Committee Opinion No 672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods

Best practices for reducing pain associated with intrauterine device placement

Intrauterine devices are highly effective, long-acting, reversible forms of contraception. Despite their benefits, limited uptake persists, particularly among underserved populations, adolescents, and young adults. While most intrauterine device placement procedures are uncomplicated, pain is commonly reported, with more severe pain reported in certain groups. No current standard of care has been established specifically to manage pain with intrauterine device placement, resulting in wide variation in clinical practice. This article aims to provide practical, evidence-based, and expert-informed guidelines for managing pain during intrauterine device placement. The authors (a group of board-certified obstetrician-gynecologists, pediatricians, and a family physician) conducted a virtual expert meeting to develop consensus-based recommendations for pain management. The meeting covered environmental considerations, nonpharmacological, and pharmacological options. Key strategies include using a person-centered care model that focuses on patient values, needs, and preferences to promote shared decision-making around pain relief. Clinicians should assist patients in setting realistic expectations, including a discussion of the placement procedure, anticipated pain, and all options for pain relief, to allow for a comprehensive informed consent process. Nonpharmacological interventions, such as the use of therapeutic language and comforting environmental, complementary and integrative, and mind-body elements, are recommended to reduce patient anxiety and discomfort. In terms of pharmacological options, clinicians may offer pre-procedural-specific nonsteroidal antiinflammatory drugs (eg, naproxen and ketorolac) and anxiolytics to patients with significant anxiety, as well as intraprocedural application of topical anesthesia and paracervical or intracervical blocks. Finally, additional techniques, such as using appropriately sized instruments and ensuring gradual and gentle procedural steps, can also help enhance patient comfort during insertion. These expert guidelines emphasize the importance of personalized, trauma-informed, and evidence-based care, prioritizing patient autonomy and preferences to facilitate a safe and acceptable insertion experience. They are critical to reducing barriers to intrauterine device uptake and improving overall patient outcomes.

Retained versus removed copper intrauterine device during pregnancy: An updated systematic review and meta-analysis

INTRODUCTION

Intrauterine devices (IUDs) are highly effective contraceptives. Despite their effectiveness, pregnancies can occur during IUD use, and the management of such cases, particularly when the pregnancy is desired, remains controversial.

MATERIAL AND METHODS

We conducted a systematic review and meta-analysis to evaluate outcomes in women who unintentionally conceived while using IUDs and chose to continue their pregnancies. We searched PubMed, Embase, and Cochrane databases to identify studies comparing women who removed their IUD after pregnancy discovery to those who retained it. The primary outcomes assessed were miscarriage, bleeding during pregnancy, and preterm delivery. Secondary outcomes included cesarean delivery, chorioamnionitis, congenital malformations, intrauterine growth restriction, preterm premature rupture of membranes, and stillbirth. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for the binary outcomes using random-effects models to account for variability across studies. The certainty of evidence was measured using the Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

From 3719 records, 4 cohorts were included. Among the 693 pregnant women analyzed, 402 had their IUD removed, while 291 retained the device. The analysis focused on copper IUDs, with most studies reporting removal during the first trimester and after ultrasound evaluation, although gaps in standardized reporting practices and removal methods were noted. Significant benefits were observed for the IUD-removed group, including reduced incidences of bleeding during gestation (OR 0.42; 95% CI 0.24 to 0.73; p < 0.01. Moderate certainty of evidence), and miscarriage (OR 0.29; 95% CI 0.17 to 0.48; p < 0.01. Moderate certainty of evidence). There was no significant difference in preterm delivery rates (OR 0.78; 95% CI 0.34 to 1.76; p = 0.55).

CONCLUSIONS

This meta-analysis, based on data from cohort studies with moderate certainty of evidence, indicates that removing an IUD after pregnancy diagnosis may reduce the odds of miscarriage and bleeding during gestation. However, further high-quality research is needed to evaluate outcomes in pregnancies associated with hormonal IUDs, as well as critical factors such as gestational age at diagnosis, timing of IUD removal, and the position of the gestational sac relative to the device.

Migrated intra-uterine device to infra-umbilical skin: a rare case report

INTRODUCTION

IUDs are effective, reversible and safe methods of contraception. The mechanism of action of IUDs as a group is inducing endometrial atrophy, apoptosis, altering tubal motility; preventing sperm permeability, fertilization, and implantation. Complications of IUD include menstrual disturbance, pelvic pain, and increased risk of ectopic pregnancy with contraceptive failure, device expulsion, uterine perforation or transmural migration with misplacement of the device. Pregnancies and IUD migration are uncommon complications, occurring in 1 to 2 from 1,000 users. The clinical presentation of migrated IUDs depends on the final anatomic location at diagnosis. Migration can be asymptomatic and incidentally found while imaging for any other diagnosis or may have various acute clinical presentations.

CASE PRESENTATION

We present the case of a 38-years-old Ethiopian woman with unusual migration of IUD to the infra-umbilical skin. She had infra-umbilical skin discoloration associated with intermittent itching for two months duration. On physical examination, there was diffuse violaceous patch over the infra-umbilical skin measuring 7 centimeters on its longest dimension and visible foreign body (IUD) with tiny sinus tract formation. Visible stem of copper-containing IUD was grasped by ring forceps and removed with gentle traction without complication during or following extraction. Removal of misplaced IUD with completely non-invasive manner makes this case special in addition to the unique site of migration to the infra-umbilical skin.

CONCLUSION AND RECOMMENDATION

To our knowledge, this is what likely to be the first reported case of IUD migration to the infra-umbilical skin which bestows a new finding to the existing literatures. Despite rare occurrence, possible IUD complications should be included in the informed consent process before insertion. Self-examination of the strings and vigilant evaluation at regular checkup is recommended for early detection of migrated IUDs.

Risk factors of uterine perforation when using contraceptive intrauterine devices

BACKGROUND

Intrauterine devices (IUDs) are one of the most popular methods of contraception, and uterine perforation has been presented among the most significant potential complications of IUD use. The aim of this study is to evaluate the risk factors of uterine perforation when using an IUD.

METHODS

In this retrospective study, all 164 women who have referred to Al-Zahra hospital in Tabriz- Iran to remove the retained IUD from March 2018 to March 2021, were investigated in two groups. Patients in case group underwent surgery to remove the dislocated device and management of its complications. In control group, the devices were removed using a Novak or ring forceps with or without hysteroscopy with no uterine perforation. Data were analyzed using SPSS software, and P < 0.05 was considered statistically significant. P-Value was obtained for qualitative data via Fisher's exact test and Chi-Squared test and for quantitative data via Mann-Whitney U test and independent T-test.

RESULTS

The mean age of patients in the groups with or without uterine perforation was 30.57 and 36.78 years respectively (P = 0.01). The frequency of two or more parities among patients with uterine perforation was higher than other patients (P = 0.13). Ultrasound study before (p = 0.037) and after (p = 0.007) IUD insertion was higher among patients without uterine perforation. The less inexperience of healthcare providers (P = 0.013) and lack of scheduled follow-up visits after the IUD insertion (P < 0.001), are the other important factors affecting the uterine perforation. Abdominal pain was the most common compliant of uterine perforation (P < 0.001) and laparoscopy was the most used surgery to remove the misplaced device.

CONCLUSION

Uterine perforation can be effectively prevented by hiring experienced health care providers and appropriate patient selection.

Intrauterine Contraceptive Device Migrated in the Urinary Tract: Case Report and Extensive Literature Review

The migration or translocation of an intrauterine device (IUD) in the urinary tract is a rare event. Here, we present the case of a 55-year-old woman who accidentally discovered the ectopic presence of an IUD following a radiological examination for pelvic pain caused by a lumbar discopathy. Over the years, the patient had several IUDs inserted without being able to specify which one had migrated. The removal of the IUD was performed laparoscopically with the minimum resection of the bladder wall and the subsequent cystorrhaphy. The evolution of the patient was favorable. To better analyze these events, we conducted an all-time extensive electronic search of the PubMed database and identified 94 eligible articles, with a total of 115 cases. The literature analysis on the IUD migrations shows either the simultaneous existence of the second IUD or of a maximum number of up to two IUD insertions during the life of patients. Thus, in the presented case, we identified five IUD insertions over time, which explained the chronic inflammatory process by forming an important mass of adherents that included the urinary bladder, uterus, omentum, sigmoid colon, and abdominal wall. Therapeutic management must be adapted to each case depending on the intra/extravesical location of the migrated IUD evaluated by imaging.

Early intrauterine pregnancy with an intrauterine device in place and terminated with spontaneous abortion: A case report

RATIONALE

The overall pregnancy rate in individuals with an intrauterine device (IUD) for contraception is <1%. If pregnancy occurs while an IUD is in place, there is a higher risk of an ectopic pregnancy. We report the case of a woman with an IUD who was 7 weeks pregnant and experienced a spontaneous abortion 1 week later.

PATIENT CONCERN

A 32-year-old woman presented to our outpatient department with intermittent vaginal staining for several days.

DIAGNOSES

She was 7 weeks pregnant and had an IUD in place for over 4 years. A vaginal examination revealed no vaginal bleeding and no blood clots; however, a parous cervix was observed. The IUD string was not visible. Transvaginal ultrasonography revealed a gestational sac in the uterine cavity, with a fetal pole and a crown-rump length of 11.4 mm. The fetal heart rate was 159 beats/min. The IUD was located in the retroplacental region. The bilateral adnexa appeared normal (right ovary, 2.9 cm; left ovary, 2.5 cm). The patient was diagnosed with an intrauterine pregnancy with an IUD in place and threatened abortion.

INTERVENTIONS

Attempts to remove the IUD were abandoned due to its location, and conservative treatment was initiated with Utrogestan (100 mg) administered 3 times a day for 1 week. Bed rest was advised.

OUTCOMES

Unfortunately, she experienced a complete abortion 1 week later.

LESSONS

The novelty of this case report lies in the rare occurrence of an intrauterine pregnancy with a long-term IUD in place, the challenges posed by the IUD's specific location, and the complex management of threatened abortion in this context. Our case highlights the diagnostic management approach for intrauterine pregnancy with an IUD in place. Furthermore, it explores the impact of IUD location on pregnancy prognosis.

CT imaging of intrauterine devices (IUD): expected findings, unexpected findings, and complications

Intrauterine devices (IUDs) are a commonly used form of long-acting reversible contraception, which either contain copper or levonorgestrel to prevent pregnancy. Although symptomatic patients with indwelling IUDs may first undergo ultrasound to assess for device malposition and complications, IUDs are commonly encountered on CT in patients undergoing evaluation for unrelated indications. Frequently, IUD malposition and complications may be asymptomatic or clinically unsuspected. For these reasons, it is important for the radiologist to carefully scrutinize the IUD on any study in which it is encountered. To do so, the radiologist must recognize that normally positioned IUDs are located centrally within the uterine cavity. IUDs are extremely effective in preventing pregnancy, though inadvertent pregnancy risk is higher with malpositioned IUDs. Presence of fibroids or Mullerian abnormalities may preclude proper IUD placement. Radiologists play an important role in identifying complications when they arise and special considerations when planning for an IUD placement. There is a wide range of IUD malposition, affecting IUDs differently depending on the type of IUD and its mechanism of action. IUD malposition is the most common complication, but embedment and/or partial perforation can and can lead to difficulty when removed. Retained IUD fragments can result in continued contraceptive effect. Perforated IUDs do not typically cause intraperitoneal imaging findings.

Pregnancy with retained intrauterine device: national-level assessment of characteristics and outcomes

BACKGROUND

Although intrauterine devices provide effective contraceptive protection, unintentional pregnancy can occur. Previous studies have shown that a retained intrauterine device during pregnancy is associated with adverse pregnancy outcomes but there is a paucity of nationwide data and analysis.

OBJECTIVE

This study aimed to describe characteristics and outcomes of pregnancies with a retained intrauterine device.

STUDY DESIGN

This serial cross-sectional study used data from the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population comprised 18,067,310 hospital deliveries for national estimates from January 2016 to December 2020. The exposure was retained intrauterine device status, identified by the World Health Organization's International Classification of Diseases, Tenth Revision, code O26.3. The co-primary outcome measures were incidence rate, clinical and pregnancy characteristics, and delivery outcome of patients with a retained intrauterine device. To assess the pregnancy characteristics and delivery outcomes, an inverse probability of treatment weighting cohort was created to mitigate the prepregnant confounders for a retain intrauterine device.

RESULTS

A retained intrauterine device was reported in 1 in 8307 hospital deliveries (12.0 per 100,000). In a multivariable analysis, Hispanic individuals, grand multiparity, obesity, alcohol use, and a previous uterine scar were patient characteristics associated with a retained intrauterine device (all P<.05). Current pregnancy characteristics associated with a retained intrauterine device included preterm premature rupture of membrane (9.2% vs 2.7%; adjusted odds ratio, 3.15; 95% confidence interval, 2.41-4.12), fetal malpresentation (10.9% vs 7.2%; adjusted odds ratio, 1.47; 95% confidence interval, 1.15-1.88), fetal anomaly (2.2% vs 1.1%; adjusted odds ratio, 1.71; 95% confidence interval, 1.03-2.85), intrauterine fetal demise (2.6% vs 0.8%; adjusted odds ratio, 2.21; 95% confidence interval, 1.37-3.57), placenta malformation (1.8% vs 0.8%; adjusted odds ratio, 2.12; 95% confidence interval, 1.20-3.76), placenta abruption (4.7% vs 1.1%; adjusted odds ratio, 3.24; 95% confidence interval, 2.25-4.66), and placenta accreta spectrum (0.7% vs 0.1%; adjusted odds ratio, 4.82; 95% confidence interval, 1.99-11.65). Delivery characteristics associated with a retained intrauterine device included previable loss at <22 weeks' gestation (3.4% vs 0.3%; adjusted odds ratio, 5.49; 95% confidence interval, 3.30-9.15) and periviable delivery at 22 to 25 weeks' gestation (3.1% vs 0.5%; adjusted odds ratio, 2.81; 95% confidence interval, 1.63-4.86). Patients in the retained intrauterine device group were more likely to have a diagnosis of retained placenta at delivery (2.5% vs 0.4%; adjusted odds ratio, 4.45; 95% confidence interval, 2.70-7.36) and to undergo manual placental removal (3.2% vs 0.6%; adjusted odds ratio, 4.81; 95% confidence interval, 3.11-7.44).

CONCLUSION

This nationwide analysis confirmed that pregnancy with a retained intrauterine device is uncommon, but these pregnancies may be associated with high-risk pregnancy characteristics and outcomes.

Pregnancy outcomes with a copper 380 mm2 intrauterine device in place: A retrospective cohort study in Turkey, 2011-2021

OBJECTIVES

To investigate pregnancy outcomes in patients with pregnancies with a copper 380 mm2 intrauterine device (IUD) in situ at conception.

STUDY DESIGN

In this retrospective study, we identified patients with pregnancies with a copper 380 mm2 IUD between 2011 and 2021 from the electronic health record system. According to their initial diagnosis, we classified the patients as having nonviable intrauterine pregnancies (IUPs), viable IUPs, or ectopic pregnancies. Among the viable IUPs, we divided the ongoing pregnancies into two subgroups as IUD-removed and IUD-retained. We compared the pregnancy loss (miscarriage before 22 weeks) rates and adverse pregnancy outcomes (at least one of preterm birth, preterm premature rupture of membranes, chorioamnionitis, placental abruption, or postpartum hemorrhage) of IUD-removed and IUD-retained pregnancies.

RESULTS

We identified a total of 246 patients with pregnancies with an IUD. We excluded six (2.4%) patients without follow-up data and seven (2.8%) patients with levonorgestrel-IUD and included the remaining 233 (44 [18.9%] ectopic pregnancy, 31 [13.3%] nonviable IUP, and 158 [67.5%] viable IUP) patients. Among the 158 women with viable IUP, 21 (13.3%) underwent abortion, leaving 137 (86.7%) who elected to continue the pregnancy. A total of 54 (39.4%) patients with ongoing pregnancy had the IUD removed. We found a lower rate of pregnancy loss among those who underwent removal (18/54 [33.3%]) compared to those with a retained IUD (51/83 [61.4%], p < 0.001). After accounting for pregnancy loss, adverse pregnancy outcomes remained increased in the IUD-retained group (17/32 [53.1%]) compared to the IUD-removed group (10/36 [27.8%], p = 0.03).

CONCLUSIONS

Pregnancy in the setting of a copper 380 mm2 IUD is high risk. Our results demonstrate that pregnancy outcomes improve by removal of the copper 380 mm2 IUD.

IMPLICATIONS

Prior studies have suggested that the removal of the IUD improves outcomes, but all have limitations. Our results from a very large series with care in a single institution provide contemporary evidence to support copper 380 mm2 IUD removal to reduce the risk of both early pregnancy loss and later adverse outcomes.

An Unusual, Delayed Presentation of a Migrated Intrauterine Contraceptive Device Into the Rectosigmoid Colon

The current literature suggests that serious complications after intrauterine contraceptive device (IUCD) insertion are rare. We present a rare case of a migrated IUCD into the rectosigmoid colon. A 33-year-old woman (parity one) presented to the emergency department with a three-day history of flank pain, upper urinary tract infection symptoms, and a low-grade fever. Differentials initially included renal colic or pyelonephritis. However, subsequent computed tomography of the kidneys, ureters, and bladder (CT-KUB) and magnetic resonance imaging of the pelvis (MRI-pelvis) showed a migrated IUCD posterior to the uterine body, with both ends closely abutting onto the adjacent proximal rectum. During further history-taking, she reported a past surgical history of an emergency caesarean section five years ago and the insertion of a copper-IUCD six weeks postnatally. She was subsequently referred to the gynaecologists. In view of the involvement of the bowels, the colorectal surgeons were consulted, and the patient was managed by a multidisciplinary team. The patient subsequently underwent diagnostic hysteroscopy, flexible sigmoidoscopy, diagnostic laparoscopy, removal of impacted IUCD, and repair of the rectum. Intraoperatively, her hysteroscopy noted a normal uterus with an intact cavity. Flexible sigmoidoscopy noted the horizontal arm of the IUCD abutting into the lumen of the rectosigmoid region; however, attempted removal with traction was unsuccessful. A partial rectotomy was done eventually to remove the IUCD. Migration of an IUCD is rare, with uterine perforation rates ranging from 0.04% to 0.2%. Albeit a rare complication, this case highlights the need for clinicians to be cognizant of complications arising from IUCD insertion, as symptoms are often non-specific and mild. This case also highlights the importance of a multidisciplinary discussion in the management of a migrated IUCD, which may include gynaecologists, colorectal surgeons, radiologists, and more. Many innovative ways were also discussed regarding the assessment of it, which includes preoperative imaging or endoscopic evaluation. Novel methods of removal of migrated IUCD in the rectosigmoid colon have also been proposed, including manual traction, proctoscopy, rigid sigmoidoscopy, and removal via a snare. They provide an alternative to the traditional diagnostic laparoscopy or laparotomy, thus reducing the need for general anaesthesia or operative intervention. Looking forward, long-term studies can be done to evaluate the need for intervention for asymptomatic patients where the risk of surgery may outweigh the benefits.

Ultrasound-guided repositioning technique for partially expelled intrauterine device: descriptive feasibility study

OBJECTIVE

To describe the feasibility of an ultrasound-guided repositioning technique for partially expelled intrauterine devices (IUDs) without use of sedation.

METHODS

This was a descriptive feasibility study of patients with a partially expelled IUD managed in our outpatient clinic from January 2016 to February 2020. The partially expelled IUDs (vertical arm extending partially or entirely through the cervical canal) were repositioned at the uterine fundus using Hartmann alligator forceps under ultrasound guidance. Paracervical or intracervical anesthesia and prophylactic antibiotics were not used. Data related to the procedure and 6-month follow-up were extracted from patient medical records. The primary outcome was the success rate of the repositioning procedure, defined as ultrasound confirmation of the entire IUD located above the internal os. Secondary outcomes included the retention and expulsion rates of the repositioned IUD at 6 months after the procedure and description of complications.

RESULTS

We included data from 55 women with a partially expelled IUD (35 levonorgestrel IUDs and 20 copper IUDs) referred for repositioning. Ultrasound-guided repositioning of the IUD was successful in 51 (92.7%) cases, while the procedure was not completed in four patients due to pain. Of the 55 procedures, 48 (87.3%) were performed by obstetrics and gynecology trainees under the supervision of a senior specialist. Among the 51 successfully repositioned IUDs, nine (17.6%) were expelled within 6 months after the procedure and six patients were lost to follow-up. No uterine perforation or infection-related complications occurred within 6 months of the procedure.

CONCLUSION

The ultrasound-guided repositioning technique appears to be a safe and feasible approach for partially expelled IUDs. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Reasons for Intent to Discontinue and Remove Long-Acting Reversible Contraceptives: National Survey of Family Growth 2017-2019

Background: Long-acting reversible contraceptives (LARCs) are highly effective forms of contraception, which can reduce the risk of unintended pregnancy. Despite LARC effectiveness, women may desire to discontinue this method. This study will examine reasons for intent to discontinue and remove LARCs among U.S. women 15-49 years of age from 2017 to 2019. Methods: The National Survey of Family Growth 2017-2019 was utilized with a sample of 6141 female respondents. Descriptive statistics for intention to discontinue LARCs, difficulty removing LARCs, and reasons for LARC discontinuation and removal were examined. Rao-Scott chi-square tests were conducted in SAS. Results: Overall, 22.9% of women reported ever using LARCs. Among LARC users, most women (81.2%) reported using LARC in the past 10 years. Among these women, 63.9% intended to discontinue LARCs, and 11.5% had difficulty removing LARCs. Reasons for wanting to discontinue LARCs include side effects (29.6%), LARC expiration (26.8%), LARC complications (19.3%), and decided to get pregnant (15.9%). Primary reasons reported for difficulty removing LARCs included: complications (68.3%), other reasons (13.4%), discouragement by provider (5.8%), and provider's inability to remove (4.9%). Conclusion: Given that women who use a LARC method rely on providers to remove this contraceptive method, understanding the reasons for discontinuation and difficulties encountered is needed. Findings from this nationally representative sample identified provider-level and system-level barriers for LARC removal. To respect the reproductive autonomy of LARC users' method for pregnancy prevention, these barriers must be overcome.

Streptococcal toxic shock syndrome in the setting of recent gynecologic surgery: A case report

Toxic shock syndrome (TSS) is an acute, toxin-mediated disease process which is commonly caused by Staphylococcus aureus or Streptococcus pyogenes. A high level of clinical suspicion is imperative, with prompt antibiotic therapy with a penicillinase-resistant penicillin (vancomycin in areas with increased methicillin-resistant Staphylococcus aureus) and clindamycin, given the high morbidity and mortality. Here, a case is reported of streptococcal-mediated TSS in a 37-year-old woman with a history of endometriosis, four days after a laparoscopic cystectomy; an intrauterine device (IUD) was left in situ at the time of uterine manipulation and not removed until hospital day 3 of the patient's readmission. Although no specific guidelines exist for removing IUDs, it is a foreign body and therefore it is recommended that early removal be considered regardless of the level of suspicion that it is the source of sepsis.

Factors associated with missing strings and expulsion after postplacental insertion of copper T380A intrauterine devices

OBJECTIVE

To identify clinical and demographic factors associated with missing strings and expulsion after postplacental insertion of copper T380A intrauterine devices (TCu380A IUD).

METHODS

This is a secondary analysis of an implementation study. We followed participants who had a postplacental TCu380A IUD insertion, at two postpartum visits: 45-90 days (visit 1) and 6-9 months (visit 2). We used multiple log-binomial regression models to evaluate the demographic and clinical variables associated with missing strings and with IUD expulsion.

RESULTS

We included 705 participants who had a postplacental IUD insertion. We observed missing strings in 275 (47.9%) participants at visit 1, and in 127 (34.2%) participants at visit 2. We identified 61 expulsions (8.9%) by visit 2. In the multiple regression models, only the delivery type was associated with missing strings and expulsion. Compared with vaginal delivery, cesarean delivery increased the risk of missing strings (adjusted relative risk [aRR] 6.21; 95% confidence interval [CI] 4.29-8.99) but reduced the risk of IUD expulsion (aRR 0.24; 95% CI 0.13-0.43).

CONCLUSION

The delivery mode was the only factor associated with missing strings and expulsion after postplacental IUD insertion. Cesarean section was associated with an increased risk of missing strings but decreased risk of expulsion after postplacental TCu380A IUD insertion.

Twelve-month Continuation of the Etonogestrel Implant in Adolescents With Polycystic Ovary Syndrome

STUDY OBJECTIVE

To identify why adolescents with polycystic ovary syndrome (PCOS) chose the etonogestrel (ENG) contraceptive implant, to determine the 12-month continuation rate, and to characterize factors related to discontinuation.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective chart review of adolescents seen at a tertiary care children's hospital between July 1, 2008, and August 30, 2019, with PCOS diagnosis confirmed per National Institutes of Health criteria and ≥12-month ENG follow-up.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Demographic characteristics, reasons for ENG insertion and removal, and information on other hormonal/contraceptive therapies were collected. Patients were categorized as ENG continuers (use ≥12 months) or discontinuers (removal at <12 months), and groups were compared.

RESULTS

A total of 96 patients met inclusion criteria (age 17.7 ± 2.2 years, body mass index 34.8 ± 8 kg/m²). Reasons for ENG were documented in 74% (51% contraception, 32% ease of use, 15% other, 13% estrogen avoidance). In all, 27% had never been sexually active, and 67% had had prior sexual activity. Treatments prior to ENG placement included 74% combined hormonal contraception, 20% medroxyprogesterone acetate withdrawal, and 17% depot medroxyprogesterone. A total of 77% continued ENG at 12 months. The main reasons for discontinuation were bleeding (41%), concern about weight gain (23%), and mood changes (18%). No preimplantation characteristics were independently predictive of continuation, although 100% of patients with type 2 diabetes (n = 11) continued. Patients who sought additional care, including telephone calls (41% vs 12%, P = .006) and clinic visits (64% vs 20%, P < .001) were more likely to discontinue.

CONCLUSIONS

The ENG implant was well tolerated in adolescents with PCOS and similar to published 12-month continuation rates.

Expulsion rate of intrauterine device: mediate vs. immediate puerperium period

Objective

To evaluate the rate of expulsion of intrauterine device (IUD) inserted during the immediate and mediate puerperium. To evaluate whether the type of delivery is a predictor of expulsion of the IUD when inserted in the puerperium period.

Material and Methods

This was a prospective observational study. Patients whose IUD (TCU-380 copper) was placed during the puerperal period were divided in two groups according to the time of placement: immediate and mediate puerperium. The decision regarding the time of IUD insertion was made in a non-randomized manner. Analysis was performed using chi-square, Mann-Whitney U, and Spearman’s correlation tests and logistic regression analysis.

Results

The total rate of IUD expulsions was 28.8% (49/170). There was no significant association between the occurrence of expulsion and the timing of IUD insertion (immediate vs mediate puerperium; 26.6% vs 34.78%, p=0.296). Among patients experiencing expulsion, 79.6% (39/49) underwent insertion after vaginal delivery and 20.4% (10/49) during cesarean section (CS). The type of delivery was a significant predictor for IUD expulsion (p<0.0001). Vaginal delivery was fourfold more likely to be associated with IUD expulsion inserted in the puerperal period than CS (odds ratio: 4.23, 95% confidence interval: 1.94-9.25). There was no significant correlation between the period between IUD insertion and the diagnosis of expulsion in regard to number of pregnancies (r=-0.160, p=0.271) or gestational age at delivery (r=-0.058, p=0.939).

Conclusion

Vaginal delivery was the most prevalent type of delivery in patients who underwent IUD insertion during the immediate and mediate puerperium. The risk of IUD expulsion after vaginal delivery was greater than CS.

Uterine dimensions and intrauterine device malposition: can ultrasound predict displacement or expulsion before it happens?

OBJECTIVE

Intrauterine devices (IUDs) are the most commonly used method of long-acting reversible contraception. IUD malpositions are described as expulsion, embedding, displacement, and perforation, which may cause contraception failure, organ injury, hemorrhage, and infection. The aim of the study was to evaluate the relationship between displacement and IUD positioning in the uterus, and uterine dimensions as measured using transvaginal ultrasonography.

MATERIALS AND METHODS

Three-hundred and eighty-four patients who had TCu380A devices inserted at a tertiary hospital were evaluated at insertion and at 1 month, 3 months, and 6 months after insertion. At the insertion visit, demographic characteristics, history of menorrhagia, dysmenorrhea, previous IUD displacement, and obstetric history were recorded. Transvaginal ultrasonographic measurement of the uterine cavity, uterine length, uterine width, cervix length, cervix width, transverse diameter of the uterine cavity, the distance between the tip of the IUD and the fundus, and endometrium were measured to evaluate IUD displacement.

RESULTS

Sixteen of 384 patients had displacement. There were significant differences in times between last pregnancy outcomes and IUD insertion and dysmenorrhea history (p = 0.004 and p = 0.028, respectively). Among TCu380A users, women with 7.5 mm IUD endometrium distances had a higher risk for displacement with a sensitivity of 81% and specificity of 37.5% (AUC: 0.607, 95% CI 0.51-0.70). Women with uterus width less than 41.5 mm were more likely to have displacement with a sensitivity of 53.8% and a specificity of 75% (AUC: 0.673, 95% CI 0.60-0.75).

CONCLUSION

IUD endometrium distance and uterus width are important parameters for displacement for TCu380A.

Long-acting reversible contraception side effect management

PURPOSE OF REVIEW

Long-acting reversible contraception (LARC) is increasingly used by adolescents and young adults (AYAs). Subsequent to LARC insertion, AYAs are presenting to their primary care providers with LARC concerns. This article seeks to equip primary care clinicians with the tools necessary to assess and manage common LARC-associated side effects.

RECENT FINDINGS

Side effects are common with progestin-only LARC, and can precipitate early discontinuation of an otherwise effective, low-maintenance form of contraception. Abnormal uterine bleeding, pelvic pain, acne, and weight change are often cited as progestin-only LARC side effects, yet the causes are poorly understood despite extensive research. While most side effects improve with time, therapeutic interventions are available for patients with undesirable side effects that prefer medical management. Research emphasizes the importance of proper patient counseling and clinical follow-up.

SUMMARY

Counseling remains essential in the management of LARC-associated side effects. However, options are available to temporarily mitigate such side effects and increase LARC satisfaction. While these therapeutic options are prescribed based on expert opinion, such regimens remain inadequately studied in AYA populations.

Long-Term Incidence of Infectious-Related Hospitalizations of Offspring Born to Mothers With Intrauterine Device: A Retrospective Population-Based Cohort Study

BACKGROUND

Pregnancy with an Intrauterine device (IUD) is a risk factor for adverse pregnancy outcomes. The purpose of this study was to examine a possible association between presence of IUD during pregnancy and long-term incidence of infectious-related hospitalizations of the offspring.

METHODS

A population-based cohort analysis was performed including all singleton deliveries between 1991 and 2014 at a single tertiary hospital. Primary exposure was defined as delivery of an infant to a mother who conceived with an IUD, that was either removed or retained during pregnancy. Offspring of mothers who conceived without an IUD comprised the comparison group. The main outcome evaluated was infectious-related hospitalizations of the offspring up to the age of 18 years.

RESULTS

The number of deliveries that met the inclusion criteria was 227,431, of which 209 were to mothers who conceived with an IUD that was removed and 52 were to mothers who retained their device. Long-term incidence of infections-related hospitalizations was compared between the groups (12.5% in the retained IUD, 12.9% in the removed IUD and 11.2% in the No-IUD group, P = 0.638). A Kaplan-Meier survival curve did not demonstrate a significantly higher cumulative incidence of infectious-related hospitalizations in offspring of women who conceived with an IUD (log-rank P = 0.340). In a Cox regression model, while controlling for confounders such as maternal age and preterm birth, conceiving with an IUD was not found to be independently associated with long-term incidence of infectious-related hospitalizations of the offspring.

CONCLUSION

Offspring of women conceiving with an IUD are not at increased risk for long-term incidence of infectious-related hospitalizations.

How Long-Acting Reversible Contraception Knowledge, Training, and Provider Concerns Predict Referrals and Placement

Context

Providing long-acting reversible contraception (LARC; eg, subdermal implants and intrauterine devices [IUDs]) can help mitigate rates of unintended pregnancy because they are the most effective reversible contraceptive methods. However, many varied barriers to LARC placement are reported. Medical education and training can be tailored if there is a better understanding of how barriers predict LARC referral and to predicting LARC placement.

Objective

To understand how a variety of key barriers to LARC placement are related to one another; to identify which of the barriers, when considered simultaneously, predict LARC referral and LARC placement; and to assess the barriers to LARC placement that persist, even when a major barrier, training, is removed.

Methods

We recruited providers (obstetricians and gynecologists, family physicians, pediatricians, internal medicine physicians, certified nurse practitioners, and certified nurse midwives) across the state of Ohio. Participants were compensated with a $35 Amazon gift card for completing an online survey comprising 38 Likert-type items, an 11-item knowledge test, LARC placement and referral questions, and demographic questions. We conducted data analyses that included correlations, odds ratios, and independent samples t tests.

Results

A total of 224 providers participated in the study. Long-acting reversible contraception knowledge, training, and provider concerns were correlated with one another. Training was found to positively predict placement and negatively predict referral when other barriers, such as knowledge and provider concerns, were considered simultaneously. Of providers who were trained to place implants, 18.6% (n=16) said they referred implant placement, and 17.4% (n=15) said they did not place implants. Of providers who were trained to place IUDs, 26.3% (n=26) said they referred IUD placement, and 27.3% (n=27) said they did not place IUDs. Those who referred placement and those who did not place LARCs reported greater barriers (in type and magnitude) to LARC placement than those who did place LARCs.

Conclusion(s)

Long-acting reversible contraception knowledge, training, and provider concerns about barriers to LARC placement were interdependent. Even when providers were trained to place LARCs, a significant portion referred or did not place them. Efforts to increase LARC placement need to address multifaceted barriers.

Vaginal misoprostol before copper IUD insertion after previous insertion failure: a double-blind, placebo-controlled, parallel-group, randomised clinical trial

Objective: The aim of the study was to assess whether vaginal administration of misoprostol before copper intrauterine device (IUD) insertion increased the success of the procedure among parous women with previous insertion failure. Methods: A single-centre, parallel-group, double-blind, placebo-controlled, randomised clinical trial was conducted at Ain Shams University Maternity Hospital, Cairo, Egypt, between October 2015 and August 2016. The study comprised 90 parous women undergoing TCu380A IUD insertion after a failed attempt. A computer-generated list of random numbers was used to assign participants to receive either misoprostol 200 μg or a placebo tablet, applied vaginally 10 h and 4 h prior to the second attempted IUD insertion, without ultrasound guidance. The primary outcome was the success of IUD insertion. Secondary outcomes were to establish the effect on insertion success of cervical dilation, cervical softening and previous mode of delivery. Results: Forty-two women (93.3%) in the misoprostol group and 24 women (53.3%) in the placebo group had a successful IUD insertion (p < .001). Cervical dilation was required in 24 women in the misoprostol group and 44 women in the placebo group. Misoprostol application significantly increased insertion success in women with previous caesarean delivery (p < .001) but did not affect insertion success in women with previous vaginal delivery (p = .481). Conclusion: Vaginal misoprostol before IUD insertion in parous women with previous insertion failure increased the rate of successful insertion, particularly in women with previous caesarean delivery.

Retained Intrauterine Device (IUD): Triple Case Report and Review of the Literature

Background

Throughout the world, intrauterine contraceptive devices (IUDs) are a frequently used, reversible, popular contraceptive method. They are usually placed without major complications. Uterine perforation is a rarely observed complication. Migration of the IUD to the pelvic/abdominal cavity or adjacent structures can occur after perforation. We present 3 cases of uterine perforation, possibly due to scarred myometrium associated with a cesarean delivery. We describe 3 perforations with IUDs lodged in the bladder serosa, the posterior cul-de-sac, and tissue adjacent to the cardinal ligament and external iliac artery.

Cases

 Case  1.  26-year-old, Gravid 4, Para 2113, nonpregnant female with a history of a cesarean delivery underwent placement of an IUD one year after an elective pregnancy termination, presenting with abdominal pain requesting removal of the IUD. On speculum, although the IUD strings were visualized, the IUD could not be removed. Sonogram imaging identified an empty endometrial cavity with the IUD in posterior cul-de-sac. The IUD was removed via laparoscopy.

Case  2

34-year-old Gravida 5, Para 4004, at 27 weeks and 3 days gestation, female with history of two previous cesarean deliveries underwent a third cesarean after spontaneous rupture of membranes with comorbid chorioamnionitis. Reproductive history was significant for placement of an IUD that had not been removed or imaged during obstetrical sonograms. The clinical evaluation revealed that the IUD had been spontaneously expelled. On the fifth operative day, the patient is febrile with CT demonstrating the IUD penetrating the anterior surface of bladder. On cystoscopy the bladder mucosa was intact. The IUD was removed via laparotomy with repair of the bladder, serosa, and muscular layer.

Case  3

26-year-old, Gravid 4, P3013, nonpregnant female with three previous Cesarean deliveries had an IUD in place. However, with the IUD in situ, the patient conceived and had a spontaneous abortion. After the spontaneous abortion, she presented to clinic to have the IUD removed due to pain that was present since placement. Although the IUD strings were visualized, attempts to remove it were unsuccessful. Imaging identified the IUD outside the uterine cavity. Palpation with a blunt probe laparoscopically revealed a hard object within the adhesion band, close to the cardinal ligament. As per radiology evaluation, IUD was embedded 1cm from the external iliac artery on the right side outside the uterus in the adnexal region. A multidisciplinary procedure with gynecologic-oncologist was scheduled for removal due to the high risk of perioperative bleeding.

Conclusion

Patients in whom uterine perforation and IUD migration are suspected should have appropriate evaluation that includes transvaginal or transabdominal ultrasound or radiographs to confirm the position of the IUD, regardless of whether they are asymptomatic or present with symptoms. It is particularly important in the presence of a scarred uterus that imaging is used to identify the location of a missing IUD. The uterine scar of a cesarean may facilitate migration of the IUD. Cross sectional imaging, such as CT or MRI scan, may be needed to rule out adjacent organ involvement before surgical removal.

Use of an Evidence-Based Guideline for Management of Side Effects from Long-Acting Reversible Contraceptives: A Quality Improvement Report

INTRODUCTION

Many health care providers believe that women who initiate long-acting reversible contraceptives (LARC) discontinue the method because of side effects too soon for the method to be economical. The purpose of this quality improvement project was to implement and evaluate an evidence-based telephone triage nursing guideline for management of side effects of LARC with an ultimate goal of reducing the number of early discontinuations.

PROCESS

A telephone triage guideline was adapted from the Contraceptive Choice Project's Clinician Call Back System, supplemented with evidence-based resources, and approved by clinicians at 2 community women's health and midwifery offices. Baseline retrospective data were collected on all women over the age of 18 who had LARC inserted at the 2 sites in the year prior to guideline implementation and in the 3 months after implementation. Rates of LARC removal at or before 3 months postinsertion, before and after guideline implementation, were evaluated.

OUTCOMES

Approximately 1 in 5 women called for help managing LARC side effects. Of the callers, 3 of 32 (9.4%) women receiving standard care discontinued their LARC prior to 3 months, whereas 0 of 24 women who were triaged using the guideline discontinued their LARC prior to 3 months (P = .12). Cramping, bleeding, and malposition or expulsion were the most common concerns and reasons for discontinuation.

DISCUSSION

Fewer women than anticipated called to report side effects, and even fewer chose to discontinue their LARC early. There were fewer discontinuations with guideline use, but this was not a statistically significant difference. Most women did not discontinue their LARC early for any reason, including side effects.

State-Identified Implementation Strategies to Increase Uptake of Immediate Postpartum Long-Acting Reversible Contraception Policies

BACKGROUND

In 2014, the Association of State and Territorial Health Officials (ASTHO) convened a multistate Immediate Postpartum Long-Acting Reversible Contraception (LARC) Learning Community to facilitate cross-state collaboration in implementation of policies. The Learning Community model was based on systems change, through multistate peer-to-peer learning and strategy-sharing activities. This study uses interview data from 13 participating state teams to identify state-implemented strategies within defined domains that support policy implementation.

MATERIALS AND METHODS

Semistructured interviews were conducted by the ASTHO team with state team members participating in the Learning Community. Interviews were transcribed and implementation strategies were coded. Using qualitative analysis, the state-reported domains with the most strategies were identified.

RESULTS

The five leading domains included the following: stakeholder partnerships; provider training; outreach; payment streams/reimbursement; and data, monitoring and evaluation. Stakeholder partnership was identified as a cross-cutting domain. Every state team used strategies for stakeholder partnerships and provider training, 12 reported planning or engaging in outreach efforts, 11 addressed provider and facility reimbursement, and 10 implemented data evaluation strategies. All states leveraged partnerships to support information sharing, identify provider champions, and pilot immediate postpartum LARC programs in select delivery facilities.

CONCLUSIONS

Implementing immediate postpartum LARC policies in states involves leveraging partnerships to develop and implement strategies. Identifying champions, piloting programs, and collecting facility-level evaluation data are scalable activities that may strengthen state efforts to improve access to immediate postpartum LARC, a public health service for preventing short interbirth intervals and unintended pregnancy among postpartum women.

Etonogestrel Implant-To Leave or Stay: A Case Series

Long-acting reversible contraception, which include etonogestrel subdermal hormonal implants, has high efficiency rates in preventing teen pregnancy. Although these numbers are increasing, teens have the lowest long-acting reversible contraception usage rate of any group, which the American Congress of Obstetricians and Gynecologists addressed with recommendations for Nexplanon placement for teens. The American Congress of Obstetricians and Gynecologists has recommended support for increased use and training of practitioners and pediatricians to gain momentum. Safety remains a concern as increased usage by practitioners and pediatricians may lead to more adverse outcomes. Despite the improvements to Nexplanon as a preloaded insertion device to prevent deep placement and malalignment, there are few known published adverse outcomes. Although different products, a review of the adverse outcomes reported with Norplant removal may closely reflect today's concerns with Nexplanon. The 3 case studies in this article are examples of similar adverse outcome with Nexplanon removal as those reported with Norplant.

LNG-IUS 12: a 19.5 levonorgestrel-releasing intrauterine system for prevention of pregnancy for up to five years

INTRODUCTION

Globally, intrauterine devices (IUDs) are the second most commonly used form of reversible contraception because of their high efficacy, safety, convenience and cost effectiveness. The levonorgestrel releasing intrauterine system with daily average release of 20 mcg (LNG-IUS 20) is the popular choice because of its favorable bleeding patterns and many noncontraceptive benefits. A three year (LNG-IUS 8) became available three years ago. More recently, the LNG-IUS 12 was added. This new IUD shares a smaller frame, narrow inserter and lower rate of amenorrhea with the LNG-IUS 8, but it offers the five years of contraceptive protection of the LNG-IUS 20. Areas covered: This article provides information on the contraceptive efficacy, safety and tolerability of this new IUS based on approximately 60,000 cycles of use. Where available, the impacts of subject age, parity and body mass index (BMI) on study outcomes are reported. Expert opinion: This new LNG-IUS 12 with mid-dose hormone levels, smaller frame and longer effective life fills a niche that may better meet the needs of women who might appreciate the narrow insertion tube and/or the lower rates of amenorrhea. Cost will ultimately help determine success.

Difficult removal of subdermal contraceptive implants: a multidisciplinary approach involving a peripheral nerve expert

OBJECTIVES

We aim to describe our experiences and identify patients who may benefit from referral to a peripheral nerve surgeon for removal of contraceptive subdermal implants in which neurovascular injury may occur, and describe a treatment pathway for optimal care.

STUDY DESIGN

We reviewed the charts of 22 patients who were referred to the Division of Family Planning for difficult removal of etonogestrel contraceptive implants between January 1, 2014, and April, 1 2016. Of these, five were referred to a peripheral nerve surgeon due to pain or location of the implant. We evaluated and described these cases and, from our findings, developed recommendations for care in a multidisciplinary team approach.

RESULTS

Two patients reported pain, including one with four previous failed removal attempts. In the two patients with pain, the implants were adherent to a sensory nerve. In another, the implant was within the biceps muscle and difficult to locate. In all cases, ultrasound imaging, general anesthesia and a wide exposure allowed for safe removal and good outcomes. Our multidisciplinary care approach has elucidated important referral and technical considerations that improve patient care and safety.

CONCLUSION

When necessary, multidisciplinary care with a Family Planning expert and possibly a peripheral nerve surgeon may be beneficial in safely removing etonogestrel contraceptive implants that would be difficult or risky to remove in an ambulatory setting.