Objective
The objective of the study was to evaluate success and safety of intrauterine device (IUD) placement in a large cohort of adolescents.
Study Design
We examined the medical records of patients aged 13–24 years at the Children’s Hospital Colorado Adolescent Family Planning Clinic with at least 1 attempt at IUD placement. We abstracted demographic, reproductive, and procedural variables. The primary outcome was successful placement at first IUD insertion visit. We compared nulliparous with parous adolescents and patients younger than 18 years with those 18 years of age and older.
Results
Between April 2009 and December 2011, 1177 adolescent women aged 13–24 years (mean age 20.8 ± 2.5 years) had an attempted IUD placement, 1012 (86%) of which were with an advanced practice clinician. The first attempt was successful for 1132 women (96.2%). The first-attempt success rate was 95.8% for nulliparous women and 96.7% for parous women ( P = .45). The first-attempt success rate was 95.5% (n = 169) for women aged 13–17 years compared with 96.3% (n = 963) for women aged 18–24 years ( P = .6). Only 1.8% (n = 21) of all first-attempt successful insertions required ancillary measures. Of the 45 patients with a failed first insertion attempt, 40% (n = 18) had a second attempt with a physician, of which 78% (n = 14) were successful. Within the first 6 months of IUD placement, no perforations were identified and 24 patients (3.0%) expelled the IUD. Insertion failures and IUD expulsions were not related to IUD type, age, or parity.
Conclusion
Intrauterine devices can be inserted in nulliparous adolescents of any age with similar success to parous adolescents, by both physicians and advanced practice clinicians. Inability to provide ancillary measures such as paracervical block or cervical dilation should not limit access to this first-line contraceptive method.
American adolescents are at high risk of unintended pregnancy: 60% report having sexual intercourse by age 18 years, and the US teen pregnancy rate is one of the highest in the developed world. Of sexually active high school students, 74.7% report they did not use noncondom contraception the last time they had sex. Adolescents and young adults need contraceptive methods that are highly effective with high levels of satisfaction, low potential for user error, and long durations of protection, criteria that are met by intrauterine contraceptive devices (IUDs).
The American College of Obstetricians and Gynecologists recommends IUDs as first-line contraceptive methods for nearly all women, including adolescents and nulliparous women. Nevertheless, although IUD use is increasing in the United States, IUDs are still considerably underutilized in adolescents. Of all women using contraception in 2009, 8.5% relied on a long-acting reversible contraceptive method (IUD or implant); among adolescents (aged 15–19 years), the rate was only 4.5%. This underutilization is partly related to provider hesitation to provide IUDs to adolescents and nulliparous women for fear of pain, insertion failure, complications, expulsion, and dissatisfaction, resulting in early discontinuation of the method.
A growing body of evidence has demonstrated the safety of modern IUDs for adolescents as well as interest in the use of IUDs among this population. A retrospective cohort study of 90,489 women compared the frequency of IUD complications and discontinuation between young women (aged 15–24 years) and older women (aged 25–44 years). They found that complications, such as pelvic inflammatory disease and ectopic pregnancies, as well as discontinuation rates did not differ between age groups.
A prospective cohort study provided scripted counseling and no-cost contraception to 9256 women; 1404 participants were adolescents. When barriers such as cost and provider reluctance were removed, 37% of adolescents chose an IUD, including 42% of those 18–19 years old. Other studies have found rates of complications, discontinuation, and efficacy among adolescents to be similar to adult populations. Whereas IUDs have thus been shown to be desired by adolescents, and safe and effective in use, many providers remain concerned about the risks and difficulty of the insertion procedure in young, nulliparous women.
The objective of this study was to describe rates of IUD placement success and failure, need for ancillary measures to assist IUD placement, and insertion complications in a large cohort of adolescent women receiving care in a Title X clinic staffed mostly by advanced practice clinicians (APCs), including nurse practitioners, certified nurse midwives, and physician’s assistants.
Materials and Methods
This retrospective cohort study was performed via review of the electronic medical record at the BC4U clinic at the Children’s Hospital Colorado (Aurora, CO). BC4U is a Title X-funded, adolescent-only family planning clinic that offers free, confidential reproductive health services to young men and women younger than 25 years of age according to the Centers for Disease Control and Prevention’s definition of adolescence.
We reviewed all attempted IUD insertions between the opening of the clinic in April 2009 and December 2011. During this time period, supplemental funding made it possible to offer immediate initiation of all contraceptive methods without charge. The IUD types available at the clinic included the copper T 380A (copper IUD; ParaGard; Teva Pharmaceutical Industries, North Wales, PA) and the levonorgestrel-releasing intrauterine system (LNG-IUS; Mirena; Bayer, Whippany NJ). At BC4U, no IUD attempt can be made prior to an order for the device being placed in the electronic medical record order system.
IUD insertion attempts were ascertained by querying the electronic medical record system (Epic Systems Corporation, Verona, WI) for the following: (1) IUD medication orders (levonorgestrel IUD, Mirena, or ParaGard), (2) discontinued or canceled orders for the previously mentioned product, (3) procedure code (encounter for insertion of intrauterine contraceptive device), and (4) billing codes (V25.11 and V25.13). In addition, all mandatory Title X visit questionnaires were reviewed for documentation of method change to intrauterine device. Lastly, the final data set derived from the previously mentioned queries was compared with the number of IUDs purchased through the Title X program for this time period.
After identification of all IUD placement attempts, each medical record was reviewed by one of the authors. All demographic variables were abstracted electronically. Data abstracted by hand included the type of provider who performed the IUD insertion attempt (physician or APC), recorded uterine depth, ancillary measures used (paracervical block, mechanical or pharmacologic dilation, second-provider assistance, and/or ultrasound guidance), success of the attempt, confirmed or suspected immediate complications, and all follow-up visits and complications through 6 months after the insertion. Furthermore, all providers in the clinic were queried regarding any procedure they remembered that was out of the ordinary, to cross-check that difficult procedures and complications were captured.
An IUD attempt was defined as a visit at which an IUD was ordered and a speculum placed in the vagina with the intention of placing the IUD in the uterus. If the patient left the clinic with the IUD in the uterus, the attempt was coded as successful on the first attempt, whether or not multiple attempts at sounding or placement were made at that visit. For example, if the provider was unable to pass the uterine sound and then was able to successfully sound and place the IUD after asking another provider to perform ultrasound guidance, this was coded as a successful first attempt with ancillary measure. If the procedure was terminated at any time after speculum placement without successful placement of the IUD in the uterus or if the patient needed a placed IUD removed prior to clinic discharge for intolerable pain, other symptoms, or concern for perforation, the attempt was considered unsuccessful.
Summary statistics were used to describe the population as well as the outcomes. IBM SPSS Statistics (version 22.0; IBM, Armonk, NY) was used for all analyses. The study was approved by the Colorado Multiple Institutional Review Board.
Results
A total of 1177 adolescent women aged 13–24 years (mean age 20.8 ± 2.5 years) had an attempted IUD placement during the study period, and this number was consistent with the number of IUD devices ordered for the clinic. Of these women, 694 participants (59.0%) were nulliparous, and 617 (52.4%) were nulligravid; 177 patients (15%) were younger than 18 years old. Nulliparous women were slightly younger, more likely to be white, and more likely to choose a LNG-IUS. Parous women were more likely to be of Hispanic ethnicity or of unreported race ( Table ).
| Characteristics | Total cohort (n = 1177), mean ± SD or n, % | Nulliparous women (n = 694), mean ± SD or n, % | Parous women (n = 483), mean ± SD or n, % | P value |
|---|---|---|---|---|
| Demographic characteristic | ||||
| Gravidity | ||||
| 0 | 617 (52.4) | • | • | |
| 1 | 330 (28.0) | • | • | |
| 2 | 150 (12.7) | • | • | |
| ≥3 | 80 (6.8) | • | • | |
| Parity | ||||
| 0 | 694 (59.0) | • | • | |
| ≥1 | 483 (41.0) | • | • | |
| Age, y | 20.8 ± 2.5 | 20.5 ± 2.7 | 21.3 ± 2.3 | < .001 b |
| Race/ethnicity | ||||
| White | 570 (48.4) | 443 (63.8) | 127 (26.3) | < .001 b |
| Black | 86 (7.3) | 54 (7.8) | 32 (6.6) | .454 |
| Hispanic | 243 (20.6) | 99 (14.3) | 144 (29.8) | < .001 b |
| Other/not reported | 278 (23.6) | 98 (14.1) | 180 (37.3) | < .001 b |
| Characteristics of first IUD insertion attempt | ||||
| Success of first insertion attempt | 1132 (96.2) | 665 (95.8) | 467 (96.7) | .446 |
| IUD type | .030 b | |||
| LNG-IUS | 907 (77.1) | 552 (79.5) | 355 (73.5) | |
| Copper-T 380A | 269 (22.9) | 142 (20.5) | 127 (26.3) | |
| Uterine sounding depth, cm | 7.1 ± 0.8 | 6.9 ± 0.7 | 7.4 ± 0.8 | < .001 b |
| Ancillary measures used | ||||
| Assistance from second clinician | 5 (0.4) | 2 (0.3) | 3 (0.6) | .388 |
| Ultrasound | 10 (0.8) | 10 (1.4) | 0 (0.0) | .008 b |
| Mechanical dilation | 10 (0.8) | 9 (1.3) | 1 (0.2) | .045 b |
| Misoprostol | 8 (0.7) | 6 (0.9) | 2 (0.4) | .355 |
| Paracervical block | 8 (0.7) | 7 (1.0) | 1 (0.2) | .100 |
| Provider type | < .001 b | |||
| Advanced practice clinician | 1012 (86.0) | 582 (83.9) | 430 (89.0) | |
| Nurse practitioner | 256 (21.8) | 158 (22.8) | 98 (20.3) | |
| Physician’s assistant | 322 (27.4) | 221 (31.8) | 101 (20.9) | |
| Certified nurse midwife | 434 (36.9) | 203 (29.3) | 231 (47.8) | |
| Physician | 165 (14.0) | 112 (16.1) | 53 (11.0) | |
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