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 

Postpartum IUD Placement, with Dr. Sarah Prager

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This week we are joined by Dr. Sarah Prager, a professor at the University of Washington in OB/GYN and Complex Family Planning. She shares with us some particular expertise in an ever-more common procedure - the postpartum IUD placement. There’s definitely a few pearls in the podcast that are worth listening for!

Definitions: 

  • Immediate postplacental insertion: within 10 minutes of placental extraction

  • Immediate postpartum insertion: 10 minutes to 48 hours after delivery

  • Delayed postpartum insertion: 48 hours to 6-8 weeks after delivery

  • Interval placement: IUD placement not related to recent delivery

  • Trans-cesarean insertion: IUD placed through the hysterotomy at the time of cesarean delivery

Exclusion criteria:

  • Chorioamnionitis/uterine infection

  • Prolonged rupture of membranes (18-24 hours)

  • Excessive postpartum bleeding that is unresolved

  • Extensive genital trauma that would be negatively impacted by IUD placement

Expulsion rates: 

  • 10% if placed in the first 10 minutes

  • Up to 25-30% if placed after 48 hours

  • Limited data on 10 minutes to 48 hours

    • Pilot study in Zambia showed 4% expulsion with “morning after delivery” IUD placement

  • Provider experience matters!

    • Study from 1985 showed providers cut their expulsion rates almost in half comparing the beginning to the end of the study

  • Take home message: don’t get discouraged! Your expulsion rate will decrease with experience!

Copper vs. LNG-IUD

  • Most older data is with various copper IUDs (primarily the Copper T 380A – ParaGard)

  • Some limited data with specifically Mirena brand LNG-IUD.

  • Recent data often pooled LNG-IUD, without separating different IUDs

  • Limited comparative data

    • Possibly higher expulsion rates with LNG-IUD than Copper IUD

    • Could be due to method used for insertion – inserter vs. no inserter

    • LNG-IUD inserters are long enough to reach the fundus of a PP uterus, ParaGard IUD inserters are not

    • There is a dedicated PP inserter for Copper IUD (longer, stiffer, but not available in USA at this time); unclear if it changes outcomes

  • Recent study out of Kaiser showed slightly lower expulsion rates for breastfeeding vs. non-breastfeeding people.

    • Largest study to date with mostly LNG-IUD

    • Expulsion rates:

      • 10.7% expulsion by 5 years with placement 0-3 days

      • 3.9% for 3 days to 6 weeks

      • 3.2%for 6-14 weeks postpartum

      • 4.9% for interval placement

Medical Eligibility Criteria:

  • CDC: category 1 or 2 at any time, regardless of type of IUD or breastfeeding status.

    • Of course, category 4 if uterus is infected

  • WHO: category more nuanced depending on type of IUD and timing of placement

Method of placement:

  • With the inserter

    • Need a long enough inserter

    • Often can use the LNG-IUD inserters

    • Also need the inserter to be stiff enough – sometimes doesn’t work with LNG-IUD inserters

    • Dedicated copper IUD inserter both longer and stiffer

  • With an instrument

    • Can use a ring forceps

    • Can use a Kelly placenta forceps (longer)

  • With your hand

    • No difference in expulsion seen compared with instrument

    • Personal bias – WAY more painful! No-one likes a hand in their uterus

      • Not reported in the early studies that compared this to using a ring

Clinical tips and tricks for successful insertion with an instrument:

  • Place a ring on the anterior lip of the cervix

  • Hold the IUD gently in a ring forceps (don’t click down if LNG-IUD – don’t want to disrupt the LNG delivery system!)

  • Know the orientation of the IUD with respect to the orientation of the ring handles to make sure you place IUD with the proper orientation in the uterus!!!

  • Once the IUD is in the lower uterine segment, gently let go of the ring on the cervix and place the non-dominant hand on the uterine fundus

  • Drop your wrist! Drop your shoulder! Aim for the fundal hand

    • Angle different from interval insertions – basically aim for the umiblicus

    • Will not go wrong if you aim for the fundus! Feel it with your fundal hand!

  • Let go of the IUD and gently remove the ring without pulling on the IUD or strings

  • If strings are visible, cut at the os

    • Can also pre-cut the strings of LNG-IUDs so they are about 10 cm

    • Cutting strings can sometimes pull the IUD lower or out

  • Can use ultrasound if you want!

If using an inserter: 

  • Pre-deploy the IUD – you do not need the narrow profile with an open cervix!

  • Personal bias – don’t use the inserter

If using your hand:

  • Change your gloves

  • Precut the strings

  • Hold between the index and middle fingers with the strings laying across your palm

  • Make sure you don’t pull it out when you remove your hand!

If trans-cesarean placement:

  • Close 1/3 – ½ the hysterotomy then place

  • Precut the strings shorter before directing down into the cervix

  • Personal bias again toward instrument placement, but usually hand and inserter also work fine

Follow-up care:

  • See patients at 1-2 weeks postpartum and trim strings as needed.

    • May need to do this again at 6-week visit

  • If strings not visible at follow-up, do an ultrasound to verify presence of IUD in the uterus

    • If IUD there, NO NEED FOR ROUTINE ULTRASOUND TO CHECK CONTINUED PRESENCE OF THE IUD

    • Counsel patient that efficacy unchanged, but removal may be more complicated if strings don’t emerge from the cervix

      • This should have been a counseling point during consent!

Emergency Contraception

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Today we spend some time with Dr. Leanne Free, who is one of Fei and Nick’s co-residents. As a rising PGY-4 at Brown, Leanne is interested in family planning fellowship and shares some of that interest with us today by talking emergency contraception!

Leanne breaks down for us the main types of emergency contraceptives — the copper IUD and pills. Much of the information Leanne shares is really nicely prepared in graphical format on the BedSider website:

One crazy thing we learned: many levonorgestrel EC formulations are available on Amazon! Though buyer beware, as there have been some news stories regarding these to be potentially expired medicines. Additionally, as Leanne states, EC is most effective immediately after unprotected intercourse, rather than the 48 hours it takes for Prime delivery. All levonorgestrel EC should be available over-the-counter without restrictions for purchase based on age, gender, or parental consent.

Additionally, patients can follow the Yuzpe method by taking birth control pills that they may already have at home. This can be useful for patients who for some reason do not have access to the emergency contraceptives we refer to in the podcast — though an annual visit is a great time to review and prescribe these options!