A 52-mg levonorgestrel-releasing intrauterine system vs bipolar radiofrequency nonresectoscopic endometrial ablation in women with heavy menstrual bleeding: long-term follow-up of a multicenter randomized controlled trial

BACKGROUND

The symptom of heavy menstrual bleeding has a substantial impact on professional, physical, and social functioning. In 2021, results from a randomized controlled trial comparing a 52-mg levonorgestrel-releasing intrauterine system and radiofrequency nonresectoscopic endometrial ablation as treatments for women with heavy menstrual bleeding were published. Both treatment strategies were equally effective in treating heavy menstrual bleeding during 2-year follow-up. However, long-term results are also relevant for both patients and healthcare providers.

OBJECTIVE

This study aimed to assess long-term differences in reintervention risk and menstrual blood loss in women with the symptom of heavy menstrual bleeding treated according to a strategy starting with a 52-mg levonorgestrel-releasing intrauterine system or radiofrequency nonresectoscopic endometrial ablation.

STUDY DESIGN

This study was a long-term follow-up study of a multicenter randomized controlled trial (MIRA trial), in which women were allocated to either a 52-mg levonorgestrel-releasing intrauterine device (n=132) or radiofrequency nonresectoscopic endometrial ablation (n=138). Women from the original trial were contacted to fill out 6 questionnaires. The primary outcome was the reintervention rate after allocated treatment. Secondary outcomes included surgical reintervention rate, menstrual bleeding measured by the Pictorial Blood Loss Assessment Chart, (disease-specific) quality of life, sexual function, and patient satisfaction.

RESULTS

From the 270 women who were randomized in the original trial, 196 (52-mg levonorgestrel-releasing intrauterine system group: n=94; radiofrequency nonresectoscopic endometrial ablation group: n=102) participated in this long-term follow-up study. Mean follow-up duration was 7.4 years (range, 6-9 years). The cumulative reintervention rate (including both medical and surgical reinterventions) was 40.0% (34/85) in the 52-mg levonorgestrel-releasing intrauterine system group and 28.7% (27/94) in the radiofrequency nonresectoscopic endometrial ablation group (relative risk, 1.39; 95% confidence interval, 0.92-2.10). The cumulative rate of surgical reinterventions only was significantly higher among patients with a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system compared with radiofrequency nonresectoscopic endometrial ablation (35.3% [30/85] vs 19.1% [18/94]; relative risk, 1.84; 95% confidence interval, 1.11-3.10). However, the hysterectomy rate was similar (11.8% [10/94] in the 52-mg levonorgestrel-releasing intrauterine system group and 18.1% [17/102] in the radiofrequency nonresectoscopic endometrial ablation group; relative risk, 0.65; 95% confidence interval, 0.32-1.34). Most reinterventions occurred during the first 24 months of follow-up. A total of 171 Pictorial Blood Loss Assessment Chart scores showed a median bleeding score of 0.0. No clinically relevant differences were found regarding quality of life, sexual function, and patient satisfaction.

CONCLUSION

The overall risk of reintervention after long-term follow-up was not different between women treated according to a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system and those treated using a strategy starting with radiofrequency nonresectoscopic endometrial ablation. However, women allocated to a treatment strategy starting with a 52-mg levonorgestrel-releasing intrauterine system had a higher risk of surgical reintervention, which was driven by an increase in subsequent endometrial ablation. Both treatment strategies were effective in lowering menstrual blood loss over the long term. The results of this long-term follow-up study can support physicians in optimizing the counseling of women with heavy menstrual bleeding, thus promoting informed decision-making regarding choice of treatment.

Endoscopic management of migrated intrauterine device in the stomach

Ectopic intrauterine devices to the gastric wall are extremely rare and they can be managed by upper gastrointestinal endoscopy.

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.

Performance of a handheld point of care ultrasonography to assess IUD position compared to conventional transvaginal ultrasonography

OBJECTIVE

To compare the performance of the abdominal handheld point-of-care ultrasonography (POCUS) Butterfly-iQ to gold standard transvaginal ultrasonography (US) in identifying the position of intrauterine devices (IUDs) in the hands of a medical doctor specialised in ultrasonography.

METHODS

In this diagnostic accuracy study, a single operator conducted abdominal POCUS followed by conventional transvaginal US. Seventy patients utilising copper or hormonal IUDs were assessed between June 2021 and October 2022. IUDs were categorised as entirely within the uterine cavity or malpositioned. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for detecting malpositioned IUDs, with conventional US results serving as the reference standard. Concordance rate and Kappa coefficient were computed to assess the agreement between the two ultrasound modalities.

RESULTS

Among the 70 patients, 46 (65.7%) used copper IUDs, and 24 (34.3%) used hormonal IUDs. Conventional transvaginal US showed IUDs entirely within the uterine cavity in 56 (80%) patients and 14 (20%) IUDs were malpositioned. Of the 14 malpositioned IUDs seen by conventional US, POCUS identified 13 demonstrating a sensitivity of 92.9% (66.1-99.8). Of the 56 IUDs entirely within the uterine cavity shown by conventional US, only two cases were considered malpositioned by POCUS demonstrating a specificity of 96.4% (87.7-99.6). The concordance rate was 95.7%, and the Kappa value was 0.87 in differentiating between IUDs entirely within the uterine cavity and those that were malpositioned.

CONCLUSION

Abdominal POCUS using Butterfly-iQ, when administered by an imaging specialist, exhibited excellent performance in confirming IUDs entirely within the uterine cavity.

Association of Intrauterine Device Malposition With Previous Cesarean Delivery and Related Uterine Anatomical Changes

OBJECTIVES

We sought to determine the association between intrauterine device (IUD) malposition and previous cesarean delivery (CD) and related uterine anatomical changes.

METHODS

A retrospective cohort of all persons with an IUD presenting for two- and three-dimensional pelvic ultrasonography over 2 years, for any gynecologic indication, was compiled. IUD malposition was defined as IUD partially or completely positioned outside the endometrial cavity. Uterine position, uterine flexion, and cesarean scar defect (CSD) size were assessed. Patient characteristics and sonographic findings were compared between those with normally positioned and malpositioned IUD. Primary outcome was the rate of IUD malposition in persons with and without a history of CD. Logistic regression analysis was used to control for potential confounders.

RESULTS

Two hundred ninety-six persons with an IUD had a pelvic ultrasound, 240 (81.1%) had a normally positioned IUD, and 56 (18.9%) had a malpositioned IUD. The most common location of IUD malposition was low uterine segment and cervix (67.9%). Malpositioned IUD was associated with referral for evaluation of pelvic pain (P = .001). Prior CD was significantly associated with a malpositioned IUD, after adjusting for confounders (aOR 3.50, 95% CI 1.31-9.35, P = .01). Among persons with prior CD, uterine retroflexion and a large CSD were independent risk factors for IUD malposition (aOR 4.1, 95% CI 1.1-15.9, P = .04 and aOR 5.4, 95% CI 1.4-20.9, P = .01, respectively).

CONCLUSIONS

Prior CD is associated with significantly increased risk of IUD malposition. Among persons with previous CD, those with a retroflexed uterus and a large CSD are more likely to have a malpositioned IUD.

Hydronephrosis Due to Intraureteral Migration of Missed Intrauterine Device

Migration of intrauterine devices (IUDs) to the ureter causing ureteral obstruction is an extremely rare event. A 45-year-old female patient was admitted to our hospital with a complaint of pain in the right flank and inferior right quadrant of the abdomen. On genitourinary system ultrasonography, grade 3 hydronephrosis was found in the right kidney. On the abdominopelvic radiography, there was an appearance consistent with two IUDs, one in the region consistent with the course of the right distal ureter and the other in the usual localisation. The first IUD was thought to have spontaneously detached from the uterus, so a second IUD was implanted. A right-sided extravesical ureteroneocystostomy (Lich-Gregoir) operation was performed. The operation was terminated with the placement of a 4.8 French, 26 cm double-J stent in the ureter. The patient was followed up in our hospital for 26 months and she was asymptomatic during follow-up, hydronephrosis was resolved completely, and no complications were encountered during follow-up clinical and ultrasonography examinations.

Evaluating resectoscopy and the levonorgestrel intrauterine system for intermenstrual bleeding associated with cesarean scar defects: A retrospective study of treatment outcomes

AIM

To compare and evaluate the efficacy of the levonorgestrel-releasing intrauterine system (LNG-IUD) and resectoscopy remodeling procedure for intermenstrual bleeding associated with previous cesarean delivery scar defect (PCDS).

METHODS

A retrospective comparative study was conducted on patients with PCDS receiving LNG-IUD (levonorgestrel 20 μg/24 h, N = 33) or resectoscopy remodeling (N = 27). Treatment outcomes were compared over 1, 6, and 12 months. Outcomes in patients with a retroverted or large uterus size, defect size, and local vascularization also were evaluated.

RESULTS

At 12 months post-treatment, there were no significant differences between groups in efficacy rate; however, the reduction of intermenstrual bleeding days was higher in the LNG-IUD group than in the resectoscopy group (13.6 vs. 8.5 days, p = 0.015). Within the first year, both groups experienced a reduction in bleeding days, but the decrease was greater in the LNG-IUD group. Individuals exhibiting increased local vascularization at the defect site experienced more favorable outcomes in the LNG-IUD group than the resectoscopy group (p = 0.016), and who responded poorly tended to have a significantly larger uterus in the LNG-IUD group (p = 0.019). No significant differences were observed in treatment outcomes for patients with a retroverted uterus or large defect in either group.

CONCLUSIONS

Our findings support that the LNG-IUD is as effective as resectoscopy in reducing intermenstrual bleeding days associated with PCDS and can be safely applied to patients without recent fertility aspirations. Patients with increased local vascularization observed during hysteroscopy may benefit more from LNG-IUD intervention than resectoscopy.

Single-Visit Long-Acting Reversible Contraception Initiation Among Adolescents Before and During COVID-19

PURPOSE

Single-visit long-acting reversible contraception (LARC) is cost-effective and convenient. Our objective was to compare incidence of single-visit LARC placement and associated factors during the year before the COVID-19 pandemic (March 15, 2020) and the first year of the pandemic.

METHODS

This retrospective cohort study analyzed electronic health records from a large healthcare system. Eligible adolescents were aged 10-19 years and received outpatient LARC from March 15, 2019 to March 14, 2021. Logistic regression models determined the relationship of patient and provider characteristics on single-visit LARC before and during COVID-19.

RESULTS

One thousand six adolescents initiated LARC during the study period. Fewer adolescents received single-visit LARC during COVID-19 (289/506, 57.1%) compared to before (315/500, 63.0%), although changes in odds of single-visit LARC were not statistically significant. Concordance between county of patient residence and the location of the LARC placement facility was associated with single-visit LARC before (adjusted odds ratio [aOR] = 2.75) and during (aOR = 1.74) the pandemic (both p < .05). During the pandemic, a few factors were associated with reduced odds of single-visit LARC: (1) public insurance (aOR = 0.49, p < .01), (2) nonobstetricians/nongynecologists providers (pediatrics [aOR = 0.35, p < .01], family medicine [aOR = 0.53, p < .01], or internal medicine [aOR = 0.14, p < .05]), and (3) advanced practice practitioners (aOR = 0.49, p < .01).

DISCUSSION

Incidence of single-visit LARC was similar before and during the pandemic. Certain factors were associated with lower odds of single-visit LARC insertion, suggesting differential access during the pandemic for subgroups of adolescents. Our findings may guide policy and programmatic interventions to improve access to single-visit LARC for all adolescent populations.

Missed Diagnosis of Perforation and Intraperitoneal Migration of an Intrauterine Device and Its Management in a Resource-Limited Setting: A Case Report

Background

The intrauterine device is a popular and highly effective form of long-acting reversible contraception. Although generally safe, complications could happen. One of the most serious complications of intrauterine device use is uterine perforation. Risk factors for perforation include, but are not limited to, postpartum period, breastfeeding, levels of experience, and excessive force exerted during insertion. This case is significant because it demonstrates risk factors for uterine perforation, how to handle missing strings, and care in places with little resources.

Case Presentation

We discuss the case of a 27-year-old black Ethiopian woman who presented with chronic pelvic pain and had a perforated intrauterine device discovered in the cul-de-sac. The device had been inserted at six weeks postpartum. The client was unable to feel the strings three months after insertion, and a wrong diagnosis of expulsion was made. After one year of insertion, the intrauterine device was located on a plain abdominal radiograph and removed via laparotomy without complications.

Conclusion

Although uterine perforation is a rare complication of intrauterine device insertion, special attention should be paid to women with risk factors. In the absence of a witnessed expulsion, assessments and investigations should be carried out before declaring a device expelled. In patients with chronic pelvic pain complaints in the presence of an intrauterine device, perforation and migration outside the uterine cavity should be considered. Abdominal X-rays and laparotomies can be used to find and manage extrauterine migrating devices in environments with limited resources.

Case Report: Iatrogenic trauma of the bladder due to long-term unidentified intrauterine device malposition inside the bladder with rectovesical fistula

According to reports, there are 1.9-3.6 incidences of IUD migration and uterine perforation for every 1000 IUD insertions. It is important to note that bladder perforation caused by a misplaced IUD is uncommon and is thought to happen most frequently during insertion. Here, we describe a patient who presented with symptoms related to the malposition of IUD inside the bladder. It is feasible to draw the conclusion that the cystoscopy technique should be taken into consideration as a suitable therapy option for such injuries in this organ. When a problem cannot be effectively treated by cystoscopy alone, laparotomy should be considered.

Postpartum contraception: A matter of guidelines

The postpartum period is the perfect time to access family planning services. WHO guidelines contraindicate combined hormonal contraceptives postpartum in breastfeeding patients between 6 weeks and 6 months after delivery (Medical Eligibility Criteria category 3). On the contrary, the Faculty of Sexual and Reproductive Healthcare and the Centers for Disease Control and Prevention guidelines do not contraindicate their use in women who breastfeed from 6 weeks to 6 months postpartum. New combined hormonal contraceptives with natural estrogens have never been studied in this setting. Guidelines agree on the prescription of the progestin-only pill postpartum in non-breastfeeding women (category 1). Differences are found in women who breastfeed. In non-breastfeeding women, an implant is considered safe (category 1) by all guidelines, without any distinction in time. Regarding postpartum breastfeeding women, the guidelines for implants give quite different indications but are still permissive. Intrauterine devices are viable options for postpartum contraception but guidelines give different indications about the timing of insertion. Postplacental intrauterine device placement can reduce the subsequent unintended pregnancy rate, particularly in settings at greatest risk of not having recommended postpartum controls. However, it has yet to be understood whether this approach can really have an advantage in high-income countries. Postpartum contraception is not a 'matter of guidelines': it is the best customization for each woman, as early as possible but at the ideal timing.

Intrauterine devices are a safe form of contraception in users with solid organ transplantation: A single-center experience

Patients who undergo organ transplantation are advised to use contraception for health optimization, yet limited data exists on safe contraceptive options for this population. This study investigates the infection risk of intrauterine devices (IUDs) in patients who have received a solid organ transplant by evaluating the incidence of pelvic inflammatory disease (PID). We performed a retrospective chart review of subjects with a solid organ transplant who used an IUD between the years of January 2007 to February 2021. We included subjects ages 22-55 years at the time of IUD placement. We abstracted demographic information, transplant type, IUD type, immunosuppressive medications, screening for sexually transmitted infections, and diagnosis of PID. We identified 29 subjects that met the inclusion criteria. Six subjects had a copper IUD (21%) and 23 had a levonorgestrel IUD (79%). The most common organ transplanted was a kidney (n = 10) and liver (n = 10) while five subjects had multiple organs transplanted. Twenty-five (86.2%) subjects took immunosuppressive medications at the time of IUD insertion. Twenty-four (82.8%) patients had their IUD placed after transplantation. The average time of IUD use was 2.5 years. . In our study of IUD use in patients with solid organ transplantation, no patients developed PID. IUDs are a safe contraceptive option for immunosuppressed transplant patients.

Asymptomatic fetal bone retention detected 12 years after termination of pregnancy: case report

Intrauterine retention of fetal bone fragments is a rare complication that can be seen after pregnancy termination, especially in advanced gestational weeks. Here, we present a case of intrauterine fetal bone retention detected during routine gynecological examination in an asymptomatic woman whose pregnancy was terminated 12 years ago. Under local anesthesia and ultrasound guidance, the fetal bone was removed with a grasper. This case report highlights the importance of post-curettage ultrasound examination to ensure that no fetal tissue is left behind after termination of pregnancy.

An Integrative Review of Extended Use of Intrauterine Devices

OBJECTIVE

To explore the evidence on the impact of extended use of intrauterine devices (IUDs) use among women of reproductive age.

DATA SOURCES

Electronic resource databases used were PubMed, CINAHL, and Google Scholar. Peer-reviewed articles published during 2012 to 2022 were considered.

ARTICLE SELECTION

Ten articles met the criteria and included data for a total of 7,420 women.

DATA EXTRACTION

Data were extracted from each study using the subheadings "Author/Date," "Participants," "Methods," "Interventions," and "Outcomes." Additionally, the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used to guide data extraction.

DATA SYNTHESIS

Common themes were identified among each of the articles that supported the purpose of this integrative review, such as adverse effects, perceived effectiveness, pregnancy prevention, and cost effectiveness of extended use of IUDs.

CONCLUSION

The available evidence supports the notion that extending IUD use beyond the original time frame approved by the U.S. Food and Drug Administration is safe and effective with minimal side effects. However, there remains a paucity of evidence examining this topic.

In Situ Photo Responsive Biodegradable Nanoparticle Forming Intrauterine Implant for Drug Delivery to Treat Ovarian Diseases: A Rationale-based Review

BACKGROUND

Ovarian disease constitutes various types of endocrine disorders, such as polycystic ovarian syndrome (PCOS), ovarian cancer, premature ovarian failure, ovarian endometriosis, and ovarian cysts. The prevalence of ovarian-related diseases is highly vulnerable in the world. The utility of various drug delivery systems for ovarian diseases has resulted in varied success. Moreover, most of them lead to severe adverse effects and are incapable of ameliorating the signs and symptoms of the condition.

HYPOTHESIS

Intrauterine devices (IUDs) have positioned themselves as a mechanism to deliver the drug for various ovarian-related diseases. Thereby avoiding various stability-related issues arising due to various physiological barriers of the female reproductive tract. However, the use of intrauterine devices for drug delivery to the ovaries has not been fully explored. This is attributed to the fact that they cause cysts in the ovaries and skepticism among patients and physicians. Photo-sensitive devices are an appealing approach for managing disorders affecting the ovaries. Photo-sensitive in situ forming intrauterine implants (IUIs) have several advantages, including simplicity in application, reduced invasiveness, as well as improved site-specific drug release control. Polymeric nanoparticles (PNPs) loaded with a drug may be a suitable choice to provide sustained release, alter the pharmacokinetics, and reduce the dose and dosing frequency.

CONCLUSION

The current manuscript hypothesizes the utility of a PNP-loaded biodegradable photo-responsive intrauterine implantable device as an alternate novel strategy for ameliorating ovarian-related diseases.

Outcomes of Intrauterine Device Insertion by Certified Midwives and Obstetric Nurse Practitioners

OBJECTIVES

to evaluate the outcomes of Interval Copper Intrauterine Device (IUD) insertion performed by certified midwives and obstetric nurse practitioners at a Peri-Hospital Birth Center.

METHODS

a cross-sectional study was conducted involving 75 women who underwent IUD insertion between January 2018 and February 2020. Data collection was carried out using medical records and telephone interviews.

RESULTS

no instances of uterine perforation were observed. Expulsion rates of the devices were 1.3% within 30 to 45 days of use and 5.3% within the first year of use. The follow-up removal rate was 4.0%. The average pain score reported was 4.2 (SD = 3.3). Among those who continued using the device, 93.1% expressed satisfaction.

CONCLUSIONS

the findings demonstrate that IUD insertion by certified midwives and obstetric nurse practitioners is a safe procedure, yielding outcomes comparable to those reported in the existing literature.

Bilateral Pyosalpinx Due to a 16-Year-Old Intrauterine Device Presented as Appendicitis

Pyosalpinx is the collection of pus in the fallopian tube. Pyosalpinx usually follows pelvic inflammatory disease, sexually transmitted disease, or rarely non-sexually transmitted infection. This is the first-ever report of bilateral pyosalpinx due to intrauterine device in situ for the past 16 years, which presented as appendicitis. Pyosalpinx should be considered in female patients with lower abdominal pain.

Intrauterine device experience in lesbian, gay, bisexual, queer, pansexual, and asexual cisgender women

Providers should not overlook counseling LGBQPA cisgender women about the benefits of an IUD given their risk of unplanned pregnancy and desire for menstrual suppression.

[Migration of an intrauterine contraceptive device outside of the uterine cavity - a case report]

Intrauterine devices (IUDs) are a safe and common form of contraception. Uterine rupture and migration of the IUD is a rare complication of insertion but can be serious and cause damage to adjacent organs. We present a case report of a 43 year old woman with chronic abdominal pain who was diagnosed with an IUD in the wall of the sigmoid colon. That IUD had been inserted in the uterine cavity 22 years earlier.

Postpartum long-acting reversible contraceptive use among active-duty, female US Army soldiers

BACKGROUND

Postpartum use of long-acting reversible contraception has been found to be effective at increasing interpregnancy intervals, reducing unintended pregnancies, and optimizing health outcomes for mothers and babies. Among female active-duty military service members, reproductive planning may be particularly important, yet little is known about postpartum long-acting reversible contraceptive use among active-duty soldiers.

OBJECTIVE

This study aimed to (1) quantify postpartum uptake of long-acting reversible contraception among active-duty female US Army soldiers and (2) identify demographic and military-specific characteristics associated with use.

STUDY DESIGN

This retrospective cohort study used longitudinal data of all digitally recorded health encounters for active-duty US Army soldiers from 2014 to 2017. The servicewomen included in our analysis were aged 18 to 44 years with at least one delivery and a minimum of 4 months of total observed time postdelivery within the study period. We defined postpartum long-acting reversible contraception use as initiation of use within the delivery month or in the 3 calendar months following delivery and identified likely immediate postpartum initiation via the proxy of placement recorded during the same month as delivery. We then evaluated predictors of postpartum long-acting reversible contraception use with multivariable logistic regression.

RESULTS

The inclusion criteria were met by 15,843 soldiers. Of those, 3162 (19.96%) initiated the use of long-acting reversible contraception in the month of or within the 3 months following delivery. Fewer than 5% of these women used immediate postpartum long-acting reversible contraception. Among women who initiated postpartum long-acting reversible contraceptive use, 1803 (57.0%) received an intrauterine device, 1328 (42.0%) received an etonogestrel implant, and 31 received both (0.98%). Soldiers of younger age, self-reported White race, and those who were married or previously married were more likely to initiate long-acting reversible contraception in the postpartum period. Race-stratified analyses showed that self-reported White women had the highest use rates overall. When compared with these women, the adjusted odds of postpartum use among self-reported Black and Asian or Pacific Islander women were 18% and 30% lower, respectively (both P<.001). There was also a trend of decreasing postpartum use with increasing age within each race group. Differences observed between age groups and race identities could partially be attributed to differential use of permanent contraception (sterilization), which was found to be significantly more prevalent among both women aged 30 years or older and among women who identified as Black.

CONCLUSION

Among active-duty US Army servicewomen, 1 in 5 used postpartum long-acting reversible contraception, and fewer than 5% of these women used an immediate postpartum method. Within this population with universal healthcare coverage, we observed relatively low rates of use and significant differences in the uptake of effective postpartum long-acting contraceptive methods across self-reported race categories.

Googling long-acting reversible contraception: A scoping review examining the information available online about intrauterine devices and contraceptive implants

ISSUE ADDRESSED

The internet is an important source of health information, however, the quality of information about long-acting reversible contraception (LARC, including intrauterine devices (IUDs) and contraceptive implants) found online is largely unknown.

METHODS

A scoping review of webpages returned in a Google search was conducted. The first three pages of results were included if they were written in English and contained information about LARC. Results were critically reviewed and assessed using the DISCERN quality of health information tool.

RESULTS

Of 778 results, 306 pages met the eligibility criteria. While most webpages provided key information about LARC, including location in the body, benefits, side effects and risks, the information provided varied considerably. Only half mentioned efficacy and many webpages did not provide information about the cost of insertion and removal, how and where to access the devices or how they work. Despite side effects being mentioned in more than three-quarters of webpages, the depth and specificity of these varied considerably and were often contradictory across different webpages.

CONCLUSIONS

Most webpages provided medically accurate information to consumers; however, many did not include key information such as cost or how they work. Descriptions of side effects varied between webpages, and this may inhibit informed decision-making. SO WHAT?: Most people make decisions about what contraceptive method they might like to use before visiting a health care provider, and most will get this information from the internet. Providing comprehensive, medically accurate and consistent information about both IUDs and contraceptive implants is vital to support informed decision-making.

Association between intrauterine device use and endometrial, cervical, and ovarian cancer: an expert review

The intrauterine device is one of the most effective forms of contraception. Use of the intrauterine device has increased in the United States over the last 2 decades. Two formulations are commercially available in the United States: the levonorgestrel-releasing intrauterine device and the copper intrauterine device. The levonorgestrel intrauterine device releases progestin, causing endometrial suppression and cervical mucus thickening, whereas the primary mechanism of action of the copper intrauterine device is to create a local inflammatory response to prevent fertilization. Whereas the protective effects of combined hormonal contraception against ovarian and endometrial cancer, and of tubal sterilization against ovarian cancer are generally accepted, less is known about the effects of modern intrauterine devices on the development of gynecologic malignancies. The best evidence for a protective effect of intrauterine device use against cancer incidence pertains to levonorgestrel intrauterine devices and endometrial cancer, although studies suggest that both copper intrauterine devices and levonorgestrel intrauterine devices reduce endometrial cancer risk. This is supported by the proposed dual mechanisms of action including both endometrial suppression and a local inflammatory response. Studies on the relationship between intrauterine device use and ovarian cancer risk show conflicting results, although most data suggest reduced risk of ovarian cancer in intrauterine device users. The proposed biological mechanisms of ovarian cancer reduction (foreign-body inflammatory response, increased pH, antiestrogenic effect, ovulation suppression) vary by type of intrauterine device. Whereas it has been well established that use of copper intrauterine devices confers a lower risk of cervical intraepithelial neoplasms, the effect of levonorgestrel intrauterine device use on cervical cancer remains unclear. Older studies have linked its use to a higher incidence of cervical dysplasia, but more recent literature has found a decrease in cervical cancer with intrauterine device use. Various mechanisms of protection are postulated, including device-related inflammatory response in the endocervical canal and prostaglandin-mediated immunosurveillance. Overall, the available evidence suggests that both levonorgestrel intrauterine devices and copper intrauterine devices reduce gynecologic cancer risk. Whereas there is support for the reduction of endometrial cancer risk with hormonal and copper intrauterine device use, and reduction of cervical cancer risk with copper intrauterine device use, evidence in support of risk reduction with levonorgestrel intrauterine device use for cervical and ovarian cancers is less consistent.

[Intrauterine Device Totally Embedded in the Bladder Wall:Report of One Case]

Intrauterine device(IUD)migrating to the bladder is rare,especially the migration far away from the uterus into the bladder wall.Due to no obvious clinical symptom in the early stage and being far away from the uterus,the IUD totally embedded in the bladder wall is prone to misdiagnosis and delay in treatment.We reported one case of such migration,aiming to improve the clinical management of the IUD totally embedded in the bladder wall.

Discontinuation Rate of Intrauterine Device and Associated Factors Among Women in the Last One Year in Angacha District, Southern Ethiopia

Background

Discontinuation of intrauterine contraceptive device is the phenomenon of starting a contraceptive method and then ending it within one year of its use. Discontinuation of an intrauterine contraceptive method often leads to unintended pregnancy; this tips to potentially unsafe abortions and unintended births. Even though Ethiopian government gives an attention to long acting reversible contraceptives, especially IUCD, there are no recent studies conducted in the study area. Thus, this study aimed to assess the discontinuation rate of IUCD and associated factors among women in the last one year in Angacha District, southern Ethiopia.

Methods

A community-based cross-sectional study was conducted from June 22 to July 22, 2020. Multistage sampling was used to select a total of 596 women who used IUCD during the last year in the Angacha district. Data were collected using pre-tested structured questionnaires. The collected data were entered into Epidata version 3.1 and exported to SPSS version 23 for analysis. Multivariate logistic regression analysis was carried out to identify factors independently associated with discontinuation IUCD. The significance level was set at a p-value of <0.05 and AOR with 95% CI was used to interpret the association.

Results

In this study, 116(19.5%) women discontinued the use of IUCD in the last year with a 95% CI of 16.3%-22.5%. Counseling before IUCD insertion [AOR (95% CI) = 2.5(1.03, 6.03)], marital status [AOR (95% CI) = 0.23(0.08, 0.69)], access to IUCD service [AOR (95% CI) = 0.29(0.12, 0.72)], and parity [AOR (95% CI) = 3.69(1.97, 8.84)] were significant with discontinuation of IUCD.

Conclusion

The overall magnitude of IUCD discontinuation in the study area was found to be high. Counseling before IUCD insertion and parity were positively associated while marital status of mothers and access to IUCD services were negatively associated with the discontinuation of IUCD.

Does Ultrasound Guidance Provide Pain Relief During Intrauterine Contraceptive Device Insertion? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To evaluate ultrasound guidance effect in pain relief during intrauterine device (IUD) insertion.

METHODS

Four different databases were searched from inception till June 2022. We selected randomized controlled trials (RCTs) that compared transabdominal ultrasound guidance versus traditional non-guided IUD insertion among women undergoing IUD placement for contraception. We used Revman software during performing our meta-analysis. Our primary outcome was the pain score during IUD insertion as evaluated by the Visual Analog Scale (VAS). Our secondary outcomes were the procedure insertion time, satisfaction, and incidences of complications and misplaced IUDs.

RESULTS

Seven RCTs were retrieved with a total number of 1267 patients. There was a significant reduction in the VAS pain score during IUD insertion among the ultrasound-guided group (MD = -1.91, 95% CI [-3.08, -0.73], P = .001). The procedure insertion time was significantly shorter within the ultrasound guidance group compared with the control group (MD = -1.35, 95% CI [-1.81, -0.88], P < .001). Moreover, more women were significantly satisfied with the procedure among the ultrasound-guided group (P < .001). In addition, ultrasound-guided IUD insertion was linked to significant decline in incidences of complications and misplaced IUDs.

CONCLUSION

Ultrasound guidance can be used as a modified technique during IUD insertion as it decreases pain, procedure time, and rates of complications and misplaced IUDs with better patient satisfaction.

Risk factors for intrauterine device embedment in postmenopausal women: an analysis of 731 participants undergoing hysteroscopy

OBJECTIVE

This study aimed to explore the risk factors for intrauterine device (IUD) embedment in postmenopausal women.

METHODS

A total of 731 women who underwent hysteroscopy for IUD removal from January 2019 to December 2021 were included in the trial, of whom 301 were diagnosed with IUD embedment (embedded group) and 430 had a normal IUD location (control group). The following data were collected from electronic medical records: demographic traits, ultrasound findings, IUD shapes, uterine features, and hysteroscopy findings. Bivariate contingency analysis and multiple logistic regression were performed to identify the significant independent variables that affect IUD embedment.

RESULTS

Prior IUD removal failure (14.3% vs 5.1%; adjusted odds ratio [aOR], 3.29; 95% CI, 1.90-5.71) and V-shaped IUD (18.9% vs 10.7%; aOR, 2.05; 95% CI, 1.33-3.16) were risk factors that were independently linked with IUD embedment. Uterine volume (22.7 [20.9-24.5] cm 3 vs 27.9 [24.8-30.9] cm 3 ; aOR, 0.99; 95% CI, 0.982-0.999) was negatively linked with IUD embedment. There were no differences in age, parity, menopause length, years with an IUD in situ, uterine position, or abortion times between the two groups. There were no differences in existing leiomyoma, prior cervical LEEP (loop electrosurgical excision procedure), or myomectomy between the two groups.

CONCLUSIONS

Prior IUD removal failure, V-shaped IUD, and a smaller uterine volume were risk factors for IUD embedment in menopausal women.

Chronic Urticaria Suspected to be Caused by a 13.5 mg Levonorgestrel Intrauterine Device (Skyla®)

Chronic urticaria (CU) is a hive-like rash lasting over six weeks. Common associations include low vitamin D, thyroid autoantibodies, and Helicobacter pylori (H. pylori) infection, among others. Progesterone has been documented to trigger CU, by endogenous or exogenous progesterone. The use of intrauterine devices (IUDs) has been a popular source of birth control, with many containing progesterone. Although rarely reported, some patients have been seen to have an urticarial reaction after implantation of an IUD. Here, we present a case of a patient with progesterone-induced chronic urticaria, likely triggered by implantation of a 13.5 mg intrauterine device implant (Skyla®, Bayer, Whippany, NJ, USA). To the best of our knowledge, this is the first case to report the association between Skyla® and chronic urticaria.

Association of Opioid Use Disorder and Provision of Highly Effective Inpatient Postpartum Contraception

We sought to examine the rates of the inpatient provision of postpartum long-acting and permanent methods (IPP LAPM) of contraception in patients with opioid use disorder (OUD). This is a retrospective cross-sectional regression analysis of the National Inpatient Sample between 2012 and 2016. Patients with a diagnosis of OUD that delivered and received postpartum permanent contraception or long acting reversible contraception placement during the same hospitalization were identified. Regression analyses were performed to identify the demographic and clinical factors associated with long acting and permanent contraception method utilization. Of the 22,294 patients with OUD who delivered during the study period, 2291 (10.3%) received IPP LAPM. The majority of patients (1989) (86.6%) with OUD who chose inpatient provision of long acting or permanent methods after delivery received permanent contraception. After adjusting for covariates, patients with OUD had an overall decreased probability of receiving IPP LAPM (aOR=0.89, 95% CI: 0.85-0.95), decreased probability of receiving permanent contraception (aOR: 0.82, 95% CI: 0.78-0.88), but an increased probability of receiving long-acting reversible contraception (aOR: 1.29, 95% CI: 1.04-1.60) compared to patients without OUD. This study highlights the continued need to ensure appropriate measures (such as antepartum contraceptive counseling, availability of access to inpatient LAPM, and removal of Medicaid policy barriers to permanent contraception) are in place so that the contraceptive needs of patients with OUD are fulfilled.

A mixed-method study

INTRODUCTION

An intrauterine device (IUD) is a highly effective long-acting and reversible contraceptive method widely available around the world. However, only a small proportion of women in developing countries, including Ethiopia, are currently using the method. Therefore, this study aimed to identify why IUD utilization is low in southwestern Ethiopia.

MATERIAL AND METHODS

A mixed-method study involving health facilities and communities was conducted. The focus group discussions and key informant interviewees for the qualitative study were selected purposively, whereas 844 women family planning users were selected using systematic random sampling from November 1-30, 2020. Quantitative data was collected using Open Data Kit and analyzed using Stata version 16.0. Multivariable logistic regression analyses were done to identify significant factors influencing IUD use. The qualitative data were tape-recorded, transcribed, and finally, thematic analyses were done.

RESULTS

A total of 784 participants were involved in the study yielding a response rate of 92.9%. Among all respondents, only 1.3%, 2.4%, and 30.0% had been using an IUD, preferred an IUD, and had the intention to use an IUD, respectively. The main reported barriers to use an IUD among qualitative participants were fear of side-effects, religious prohibitions of contraception use, husband disapproval, lack of training by health workers, misconceptions, and longer duration of use. IUD information (AOR = 2.19 [CI: 1.56-3.08]), and rich wealth status (AOR = 1.70 [CI: 1.13-2.56]) were associated with the intention to continue or start to use an IUD.

CONCLUSIONS

IUD use and information on IUDs in the study area was very low. Information about IUDs, wealth status, and partner disapproval were determinant factors for intention to use an IUD. Thus, a regular awareness creation program using accessible media platforms by the government and stakeholders on IUD use is necessary to provide reliable information to the community and resolve misconceptions. In addition, women's empowerment to balance partner dominance on decision-making of contraception use and health care worker training on long-acting reversible contraceptives (LARCs) to increase access to LARC services are necessary to increase uptake of LARCs in general and of IUDs, in particular in the study regions.

The potential association between psychiatric symptoms and the use of levonorgestrel intrauterine devices (LNG-IUDs): A systematic review

BACKGROUND

Levonorgestrel (LNG)-intrauterine devices (IUDs) are an effective method of contraception; however, there is growing evidence regarding potential psychiatric side effects such as depressive symptoms, anxiety, and suicidal thoughts. Therefore, we conducted this systematic review to summarise the psychiatric effects of using LNG-IUDs.

METHODS

We searched six databases (MEDLINE, Web of Science, Scopus, Science Direct, Cochrane Library, and PsycInfo), and we included all study designs. The included studies were extracted, quality assessed, and qualitatively summarised.

RESULTS

Out of the screened studies, only 22 were finally included. While ten studies showed increased depressive symptoms, two studies showed reduced symptoms. Moreover, one study showed increased anxiety, another one reported an increased risk of suicide, four studies concluded no association with depressive symptoms, and four other studies showed uncertainty about a potential association but mentioned other psychiatric symptoms.

CONCLUSION

Despite unreliable data, many studies report psychiatric symptoms associated with LNG-IUDs, predominantly depression. Gynaecologists, general practitioners, and psychiatrists should therefore be aware of these potential risks, especially depressive symptoms and suicidality. Counselling patients about these risks should be mandatory. Further studies should investigate the absolute risk of mental disorders associated with LNG-IUDs and other hormonal contraceptives.KEY MESSAGESMany researchers are reporting adverse psychiatric events associated with levonorgestrel intrauterine devices (LNG-IUDs).Despite their effectiveness, a proper psychiatric assessment should be done before inserting LNG-IUDs.Proper counselling regarding the depressive symptoms and suicidality should be done by the treating obstetrician.Further studies should investigate the absolute risk of mental disorders associated with LNG-IUDs and other hormonal contraceptives.

Avoiding unintended pregnancy during transition from copper intrauterine device to etonogestrel contraceptive implant: A case report

We present a patient who experienced an unintended pregnancy after transitioning from the copper intrauterine device to the etonogestrel subdermal implant. When switching from contraceptive methods that do not reliably suppress ovulation, clinicians should consider backup contraception and additional counseling, depending on specific timing of removal.

Effect of the timing of insertion of postpartum intrauterine contraceptive device (PPIUCD) copper T380A on expulsion rates

Background & objectives

Postpartum intrauterine contraceptive device (PPIUCD) is well accepted and recommended for contraception. However, anxiety at the time of delivery may restrict the acceptance of a PPIUCD for its immediate insertion. So far there is limited evidence to conclude anything concrete on the association between the expulsion rates and the timing of insertion following a vaginal delivery. Thus, this study was undertaken to compare the expulsion rates in immediate and early insertions and their safety and complications.

Methods

This prospective comparative study was carried out over 17 months on women delivering vaginally in a tertiary care teaching hospital in South India. A copper device (CuT380A) was inserted using Kelly's placental forceps either within 10 min of placental delivery (immediate group, n=160) or between 10 min upto 48 h postpartum (early group, n=160). Ultrasound was done before discharge from the hospital. The expulsion rates and any other complications at six-week and three-month follow up were studied. Chi-square test was used to compare the difference in expulsion rates.

Results

The expulsion rate was five per cent in the immediate compared to 3.7 per cent in the early group (no significant difference). In ten cases, the device was found to be in the lower uterus upon ultrasound before discharge. These were repositioned. There was no case with perforation, irregular bleeding or infection up to the three-month follow up. Higher age, higher parity, lack of satisfaction and motivation to continue were predictors of expulsion.

Interpretation & conclusions

In the present study PPIUCD was found to be safe with overall expulsion in 4.3 per cent. It was marginally, though not significantly, higher in the immediate group.

Same-day long-acting reversible contraceptive utilization after a statewide contraceptive access initiative

BACKGROUND

Same-day placement of long-acting reversible contraceptives, occurring when the device is requested and placed within a single visit, reduces barriers to the patient and reduces unintended pregnancies. Despite the safety and efficacy of same-day placement, access to same-day services remains low.

OBJECTIVE

This study aimed to evaluate the effects of the Delaware Contraceptive Access Now initiative, a statewide initiative in Delaware focused on increasing same-day access to effective contraception on same-day receipt of long-acting reversible contraceptives.

STUDY DESIGN

We used Medicaid claims and encounter data to identify instances of same-day and multivisit receipts of long-acting reversible contraceptives among Medicaid-enrolled individuals in Delaware and Maryland aged 15-44 years who were covered in a full-benefits or family planning Medicaid aid category during the month of the placement and the 2 previous months. We used a difference-in-differences design that compared changes in the outcome from before to after implementation of the initiative among placements at agencies that participated in the initiative (n=6676) vs 2 alternative comparison groups: placements at Delaware agencies that did not participate (n=688) and placements in Maryland (n=35,847).

RESULTS

We found that the intervention was associated with a 13.3 percentage point increase (95% confidence interval, 1.9%-24.7%) in receipt of same-day long-acting reversible contraceptives using a nonparticipating Delaware comparison group, a 21.1 percentage point increase (95% confidence interval, 13.7%-28.6%) using a Maryland comparison group, and a 21.0 percentage point increase (95% confidence interval, 14.1%-27.9%) using a pooled comparison group. The effects were larger for implants than intrauterine devices.

CONCLUSION

The Delaware Contraceptive Access Now initiative substantially increased the number of patients receiving long-acting reversible contraceptives through a single-visit encounter. Our findings suggested that coordinated interventions involving provider and staff training and capital investments that seed device stocking can increase the number of patients receiving same-day long-acting reversible contraceptives.

One-year pregnancy and continuation rates after placement of levonorgestrel or copper intrauterine devices for emergency contraception: a randomized controlled trial

BACKGROUND

Recent evidence demonstrates the effectiveness of the levonorgestrel 52-mg intrauterine device for emergency contraception vs the copper T380A intrauterine device. Of note, 1-year pregnancy and continuation rates after intrauterine device placement for emergency contraception remain understudied.

OBJECTIVE

This study compared 1-year pregnancy and intrauterine device continuation rates and reasons for discontinuation among emergency contraception users randomized to the levonorgestrel 52-mg intrauterine device or the copper intrauterine device.

STUDY DESIGN

This participant-masked, randomized noninferiority trial recruited emergency contraception individuals desiring an intrauterine device from 6 Utah family planning clinics between August 2016 and December 2019. Participants were randomized 1:1 to the levonorgestrel 52-mg intrauterine device group or the copper T380A intrauterine device group. Treatment allocation was revealed to participants at the 1-month follow-up. Trained personnel followed up the participants by phone, text, or e-mail at 5 time points in 1 year and reviewed electronic health records for pregnancy and intrauterine device continuation outcomes for both confirmation and nonresponders. We assessed the reasons for the discontinuation and used Cox proportional-hazard models, Kaplan-Meier estimates, and log-rank tests to assess differences in the continuation and pregnancy rates between the groups.

RESULTS

The levonorgestrel and copper intrauterine device groups included 327 and 328 participants, respectively, receiving the respective interventions. By intention-to-treat analysis at 1 year, the pregnancy rates were similar between intrauterine device types (2.8% [9/327] in levonorgestrel 52-mg intrauterine device vs 3.0% [10/328] in copper intrauterine device; risk ratio, 0.9; 95% confidence interval, 0.4-2.2; P=.82). Most pregnancies occurred in participants after intrauterine device removal, with only 1 device failure in each group. Of note, 1-year continuation rates did not differ between groups with 204 of 327 levonorgestrel 52-mg intrauterine device users (62.4%) and 183 of 328 copper T380A intrauterine device users (55.8%) continuing intrauterine device use at 1 year (risk ratio, 1.1; 95% confidence interval, 1.0-1.2; P=.09). There were differences concerning the reasons for discontinuation between intrauterine device types, with more bleeding and cramping cited among copper intrauterine device users.

CONCLUSION

The pregnancy rates were low and similar between intrauterine device types. Of note, 6 of 10 intrauterine device emergency contraception users continued use at 1 year. Moreover, 1-year continuation rates were similar between intrauterine device types.

Vacuum-induced hemorrhage control versus uterine balloon tamponade for postpartum hemorrhage

OBJECTIVE

To compare maternal outcomes of uterine balloon tamponade (UBT) versus an intrauterine vacuum-induced hemorrhage-control device (VHD) for the management of primary postpartum hemorrhage (PPH).

METHODS

Retrospective cohort of all patients with PPH due to uterine atony treated with an intrauterine device within a university health system from January 2019 to June 2021. The primary outcome of massive transfusion, defined as PPH requiring transfusion of ≥ 4 units of packed red blood cells (PRBC), was compared between 2 groups: UBT (n = 78) versus VHD (n = 36). Statistical analysis included use of Chi-squared and Wilcoxon rank sum tests with statistical significance set at P < 0.05.

RESULTS

Baseline characteristics were similar between the 2 groups. The proportion of patients who received ≥ 4 units of PRBC was significantly lower in the VHD group compared to the UBT group (2.8% vs. 20.5%, P = <0.01). The proportion of patients who were transfused ≥ 2 units of PRBC and median estimated blood loss (EBL) were also both significantly lower in the VHD group compared to the UBT group (36.1% vs. 57.7%, P = <0.01, and 1 500 mL vs. 1 875 mL, P = 0.02, respectively). Rates of other secondary outcomes were similar between the 2 groups.

CONCLUSION

Our data suggest that the use of intrauterine VHD in the management of PPH is associated with a lower number of massive transfusions and EBL compared to UBT. Randomized controlled trials are needed before drawing definitive conclusions on which device is more effective in this setting.

Chitosan combined with intrauterine device prevents intrauterine adhesions after hysteroscopic adhesiolysis: A target trial emulation study

AIM

To compare the efficacy of chitosan and intrauterine device (IUD) combination with an IUD alone in patients with intrauterine adhesions (IUAs) who underwent hysteroscopic adhesiolysis.

METHODS

This retrospective study assessed 303 patients with moderate-to-severe IUA (American Fertility Society [AFS] score ≥5) who underwent hysteroscopic adhesiolysis between January 2018 and December 2020. Using observational data under a cohort design, we emulated a target trial with two treatment arms: chitosan plus IUD and IUD alone groups. Second-look hysteroscopy was performed in all patients 3 months after the initial hysteroscopy. The primary outcome was improved adhesion assessed using the AFS scoring system.

RESULTS

The baseline characteristics were balanced between the two groups. The second hysteroscopy revealed significantly better AFS scores in group A than in group B (values: 3 [1-4] vs. 4 [2-6], p < 0.001; change: 63% [50%-80%] vs. 44% [33%-67%], p < 0.001, respectively). Significantly better menstruation conditions (improved rate: 66% vs. 49%, p = 0.004) and endometrial thickness (mean: 7.0 mm vs. 6.0 mm, p < 0.001) were also observed in group A than in group B. Moreover, group A showed a significantly higher 1-year clinical pregnancy rate (40% vs. 28%, p = 0.037) and better quality of life (p < 0.001) than group B.

CONCLUSIONS

Chitosan and IUD combination showed better efficacy in reducing adhesions and improving clinical outcomes in patients with moderate-to-severe IUA after hysteroscopic adhesiolysis.

Ectopic Pregnancy Observed With Kyleena Intrauterine Device Use: A Case Report

Kyleena (levonorgestrel 19.5 mg), a type of intrauterine device (IUD), has an efficacy rate of 99% in preventing pregnancy. Because the overall failure rate of IUDs is low, ectopic pregnancy (EP) with IUD use is uncommon. This case reports an EP observed in a female with the Kyleena IUD in place. She had no known risk factors for an EP, which makes this case noteworthy. Ultrasound and surgery confirmed a 4 cm EP in the ampulla of the left fallopian tube. Insufficient evidence exists to conclude whether the Kyleena IUD has a higher risk of EP compared to other hormonal IUDs. As the Kyleena IUD becomes a more popular option for women in search of an effective contraceptive, patients and clinicians should be aware of this potential risk. Our case emphasizes that continued research on the prevalence of EP with Kyleena use is necessary.

An Integrative Review of the Relationship Between Intrauterine Devices and Bacterial Vaginosis

OBJECTIVE

To examine the relationship between intrauterine devices (IUDs) and bacterial vaginosis (BV) through an integrative review of the current literature.

DATA SOURCES

CINAHL, MEDLINE, Health Source, Evidence-Based Medicine's Cochrane Central Registry of Controlled Trials, Embase, and Web of Science databases were searched.

STUDY SELECTION

Cross-sectional, case-control, cohort, quasi-experimental, and randomized controlled trials examining copper (Cu-IUD) and levonorgestrel (LNG-IUD) use in reproductive- age users with BV occurrence confirmed with Amsel's criteria or Nugent scoring were included. Articles included were published in the past 10 years.

DATA EXTRACTION

Fifteen studies met criteria, after an initial search identified 1,140 potential titles, and two reviewers assessed 62 full-text articles for inclusion.

DATA SYNTHESIS

Data were categorized into three groups: retrospective descriptive cross-sectional studies identifying point prevalence of BV among IUD users; prospective analytic studies examining BV incidence and prevalence among Cu-IUD users; and prospective analytic studies examining BV incidence and prevalence among LNG-IUD users.

CONCLUSION

Synthesis and comparison of studies were difficult because of disparate study designs, sample sizes, comparator groups, and inclusion criteria for individual studies. Synthesis of data from cross-sectional studies showed that all IUD users combined may have an increased point prevalence of BV compared with non-IUD users. These studies did not delineate LNG-IUDs from Cu-IUDs. Findings from cohort and experimental studies suggest a possible increase in BV occurrence among Cu-IUD users. Evidence is lacking to show an association between LNG-IUD use and BV.

Intrauterine adhesion after hysteroscopic myomectomy of submucous myomas

PURPOSE

To evaluate the frequency of intrauterine adhesion (IUA) after hysteroscopic myomectomy, and to analyze the association of IUA and the location of submucous myomas and the use of postoperative barrier (POB).

METHODS

Hysteroscopic myomectomy was performed in 217 patients with submucous myomas. The retrospective investigation was performed, and the cases were divided into three groups: cases with solitary submucous myoma (SSM; group 1), cases with apposing submucous myomas (ASMs; group 2) and cases with submucous myomas that were far from each other or not in apposition to one another (not apposing submucous myomas: NASMs; group 3). As POB, intrauterine device with oxidized regenerated cellulose and silicon sheet was inserted immediately after surgery.

RESULTS

IUA formation after hysteroscopic myomectomy was more frequent in group 2 than groups 1 and 3 (p = 0.03 and 0.01, respectively), despite the higher rates of POB use (p = 0.02). There was no significant difference in IUA formation in cases with POB between each group (p = 0.06 and 0.21, respectively). But in cases without POB, group 2 showed higher rates of IUA formation than group 1 (p = 0.04) and group 3 (p = 0.03). Multivariable analysis for IUA formation demonstrated that ASMs were a risk factor of IUA (hazard ratio [HR] = 27.9, p < 0.01), and the use of POB was a prognostic factor for reduction of IUA formation (HR = 0.08, p < 0.01).

CONCLUSION

ASMs appear to be a risk factor for IUA formation. The use of POB may be associated with preventing IUA formation after hysteroscopic myomectomy.

Neglected Intrauterine Device Migration Complications: Case Reports

This series of four cases describes unusual intrauterine device (IUD) migration complications, associated etiologic factors, and their management. Recent increases in sociopolitical and medical forces worldwide contributed to inattention to these patients with subclinical IUD complications. The international movement of patients, delays in gynecologic care due to the COVID-19 pandemic, lack of health care access, shifts away from annual examinations, and patients' lack of medical records or IUD awareness can lead to long durations of neglected IUDs and associated complications. These complications might have been avoided or minimized with regular gynecologic health care. Physicians should consider moving toward routine examinations of all IUD patients, rather than away from annual examinations as has been promulgated by some medical societies. Patient education is needed on the importance of routine monitoring of IUDs and retention of device records. Clinicians should become familiar with IUDs from around the world as well as devices no longer being prescribed, as their appearance, associated complications, and presentations may differ from locally currently available devices.

Pseudo tumor pelvic actinomycosis revealed by colonic obstruction with hydronephrosis: Can extensive surgery be avoided? A case report

Pelvic actinomycosis with an intrauterine device accounts for approximately 3% of all actinomycoses. It is a chronic infectious disease characterized by infiltrative, suppurative, or granulomatous inflammation, sinus fistula formation, and extensive fibrosis, and caused by filamentous, gram-positive, anaerobic bacteria called Actinomyces israelii. The slow and silent progression favors pseudo tumor pelvic extension and exposes the patient to acute life-threatening complications, namely colonic occlusion with hydronephrosis. Preoperative diagnosis is often difficult due to the absence of specific symptomatology and pathognomonic radiological signs simulating pelvic cancer. We discuss the case of a 67-year-old woman who complained of pelvic pain, constipation, and weight loss for 4 months, and who presented to the emergency department with a picture of colonic obstruction and a biological inflammatory syndrome. The computed tomography scan revealed a suspicious heterogeneous pelvic mass infiltrating the uterus with an intrauterine device, the sigmoid with extensive upstream colonic distension, and right hydronephrosis. The patient underwent emergency surgery with segmental colonic resection and temporary colostomy, followed by antibiotic therapy. The favorable clinical and radiological evolution under prolonged antibiotic therapy with the almost total disappearance of the pelvic pseudo tumor infiltration confirms the diagnosis of pelvic actinomycosis and thus makes it possible to avoid an extensive and mutilating surgery with important morbidity.

The effect of the combined use of an intrauterine device and a Foley balloon in the prevention of adhesion following hysteroscopic adhesiolysis

The aim of this study was to determine whether intrauterine device (IUD) combined with Foley balloon could obtain better efficacy in preventing re-adhesion for patients with intrauterine adhesions (IUAs). The data of 89 patients with IUAs, who underwent transcervical resection of adhesion (TCRA) operation, were retrospectively collected. According to the method used for preventing re-adhesion of the uterine cavity after TCRA, the enrolled patients were divided into IUD group, Foley balloon group and the combined group. The second-look hysteroscopy was carried out at 3 months after TCRA surgery. The severity and extent of IUA were scored by American Fertility Society (AFS) scoring system. The endometrial thickness (EMT) was measured by ultrasound. Furthermore, the menstruation and pregnancy outcomes were also assessed. Our results showed that the postoperative decrease in AFS score was significantly greater in the combined group than in the IUD group or in the Foley balloon group. The increase in menstrual score among the 3 groups was not significantly different. The difference between preoperative and postoperative values of EMT was greater in the combined group than in the other 2 groups. In conclusion, the effect of a Foley balloon combined with IUD in preventing re-adhesion after TCRA might be better than that of IUD or Foley balloon alone.

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.

Intrauterine contraceptive discontinuation reasons among female trial participants living with HIV in Cape Town, South Africa: A qualitative analysis

Introduction

While young women in South Africa may navigate both HIV infection and pregnancy risks, intrauterine contraceptive (IUC) use is low. Though IUCs have low failure rates, concerns exist about whether the IUC is an appropriate method choice for women living with HIV (WLHIV). In this qualitative study, we explore WLHIVs' experiences of using IUC and reasons for discontinuation.

Methods

This qualitative study included in-depth interviews (IDIs) with 17 WLHIV who electively discontinued their allocated IUC while participating in a randomized controlled trial comparing the safety of the levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (C-IUD) in Cape Town, South Africa. The transcripts were coded and emergent themes were grouped to examine women's experiences with IUC use and reasons for discontinuation, highlighting experiential differences between the two methods.

Results

Women's experience with the allocated IUC related most commonly to bleeding and/or abdominal pain just after insertion. Most C-IUD discontinuers, but only one LNG-IUS discontinuer, complained of pain and/or increased bleeding as the main reason for removal. Three women (two LNG-IUS, one C-IUD) requested removal because they desired pregnancy, while two others discontinued due to fears the IUC was exacerbating non-gynecologic conditions (hypertension, diabetes). Generally, women acknowledged advantages of IUC use and many expressed their desire to continue use if not for the side effects.

Conclusions

In the South African context, IUC use for WLHIV should be promoted with specific counseling considerations. Both providers and potential users should receive specific information about potential menstrual-related side effects and countering common misperceptions to enable informed contraceptive decision-making.

Levonorgestrel 52 mg intrauterine system efficacy and safety through 8 years of use

BACKGROUND

Extending hormonal intrauterine system duration will allow users to have less need for procedures to provide long-term contraception.

OBJECTIVE

This study aimed to evaluate the efficacy and safety of the levonorgestrel 52 mg intrauterine system during years 7 and 8 of use.

STUDY DESIGN

A total of 1751 nulliparous and multiparous participants aged 16 to 45 years enrolled in a phase 3, multicenter trial to evaluate the efficacy and safety of the use of the Liletta levonorgestrel 52 mg intrauterine system for up to 10 years. Participants aged 36 to 45 years at enrollment underwent safety evaluation only. After the first year, we evaluated participants every 6 months for intrauterine system location confirmation and urine pregnancy testing at each visit. We assessed the Pearl Indices in years 7 and 8 and the life-table analysis for cumulative pregnancy rates through 8 years of use. For the primary efficacy analyses, all participants aged 16 to 35 years at enrollment were included through year 6; years 7 and 8 included only users aged ≤39 years at the start of each use year. Safety outcomes were assessed in all participants regardless of duration of use. We assessed amenorrhea rates, defined as no bleeding or spotting in the 90 days before the end of the year.

RESULTS

After intrauterine system placement, we followed 1568 participants aged 16 to 35 years and 146 participants aged 36 to 45 years. The 16- to 35-year-old participants included 986 (57.5%) nulliparous and 433 (25.3%) obese users. Overall, 569 participants started year 7, 478 completed year 7 (380 aged ≤39 years at beginning of year) and 343 completed year 8 (257 aged ≤39 years at beginning of year); 77 completed 10 years of use. Eleven pregnancies occurred over 8 years, 7 (64%) of which were ectopic. Two pregnancies occurred in year 7 (Pearl Index, 0.49; 95% confidence interval, 0.06-1.78), 1 in a participant with implantation 4 days after a desired removal; no pregnancies occurred in year 8. The cumulative life-table pregnancy rate in the primary efficacy population through year 8 was 1.32 (95% confidence interval, 0.69-2.51); without the postremoval pregnancy, the rate was 1.09 (95% confidence interval, 0.56-2.13). Two perforations (0.1%) occurred, none noted after year 1. Expulsion occurred in 71 (4.1%) participants overall, with 3 in year 7 and 2 in year 8. Pelvic infection was diagnosed in 16 (0.9%) participants during intrauterine system use, 1 each in years 7 and 8. Only 44 (2.6%) participants overall discontinued because of bleeding complaints (4 total in years 7 and 8) with rates per year of 0.1% to 0.5% for years 3 to 8. Amenorrhea rates were 39% at both years 7 and 8.

CONCLUSION

The levonorgestrel 52 mg intrauterine system is highly effective over 8 years of use and has an excellent extended safety profile. This report details the longest period of efficacy and safety data for continuous use of a levonorgestrel 52 mg intrauterine system for contraception.

Contraceptive efficacy and safety of the 52-mg levonorgestrel intrauterine system for up to 8 years: findings from the Mirena Extension Trial

BACKGROUND

The 52-mg levonorgestrel-releasing intrauterine system is an established, long-acting contraceptive option with approved use for up to 7 years.

OBJECTIVE

The Mirena Extension Trial evaluated the efficacy and safety of the 52-mg levonorgestrel-releasing intrauterine system during extended use beyond 5 and up to 8 years.

STUDY DESIGN

This was a multicenter, single-arm study in the United States, enrolling existing users of the 52-mg levonorgestrel-releasing intrauterine system, aged 18 to 35 years, who have had the system for 4.5 to 5 years. We assessed the contraceptive efficacy (Pearl Index) and cumulative failure rate (using the Kaplan-Meier method) of the 52-mg levonorgestrel-releasing intrauterine system during extended use. We also evaluated bleeding outcomes and adverse events.

RESULTS

Of the 362 participants starting year 6, 243 entered and 223 completed 8 years of 52-mg levonorgestrel-releasing intrauterine system use. Just more than half the participants were parous. The mean (standard deviation) age was 29.2 (±2.9) years, and all participants were aged ≤36 years at the end of year 8. Two pregnancies occurred, both with the device in situ. The year 6 pregnancy was of undetermined location and resolved spontaneously. The pregnancy in year 7 was ectopic and resolved with methotrexate treatment. In both cases, the 52-mg levonorgestrel-releasing intrauterine system was removed and the participants left the trial. For years 6 to 8, the 3-year Pearl Index (95% confidence interval) was 0.28 (0.03-1.00) with a 3-year cumulative failure rate of 0.68% (0.17-2.71). Pearl Indexes for years 6, 7, and 8 were 0.34 (0.01-1.88), 0.40 (0.01-2.25), and 0.00 (0.00-1.90), respectively. The 3-year (years 6-8) ectopic pregnancy Pearl Index was 0.14 (0.00-0.77). We found treatment-emergent adverse events in 249 of 362 participants (68.8%), with 65 (18.0%) events considered to be related to the 52-mg levonorgestrel-releasing intrauterine system. The discontinuation rate was 38.4% (139/362), most commonly because of desire for pregnancy (12.2%, 44/362). During extended use beyond 5 years and up to 8 years, participants reported a decrease in the mean number of bleeding or spotting days with approximately half of the women experiencing amenorrhea or infrequent bleeding. We did not enroll a sufficient number of women using the 52-mg levonorgestrel-releasing intrauterine system for contraception and heavy menstrual bleeding to assess extended use for that indication. At the end of year 8, most (98.7%, 220/223) of the participants who completed the study remained satisfied with the continued use of the 52-mg levonorgestrel-releasing intrauterine system. Of the 31 women who discontinued early because of desire for pregnancy with evaluable data for return-to-fertility analysis, 24 reported a posttreatment pregnancy within 1 year, giving a 12-month return-to-fertility rate of 77.4%.

CONCLUSION

The 52-mg levonorgestrel-releasing intrauterine system, initially approved for 5 years, maintains high contraceptive efficacy, user satisfaction, and a favorable safety profile through 8 years of use. Participants reported 26 posttreatment pregnancies in total, of which 24 occurred in women who had discontinued the 52-mg levonorgestrel-releasing intrauterine system because of a desire for pregnancy. Of note, among women who elected to continue use through 8 years, bleeding patterns remained highly favorable. These findings support continued 52-mg levonorgestrel-releasing intrauterine system use for up to 8 years in women who wish to continue treatment.

Outpatient hysteroscopic removal of intrauterine devices in early pregnancy: feasibility and outcomes

OBJECTIVE

To describe our experience with outpatient hysteroscopy for removal of intrauterine devices (IUDs) in pregnant patients, along with the pregnancy-related outcomes.

DESIGN

Retrospectively and prospectively collected data between January 2015 and April 2021.

SETTING

Hysteroscopic outpatient clinic (See and Treat Clinic) at a university affiliated, tertiary medical center.

PATIENT(S)

Forty-one patients with an inadvertent but desired pregnancy up to 12 weeks + 6 days gestational age with an IUD in situ, with documented failed attempts of IUD removal.

INTERVENTION(S)

After ultrasonographic confirmation of IUD location, gestational age, and viability, a small-caliber hysteroscope was introduced via a vaginoscopic approach. The uterus was distended using 0.9% normal saline until a clear view was achieved. On visualization, the IUD was grasped by its strings, tail, or lateral arm using a semirigid hysteroscopic grasper. Oral antibiotic prophylaxis was prescribed in all cases.

MAIN OUTCOME MEASURE(S)

The primary outcome of interest was term delivery, from 37 weeks of gestation. Secondary outcomes included patient-reported tolerability and satisfaction, and procedure-related and pregnancy related complications.

RESULT(S)

The procedure was completed successfully in all 41 patients. Thirty-three patients continued their pregnancies, resulting in 32 full-term singleton deliveries and 1 singleton preterm delivery at 33 + 4 weeks. Median gestational age at delivery was 39 weeks, with a median birthweight of 3,450 grams. Eight patients (19.5%) miscarried, 4 of these within a week of the procedure.

CONCLUSION(S)

In cases of desired pregnancy with an IUD, outpatient hysteroscopic removal of the IUD is a safe and effective management option. Broader uptake of outpatient hysteroscopy and development of hysteroscopic skills will allow more clinicians to offer patients this effective solution.

Effectiveness of ultrasound-guided removal of intrauterine devices

A retrospective review over 12 months was conducted to assess the success rates for ultrasound-guided removal of an intrauterine device (IUD). Cases were broken up into two groups. There were 241 cases in which removal had been unsuccessful in the office setting. Where the strings were not visible the device was successfully removed in 97.7% of attempts. The second group had visible strings and 100% were successfully removed. The success rate for ultrasound-guided removal of IUDs when the strings are not visible supports the pilot study published in 2012. This approach can successfully avoid the need for sedation and or hospital admission in over 97% of cases.

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

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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