effective than short-acting reversible contraceptives with failure rates that are equivalent to those observed with permanent contraception. However, few long-term studies have investigated this category of women to definitively establish the role of IUD/IUS as effective means of contraception.

Timing of insertion affects expulsion in patients using the levonorgestrel 52 mg intrauterine system for noncontraceptive indications

OBJECTIVE

To evaluate levonorgestrel 52 mg intrauterine system (IUS) expulsion risk by menstrual cycle day of insertion (days 1-8 vs days 9 and beyond) in women using the IUS for noncontraceptive indications.

STUDY DESIGN

We performed a retrospective cohort study of patients with a levonorgestrel IUS inserted for the management of noncontraceptive, gynecologic conditions at Kaiser Permanente-Hawaii between January 2009 and December 2010. We used multivariable logistic regression models to estimate the likelihood of IUS expulsion adjusting for demographic and clinical factors and a Kaplan-Meier curve for survival analysis.

RESULTS

Of 176 patients identified, insertion occurred in 42 patients in cycle days 1 to 8 and 87 patients after day 8. Patient follow-up within the Kaiser system ranged from 1 to 71 months. Thirty-nine (22%) patients experienced expulsion, 16 (38%) and 15 (17%) for the 2 timing groups, respectively. Expulsion was more likely if the IUS placement occurred during the menstrual cycle days 1 to 8 (adjusted odds ratio 3.57 [95% confidence interval 1.13, 11.31]), which was consistent with the Kaplan-Meier analysis (p = 0.008).

CONCLUSION

Levonorgestrel IUS expulsion among women using the IUS for noncontraceptive indications occurred more frequently if insertion occurred during the first eight days of the menstrual cycle.

IMPLICATIONS

In women planning to use the levonorgestrel IUS to treat gynecologic conditions such as abnormal uterine bleeding, dysmenorrhea, and endometrial hyperplasia, providers should consider waiting until after cycle day 8 to perform insertion.

Evaluation of clinical performance when intrauterine devices are inserted by different categories of healthcare professional

OBJECTIVE

We evaluated clinical performance when the TCu380A intrauterine device (IUD) and the levonorgestrel (LNG) 52-mg intrauterine system (IUS) were inserted by different categories of healthcare professionals.

METHODS

A retrospective study was conducted at the University of Campinas, Brazil. The medical records were reviewed of all women in whom an IUD was inserted between January 1980 and December 2018, with data for at least 1 year, and for whom information on the healthcare provider who inserted the device was available.

RESULTS

Overall, 19 132 (76.9%) IUD and 5733 (23.1%) LNG-IUS insertions were included, with residents/interns performing 13 853 (55.8%), nurses 7024 (28.2%), and physicians 3988 (16.0%). Removals for pregnancy and infection were significantly higher when physicians inserted the device, while removals for bleeding/pain and other medical reasons were more common when nurses performed the insertion. Expulsion and removals for personal reasons were similar for all three categories.

CONCLUSION

Clinical outcomes were similar regardless of whether trained nurses, residents/interns, or physicians inserted the device, and were irrespective of users' age and parity. These results could stimulate other healthcare services, particularly in regions where there is a shortage of physicians, to invest in training nurses to perform insertions of IUDs.

Levonorgestrel-Releasing Intrauterine System as a Contraceptive Method in Nulliparous Women: A Systematic Review

The aim of this review was to summarize the available evidence about the use of levonorgestrel-releasing intrauterine system (LNG-IUS) as a contraceptive method in nulliparous women. For this purpose, studies evaluating the efficacy, safety, bleeding pattern, satisfaction and discontinuation of the levonorgestrel-releasing intrauterine system in nulliparous women were analyzed. Only original research articles published in English between 1990–27th March 2020 were considered eligible. Reviews, book chapters, case studies, conference papers, opinions, editorials and letters were excluded. The systematic literature search of PubMed/MEDLINE, Scopus, Embase and Cochrane Library databases identified 816 articles, 23 of which were analyzed. The available evidence indicates that LNG-IUS is an effective and safe contraceptive method for nulliparous women that achieves high levels of satisfaction among patients. Moreover, nulliparous women seem to experience fewer expulsions than parous ones. Bleeding pattern is acceptable for the majority of patients, and bleeding disorders mainly occur in the first months after the insertion. More in-depth, long-term prospective studies are needed in this patient group to determine risk factors for the occurrence of side effects and associated discontinuations, which should not, however, delay the wider use of the method in this group, given the number of advantages.

Indications and reasons for discontinuing the levonorgestrel-releasing intrauterine system (LNG-IUS)

Abstract Objectives: to identify the main indications and reasons for discontinuing the use of the Levonorgestrel-Releasing Intrauterine System (LNG-IUS). Methods: a cross-sectional study was carried out from medical records of 327 women who used the LNG-IUS 52mg between January 2011 and December 2016 at a public hospital in the Northeast of Brazil. Results: the main indications for the use of the LNG-IUS were: contraception (32.7%), myoma/metrorrhagia (28.7%) and endometriosis/pelvic pain (22.3%). Of the 327 women, 68 (20.8%) had discontinued using the device. The most frequent reasons for discontinuation were: expulsion (9.2%), LNG-IUS expiration (3.7%), bleeding (2.4%) and pain (1.5%). Most patients had no difficulty in the insertion and did not require anesthesia/sedation. Among the 30 women who expelled the device, 17 (56.7%) had used it for metrorrhagia and myoma, 8 (26.7%) for contraception, and 5 (16.6%) for endometriosis/pelvic pain. Conclusions: the LNG-IUS is a well-accepted contraceptive method, with therapeutic applications for some gynecological conditions and a low expulsion rate.

Providing Long-acting Reversible Contraception to Adolescents: A Review

Unintended teen pregnancy continues to be a problem in the United States which has the highest rate of adolescent pregnancy among developed nations. Long-acting reversible contraception (LARC) has much higher continuation rates compared with moderately effective reversible contraception; however, moderately effective reversible contraception is more commonly used by adolescents. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend LARC as first-line contraception for adolescents. Clinicians providing contraception to adolescents should be knowledgeable of LARC indications, side effects, initiation guidelines, management of adverse reactions, and adolescent specific issues regarding LARC counseling, initiation, and continuation.

Potential for Improving Intrauterine Device (IUD) Service Delivery Quality: Results from a Secondary Data Analysis

Background: To accelerate progress toward Family Planning 2020 (FP2020) goals, the government of India focused on improving the quality of intrauterine device (IUD) services. EngenderHealth, an international sexual and reproductive health and rights organization, has been supporting the governments of Gujarat and Rajasthan since 2014 through the Expanding Access to IUD Services in India (EAISI) project by building the capacity of service providers, monitoring compliance with standard practices, and strengthening health systems. This study sought to assess whether EAISI-trained providers offer higher quality IUD services than non-EAISI-trained providers, as indicated by a reduction in confirmed IUD complications.

Methods: The study team conducted an analytical cross-sectional study of secondary data collected from follow-up registers at 176 intervention facilities (38 in Gujarat and 138 in Rajasthan) during Phase I of the EAISI project. The analysis included follow-up clients who returned to the same facility between April 2018 and March 2019. We performed a multivariate logistic regression to determine factors associated with IUD complications.

Results: During the period of assessment, 56,733 clients received IUD insertions, and 10,747 (18.9%) clients returned for follow-up services. Of the returning clients, 49.4% (N=5,305) had received IUDs from EAISI-trained providers, while 50.6% (N=5,442) had received IUDs from non-EAISI-trained providers. A total of 4.0% (N=432) of all returning clients experienced complications (expulsion: 1.3%, missing strings: 1.7%, infection: 1.1%). Clients who received IUDs from non-EAISI-trained providers were 55.5% more likely (95% CI [26.2%, 91.5%], p<0.0005) to have experienced complications than clients who received insertions from EAISI-trained providers. The type of IUD, the timing of the insertion, and the timing of the follow-up visit also affected complication prevalence.

Conclusion: Our findings indicate that intensive, practical clinical skills training for IUD insertion can reduce the prevalence of complications.

"A Résumé for the Baby": Biosocial Precarity and Care of Substance-Using, Pregnant Women in San Francisco

In the United States, the historical condemnation and punitive legal consequences of substance use during pregnancy-ranging from incarceration to termination of parental custody of a newborn-render pregnant women in state of biosocial precarity. Yet pregnant women who use illicit substances who desire to parent must generate a legible narrative for bureaucratic groups, such as Child Protective Services, through engagement with biomedical care in order to demonstrate parental capacity. Based on longitudinal interviews with pregnant women who were actively using illicit substances and attempting to parent after delivery, we posit that the relationship between biosocial precarity and biomedical care is a procedural interaction that is rooted in the potential to parent, described as the ability to have a "take-home baby." In order to achieve this goal, the need for engagement in biomedical care and the creation of a biomedical narrative, described as a "résumé for the baby" is required. The relationship between care and biosocial precarity is a unique, underdeveloped concept within medical anthropology and has important consequences not only for the ethical turn within anthropology, but also how applied researchers consider engagement with this highly marginalized, vulnerable population.

Contraception for Adolescents

Although pregnancy and abortion rates have declined in adolescents, unintended pregnancies remain unacceptably high in this age group. The use of highly effective methods of contraception is one of the pillars of unintended pregnancy prevention and requires a shared decision making process within a rights based framework. Adolescents are eligible to use any method of contraception and long-acting reversible contraceptives, which are “forgettable” and highly effective, may be particularly suited for many adolescents. Contraceptive methods may have additional non-contraceptive benefits that address other needs or concerns of the adolescent. Dual method use should be encouraged among adolescents for the prevention of both unintended pregnancies and sexually transmitted infections. Health care providers have an important role to play in ensuring that adolescents have access to high quality and non-judgmental reproductive health care services and contraceptive methods in adolescent-friendly settings that recognize the unique biopsychosocial needs of the adolescent.

Real-world experience with the IUB Ballerine MIDI copper IUD: an observational, single-centre study in Israel

Objective: The aim of the study was to assess the acceptability of the intrauterine ball IUB Ballerine MIDI copper intrauterine device (IUD), using real-world data collected from users and physicians in Israel.Methods: In this retrospective, observational study, conducted in a single clinic in Israel, healthy women (n = 175) who had had the device inserted ≥12 months prior to enrolment, and their physician, completed questionnaires relating to device insertion, user experience and performance.Results: The mean age at insertion was 32.8 ± 6.7 years; most women were married (80.6%) and multigravid (89.1%). At the time of the study, 131 (74.9%) women were still using the device; in 13 cases (7.4%), premature removal was due to desire to conceive. The 12 month continuation rate, excluding the women seeking to conceive, was 90.1%. The expulsion rate was 3.4% (n = 6) and the pregnancy rate was 0.57% (n = 1). Most of the women still using the device reported no to moderate pain or cramps (90.0%) and moderate to high (72.6%) satisfaction with the device; 76.3% said they would recommend it to friends and relatives. Most of the insertion procedures (86.9%) were uneventful and none required cervical dilation.Conclusion: The IUB Ballerine MIDI raised no major safety concerns and was both effective and highly accepted in a cohort of women, covering a broad age range, treated in a gynaecology clinic in Israel.

Long-acting reversible contraceptive (LARCs) methods

Unplanned pregnancy (UP) is a public health problem, which affects millions of women worldwide. Providing long-acting reversible contraceptive (LARC) methods is an excellent strategy to avoid or at least reduce UP, because the effectiveness of these methods is higher than other methods, and is indeed comparable to that of permanent contraception. As the initial introduction of the inert plastic intrauterine device (IUD) and of the six-rod implant, pharmaceutical companies have introduced a copper IUD (Cu-IUD), different models of levonorgestrel-releasing intrauterine system (LNG IUS), and one and two-rod implants, which certainly improved women's LARC options. The main characteristic of LARCs is that they provide high contraceptive effectiveness with a single intervention, and that they can be used for a long time. Emerging evidence from the last few years has demonstrated that it is possible to extend the use of the 52 mg LNG IUS and of the etonogestrel-implant beyond five- and three years, respectively, which adds new value to these LARCs.

Contraception with the new intrauterine systems: a winning choice if shared!

Today the rate of unexpected pregnancy is still unacceptably high; long-acting reversible contraceptives, (LARC) seem to be an effective and modern solution. Intrauterine contraception (IUC) is the main exponent of the LARC and it is living a new exponential spread in the last years. Today IUC is the most widely used reversible contraceptive method and it is recommended by the major scientific gynecological societies. This review of the literature aims to retrace the history of intrauterine contraception and to focus attention on intrauterine systems (IUS), its last and most modern form. The three systems (LNG-IUS 52 mg; LNG-IUS 13.5 mg; LNG-IUS 19.5 mg) base their extraordinary effectiveness on the same mechanism of action, however they present some important differences that can be used to enhance and customize the treatment, not just contraceptive, based on the woman's needs.

K, O’Connell KA, Cagatay L, Sengupta S, Singal S. Could EAISI-trained providers provide better quality of IUD services? Results of a secondary data analysis of complications as a proxy indicator

Background: For accelerating its progress towards FP2020 goals, the Government of India has focused on improving the quality of intrauterine device (IUD) services. EngenderHealth has supported the Governments of Rajasthan and Gujarat since 2014 through its Expanding Access to IUD Services in India (EAISI) project by building the capacity of service providers, monitoring their compliance with standard practices, and strengthening health systems. This study sought to assess whether EAISI trained providers provide a better quality of IUD services as compared to non-EAISI trained providers, as indicated by a reduction in confirmed IUD complications? Methods: This study was an analytical cross-sectional study of secondary data collected from the follow-up registers of 176 intervention facilities (138 in Rajasthan and 38 in Gujarat) during Phase I of EAISI project. The analysis included clients who returned between April 2018 and March 2019 to the same facility for a follow-up visit. Multivariate logistic regression was performed to determine factors associated with IUD complications. Results: A total of 56,733 IUD insertions were conducted, and 10,747 (18.9%) client follow-ups were documented. Of these, 49.4% (N=5,305) clients received IUDs from EAISI-trained providers, while 50.6% (N=5,442) received IUDs from non-EAISI trained providers. A total of 4.0% (N=432) of clients experienced complications (Expulsion: 1.3%, Missing Strings: 1.7%, Infection: 1.1%). Clients who received IUDs from non-EAISI-trained providers were 55.5% more likely [95% CI (26.2%, 91.5%), p<0.0005] to have complications compared to clients who received insertions from EAISI-trained providers. Other significant factors include the type of IUD, timing of the follow-up visit and timing of the insertion. Conclusion: The findings demonstrate that intensive, hands-on training of providers to improve clinical skills for IUD insertions can have a positive impact on the reduction of post-insertion complications.

Contraception for midlife women: a review

Family planning represents a key component of reproductive health care. Accordingly, the provision of contraception must span the reproductive age spectrum, including perimenopause. The risk of pregnancy is decreased, but not trivial, among women over 40 years of age. Evidence-based guidelines for contraceptive use can assist clinicians in counseling their patients in this population. Intrauterine contraception is one of the most effective methods and is safe to use in midlife women with few exceptions. Progestin-only contraception is another safe option for most midlife women because it is not associated with an increased risk of cardiovascular complications. Combined (estrogen-containing) contraception can be safely used by midlife women who do not have cardiovascular risk factors. Unique noncontraceptive benefits for this population include: improvement in abnormal uterine bleeding, decreased hot flashes, and decreased cancer risk. Finally, guidelines state that contraception can be used by midlife women without medical contraindications until the age of menopause, at which time they may consider transition to systemic hormone therapy.

International Perspectives: IUDs and Adolescents

Unplanned or unwanted pregnancy among adolescents is a worldwide public health issue. In many countries unmarried young women are denied contraceptive services. Long-acting reversible contraceptive methods such as the intrauterine devices (IUDs) have been shown to be more effective than short-acting such as the pill, and safe also for adolescents. The popularity has varied a lot with time and between populations. Health care providers, health system, and user factors all influence IUD use. A good sexuality education through school provides a foundation, and health care providers give specific individual counseling. International and country-specific guidelines have been published during the past decade indicating the advantage of IUDs. New smaller size devices make placement easier for nulliparous adolescents. Still the uptake has remained rather low in most regions, cost being one barrier. Several municipalities have started to provide long-acting reversible contraceptive methods for adolescents free of charge, and this has led to a significant increase in IUD use, accompanied by a reduction in abortion rates. Adolescent-friendly services should offer low-cost or free contraception, including male and female condoms, emergency contraception, and a full range of modern methods, including long-acting reversible methods, according to adolescents' preferences and needs.

Real-world experience with the IUB Ballerine MIDI copper IUD: an observational study in the French-speaking region of Switzerland

Objective: The aim of the study was to assess the acceptability of the intrauterine ball IUB Ballerine MIDI copper intrauterine device (IUD), using real-world data collected from users and physicians. Methods: In this retrospective, observational study, conducted in the French-speaking region of Switzerland, healthy women (n= 207) who had had an IUB Ballerine MIDI inserted ≥12 months before enrolment, and their physicians completed questionnaires relating to device insertion, user experience and outcome. Questions relating to current menstrual patterns, physical comfort and product satisfaction were only posed to women still using the device. Results: The mean age at insertion was 30.8 ± 7.2 years, with an average 14.2 ± 2.9 month lapse from time of insertion until study commencement. At the time of the study, 140 (67.6%) women were still using the device. The expulsion rate was 5.3% (n= 11) and the pregnancy rate was 1.4% (n= 3). Most of the women still using the device reported no to moderate pain or cramps (80.7%). The majority of women reported moderate to high (65.7%) satisfaction with the device, with 81.4% claiming they would recommend it to friends and relatives. Over 84.8% of physicians reported that the device was easy to insert, with no difficulties encountered during the procedure. Conclusions: The IUB Ballerine MIDI was demonstrated to be safe and acceptable in different clinical settings and risk groups among a socioeconomically and demographically diverse study population.

K, O’Connell KA, Cagatay L, Sengupta S, Singal S. Could trained providers provide better quality of IUD services? Results of a secondary data analysis of complications as a proxy indicator

Background: For accelerating its progress towards FP2020 goals, the Government of India has focused on improving the quality of intrauterine device (IUD) services. EngenderHealth has supported the Governments of Rajasthan and Gujarat since 2014 through its Expanding Access to IUD Services in India (EAISI) project by building the capacity of service providers, monitoring their compliance with standard practices, and strengthening health systems. This study sought to assess whether EAISI trained providers provide a better quality of IUD services as compared to non-EAISI trained providers, as indicated by a reduction in confirmed IUD complications? Methods: This study was an analytical cross-sectional study of secondary data collected from the follow-up registers of 176 intervention facilities (138 in Rajasthan and 38 in Gujarat) during Phase I of EAISI project. The analysis included clients who returned between April 2018 and March 2019 to the same facility for a follow-up visit. Multivariate logistic regression was performed to determine factors associated with IUD complications. Results: A total of 56,733 IUD insertions were conducted, and 10,747 (18.9%) client follow-ups were documented. Of these, 49.4% (N=5,305) clients received IUDs from EAISI-trained providers, while 50.6% (N=5,442) received IUDs from non-EAISI trained providers. A total of 4.0% (N=432) of clients experienced complications (Expulsion: 1.3%, Missing Strings: 1.7%, Infection: 1.1%). Clients who received IUDs from non-EAISI-trained providers were 55.5% more likely [95% CI (26.2%, 91.5%), p<0.0005] to have complications compared to clients who received insertions from EAISI-trained providers. Other significant factors include the type of IUD, timing of the follow-up visit and timing of the insertion. Conclusion: The findings demonstrate that intensive, hands-on training of providers to improve clinical skills for IUD insertions can have a positive impact on the reduction of post-insertion complications.

Long-acting reversible contraceptives: Addressing adolescents' barriers to use

NPs caring for adolescent females have an opportunity to reduce US teen pregnancy rates through unbiased counseling on contraception options, including highly effective long-acting reversible methods. Intrauterine devices and subdermal implants are safe, effective contraception options for adolescents, but their rates of use remain low among this patient population. This article discusses current adolescent contraceptive practices, barriers to access, and current recommendations for long-acting reversible contraceptive use.

[Intrauterine contraception: CNGOF Contraception Guidelines]

OBJECTIVE

To provide national clinical guidelines focusing on intrauterine contraception.

METHODS

A systematic review of available literature was performed using Pubmed and Cochrane libraries. American, British and Canadian guidelines were considered as well.

RESULTS

Intrauterine contraception (IUC) displays a wide panel of indications, including adolescents, nulliparous, patients living with HIV before AIDS (Grade B) and women with history of ectopic pregnancy (Grade C). Cervical cancer screening should not be modified in women with IUC (Grade B). Bimanual examination and cervix inspection are mandatory before device insertion (Grade B). Patients should not systematically undergo screening for sexually transmitted infections (STI) before device insertion (Grade B). Screening for STI should be preferably done before insertion but it can be performed at the time of device insertion in asymptomatic women (Grade B). Routine antibiotic prophylaxis and premedication are not recommended before insertion (Grade A). A follow-up visit may be offered several weeks after insertion (Professional consensus). Routine pelvic ultrasound examination in not recommended after device insertion (Grade B). In patients with IUC, unscheduled bleeding, when persistent or associated with pelvic pain, requires further investigation to rule out complication (Professional agreement). Suspected uterine perforation warrants radiological workup to locate the device (Professional consensus). Laparoscopic approach should be preferred for elective removal of intrauterine device from abdominal cavity (Professional consensus). In case of accidental pregnancy with intrauterine device in situ, ectopic pregnancy should be excluded (Grade B). In case of viable and desired intrauterine pregnancy, intrauterine device removal is recommended if the strings are reachable (Grade C). Detection of Actinomyces-like organisms on pap smear in asymptomatic patients with intrauterine contraception does not require further intervention (Grade B). Immediate removal of intrauterine device is not recommended in case of STI or pelvic inflammatory disease (Grade B). Device removal should be considered in the absence of clinical improvement after 48 to 72 hours of appropriate treatment (Grade B).

CONCLUSION

Intrauterine contraception is a long-acting and reversible contraception method displaying great efficacy and high continuation rate. In contrast, complication rate is low. It should thus be offered to both nulliparous and multiparous women.

Levonorgestrel-releasing intra-uterine systems as female contraceptives

INTRODUCTION

The availability and use of long-acting reversible contraceptives (LARCs), such as levonorgestrel intrauterine systems (LNG-IUSs), have increased in recent times.

AREAS COVERED

The authors provide a narrative review of the LNG-IUSs currently available worldwide as female contraceptives (LNG-IUS 13.5, 19.5 and 52 mg). Specific features of the devices and their parameters of efficacy and tolerability were considered as outcomes.

EXPERT OPINION

The one-handed 3.8-mm-diameter inserter of LNG-IUS 13.5 mg and 19.5 mg may be particularly suitable in nulliparous women. While LNG-IUSs 13.5, 19.5 mg and LNG 52 mg should be used by women simply looking for an effective contraceptive method for up to 3, 4 or 5 years, LNG-IUS 52 mg has also been approved for the treatment of heavy menstrual bleeding and endometrial protection during hormone replacement therapy. LNG-IUS 52 mg is ideal for women who are experiencing a certain hyperestrogenic hormonal environment, with heavy menstrual bleeding due to hormonal imbalances, adenomyosis or fibroids, in the case of symptomatic endometriosis or for endometrial protection during hormone estrogenic replacement therapy in non-hysterectomized women.