Objectives
To provide updated and more detailed pooled intrauterine device expulsion rates and expulsion risk estimates among women with postpartum intrauterine device placement by timing of insertion, delivery type, and intrauterine device type to inform current intrauterine device insertion practices in the United States.
Data Sources
We searched PubMed, Cochrane Library, and ClinicalTrials.gov through June 2019.
Study Eligibility Criteria
We included all studies, of any study design, that examined postpartum placement of Copper T380A (copper) or levonorgestrel-containing intrauterine devices that reported counts of expulsion.
Study Appraisal and Synthesis Methods
We evaluated intrauterine device expulsion among women receiving postpartum intrauterine devices in the “immediate” (within 10 minutes), “early inpatient” (>10 minutes to <72 hours), “early outpatient” (72 hours to <4 weeks), and interval (≥4 weeks) time periods after delivery. We assessed study quality using the US Preventive Services Task Force evidence grading system. We calculated pooled absolute rates of partial and complete intrauterine device expulsion separately and estimated adjusted relative risks by the timing of postpartum placement, delivery type, and intrauterine device type using log-binomial multivariable regression.
Results
We identified 48 level I to II-3 studies of poor to good quality that reported a total of 7661 intrauterine device placements. Complete intrauterine device expulsion rates varied by timing of placement as follows: 10.2% (range, 0.0−26.7) for immediate; 13.2% (3.5−46.7) for early inpatient; 0% for early outpatient; and 1.8% (0.0−4.8) for interval placements. Complete intrauterine device expulsion rates also varied by delivery type: 14.8% (range, 4.8−43.1) for vaginal and 3.8% (0.0−21.1) for cesarean deliveries. Among immediate postpartum vaginal placements, the expulsion rate for levonorgetrel intrauterine devices was 27.4% (range, 18.8−45.2) and 12.4% (4.8−43.1) for copper intrauterine devices. Compared with interval placement, immediate and early postpartum placements (inpatient and outpatient combined) were associated with greater risk of complete expulsion (adjusted risk ratio, 8.33; 95% confidence interval, 4.32−16.08, and adjusted risk ratio, 5.27; 95% confidence interval, 2.56–10.85, respectively). Among immediate postpartum placements, risk of expulsion was greater for placement after vaginal compared with cesarean deliveries (adjusted risk ratio, 4.57; 95% confidence interval, 3.49−5.99). Among immediate placements at the time of vaginal delivery, levonorgestrel intrauterine devices were associated with a greater risk of expulsion compared with copper intrauterine devices (adjusted risk ratio, 1.90; 95% confidence interval, 1.36−2.65).
Conclusion
Although intrauterine device expulsion rates vary by timing of placement, type, and mode of delivery, intrauterine device insertion can take place at any time. Understanding the risk of intrauterine device expulsion at each time period will enable women to make an informed choice about when to initiate use of an intrauterine device in the postpartum period based on their own goals and preferences.
Introduction
Intrauterine devices (IUDs) provide highly effective contraception and are commonly placed at an interval postpartum visit typically 4−6 weeks after delivery for women who desire intrauterine contraception. However, the timing of providing postpartum contraception around 6 weeks after delivery is based on historical precedent, not evidence. By 6 weeks postpartum, more than half of women have resumed intercourse. Non-breastfeeding women may ovulate as early as 25 days postpartum, and at least 30% will have ovulated by 8 weeks. Therefore, delaying access to postpartum contraception until 6 weeks postpartum may increase the risk of rapid repeat pregnancy.
Why was this study conducted?
This review was conducted to provide more detailed estimates of expulsion risk among women with intrauterine device (IUD) placement in the postpartum period than previously published, further describing pooled rates and risk estimates by timing of insertion, IUD type, and delivery type to better inform current IUD practices in the United States.
Key findings
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This analysis is consistent with previous findings that the risk of IUD expulsion is greater when IUDs are placed in the immediate and early postpartum periods compared with placement at an interval postpartum visit (4 weeks or more).
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Novel analyses demonstrate that the risk of IUD expulsion after early inpatient postpartum placements is similar to that for immediate postpartum placements and greater than for early outpatient or interval placements.
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Three studies of early outpatient postpartum placements between 13 and 24 days postpartum demonstrated no expulsions after 136 placements with 6 months of follow-up.
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New analyses comparing IUD types highlight that the risk of expulsion is greater when initiating levonorgestrel (LNG)−containing IUDs compared with copper IUDs in the early inpatient postpartum period, and in the immediate postpartum period with vaginal delivery. THe IUD type was not associated with an increased risk of expulsion at the time of cesarean delivery for any time period.
What does this add to what is known?
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This review provides new pooled rates of IUD expulsion after postpartum placement by timing of placement, delivery type, and IUD type, with a focus on IUDs that are currently available in the United States, to better inform patient-centered counseling in the United States.
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This review provides new pooled rates of IUD expulsion and expulsion risk estimates when IUDs are placed in the early inpatient postpartum time period between 10 minutes and 72 hours after delivery and in the early outpatient time period (from 72 hours to less than 4 weeks).
Immediate postpartum IUD placement, within 10 minutes of delivery, is safe and effective as well as convenient for providers and patients. Despite the benefits of immediate IUD insertion, there are significant barriers to widespread implementation, including barriers to receiving insurance reimbursement for devices placed in the hospital and lack of standardized provider training on the technique for device placement. In addition, there are gaps in knowledge about the risks of expulsion for immediate postpartum IUD placement. For example, the risk of expulsion is greater among women receiving immediate IUDs compared with interval placement, but it is unclear whether the risk of expulsion varies by IUD type.
Efforts are currently in place to increase access to immediate postpartum IUDs, including practice guidance from the American College of Obstetricians and Gynecologists (ACOG) and expanded state Medicaid payment strategies that improve reimbursement for inpatient devices. However, expanding the timeframe when IUDs are placed in the postpartum period beyond the immediate and interval time periods may allow for increased access to highly effective contraception among postpartum women. The early postpartum period, from 10 minutes to 4 weeks after delivery, provides additional convenient times for women to receive contraception, including IUDs. An IUD can be placed any time before a woman leaves the hospital after delivery or at a postpartum visit within the first few weeks after delivery. The US Medical Eligibility Criteria for Contraceptive Use supports the safety of IUD placement during this early time period. Providing IUDs during the early postpartum period, rather than waiting for an interval postpartum placement at more than 4 weeks, may offer additional benefits, including the following: (1) it is unlikely that women are pregnant at this time; (2) a visit can be co-located with other health visits, such as well-baby visits ; and (3) the timing may offer opportunities to screen women for postpartum depression or to evaluate cesarean delivery incisions. Finally, recent recommendations from the ACOG support contact between women and a maternal health provider within the first 3 weeks after delivery, so women may increasingly be seen for routine early postpartum visits in the United States.
A previous meta-analysis of 48 studies suggested that the risk of expulsion may be greater among women receiving early postpartum IUDs between 10 minutes and 4 weeks postpartum compared with immediate postplacental placement (within 10 minutes), and both were significantly greater than interval placement (≥4 weeks after delivery); it also provided pooled rates of expulsion by placement timing, delivery method, and IUD type. Given the new ACOG recommendations and interest in more detailed analyses, we aimed to update the previous analysis by calculating pooled absolute rates of expulsion for immediate placements by IUD type and delivery type, and for early placements, divided into more clinically relevant time periods, and assessed by IUD type. In addition, we focused on IUD types currently used in the United States to better inform patient-centered counseling in the United States.
Objective
The purpose of this updated review and secondary analysis was to calculate more detailed pooled absolute expulsion rates among women with postpartum IUD placement and to estimate relative risk for expulsion in further detail. We sought to calculate updated pooled expulsion rates for immediate postpartum placements (<10 minutes) and to provide new pooled expulsion rates for immediate postpartum placements by delivery type and IUD type. We also sought to calculate pooled expulsion rates for early placements, further presented as early inpatient (>10 minutes to <72 hours) and early outpatient (72 hours to <4 weeks) placements, and additionally categorized by IUD type. Finally, we aimed to focus our analysis on IUD types currently available in the United States.
Methods
Information sources
We updated the previous search in PubMed, Cochrane Library, and ClinicalTrials.gov , published from May 2018 through June 2019, that examined placement of IUDs in the postpartum period.
Search strategy
We searched using the search strategy previously published :((((“ Intrauterine Devices” [Mesh] OR “ Intrauterine Devices, Copper” [Mesh] OR “ Intrauterine Devices, Medicated” [Mesh] OR ((intrauterine OR intrauterine) AND (device OR system OR contracept∗)) OR IUD OR IUC OR IUCD OR IUS OR mirena OR Skyla OR liletta OR paragard OR “ Copper T380” OR CuT380 OR “ Copper T380a” OR “ Cu T380a” ) AND (postpartum OR Puerperium∗) NOT (“Animals” [Mesh] NOT “ Humans” [Mesh])))). We searched Cochrane Library and ClinicalTrials.gov for any published reviews or additional studies including “ Postpartum AND IUD.” No methodological filters were used. We hand-searched relevant articles and reviews for additional references. Interim results were not included; only trials with full data were included. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting.
Study selection
Our population of interest was women who received a postpartum IUD after a vaginal or cesarean delivery. IUD placement data were stratified by “immediate” (within 10 minutes), “early inpatient” (>10 minutes to <72 hours), “early outpatient’ (≥72 hours to <4 weeks), and interval (≥4 weeks). Our primary outcome of interest was complete expulsion of the IUD. We included all primary research studies with any study design, in any language, that reported counts of IUD expulsion after postpartum IUD placement that clearly defined the timing of IUD placement by hours, days, or weeks from delivery. Studies that straddled the early and interval timing categories of interest were excluded. We included studies with any length and rate of follow-up.
We included only those studies that reported expulsion rates for IUD types currently available in the United States, including copper (CuT380A) and levonorgestrel (LNG) IUDs, to focus analyses on current practice in the United States. We excluded studies that evaluated IUDs that were modified from their standard structure. We included studies evaluating IUD placement after vaginal and/or cesarean delivery.
Data extraction
Results from the initial search of the previous publication and the new search were reviewed by 2 co-authors (SHA and YE), including titles, abstracts, and full-text articles when necessary, to determine whether the studies met inclusion criteria. Two co-authors (SHA and TCJ) independently reviewed newly identified studies and extracted the following: author, year of publication, country, study design, IUD type, timing of IUD placement, delivery type, length of study follow-up, number of women enrolled or randomized, number of IUDs initially placed, number of women with any follow-up, and counts of expulsion (overall, complete, and partial).
Assessment of risk of bias
Newly identified studies were independently assessed for quality separately by 2 co-authors (SHA and TCJ) according to the US Preventive Services Task Force system as previously described. To assess study quality, 2 coauthors independently reviewed each study to evaluate study design and risk of bias, such as potential for selection bias (eg, groups not comparable at baseline for randomized controlled trials), misclassification (eg, outcome of expulsion diagnosed inconsistently by nonblinded healthcare provider), and confounding (eg, parity and breastfeeding status not collected or adjusted for). Studies were classified as “good,” “fair,” or “poor” based on the risk of bias assessment. Any discrepancies between authors for selection, abstraction, or risk of bias assessment were resolved through discussion.
Data synthesis
We calculated pooled expulsion rates by dividing the total pooled number of expulsions by the total pooled number of IUD placements within each strata weighted by study sample size. For our primary analysis, we assumed that expulsions were “complete” if not otherwise defined. We additionally collected counts of partial expulsion when reported by study authors or when counts were provided for IUDs visualized in the cervix by speculum or ultrasound examination to calculate pooled partial expulsion rates.
We calculated pooled expulsion rates for IUDs placed in each of the following time periods: immediate, early inpatient, early outpatient, early inpatient and early outpatient combined, mixed (immediate, early inpatient, and early outpatient combined), or interval placement, and by delivery type (cesarean, vaginal, or either cesarean or vaginal [mixed]). We reported the rate of IUD expulsion over each time period and the range of expulsion rates reported. We stratified by IUD type when possible (copper, LNG IUD, or either copper or LNG IUD [mixed]), and by length of study follow-up.
We used a log-binomial regression model to estimate adjusted risk ratios (aRRs) of IUD expulsion (for complete and partial expulsions separately) with associated 95% confidence intervals. For IUDs placed in the immediate time period, we reported aRRs by delivery type and IUD type, and adjusted for the following covariates: World Health Organization study region, study quality, and length of study follow-up. We adjusted for study region because of potential differences in regional practice in which type of clinicians provide IUDs and the technique that they use to place them, as well as differences in IUD prevalence in different regions. For IUDs placed in the early inpatient time period, we reported aRRs by IUD type, adjusting for the same 3 covariates as immediate placements as well as for delivery type. Analyses were completed using SAS 9.4 software (SAS Institute Inc, Cary NC).
Results
Study selection
The previous meta-analysis included data from 48 studies. For this analysis, we excluded 4 studies from the previously published meta-analysis that described IUDs not currently available or in use in the United States (CuT200, Cu7) and 1 study that included early postpartum placements but did not report expulsions by our pre-identified timing categories: immediate, early inpatient, early outpatient, or interval. Therefore, we included 43 studies from the original meta-analysis.
We identified an additional 98 studies in PubMed published between May 1, 2018, and June 1, 2019. There were no new studies identified with published data from ClinicalTrials.gov or Cochrane reviews. We removed 3 duplicate studies and screened the titles and abstracts of 95 records. We excluded 84 articles not relevant to our search. We read the full texts of 11 additional articles. We excluded 6 that did not meet inclusion criteria because they did not specify IUD type or timing of IUD placement, or did not provide individual counts for expulsion. We included an additional 5 new studies in this analysis for a total of 48 studies ( Figure 1 ).
Study characteristics
Studies included were published between 1999 and 2019. The level of evidence ranged from I to II-3. Five studies were rated as good quality , , and the remainder were fair or poor quality. The majority of studies examined IUDs placed in the immediate time period, whereas 6 examined early inpatient , and 3 examined early outpatient placements. In all, 13 studies included IUDs placed in the interval time period as a comparison group, , , , A total of 24 studies included only copper IUDs, , , , , , , , 14 studies included only LNG IUDs, , , , , , , , , and 10 studies included data on both types of IUDs. , , , , A total of 16 studies included only IUDs placed at cesarean delivery, , , , , , , , , , , , 14 studies included only IUDs placed at vaginal delivery, , , , , , , , , , and 18 studies included data on both types of delivery. , , , , , , , , , , , , , Follow up ranged from 4 weeks to 5 years, and study sample size ranged from 7 to 2733 women. All studies included are listed in Table 1 .
| First author, year, reference | Region a | Level of evidence b | Study quality c | IUD type d | Placement timing e | Delivery type f | Length of follow-up | No. enrolled or randomized | No. of women with IUDs placed | No. of women with IUDs placed with follow-up (%) |
|---|---|---|---|---|---|---|---|---|---|---|
| Agarwal, 2017 | SE Asia | II-3 | Fair | CuT380A | Immediate | Cesarean | 3 mo | 50 | 50 | 50 (100) |
| Baldwin, 2016 | N America | I | Fair | Mixed | Mixed | Mixed | 6 mo | 201 | 139 | Unknown (66 g ) |
| Blumenthal, 2018 | SE Asia | II-3 | Good | CuT380A | Mixed | Vaginal | 6 wk | 500 | 496 | 480 (97) |
| Braniff, 2015 | W. Pacific | I | Fair | LNG IUD | Mixed | Cesarean | 6 mo | 48 | 42 | Unknown (84 g ) |
| Bryant, 2013 | Africa | I | Poor | CuT380A | Mixed | Vaginal | 12 wk | 49 | 28 | 28 (100) |
| Celen, 2011 | E. Mediterranean | II-3 | Good | CuT380A | Immediate | Cesarean | 12 mo | 245 | 245 | 245 (100) |
| Chen, 2010 | N America | I | Good | LNG IUD | Mixed | Vaginal | 6 mo | 124 | 96 | 84 (88) |
| Chen, 2017 | N America | II-2 | Poor | Mixed | Mixed | Mixed | 6 mo | 74 | 74 | 59 (80) |
| Cohen, 2016 | N America | II-3 | Poor | Mixed | Immediate | Mixed | 12 mo | 82 | 82 | 67 (82) |
| Cole, 2019 | N America | II-3 | Poor | LNG IUD | Immediate | Mixed | 6 mo | 116 | 116 | 87 (75) |
| Colwill, 2018 | N America | II-2 | Fair | CuT380A | Immediate | Mixed | 6 wk | 210 | 210 | 169 (80) |
| Dahlke , 2011 | N America | I | Poor | LNG IUD | Mixed | Vaginal | 6 mo | 53 | 46 | 45 (98) |
| Dias, 2015 | SE Asia | II-2 | Poor | CuT380A | Immediate | Mixed | 6 wk | 91 | 91 | 91 (100) |
| Eggebroten, 2017 | N America | II-2 | Poor | Mixed | Immediate | Mixed | 6 mo | 211 | 211 | 186 (88) |
| Elsedeek, 2012 | E. Mediterranean | II-3 | Fair | LNG IUD | Immediate | Cesarean | 2 y | 65 | 65 | 62 (95) |
| Elsedeek, 2015 | E. Mediterranean | II-3 | Fair | LNG IUD | Immediate | Cesarean | 5 y | 80 | 80 | 80 (100) |
| Eroglu, 2006 | E. Mediterranean | II-2 | Fair | CuT380A | Mixed | Vaginal | 12 mo | 268 | 268 | 257 (96) |
| Goldthwaite, 2017 | N America | II-2 | Fair | Mixed | Immediate | Vaginal | 12 wk | 123 | 123 | 96 (78) |
| Gueye , 2013 | Africa | II-3 | Fair | CuT380A | Immediate | Cesarean | 6 mo | 46 | 46 | 39 (85) |
| Gupta, 2014 | SE Asia | II-3 | Fair | CuT380A | Immediate | Mixed | 6 mo | 100 | 100 | 92 (92) |
| Gurney, 2018 | N America | II-3 | Good | CuT380A | Immediate | Vaginal | 6 mo | 200 | 195 | 162 (83) |
| Hayes, 2007 | N America | II-3 | Fair | LNG IUD | Immediate | Vaginal | 10 wk | 20 | 20 | 16 (80) |
| Heller, 2016 | Europe | II-3 | Fair | Mixed | Immediate | Cesarean | 12 mo | 120 | 114 | 99 (87) |
| Hinz, 2019 | N America | II-3 | Fair | Mixed | Immediate | Mixed | 6 mo | 118 | 118 | 114 (97) |
| Hooda, 2016 | SE Asia | II-2 | Poor | CuT380A | Immediate | Mixed | 6 wk | 593 | 593 | 171 (29) |
| Jatlaoui, 2014 | N America | II-3 | Fair | Mixed | Immediate | Vaginal | 6 mo | 99 | 99 | 88 (89) |
| Kumar, 2019 | SE Asia | II-3 | Poor | CuT380A | Mixed | Mixed | 12 mo | 1200 | 1200 | 844 (70) |
| Kumar, 2014 | SE Asia | II-3 | Poor | CuT380A | Mixed | Mixed | 6 wk | 2733 | 2733 | 1730 (63) |
| Lester, 2015 | Africa | I | Poor | CuT380A | Mixed | Cesarean | 6 mo | 68 | 52 | Unknown (90 g ) |
| Letti Müller, 2005 | S America | II-2 | Fair | CuT380A | Immediate | Mixed | 1 mo | 38 | 38 | 37 (97) |
| Levi, 2012 | N America | II-3 | Fair | CuT380A | Immediate | Cesarean | 6 mo | 90 | 90 | 42 (47) |
| Levi, 2015 | N America | I | Good | Mixed | Mixed | Cesarean | 6 mo | 112 | 87 | Unknown (88 g ) |
| Mishra, 2014 | SE Asia | II-3 | Poor | CuT380A | Immediate | Mixed | 4−6 wk | 564 | 564 | 434 (77) |
| Nelson, 2009 | N America | II-3 | Fair | CuT380A | Immediate | Cesarean | 6 wk | 7 | 7 | 7 (100) |
| Puzey, 2005 | Africa | II-3 | Poor | LNG IUD | Immediate | Cesarean | 6 mo | 33 | 33 | 20 (61) |
| Ragab, 2015 | E Mediterranean | II-3 | Fair | CuT380A | Immediate | Cesarean | 12 mo | 40 | 40 | 40 (100) |
| Singal, 2014 | SE Asia | II-3 | Fair | CuT380A | Immediate | Cesarean | 12 mo | 300 | 300 | 300 (100) |
| Singh, 2016 | SE Asia | II-3 | Fair | CuT380A | Mixed | Vaginal | 8 wk | 80 | 80 | 80 (100) |
| Soon, 2018 | N America | I | Poor | LNG IUD | Mixed | Vaginal | 6 mo | 11 | 8 | 7 (88) |
| Stuart, 2012 | N America | II-3 | Fair | LNG IUD | Early | Vaginal | 6 mo | 40 | 29 | 27 (93) |
| Stuart, 2015 | N America | I | Poor | LNG IUD | Mixed | Vaginal | 6 mo | 35 | 31 | Unknown (80 g ) |
| Sucak, 2015 | E Mediterranean | II-2 | Fair | CuT380A | Immediate | Mixed | 12 mo | 160 | 160 | 153 (96) |
| Turok, 2017 | N America | I | Poor | LNG IUD | Mixed | Mixed | 8 wk | 285 | 228 | 214 (94) |
| Unal, 2018 | E Mediterranean | II-3 | Fair | CuT380A | Immediate | Cesarean | 3 mo | 70 | 70 | 68 (97) |
| Whitaker, 2014 | N America | I | Poor | LNG IUD | Mixed | Cesarean | 12 mo | 42 | 37 | Unknown (81 g ) |
| Woo, 2015 | N America | II-3 | Poor | Mixed | Immediate | Mixed | 12 mo | 76 | 76 | 43 (57) |
| Xu, 1999 | W Pacific | II-3 | Fair | CuT380A | Immediate | Vaginal | 36 mo | 384 | 384 | 381 (99) |
| Zerden, 2017 | N America | II-3 | Fair | LNG IUD | Delayed | Mixed | 6 mo | 50 | 50 | 43 (86) |
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