Clinical Challenges of Long Acting Reversible Contraception (LARC)

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Read along with CO 672: Clinical Challenges of Long-Acting Reversible Contraceptive Methods 

Increased LARC Use 

  • There has been an increase in LARC use over the last few decades 

    • As high as 13.1% in women 20-29 and 11.7% in women 30-39 years of age in 2018 

    • This is compared to 2.4% of all women in 2002 

    • While overall complication of IUDs and implants are low (<1%), the absolute number of these complications will increase as more patients use them.

Complications with IUDs

  • Pain with IUD insertion 

    • IUD insertion can be painful, especially for nulliparous women 

    • Unfortunately, a 2015 Cochrane Review concluded that lidocaine 2% gel, NSAIDs, and misoprostol for cervical ripening were not effective for reducing pain associated with insertion

    • A word on misoprostol use

      • Can cause nausea and abdominal cramping per some trials 

      • Does also require a delay - can be a barrier to access  

    • Paracervical block 

      • Has demonstrated effectiveness in other office transcervical procedures 

      • Studies have shown reduced pain with tenaculum placement after local injection of anesthetic at the tenaculum site 

      • However, other studies have shown no difference in pain with treatment vs. no treatment 

      • Meta-analysis of various analgesic measures did conclude that lidocaine paracervical block reduces pain scores associated with tenaculum placement and IUD insertion 

    • Recommendation: 

      • Routine misoprostol use before IUD insertion in nulliparous women is not recommended, but can be considered with difficult insertions 

      • Pain with IUD insertion needs to be addressed, and one possible way is via a parcervical block as well as injection of lidocaine at the tenaculum site  

    • One last note: patients’ pain should be believed, and discussion for pain relief should be individualized.

      • Some patients may require nothing other than oral medications, but if appropriate and after discussion, some patients may require anesthesia and an OR procedure 

  • Nonvisualized strings 

    • The most common reason for nonvisualized IUD strings is string retraction into the cervical canal or uterine cavity 

      • First step: use a cytobrush to sweep the canal and see if strings are retrievable 

    • However, nonvisualized strings can also indicate other complications such as pregnancy, expulsion, or uterine perforation 

    • If strings cannot be visualized after cytobrush, then rule out pregnancy

      • Can also offer emergency contraception if indicated 

      • Next step is to obtain a pelvic ultrasound 

      • If IUD is not visualized with the pelvic ultrasound, then obtain Xray of the abdomen and pelvis - if not visualized, then IUD is likely expelled 

      • If the IUD is visualized, then this may require laparoscopic removal if there is true perforation and migration 

ACOG CO 672

  • Difficult removal of IUD 

    • If IUD removal is requested, and strings cannot be visualized, alligator forceps can be used to remove the IUD 

    • However, before instrumenting, should confirm that IUD is truly in the uterus 

    • IF strings cannot be visualized, follow above procedure 

  • Malposition/nonfundal position of IUD 

    • If an IUD is in the cervix, this is considered a partial expulsion 

      • Recommendation is to remove the IUD and replace it if it is desired 

    • If an IUD is in the lower uterine segment or low-lying, the ideal management is less clear 

      • Shared decision making - if patient is asymptomatic and IUD is above the internal os, it can be retained and will be effective

        1. However, more studies need to be done to see if failure rates of IUDs are higher when the IUD is located in the lower uterine segment 

        2. Also, many IUDs that are non fundal shortly after insertion move to a fundal position after 3 months 

  • Expulsion/Uterine Perforation 

    • Expulsion can happen in 2-10% of users and varies by IUD type and when the IUD is placed 

      • Risk factors include age <20, heavy bleeding, dysmenorrhea, placement immediately postpartum, and anatomic distortion of the uterine cavity 

      • Recommendation: if IUD is found to be expelled, rule out pregnancy and then counsel regarding contraceptive choices 

    • Perforation into the peritoneal cavity is rare and occurs <1/1000 insertions 

      • Recommendation: rule out pregnancy and then surgical removal 

      • Laparoscopy is preferred 

      • However, depending on location of IUD, it may be possible that it should be left in place if surgical risks associated with removal and considered too great 

      • Replacement of another IUD under laparoscopic guidance can be done if patient desires 

  • Infection 

    • IUDs should not placed if there is active infection 

    • Infection after IUD insertion is rare, and while the risk of PID developing is increased in the first 20 days after IUD insertion, the risk drops to baseline population risk after 

    • In patients with PID who have an IUD, the IUD can be left in-situ unless there is no clinical improvement 

      • IUD removal can be considered after this 

  • Pregnancy with IUD in place 

    • The risk of pregnancy with IUD in place is 2% after 10 years, similar to tubal sterilization procedures 

    • Ectopic pregnancy must be ruled out - first obtain pelvic ultrasound 

      • If ectopic pregnancy is present, then this needs to be managed medically or surgically. The IUD can be retained if desired  

    • If there is an intrauterine pregnancy

      • If undesired, then IUD can be removed at time of surgical abortion or before medical abortion 

      • If desired, then IUD can be removed if strings are visible 

        1. If strings are not visualized, then ultrasound should be done 

          1. If the IUD is in the cervix, then removal can be attempted 

          2. If IUD is above the cervix, then IUD should not be removed; instead, discussion should be had with patient about increased risk of obstetric complication in setting of pregnancy with IUD

            1. These include increased risk of SAB, infection, and preterm delivery 

          3. If no IUD is seen, then Xray should be done of the abdomen/pelvis after pregnancy  

Complications with Implants 

  • Nonpalpable Implant and Deep Insertion 

    • If an implant is not palpable, first thing is to rule out pregnancy 

    • Do not attempt removal unless implant location is determined

    • Obtain imaging to locate the implant 

      • As there is barium in the implant, X-ray, CT, and fluoroscopy can all be used 

      • Ultrasound and MRI can also be used if needed 

    • If there is a deep insertion that cannot be removed in office: 

      • Consult with family planning specialist or general surgery for removal 

      • If implant is not deeply located within muscle or near neurovascular bundle, then outpatient removal can be attempted with local anesthesia and ultrasound 

      • If the implant is deeply embedded into muscle or nearby neurovascular bundle, then attempt should only be made in the operating room with specialist or surgeon 

    • If imaging is not able to locate the implant, then an etonogestrel serum assay can be done – if itis negative, then there is no implant in the person’s body 

  • Pregnancy with Implants 

    • Risk overall is <1%, but if pregnancy is confirmed, there is a higher risk of ectopic pregnancy 

    • An ectopic pregnancy should be managed medically or surgically per guidelines 

    • If patient desires termination of pregnancy, the implant can be retained 

    • If the pregnancy is desired, then the implant should be removed 

      • Etonogestrel is not teratogenic