Clinical Challenges of Long Acting Reversible Contraception (LARC)

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 

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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 

The Contraceptive CHOICE Project

Background 

• Title: The Contraceptive CHOICE Project: Reducing Barriers to Long-Acting Reversible Contraception 

• Publishing Info:

  • Done by a group at the department of Ob/Gyn at Washington St. Louis School of Medicine (first author was a PhD!) 

  • Published in AJOG in 2010 (first 2500 patients) 

  • Follow up was published in Clinical Ob/Gyn 2014 - 9256 women 

• Who funded this study 

  • Funded by an anonymous foundation + also Midcareer Investigator Award in women’s Health Research, Clinical Translational Science Award, and NCRR 

• Why was this study done? 

  • About half of the pregnancies that occur in the US are unintended 

  • A lot of pregnancies results from incorrect or inconsistent use of birth control methods 

  • At the time, LARC use was low, <3% of women in the US used a LARC 

  • CHOICE was done to promote use of LARCs in the St. Louis region 

• Goal: 

  • Objective: provide no-cost contraception to a large number of women in that region 

    • Secondary: reduce unintended pregnancy at the population level 

  • In order to accomplish, had to overcome two barriers: 

    • Financial obstacles 

    • Lack of patient awareness of LARC method safety and efficacy 

Methods 

• Type of study

  • Prospective cohort study of 10,000 women in St. Louis region

• Intervention

  • Provided each participant with the contraceptive of her choice at no cost for three years  

• Subject recruitment

  • Convenience sample - meaning no randomization, etc. Just chose women at specific clinic locations and via general awareness of CHOICE through medical providers 

    • Clinics were university-affiliated clinics, two facilities providing abortion services, community clinics, etc. 

  • Eligibility: 

    • Age 14-45

    • Reside in or seek clinical services at recruitment sites in St. Louis region 

    • Sexually active with male partner in last 6 months or anticipate sexual activity with male partner in next 6 months 

    • No tubal or hysterectomy 

    • Does not desire pregnancy in next year 

    • Not currently using contraceptive method or interested in starting a new reversible contraceptive method 

  • Recruitment and screening was done by person on site or by telephone 

    • Person was trained with scripted intro to LARC methods if LNG-IUD, copper IUD, and subdermal implant

    • Enrollment occurs in 1.5-2 hr in person process

      • Rule out pregnancy

      • Due to staff constraints, not everyone got the same counseling - so at the community sites, patients received routine family planning counseling 

    • Informed consent 

  • LARC method

    • If they wanted a LARC method, then they had insertion by trained professional 

    • Emergency contraception was provided if needed  

  • Follow up: phone follow up at 3, 6, 12, 18, 24, 30, 36 months post enrollment 

    • Given $10 for each completed survey 

    • Also screened for gonorrhea and chlamydia at 12, 24, and 36 month contacts 

    • Huge undertaking to follow people for 3 years! 

    • Collected info on baseline demographics, OB and gyn history, etc. 

Results 

• Findings for first 2500 women (2010 study) 

  • Population

    • Between August 2007 - December 2008, screened 4107 women, 3522 met eligibility criteria, 2500 enrolled 

    • 74% (1845/2500) of enrollments occurred at university-based recruitment site  

    • Average age: 25 (range 14-45), majority were 25 or younger (only 36.9% >25)  

    • 49% white, 44% black 

    • 42% no insurance, more than half reported difficulty paying for transportation food, housing, or medications 

    • 63.7% single or never married

    • 41% nulliparous, 54% of parous women reported having 2 or more children 

    • 67.1% chose a LARC, and 32.9% chose other methods 

      • Of those that chose LARCs: 46.8% LNG-IUD, 9.3% Copper IUD, 11.0% subdermal implant 

      • LARC users more likely to be recruited at an abnortion clinic (RR 1.2, 95% CI 1.1-1.2), report greater parity, or history of abrotion 

      • Those who reported black or other race, single or never married, one or no lifetime partners were less likely to choose LARC 

• Findings for all the patients 

  • Demographics were overall pretty similar 

  • At the end of the study:

    • LARC users were more likely than non-LARC users to continue at the 12 and 24 months with method (86% vs. 55% at 12 months, 77% vs 41% at 24 months)  

    • At 12 months, the IUDs had highest continuation rates (88% for LNG-IUD, 84% for copper iUD), same at 24 months (79% for LNG-IUD and 77% copper) 

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• Some people voiced concern that with increased LARC use, there may be increase in high risk sexual behavior — no evidence to suggest that there was increased sexual risk-taking 

  • 71% reported no change in their number of sexual partners at 6 and 12 months; only 16% report increase, and of those, 80% experienced a change from 0 to 1 partners 

  • Percent of women reporting multiple partners at baseline was significantly reduced at 6 and 12 months (5.2%, 3.5%, 3.3% respectively) 

• Reduction of unintended pregnancies! 

  • Failure rates for pill, patch, and ring = 4.8%, 7.8%, 9.4% at 1, 2, and 3 years 

  • Failure rate for LARC users remained <1% throughout the 3 year follow up (cumulative was 0.3%, 0.6%, and 0.9% at each year respectively) 

  • Non-LARC users were 22x as likely to experience an unintended pregnancy compared to LARC counterparts 

  • Adolescent users of pill, patch, or ring were twice as likely as older women to experience unintended pregnancies 

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Very cool: super decreased rates of pregnancy, birth and abortion among teens! 

National for each: 158/1000, 94/1000, 41/1000

CHOICE: 34/1000, 19.4/1000, 9.7/1000 - Greater than 75% reduction! 

• Contraception in the overweight and obese populations 

  • BMI was not found to be significant factor associated with increased risk of method failure for pill, patch, or vaginal ring (there were a total of 334 unintended pregnancies, 128 were determined to be contraceptive failure)

  • Weight gain

    • Those who perceived weight gain were more likely to be implant or DMPA users 

    • Objective weight gain on average was 10.3 lbs 

    • Adjusted models only identified black race as having significant association with weight gain in 12 months 

•  STIs: Prevalence of GC, CT, and trich were higher in the CHOICE cohort than the national average at baseline 

  • 7.9% had one or more 

Conclusions 

• Huge # of women seeking reversible contraception 

  • When barriers of cost, access, and knowledge are removed, women choose the most effective and least-user dependent methods more often 

    • In general population, LARC use was 3% 

    • In this population, 46% chose LNG IUD, 11.9% chose Copper IUD, and 16.9% chose implant 

  • Continue to use them 

  • Also found they were highly satisfied 

  • Also decrease risk of unintended pregnancies, teen pregnancies 

What do we do now? 

• Some pretty cool follow up: 

  • Colorado Family Planning Initiative - provides access to long-acting reversible contraception 

  • Teen birth rates cut in half, abortion rates cut in half 

  • Average rate of first birth increased by 1.2 years among all women 

  • Cost avoided: $66.1-69.6 million

• Per CDC we have definitely increased LARC use now! 

  • 2015-2017: LARC use was up to 10.3% 

  • LARC was highest among women 20-29 (13.1%)

Long Acting Reversible Contraceptive Methods (LARC)

Today we review the classic topic of LARCs! We’ll spend our focus on the specifics of each method. However, in general LARCs are recommended by ACOG as the most effective form of reversible contraception. This is in large part due to their effectiveness independent of coitus and user motivation/adherence to the method. They also enjoy the highest continuation rate and user satisfaction of any method, along with their quality of being reversible with rapid return to fertility. There are also few contraindications to these methods — so what’s not to love?

We’ve put together a comparison table for your studying.

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(c) CREOGS over Coffee, 2019